**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2) On 08/15/2023 the State Agency received an Online Incident Report (FRI) from the facility alleging physical abuse when RI #290 struck RI #288 on the left side of the face and upper stomach. RI #288 was readmitted to the facility on [DATE] and had diagnosis to include: Epilepsy and Dementia. RI #290 was admitted to the facility on [DATE] and had diagnosis to include: Parkinson's Disease and Dementia. Review of the facility investigative file revealed a report titled Opening Statement that documented: . At approximately 11:30am . (RI #290) . came out of (his/her) room . became difficult to redirect and proceeded to nurses station picked up the hand sanitizer and was trying to swing at partners (employees) and then wanted (his/her) phone. was given (his/her) phone . At approximately 12:30pm . (RI #290) . walked over to the day area where lunch was being served. (RI #288), stood from where (he/she) was seated and . (RI #290) walked over and struck (RI #288) on the cheek and then in the abdomen area. Staff was able to intervene and assist (RI #290) back to (his/her) room until the MD (physician) could be notified and was given orders to send (him/her) to the ER (emergency department) for evaluation. (RI #288) was assessed for injury and no injuries were noted other than a red area to (his/her) face . The facility's investigative file contained an undated report titled Conclusion which documented: . it was determined that physical abuse could not be substantiated. (RI #288) may have gotten up to hug (RI #290) . (he/she) reacted with physical aggression. A Witness Statement Form dated 08/15/2023 for RI #288, the victim, documented an incident type of physical and RI #288's statement as follows: . (RI #288) stated (he/she) hit me. (He/she) knew better . (RI #288) was crying. A facility . Body Audit Form . dated 08/15/2023 at 12:40 PM documented . Slight Redness to (L/left) Cheek . with a line drawn on the left side of the face on the figure on the form. A Witness Statement Form dated 08/15/2023, signed by Certified Occupational Therapy Assistant (COTA) #13 documented an incident type of Physical and COTA #13's statement as follows: . I was walking to a . room, when (RI #290) was walking out. The CNAs were moving beds. So I tried to redirect (him/her), but (he/she) became aggressive. (RI #290) started running (his/her) walker into me (and) pushing me away. (He/she) continues to be aggressive, so I backed away to let the CNAs handle it. During an interview on 10/24/2024 at 2:07 PM with COTA #13, she stated she did observe RI #290 push his/her rollator in the way of staff in the hall so they could not get by and when she tried to intervene, RI #290 pushed the rollator into her, so she stepped aside and reported to the nurse, but not sure which nurse. A Witness Statement Form dated 08/15/2023, signed by CNA #11 documented an incident type of Patient-on-Patient and CNA #11's statement as follows: . Between 11:30 am and 12:00 pm while the nurse and I were moving a patient . (in the patient's bed) through the hall . (RI #290) would not let us pass. A member of therapy tried to redirect (RI #290) and (RI #290) ramed (rammed) the bed with (his/her) walker and began to ram the therapist. (RI #290) grabbed the Sanitizer dispenser from the desk . and began to swing it. When we got it away from (RI #290), (he/she) asked for (his/her) phone. (He/she) calmed down and stood at the desk for awhile. (He/she) walked over to the Dayroom and stood for a few minutes. (RI #288) stood up to go to the table to eat lunch. When (RI #288) stood up, (RI #290) punched (RI #288) in the chest area and then again in the face. On 10/23/2024 at 4:20 PM CNA) #11 was asked about the incident on 08/15/2023. CNA #11 stated, a short time prior to the incident between RI #290 and RI #288, RI #290 displayed aggressive behavior by using an electronic hand sanitizer dispenser as a weapon against the staff when RI #290 was mad for some reason and began to swing the dispenser at her and a nurse. CNA #11 said, it took several staff to take the dispenser away from RI #290. CNA #11 said, then RI #290 appeared to calm down and went over to the dayroom where RI #288 was. CNA #11 said, this was about 30 minutes later and they were singing in the watch area and RI #288 came up an started talking loudly (RI #288 is deaf) and RI #290 stood up and punched RI #288 in RI #288's face and chest. CNA #11 said, this was physical abuse and it would make someone in that situation feel terrified, upset, and angry. A Witness Statement Form dated 08/15/2023, signed by CNA #12 documented an incident type of physical and CNA #12's statement as follows: . I was in the watch .(area) sitting in between (another resident and RI #288). (RI #290) came and sat beside (RI #288). (RI #288) may have thought (RI #290) was a friend and went in to hug (RI #290). (He/she) punched (RI #288) in the upper right side of (his/her) face and upper right side of chest. (RI #288) was taken to safety and (RI #290) was taken to room. On 10/23/2024 at 3:53 PM CNA #12 was asked about the incident on 08/15/2023. CNA #12 stated, while on the unit assisting with activities RI #288 came up to RI #290 and tried to give RI #290 a hug. CNA #12 stated, RI #290 hit RI #288 in the face and upper chest. CNA #12 said, this was physical abuse and it would make someone in that situation feel angry. A Witness Statement Form dated 08/15/2023, signed by Licensed Practical Nurse (LPN) #14 documented an incident type of assault and LPN #15's statement as follows: . Resident was standing with (his/her) walker in front of (him/her). The nurse . (with a cart) . the CNA needed to pass. The resident began using (his/her) wheelchair to stop the . nurse and CNA . The resident then attempted to us (his/her) walker to stop PT person (physical therapist). The resident used (his/her) walker to attempt to stop the stretcher (resident being moved to another room). When that did not work, the resident picked up a metal hand sanitizer object (that was at the desk) to throw. Staff was able to get the object from the resident. (The resident was continuing to stop the stretcher . the stretcher had a resident on it as well). There was the potential to hurt the other resident and staff. The next thing was the resident had remained in the day area hit another resident twice. Once in the face and once in the chest. We all came to assist in stopping any further problems. The resident with the walker continued to walk towards the hit resident. Resident sat in chair yet still was wanting to hit at staff and the other resident. The resident continued attempting to hit at, punch at, grimace at. We phoned for help . assisted to (his/her) room until transport came. On 10/24/2024 at 2:30 PM LPN #14 was asked about the incident on 08/15/2023. LPN #14 reviewed and agreed, that was her written statement, and said, the incident was physical abuse. During an interview on 10/24/2024 at 3:55 PM with Director of Nursing (DON), she stated she was called to the unit by nursing staff who reported RI #290 had hit RI #288 in the left side of the face and chest. The DON stated, after the incident RI #288 was crying and saying RI #290 had hit him/her and RI #290 knew better. The DON said, she asked RI #290 what happened and RI #290 just shook his/her head and mumbled. The DON said, the physician was notified, RI #290 was sent to the hospital for evaluation, was admitted and returned to the facility on [DATE]. The DON stated, she was not aware of the behaviors RI #290 displayed prior to the incident. The DON was asked what the facility could have done to prevent this from happening since RI #290 had displayed behaviors prior to the incident. The DON replied, they could have called the doctor for medication or could have sent to the hospital sooner or called the family to come sit with resident. The DON stated, the staff should have kept RI #290 away from other residents when he/she started having behaviors and the physician should have been notified when the behavior pattern began. The DON said, the incident was physical abuse and someone in that situation would feel upset, angry, and have hurt feelings. Based on interviews, record review, review of a facility policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, review of Facility Reported Incidents (FRIs) received by the State Agency, and review of the facility's investigative files, the facility failed to protect the rights of residents to be free from abuse perpetrated by other residents of the facility. Specifically, on 05/22/2023 Resident Identifier (RI) #237 was physically abused by RI #239 when facility staff witnessed RI #239 grab RI #237's wrists and pull RI #237 from a recliner onto the floor and punch RI #237 multiple times. The facility failed to prevent this from occurring as staff members were aware RI #239 was annoyed with RI #237 yelling and RI #239 had already told RI #237 to shut up, earlier in the night. RI #237 was assessed with redness and bruising to the right wrist. RI #237 told staff after the incident, he/she had been attacked and wanted the police. Facility staff said, the abuse against RI #237 would have made someone in that situation feel hurt, scared, and upset. Further, on 08/15/2023 RI #288 was physically abused by RI #290 when RI #290 struck RI #288 in the face and chest. After the incident RI #288 was seen crying and told staff he/she had been hit. Witnesses of the incident said it was physical abuse and someone in that situation would have felt terrified, upset, angry, and hurt. The facility failed to prevent this from occurring when just minutes prior to this incident RI #290 had used an electronic hand sanitizer as a weapon to swing at staff and had aggressively pushed a rollator (rolling walker) into staff and toward another resident. The facility further failed to substantiate RI #288 was physically abused by RI #290. This deficient practice was cited as a result of the investigation of complaint/report numbers AL00044297 and AL00045279 and affected RI #237 and RI #288, two of five residents sampled for abuse. Findings include: A facility policy titled Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, with a revision date of 02/01/2023, documented the following: . DEFINITION POLICY Abuse, Neglect, Misappropriation of Patient Property and exploitation . will not be tolerated by anyone, including . patients . The patient has the right to be free from abuse, neglect, . The center administrator is responsible for assuring that patient safety, including freedom from risk of abuse or neglect, holds the highest priority. DEFINITIONS: Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Physical Abuse: includes hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment. PREVENTION POLICY . A. The center will provide supervision and support services designed to reduce the likelihood of abusive behaviors. All supervisory partners who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors. C. Patients with needs and behaviors that might lead to conflict with partners or other patients will be identified by the Care Planning team, with interventions and follow through designed to minimize the risk of conflict. The interventions designed to meet the needs of such patients will include but will not be limited to 1. Identification of patients whose personal histories render them at risk for abusing other patients or partners, 2. Assessment of appropriate intervention strategies to prevent occurrences, 3. Monitoring the patient for any changes that would trigger abusive behavior, . 1) On 05/22/2023 the State Agency received an Online Incident Report (FRI) from the facility alleging physical abuse when staff witnessed RI #239 grab RI #237 by the wrists and pull RI #237 onto the floor from a recliner and RI #239 punched at RI #237. RI #237 was admitted to the facility on [DATE] with diagnoses to include Cerebrovascular Disease, Vascular Dementia with Severe Agitation and History of Falling. RI #237's admission Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 03/08/2023 documented a Brief Interview for Mental Status (BIMS) score of six of 15, which indicated severely impaired cognition. RI #239 was admitted to the facility on [DATE] with diagnoses to include History of Traumatic Brain Injury, Disorders of Brain-Encephalomalacia, Depression, and History of Transient Ischemic Attack. The facility's investigative file included a report titled Opening Statement that documented: . On 5/22/23 at approximately 3:30am, . (RI #237) and (RI #239) were both up in the dayroom and had an altercation, and (RI #239) pulled (RI #237) out of the recliner and began hitting at (RI #237). Staff responded immediately and separated the two patients and took (RI #239) back to (his/her) room with staff supervision. MD (physician) was notified and orders were received to transfer (RI #239) to the adult . (psychiatric) unit . Calls were made to both patient's families and an immediate investigation was initiated. (RI #237) was assessed and it was noted that (he/she) had redness to (his/her) right ear and right wrist. The facility's investigative file also contained a form titled Incident Investigation Summary, dated 05/25/2023 signed by the Administrator (ADM) that documented: . Conclusion Summary: Physical abuse was substantiated . The facility investigative file contained a handwritten statement signed by Registered Nurse (RN) #5 dated 05/22/2023 that documented: On May 22, 2023 at 0340 (3:40 AM), Nurse from memory care unit called me down . due to rehab patient dragging memory care/long term patient to the floor from recliner and punching (him/her) multiple times up until 4 members of staff were able to get (him/her) off of them. I did not witness any of this. Upon speaking . (with) patient that was allegedly hit, patient states, I was pulled out my chair and attacked. I want the police. Upon speaking (with) patient that allegedly hit the other patient, patient states, I told (him) to shut up. I told y'all I can not take all this noise here. On 10/23/2024 at 2:23 PM RN #5 was asked about the incident with RI #237. RN #5 said, she had been called over to help with a resident who had pulled another resident to the floor, RI #237 was sitting in a chair, and she asked RI #237 what happened. RN #5 stated, RI #237 told her I was pulled out of a chair and attacked, I want the police. RN #5 said, she tried to call the abuse coordinator/Social Service Director (SSD) and could not reach her so she notified the Director of Nursing who said to separate the residents. RN #5 said, she then notified RN #4 to continue to try to notify the SSD, Administrator, physician, and families; and then RN #5 returned to her own hall. The facility's investigative file contained an undated handwritten statement signed by CNA #6 that documented: (RI #239) was in the day area and I saw (him/her) drag (RI #237) out of the recliner and start punching (RI #237) repeatedly. The Nurse, CNAs and I immediately went over and removed (RI #239) away from (RI #237) . On 10/23/2024 at 9:24 AM CNA #6 was asked what she remembered about the incident on 05/22/2023. CNA #6 said, she witnessed RI #239 rolling up to RI #237 and pulling RI #237 out of a recliner and RI #239 hit RI #237. CNA #6 said, she did not remember where RI #237 was hit but they separated the residents and took RI #239 to his/her room. CNA #6 said, what she witnessed would make someone in that situation feel hurt or scared. The facility's investigative file contained an undated handwritten statement signed by CNA #7 that documented: (RI #237) . was in the day area, and I seen (RI #239) pulled (RI #237) out of the recliner and start punching (him/her) repeatedly. It took all of us to pull (RI #239) off of (RI #237) and remove (him/her) from the room. We took (RI #239) to (his/her) room where a CNA had to sit with (him/her). On 109/23/2024 at 10:17 AM CNA #7 was asked what she remembered about the incident on 05/22/2023. CNA #7 said, both residents were in the dayroom and she saw (RI #237) on the floor and RI #239 was leaning over RI #237. CNA #7 said, staff immediately separated the residents. CNA #7 said, RI #237 did not complain of pain but wanted the staff to call the police. CNA #7 said what she witnessed was physical abuse and someone in that situation would feel upset. The facility's investigative file contained an undated handwritten statement signed by CNA #8 that documented: I witnessed (RI #237) was sitting in the day room in the recliner when (RI #239) pulled (him/her) out the recliner and proceeded to punch (him/her) multiple times me and other staff pulled (him/her) off and redirected patient . (RI #239) stated (RI #237) was annoying and I quote The Shit out of him. CNA #8 was unavailable for interview. The facility's investigative file contained an undated handwritten statement signed by CNA #9 that documented: I witnessed (RI #239) pull (RI #237) out of (his/her) chair and proceeded to punch (him/her) multiple times. It took 4 CNAs to pull (RI #239) off of (RI #237). CNA #9 was unavailable for interview. RI #237's nursing progress note dated 05/22/2023 electronically signed by RN #4 documented: . Pt (patient) had been in day room in recliner for most of this shift. Pt yelling out but when asked what (he/she) needs (he/she) states (he/she) doesn't know or that (he/she) needs to urinate, . Another patient rolled over to (RI #237) . My CNAS (Certified Nursing Assistant) reported to me that the patient pulled (RI #237) from recliner when I came around the corner I seen the patient punching (RI #237). Pt was stopped and separated . assessed for injuries. Redness noted to (R/right) wrist and Ear. A handwritten statement signed by RN #4 and dated 05/22/2023 documented: . (RI #237) was in recliner in the day room. Pt yells out often and was this night. (RI #239) told pt to shut up and stated the yelling was annoying. Moments later . (RI #239) was sitting in wheelchair speaking in normal tones to (RI #237). I was behind my (medication) cart when I heard my CNAs say Oh no and rushed out to day room. When I came around the corner I witnessed (RI #239) punching (RI #237) and (RI #237) was on the floor. CNAs stated to me that (RI #237) was pulled out of the chair by (RI #239). (RI #239) was removed and taken to room . Notified (physician/social services) and DON . verbal order to send pt (RI #239) out. On 10/23/2024 at 10:45 AM RN #4 was asked about the incident occurring on 05/22/2023 involving RI #237 and RI #239. RN #4 said, RI #237 who typically slept in the recliner started yelling out as he/she had a history of doing. RI #239 self propelled in wheelchair and yelled at RI #237 to shut up and RI #237 was annoying. RI #239 was re-directed to his/her room and a little while later, about an hour and a half, RI #239 came up the hall to the dayroom back toward RI #237, close to RI #237's chair. RN #4 said, the next thing she remembered was CNA #6 and CNA #8 jumped up from the desk and said, Oh no. RN #4 continued, she ran with them and saw RI #237 down on the floor and RI #239 leaning over RI #237 from the wheelchair punching at RI #237. RN #4 said, the incident she observed was physical abuse that would make someone in that situation feel upset and scared. The Abuse Coordinator (AC) was interviewed on 10/23/2024 at 3:19 PM. She stated RN #4 had reported the 05/22/2023 resident-on-resident altercation involving RI #237 and RI #239. The AC said, RN #4 had reported the incident to her, that the two residents had an altercation and RI #239 hit RI #237. The AC further concluded the incident was substantiated due to resident-on-resident abuse. On 10/26/2024 at 7:03 PM a follow up interview was conducted with the Abuse Coordinator and she was asked her professional opinion about what could have been done to prevent the abuse from occurring. The AC said, the nurse or the CNAs could have assessed for toileting needs, hunger, thirst, pain, or they could have offered quiet time in bed. The AC also said, the physician could have been notified or they could have called the family. The AC said, these things were not done. The Director of Nursing, (DON), was interviewed on 10/23/2024 at 4:30 PM. When asked if she recalled the resident-on resident altercation on 05/22/2023 involving RI #237 and RI #239, she said, yes. The DON confirmed the nurse had reported the incident to her, and that the two residents had an altercation and RI #239 hit RI #237. The DON stated this conclusion was physical abuse. On 10/26/2024 at 6:47 PM a follow up interview was conducted with the DON and she was asked her professional opinion about what could have been done to prevent the abuse from occurring. The DON said, the physician could have been notified of RI#237's behaviors and they could have taken RI #237 to his/her room for quiet time. The DON also said, the staff also could have assessed RI #237 for pain, hunger, thirst, toileting needs, or they could have called the family. The DON said, these things were not done.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, resident record reviews, review of the facility policy titled BEHAVIORAL HEALTH SERVICES, the facility failed to provide immediate and necessary behavioral interventions and supervision to prevent Resident Identifier (RI) #290, a resident exhibiting physically aggressive behaviors, from physically abusing RI #288. On 08/15/2023 RI #290 displayed physically aggressive behaviors toward the facility staff, ramming them with his/her walker and swinging at them with a dispenser for hand sanitizer. RI #290 was then allowed to walk into a day room area with other residents and staff who were preparing for lunch. RI #290 hit RI #288 in the face and chest. This affected RI #288 one of five residents reviewed for behaviors. Findings include: Cross-reference F 600. Review of a facility policy titled BEHAVIORAL HEALTH SERVICES, revised date of 2/2019, revealed the following: . The center must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care . Assessment of mental health needs of a patient is the responsibility of the interdisciplinary care plan team, including the physician or physician/extender . When additional professional evaluation and /or development of a treatment plan is recommended, the attending physician or physician extender may order a mental health consult. The observations and recommendations of mental health professionals are included in the patient's overall care plan . Persons identified as being in need of acute inpatient psychiatric care are . referred to appropriate treatment facilities. The center will ensure they have sufficient and competent staff to provide behavioral health services . On 08/15/2023 the State Agency received an Online Incident Report from the facility alleging physical abuse when RI #290 struck RI #288 on the left side of the face and upper stomach. RI #288 admitted to facility on 03/28/2023 with diagnosis Epilepsy, Down Syndrome, and Unspecified Dementia with Psychotic Disturbance. RI #290 was admitted to the facility on [DATE] with diagnosis Parkinson's Disease and Dementia, Behavioral Disturbance and Mood Disorder. The facility investigative file contained a report titled Opening Statement which documented: . At approximately 11:30am . (RI #290) . came out of (his/her) room . became difficult to redirect and proceeded to nurses station picked up the hand sanitizer and was trying to swing at partners (employees) and then wanted (his/her) phone. was given (his/her) phone . At approximately 12:30pm . (RI #290) . walked over to the day area where lunch was being served. (RI #290) walked over and struck (RI #288) on the cheek and then in the abdomen area. Staff was able to intervene and assist (RI #290) back to (his/her) room until the MD (physician) could be notified and was given orders to send (him/her) to the ER (emergency department) for evaluation. (RI #288) was assessed for injury and no injuries were noted other than a red area to (his/her) face . A Witness Statement Form dated 08/15/2023 for RI #288, the victim, documented an incident type of physical and RI #288's statement as follows: . (RI #288) stated (he/she) hit me. (He/she) knew better . (RI #288) was crying. Review of a facility . Body Audit Form . dated 08/15/2023 at 12:40 PM documented . Slight Redness to (L/left) Cheek . with a line drawn on the left side of the face on the figure on the form. On 10/23/2024 at 4:20 PM CNA #11 who witnessed the incident said, was RI #290 displayed aggressive behavior by using an electronic hand sanitizer dispenser as a weapon against the staff when RI #290 was mad for some reason and began to swing the dispenser at her and a nurse. CNA #11 said, it took several staff to take the dispenser away from RI #290. CNA #11 said, then RI #290 appeared to calm down and went over to the dayroom where RI #288 was. CNA #11 said, about 30 minutes later they were singing in the watch area and RI #288 came up an started talking loudly (RI #288 is deaf) and RI #290 stood up and punched RI #288 in RI #288's face and chest. CNA #11 said, this was physical abuse and it would make someone in that situation feel terrified, upset, and angry. On 10/23/2024 at 3:53 PM an interview was conducted with CNA #12, and he stated while on the unit assisting with activities RI #288 came up to RI #290 and tried to give RI #290 a hug and RI #290 hit RI #288 in the face and upper chest. During an interview on 10/24/2024 at 3:55 PM with Director of Nursing (DON), she stated she was called to the unit by nursing staff who reported RI #290 had hit RI #288 in the left side of the face and chest. The DON stated RI #288 was crying and said RI #290 had hit him/her. The DON said, she asked RI #290 what happened and he/she just shook his/her head and mumbled. The physician was notified, and RI #290 was sent to the hospital for evaluation and was admitted to the hospital. The DON stated she was not aware of the behaviors RI #290 displayed prior to this incident. The DON was asked what the facility could have done to prevent this from happening since RI #290 had displayed behaviors just prior to this incident and she stated they could have called the MD for medication to calm him/her or to get him/her to the hospital sooner or called the family to come sit with resident. She further stated the staff should have kept RI #290 away from other resident when he/she started having behaviors and should have notified the physician when behavior pattern began.