**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to protect the resident's right to be free from physical abuse (deliberate, aggressive, or violent behavior with the intention to cause harm) for two of eight sampled residents (Resident 9 and Resident 42), who was subjected to Resident 392's physical aggression, who had diagnoses of schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior). The facility failed to: -Implement the facility's policy and procedure titled, Abuse Prevention Program, dated 1/16/2025 to protect residents from abuse by anyone including other residents. -Develop a resident specific schizoaffective disorder bipolar type care plan for Resident 392, with interventions to monitor behavior. As a result, on 2/9/2025 at 8:24 pm, Resident 392 hit Resident 42 in the room they shared. On 2/10/2025, Resident 392 hit Resident 9 (his new roommate) above his right eye while Resident 9 was lying in bed. Resident 392 was transferred to the General Acute Care Hospital (GACH) on 2/10/2025 for altered mental status (a noticeable change in someone's mental state, like being confused, disoriented, not acting like themselves, or having difficulty thinking clearly) and agitation. This deficient practice caused an increased risk for Resident 42's psychological harm and Resident 9 sustained a scratch on his neck and remained angry and upset days after the incident. Findings: A review of the GACH Therapy record dated 1/28/2025, indicated Resident 392 was combative, agitated (a feeling of extreme restlessness, tension, or irritability), and required a sitter for monitoring behavior. A review of Resident 392's GACH Consultation record dated 1/29/2025, indicated the resident had an altered mental state (a noticeable change in someone's mental function, like being confused, disoriented, unusually sleepy, or acting strangely), and had aggressive behavior that required antipsychotic medication (generally used to treat the symptoms of psychosis [a collection of symptoms that affect the mind, where there has been some loss of contact with reality]). The GACH Consultation record indicated Resident 392 had poor attention, was confused, had impoverished thought content (issues with thinking often associated with schizophrenia [a serious mental disorder in which people interpret reality abnormally, may result in delusions and behavior that impairs daily functioning, may have grandiose delusions]), dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning), severe depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with your daily activities of living), and poor judgement and insight (a person is unable to recognize changes in their own behavior and emotions). A review of Resident 392's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including metabolic encephalopathy (a change in how your brain works due to an underlying condition), schizoaffective disorder bipolar type (a mental illness that can affect thoughts, mood, and behavior), and unspecified dementia (a chronic condition that causes a gradual decline in cognitive abilities, such as thinking, remembering, and reasoning). A review of the Physician's Order Summary Report dated 2/7/2025, indicated Resident 392 had an order for Zyprexa (medication used to treat schizophrenia) 5 milligrams (mg- metric unit of measurement) by mouth two times a day for schizoaffective disorder. The physician's order summary report indicated to monitor behavior of wide mood swings every shift for use of Zyprexa (an antipsychotic medication that can treat several mental health conditions like schizophrenia) starting 2/8/2025. A review of Resident 392's History and Physical (H&P) dated 2/8/2025, indicated the resident was not competent to understand his medical condition and bill of rights. The H&P indicated Resident 392 had a diagnosis of anxiety. According to a review of the Progress Note documented by Registered Nurse (RN) 1, dated 2/9/2025 at 8:24 pm, Resident 392 hit Resident 42 in the room they shared on 2/9/2025. The progress note indicated Resident 392 had a small scratch on his face and the facility moved Resident 392 to Resident 9's room on the same day. A review of Resident 392's care plan dated 2/9/2025 indicated the resident was involved in a physical altercation with a resident (Resident 42). The care plan goal was for Resident 392 to verbalize understanding and the need to control his behavior. The care plan intervention indicated to identify Resident 392's behavior and intervene and monitor for signs of psychological distress (when someone is experiencing a lot of negative emotions or mental discomfort that interferes with their daily life). The care plan also indicated that social services would do daily wellness checks for 72 hours and the facility would be attentive/responsive to Resident 392's behavior and would remove and identify behavior triggers (something that brings on or worsens symptoms). A review of Resident 392's Minimum Data Set (MDS - a resident assessment tool), dated 2/10/2025, indicated the resident's preferred language was non-English, and needed or wanted an interpreter for communication with a doctor or health care staff. The MDS indicated Resident 392 sometimes was able to make himself understood and sometimes able to understand others. The MDS indicated Resident 392 was unable to respond when asked about his health literacy, was inattentive (not able to pay attention), and had issues with sleep and trouble concentrating. A review of Resident 392's Psychiatric Consultation Note dated 2/10/2025, indicated a Psychiatric Mental Health Nurse Practitioner (NP) - a registered nurse who specializes in mental health care) saw Resident 392, but did not indicate the time the resident was seen. The note indicated the NP used a translator during his assessment of Resident 392 and that the resident was anxious, uncooperative, and avoiding eye contact. The consultation note indicated Resident 392 stared blankly at the NP when asked about his altercation with Resident 42. The note indicated Resident 392 was disorganized, irritable, and agitated. The note indicated Resident 392 had poor insight, impaired judgement, poor concentration and limited attention span with a diagnosis of schizoaffective disorder and bipolar type. According to a review of the Interdisciplinary Team (IDT - a group of people with different areas of expertise, like doctors, therapists, and social workers, who work together to solve a problem by combining their unique knowledge and skills to achieve the best possible outcome, especially when dealing with complex situations) Review notes dated 2/10/2025, Resident 392 had periods of confusion and struck his roommate (Resident 42) on 2/9/2025. The IDT notes indicated the facility would monitor Resident 392's behavior and refer him for a psychiatric evaluation (a mental health assessment that helps identify and treat mental health conditions). The notes indicated the SSD would perform wellness visits for 72 hours, the facility would encourage Resident 392 to attend activities of his choice, encourage Resident 392 to verbalize his feelings, and continue the care plan developed on 2/9/2025. The IDT also indicated Resident 392's primary language was English, which was a discrepancy compared to the MDS. A review of the Change of Condition (COC) Situation, Background, Assessment, Recommendation - SBAR) form dated 2/10/2025 at 7 pm, indicated Resident 392 was having a physical confrontation with his new roommate (Resident 9) on 2/10/2025. The COC SBAR form indicated a Certified Nursing Assistant (CNA) separated the residents and the facility placed Resident 392 on visual monitoring for the safety of other residents. The COC SBAR form indicated Resident 392 was transferred to the hospital at 7:30 pm on 2/10/2025 for altered mental status (a noticeable change in someone's mental state, like being confused, disoriented, not acting like themselves, or having difficulty thinking clearly) and agitation. A review of Resident 42's admission Record indicated the facility admitted the resident on 9/4/2024 with diagnoses including schizophrenia, lack of coordination (not being able to move different parts of your body smoothly together), muscle weakness, low back pain. A review of the MDS, dated [DATE], indicated Resident 42 was able to make himself understood and had the ability to understand others. According to a review of Resident 42's investigation report titled, Resident to Resident Altercation, a CNA standing near Resident 42's room heard a loud disturbance at approximately 7:15 pm on 2/9/2025. The investigation report indicated the CNA intervened right away. Resident 42 reported he was in his wheelchair when Resident 392 approached him and struck him. The investigation report indicated Resident 392 was moved to another room on the opposite end of the building and Resident 42 did not sustain any injury. The investigation report indicated Resident 392 had a superficial scratch on the left side of his jaw. During an interview on 2/10/2025 at 9:37 am with Resident 42 in his room, Resident 42 stated he was done talking about the incident with his former roommate, Resident 392 who had hit him. Resident 42 stated he did not want to talk to anyone anymore. A review of Resident 9's admission Record indicated the facility admitted Resident 9 on 6/6/2024 with diagnoses including chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), muscle weakness, and history of traumatic brain injury (brain damage caused by an external force, such as a blow to the head or an object penetrating the brain). A review of Resident 9's MDS, dated [DATE], indicated Resident 9 was able to make himself understood and had the ability to understand others. A review of the Resident 9's investigation report titled, Resident on Resident Altercation, indicated on 2/10/2025 a CNA heard a loud voice from Resident 9's room and immediately responded. The CNA observed Resident 392 holding Resident 9's necklace and was striking Resident 9 in the face. The investigation report indicated Resident 392 had an order to transfer to a hospital on 2/10/2025 and was waiting for transportation. During an interview on 2/11/2025 at 10:44 am, in Resident 9's room, Resident 9 stated that his roommate, Resident 392, pulled the necklace from Resident 9's neck and punched him over his right eye on 2/10/2025. Resident 9 stated he was angry and upset that Resident 392 hit him and that he would be upset if Resident 392 returned to the facility. Resident 9 used curse words when talking about Resident 392, that he would hurt Resident 392 after what Resident 392 did to him, and that the attack was unprovoked. Resident 9's face was red, and his voice elevated when describing what happened. During a concurrent observation and interview on 2/13/2025 at 8:59 am, in Resident 9's room, Resident 9 was irritable. Resident 9 stated he remained upset regarding the incident when Resident 392 hit him. Resident 9 stated Resident 392 hit him without provocation (something happened for no reason). During an interview on 2/13/2025 at 10:10 am in Resident 42's room, Resident 42 stated that Resident 392 was acting weird, would go between the curtain and the window that was next to Resident 42's bed on 2/9/2025. Resident 42 stated Resident 392 was on the right side of his bed, then Resident 392 hit Resident 42 without warning. Resident 42 then stated he no longer wanted to talk about what happened since he had already spoken about it with others. During an interview on 2/14/2025 at 11:49 am, CNA 11 stated she heard a sound from Resident 9's and Resident 392's room on 2/10/2025. CNA 11 stated she witnessed Resident 392 pulling Resident 9's necklace and stated she separated the residents right away. On 2/14/2025 at 11:55 am during an interview with the Director of Nursing (DON) and the facility Administrator (ADM), the DON and ADM stated they made arrangements for Resident 392 to be transferred to the hospital and while waiting for the ambulance, Resident 392 hit his roommate, Resident 9. The ADM stated the facility had a care plan (the physical altercation care plan with Resident 42) and a sitter was not needed. During an interview on 2/14/2025 at 2:24 pm, Registered Nurse Consultant 1 (RNC 1), stated the diagnosis of schizoaffective disorder for Zyprexa was not present on Resident 392's admission record, and the facility should have clarified with the Medical Doctor (MD). RNC 1 stated once clarified they would have assessed Resident 392 and created a care plan for schizoaffective disorder on admission. RNC 1 stated since the facility did not verify the diagnosis of schizoaffective disorder, there was no care plan in place for the resident and the interventions may not have been appropriate for Resident 392. The RNC 1 stated the facility staff should have verified the diagnosis to make sure the treatment Resident 392 received was appropriate. The RNC 1 stated there was a risk of Resident 392 to decline in behaviors since there was no schizoaffective care plan developed in accordance with facility policy and the facility may not be able to manage the resident's changes of behavior. During an interview on 2/14/2025 at 2:42 PM, regarding Resident 392 not having a care plan for schizoaffective disorder RNC 1 stated the care plan was important because it guided the staff to follow the interventions for the resident's care needs and to re-evaluate for effectiveness. During an interview on 2/14/2025 at 2:59 pm, when asked about Resident 392 receiving Zyprexa for schizoaffective disorder dated 2/7/2025, but the admission record did not have the diagnosis of schizoaffective disorder indicated until 2/14/2025, the DON stated the facility staff should have verified the diagnosis with the MD. The DON stated once verified, the facility staff should have developed a care plan for schizoaffective disorder to better care for Resident 392. The DON stated since there was no care plan in place, this affected how the staff cared for Resident 392. When asked about the consequences of not managing Resident 392's behavior, the DON declined to answer. A review of the facility's policy and procedure (P&P) titled, Abuse Prevention Program, dated 1/16/2025, indicated the residents have a right to be free from abuse and the facility would protect residents from abuse by anyone including other residents. The P&P indicated the facility would implement measures to address factors that may lead to abusive situations. A review of the facility's P&P titled, Care Planning - Interdisciplinary Team (IDT), dated 1/16/2025, indicated the IDT would be responsible for developing an individualized comprehensive care plan for each individual. A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated 1/16/2025, indicated the IDT and the resident and his/her family or legal representative would develop and implement a person-centered care plan for each resident. The P&P indicated the care plan would have measurable objectives and timeframes, describe the services to be furnished to help the resident maintain their highest practicable level in regard to physical, mental, and psychosocial well-being. The P&P indicated the care plan would have goals, timetables, objectives, interventions, and desired/measurable outcomes. The P&P indicated the care plan would include problem areas and risk factors associated with identified problems. The P&P indicated the care plan would help in preventing or reducing a resident's decline, identify problem areas, and develop interventions that the facility targeted and was meaningful to the resident. The P&P indicated the facility would revise the care plan when a resident's condition changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one sampled resident (Resident 77), who had diagnoses pneumonia (an infection / inflammation in the lungs that causes inflammation, leads to the accumulation of fluid and pus in the lungs, making it difficult to breathe) and chronic obstructive pulmonary disease (COPD-a chronic lung disease causing difficulty in breathing), received necessary care and services in accordance with professional standards of practice by failing to: -Implement the Speech Therapy at Risk for Aspiration care plan interventions dated 1/29/2025, for Resident 77 to receive oral pharyngeal stimulation and exercises (a series of movements designed to strengthen the muscles in the mouth and throat). -Develop a comprehensive, person-centered care plan to include the Physician's Order, for Resident 77 to receive oxygen at two liters per minute via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) as needed for shortness of breath related to COPD and include the oxygen use in the comprehensive assessment. -Ensure Resident 77's vital signs documented by the Licensed Vocational Nurse (LVN 4) were accurate on 2/8, 2/9 and 2/11/2025. -Implement the facility's policy and procedure (P&P) titled Routine Resident Checks as there was no routine resident check at least once per each 8-hour shift for Resident 77. The last skilled nursing assessment was documented on 2/11/2025 at 1:45 PM. As a result, Resident 77 was found unresponsive in his room on 2/12/2025 at 7:32 AM by LVN 3. Cardiopulmonary Resuscitation (CPR, consisting of chest compressions, combined with artificial ventilation [breathing], or mouth-to-mouth in an effort to manually preserve the brain) was initiated and Emergency Medical Services (EMS - immediate medical assistance via ambulance) was called. At 8:08 AM Resident 77 was pronounced dead by the paramedics. Findings: A review of Resident 77's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including pneumonia, COPD, bacteremia (condition where bacteria are present in the bloodstream, an abnormal infection in the blood), and dysphagia. A review of Resident 77's History and Physical (H&P) dated 1/29/2025 indicated the resident was not competent to understand his medical condition. A review of the Physician's Orders for Life-Sustaining Treatment (POLST, provides seriously ill patients more control over their end-of-life care) dated 1/29/2025, indicated Resident 77 was a 'Full Code' (a medical term that indicates a patient's wish to receive all possible life-saving measures in the event of a cardiac or respiratory arrest). The POLST was signed by the Attending Physician and Resident 77's responsible party (RP 1). A review of the Physician's Order dated 1/29/2025 indicated Resident 77 to receive oxygen at two liters per minute via nasal cannula, as needed for shortness of breath related to COPD. According to a review of Resident 77's Speech Therapy (ST) care plan dated 1/29/2025, the resident was at risk for aspiration (the accidental inhalation of foreign substances, such as food, liquid, or vomit, into the lungs). The care plan interventions indicated for Resident 77 to receive oral pharyngeal stimulation and exercises (a series of movements designed to strengthen the muscles in the mouth and throat), safe swallowing strategies, and patient and caregiver education. A review of Resident 77's Pneumonia Care Plan dated 1/30/2025 indicated the goal was for the resident's pneumonia to be resolved without any complications. The care plan interventions indicated to elevate the head of the bed for comfort and lung expansion. The care plan did not indicate Oxygen Use interventions for the physician ordered oxygen at two liters per minute as needed. A review of the Acute Respiratory Failure with Hypoxia (low oxygen in the blood) care plan dated 1/30/2025, indicated the goal for Resident 77 was to not have complications related to shortness of breath (SOB). The care plan interventions indicated to encourage sustained deep breaths using an incentive spirometer (a medical device used to help patients improve their lung function with deep inhale and exhale) and asking the resident to yawn. The care plan did not indicate Oxygen Use interventions for the physician ordered oxygen at two liters per minute as needed. A review of the medical record indicated Resident 77 did not have an Oxygen Use care plan with person-centered interventions. A review of the Dysphagia Care Plan dated 1/30/2025, indicated staff interventions to provide Resident 77 with a healthy heart, pureed texture, honey consistency diet as ordered, and a ST evaluation and treatment as ordered. According to a review of the Minimum Data Set (MDS - a resident assessment tool) dated 2/1/2025, Resident 77 had severe cognitive impairment (problems with a person's ability to think, remember, use judgement, and make decisions) and was dependent on facility staff with showering and transfers. The MDS indicated Resident 77 had diagnoses of pneumonia, septicemia (blood poisoning, especially that caused by bacteria or their toxins), hypertension (HTN, high blood pressure), COPD, respiratory failure (a condition where the lungs cannot adequately exchange oxygen), and dysphagia. The MDS did not indicate that Resident 77 was on oxygen therapy. A review of the Medication Administration Record (MAR) dated 2/8/2025 indicated Resident 77's vital signs during the 3 PM -11:30 PM shift was noted as Blood Pressure (BP): 128/76, Temperature (Temp): 97.1, Pulse: 72, Respirations (Resp): 18, and Oxygen Saturation (O2 Sats): 97. All within normal limits. A review of the MAR dated 2/8/2025 indicated Resident 77 vital signs during the 11 PM - 7:30 AM shift were Blood Pressure (BP): 128/76, Temperature (Temp): 97.1, Pulse: 72, Respirations (Resp): 18, and Oxygen Saturation (O2 Sats): 97, exactly the same as the prior shift (3 PM - 11:30 PM). All within normal limits. A review of the MAR dated 2/9/2025 indicated Resident 77's vital signs during the 3 PM - 11:30 PM was noted as BP: 121/70, Temp: 97.8, Pulse: 74, Resp: 18, O2 Sats: 98. A review of the MAR dated 2/9/2025 for the 11 PM - 7:30 AM shift for Resident 77, were exactly the same as the shift prior (3 PM - 11:30 PM). All within normal limits. A review of the Medication Administration Record (MAR) dated 2/11/2025 indicated Resident 77's vital signs during the 3 PM -11:30 PM shift was noted as BP: 126/71, Temp: 97.1, Pulse: 72, Resp: 18, O2 Sats: 96. A review of the MAR dated 2/11/2025 indicated Resident 77 vital signs during the 11 PM- 7:30 AM shift were exactly the same as the prior shift (3 PM - 11:30 PM). All within normal limits. The MAR's for Resident 77 dated 2/8, 2/9 and 2/11/2025 during the 11 PM - 7:30 AM shift were documented by the same LVN (LVN 4). A review of the Medication Administration Record (MAR) dated 2/8, 2/9, 2/10 and 2/11/2025 indicated Resident's 341, 32, 62, 21, and 19 (five additional residents) vital signs during 11 PM - 7:30 AM shift were exactly the same as the prior shift (3 PM - 11:30 PM). All within normal limits and all documented by the same LVN (LVN 4). According to a review of the Nurses Note dated 2/11/2025 at 1:45 PM, Resident 77 was alert and able to follow directions. Resident 77's breathing was regular, had normal breath sounds, and had no cough. The nurses note indicated vital signs were within normal limits and the resident had no pain or discomfort. This was the last nursing note documented for Resident 77 (excluding the vital signs) as there was no nursing notes during the 3 PM - 11:30 PM shift, nor the 11 PM - 7:30 AM shift (approximately 16 hours), A review of the Change of Condition (COC) report, dated on 2/12/2025 at 7:32 AM indicated Resident 77 was found unresponsive in his room by LVN 3. The COC indicated further assessment by LVN 3 included Resident 77 had no pulse, was not breathing, and vital signs were unobtainable. Cardiopulmonary Resuscitation (CPR) was initiated, and EMS was called. A review of the Paramedic Care Report dated 2/12/2025 at 7:38 AM indicated EMS arrived on site with Resident 77 laying in the bed without a pulse and apneic (a condition where breathing stops or is severely reduced). The report indicated the last know well time for Resident 77 was approximately one hour prior to arrival and CPR was initiated. The Paramedic Report indicated EMS administered Resident 77, 15 liters of oxygen per minute via bag valve mask and three rounds of epinephrine (also known as adrenaline, plays an important role in your body's fight-or-flight response, a medication to treat many life-threatening conditions). The Paramedic Report indicated Resident 77 was in asystole (a medical condition where the heart stops to produce electrical activity and contractions, the heart no longer pumps blood throughout the body) and remained in asystole for the duration of CPR. The Paramedic Report indicated Resident 77 had a severe distress level, pupils were fixed and dilated and Resident 77's time of death was 8:08 AM. During an interview on 2/12/2025 on 12:45 PM with the Medical Director (MD, who was also Resident 77's physician), the MD stated he believed that an assessment for Resident 77 should have been conducted every shift and that it was another form of communication. The last skilled nursing assessment was documented on 2/11/2025 at 1:45 PM (two shifts missing documentation prior to Resident 77's death). The MD stated when there was no documentation staff would not know the resident's condition or needs and would not understand the trends of the resident's condition. During a concurrent interview and record review on 2/12/2025 at 1:57 PM, with the Director of Nursing (DON), Resident's 77's MARs were reviewed. The DON stated that she could not consider the vital sign documentation for Resident 77 and the additional five residents as falsification (the act of deliberately lying about or misrepresenting something) of records. The DON stated and agreed the vital sign records for Resident 77 for 2/8, 2/9 and 2/11/2025 on the 3 PM-11:30 PM and 11 PM-7:30 AM shift were exactly the same. The DON stated and agreed the vital sign records for Residents 341, 32, 62, 21, and 19 (five additional residents) during the 11 PM - 7:30 AM shift were exactly the same as the prior shift (3 PM - 11:30 PM). The DON stated the Nursing Note documentation was required by the LVN to be done daily and did not need to be completed for each shift. The DON stated she did not have a policy that stated this specifically and could not provide a policy that showed how often documentation needed to be done for Resident 77. A review of the facility's policy and procedure (P&P) titled, Routine Resident Checks, indicated that nursing staff shall make routine resident checks at least once per 8-hour shift. It further stated the nursing supervisor or charge nurse shall keep documentation related to these routine checks, including the time, identity of the person making checks, and any outcomes of each check. This P&P indicated a discrepancy with the DON's statement regarding documentation. During a telephone interview on 2/12/2025 at 2:47 PM, LVN 4 stated he worked the 11 PM -7:30 AM shift on 2/8, 2/9, 2/10 and 2/11/2025 and documented the vital signs for Resident 77 (including the vital signs for the additional five residents). LVN 4 stated he could not explain how the vital signs on 2/8, 2/9, 2/10 and 2/11/2025 from his shift were exactly the same as the prior shift 3 PM -11:30 PM. During an interview on 2/13/2025 at 11:24 AM, Registered Nurse (RN) 1 stated he received Resident 77 upon admission on [DATE] receiving oxygen via nasal cannula at two liters per minute (LPM). RN 1 stated there was no need to continue Resident 77 on oxygen and there was no need for an incentive spirometer because the resident did not have any respiratory issues. RN 1 stated he placed Resident 77's head of bed up and instructed Resident 77 to take deep breaths, but there was no documentation indicating this. During an interview on 2/13/25 at 1:42 PM, CNA 5 stated Resident 77's meal card indicated he had swallowing issues and to feed with small bites. CNA 5 stated she was not informed regarding any speech therapy recommendations required for Resident 77 and that she did not document the interventions that she completed with the resident. CNA 5 stated that it was important to document because if it was not documented it means it was not done. During an interview on 2/13/2025 at 2:35 PM, the DON stated Resident 77 was on oxygen as needed at the General Acute Care Hospital (GACH). The DON stated the Acute Respiratory Failure care plan and the Pneumonia care plan was not required to include the as needed (PRN) order of oxygen use for Resident 77. During an interview on 2/13/2025 at 2:26 PM the Minimum Data Set Nurse (MDSN) stated Resident 77 had an as needed (PRN) order for oxygen and a care plan should have been initiated. The MDSN stated and confirmed Resident 77's comprehensive assessment (MDS dated [DATE]) did not include the oxygen use but should have been included. During an interview with the Administrator (ADM) on 2/14/2025 at 8:30 AM, the ADM stated that LVN 4 was suspended as of 2/13/2025 pending the facility's internal investigation. When asked the reason of LVN 4's suspension, the ADM stated it was for charting and documentation. During a concurrent interview, the DON stated that an in-service meeting was done with staff on 2/13/2025 regarding accurate documentation of resident vital signs. During a telephone interview on 2/14/2025 at 10:05 AM, the Speech Therapist stated Resident 77 was assessed upon admission due to the dysphagia diagnosis. The ST stated she saw Resident 77 during mealtimes with the CNAs and she gave the CNAs her recommendations to have the head of bed in an upright posture, observe any coughing, and to report any issues to the ST, but this was not documented. The ST stated sometimes Resident 77 would feed himself and sometimes he would need feeding. During a telephone interview on 2/14/2025 at 12:13 PM, the MD stated, in his opinion Resident 77 could have aspirated. The Medical Director stated Resident 77 had some cognitive decline which may have contributed to the aspiration. A review of the facility's P&P titled, Charting and Documentation, reviewed on 1/16/2025, indicated that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team (IDT) regarding the resident's condition. The P&P indicated that documentation in the medical record would be objective, complete, and accurate. A review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, reviewed on 1/16/2025, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs was developed and implemented for each resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide therapy services for two of eight sampled residents (Residents 48 and 6) who had limited range of motion (ROM, full movement potential of a joint [where two bones meet]) by failing to: -Provide Occupational Therapy (OT, rehabilitative profession aimed to increase or maintain a person's capability to participate in everyday life activities) evaluation after identifying a decline in Resident 48's range of motion in the left shoulder, left elbow, left wrist, and left hand during the OT Joint Mobility Screen (JMS, brief assessment of a resident's ROM) dated 8/22/2024. -Provide OT Evaluation and treatment for Resident 48 prior to the application of a left resting hand splint (rigid material or apparatus used to support and immobilize a broken bone or impaired joint) for one to six (1-6) hours in accordance with professional standards of practice on 8/22/2024. -Provide Restorative Nursing Aide program (RNA, nursing aide program that help residents to maintain their function and joint mobility) treatment from 8/2024 to 2/2025 (over five months) to Resident 48 for passive range of motion (PROM, movement at a given joint with full assistance from another person) to left upper extremity (UE, shoulder, elbow, wrist, hand/fingers) in all planes (all possible joint movements) five (5) times a week in accordance with the physician's order dated 8/22/2024 . -Provide RNA treatment from 8/2024 to 2/2025 (over five months) for the application of a left resting hand splint for 1-6 hours as tolerated five times a week in accordance with the physician's order dated 8/22/2024. -Report Resident 48's refusals and missed RNA treatments on 9/2024, 10/2024, 12/2024, 1/2025, and 2/2025 to the Charge Nurse and Therapy staff in accordance with the facility's job description titled, Restorative Nursing Assistant/CNA. -Provide Resident 48 with a nursing assessment after Restorative Nursing Aide (RNA 3) reported Resident 48's refusals to participate in RNA throughout 11/2024 in accordance with facility policy and procedure. -Provide an appropriate RNA order for Resident 6 who wore left ankle foot orthotics (AFO, an orthotic device designed to correct or address problems with the ankle and foot) for no more than four (4) hours as established by physical therapy (PT, a profession aimed in restoration, maintenance, and promotion of optimal physical function). -Ensure Resident 6 did not have a delay in the start of RNA services for PROM with both lower extremities (LE, hip, knee, ankle, foot) five times a week and application of left AFO five times a week ordered on 2/4/2025 to start on 2/5/2025. These failures resulted in Resident 48's worsening contracture (loss of motion of a joint) of the left hand from 9/2024 to 1/2025 (over four months) into a fisted position with the left thumb positioned under the left index finger and over the middle finger. This fisted position resulted in the development of Resident 48's Stage IV pressure injury (Full-thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone) on the left middle finger, which was identified on 1/15/2025. These failures had the potential for Resident 6 to be injured due to the application of the left AFO. Findings: a. A review of Resident 48's admission Record indicated the resident was admitted to the facility on [DATE] with diagnoses including hemiplegia (weakness to one side of the body) and hemiparesis (inability to move one side of the body) following cerebral infarction (blockage of the flow of blood brain, causing or resulting in brain tissue death) affecting left non-dominant side and muscle weakness. A review of Resident 48's Care Plan initiated on 9/15/2022 indicated the resident had the potential for limitations in joint mobility related to decreased physical mobility, history of cerebrovascular accident (CVA-stroke, loss of blood flow to a part of the brain), osteoporosis (weak and brittle bones) and osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage). The care plan goal indicated Resident 48 would have no further loss of ROM daily for three months. The care plan interventions indicated to monitor for pain or stiffness, position resident to prevent further contractures with pillow or splint as needed, RNA to perform PROM to left UE (LUE) in all places as tolerated 5 times a week, RNA to apply left resting hand splint for 1-6 hours or as tolerated 5 times a week. A review of Resident 48's Care Plan initiated on 9/15/2022 indicated the resident was at risk for complications due to alteration in musculoskeletal status related to diagnosis of hemiplegia and hemiparesis, osteoarthritis of knee and hip, osteoporosis, advanced age, contractures, joint pain. The care plan goal indicated complications related to fracture (broken bone), such as contracture formation, and immobility would be minimized. The care plan interventions included to assist the resident with the use of supportive devices (splints) as recommended; monitor/document/report to medical doctor (MD) as needed signs and symptoms or complications related to arthritis (swelling and tenderness of a joint causing pain and stiffness): joint pain, joint stiffness, swelling, decline in mobility, decline in self-care ability, contracture formation/joint shape changes, pain after exercises. A review of Resident 48's OT Joint Mobility Screening (JMS) dated 2/14/2024 indicated the resident had full range of motion in both wrists, both hand/fingers, both elbows, and both shoulders. The JMS indicated Resident 48 did not have minimal to severe loss of UE passive ROM and did not have a diagnosis or condition that placed Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation and RNA program was not recommended. A review of Resident 48's OT JMS dated 6/1/2024, indicated the resident had full range of motion in both wrists, both hand/fingers, both elbows, and both shoulders. The JMS indicated Resident 48 did not have minimal to severe loss of UE passive ROM and did not have a diagnosis or condition that placed Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation and RNA program was not recommended. A review of Resident 48's OT JMS dated 8/22/2024, indicated the resident had full range of motion in the right wrist, right hand/fingers, right elbow, and right shoulder. The JMS indicated Resident 48 had moderate loss (26-50 percent (%) loss) of range of motion in the left wrist, left hand/fingers, and left shoulder and minimal loss (less than 25% loss) range of motion in the left elbow. The JMS indicated Resident 48 had minimal to severe loss of UE passive ROM and had a diagnosis or condition that placed Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation was not recommended, and RNA program was recommended. The comments indicated PROM left UE, left resting hand splint, [right]UE AAROM. According to a review of the Physician's Order Summary Report (OSR) dated 8/22/2024, Resident 48 was to receive RNA services, perform PROM LUE in all planes as tolerated, frequency five times a week. The OSR indicated the RNA to apply left resting hand splint for 1-6 hours or as tolerated, frequency 5 times a week. A review of Resident 48's 8/2024 RNA Daily Survey Report (DSR), the DSR indicated Resident 48 did not complete RNA treatment (RNA entry was blank or not available) to perform PROM LUE in all planes as tolerated, 5 times a week on the following days: 8/30/24. During a review of Resident 48's 8/2024 RNA DSR, the DSR indicated Resident 48 refused RNA treatment to perform PROM LUE in all planes as tolerated, 5 times a week on 8/26/24. Resident 48 did not complete RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on 8/30/24. The DSR indicated Resident 48 refused RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on 8/26/24. During a review of Resident 48's OT JMS dated 9/1/24, the JMS indicated Resident 48 had full range of motion in the right wrist, right hand/fingers, right elbow, and right shoulder. The JMS indicated Resident 48 had moderate loss of motion in the left wrist, left hand/fingers, and left shoulder and minimal loss of motion in the left elbow. The JMS indicated Resident 48 had minimal to severe loss of UE passive ROM and had a diagnosis or condition that put Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation was not recommended. During a review of Resident 48's Minimum Data Set (MDS, a resident assessment tool) dated 9/1/24, the MDS indicated Resident 48 had severe cognitive impairments. The MDS indicated Resident 48 did not exhibit any behavior for rejection of care that was necessary to achieve health and well-being. The MDS also indicated Resident 48 required substantial/maximal assistance from staff for oral hygiene, bathing, dressing, personal hygiene, sit to stand, and bed to chair transfers. The MDS indicated Resident 48 had functional range of motion impairments on one side of the upper extremity and impairments on one side of the lower extremity. During a review of Resident 48's 9/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to perform PROM LUE in all planes as tolerated, 5 times a week on the following days: 9/2, 9/4, 9/5, 9/11, 9/17, 9/18, 9/24, 9/25, and 9/30/2024. During a review of Resident 48's 9/2024 RNA DSR, the DSR indicated Resident 48 refused RNA treatment to perform PROM LUE in all planes as tolerated, 5 times a week on 9/13/24. The DSR indicated Resident 48 did not complete RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 9/2 - 9/5, 9/11, 9/13, 9/16, 9/17, 9/18, 9/20, 9/24 - 9/27 and 9/30/2024. According to a review of Resident 48's 10/2024 RNA DSR, Resident 48 did not complete RNA treatment to perform PROM LUE in all planes as tolerated, 5 times a week on the following days: 10/1, 10/2, 10/4, 10/8, 10/11, 10/14, 10/18, 10/21, 10/22, 10/25, 10/28 and 10/31/2024. The DSR indicated Resident 48 did not refuse RNA treatment to perform PROM LUE in all planes as tolerated, five times a week. During a review of Resident 48's 10/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 10/1, 10/4, 10/8, 10/11, 10/14, 10/18, 10/21, 10/22, 10/25, 10/28 and 10/31/2024. The DSR indicated Resident 48 refused RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 10/7, 10/15, 10/17, 10/23 and 10/24/2024. During a review of Resident 48's RNA Weekly Summary (WS) dated 10/1/24, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM, PROM, and splint application. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's RNA WS dated 10/8/24, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM, PROM, and splint application for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's RNA WS dated 10/22/24 an 10/30/2024 the WS indicated Resident 48 completed RNA treatment for AAROM and PROM. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's 11/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 11/4, 11/7, 11/13, 11/21 and 11/25/2024 and refused RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 11/1/24, 11/8/24, 11/11/24, 11/12/24, 11/15/24, 11/19/24, 11/20/24, 11/22/24, 11/26 - 11/29/24 During a review of Resident 48's 11/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 11/1/24, 11/4/24, 11/6/24, 11/7/24, 11/13/24, 11/15/24, 11/20/24, 11/21/24, 11/25/24, 11/26/24, 11/27/24 and refused RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 11/8/24, 11/11/24, 11/12/24, 11/14/24, 11/19/24, 11/22/24, 11/28/24, 11/29/24. According to a review of Resident 48's RNA WS dated 11/1/24, Resident 48 completed RNA treatment 5 times in the last week for AAROM and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's RNA WS dated 11/8/24 and 11/15/2024, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM of both lower extremities, PROM of LUE, and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. The WS indicated refuse in comments. The WS was reviewed and co-signed by an unidentified nursing staff. During a review of Resident 48's RNA WS dated 11/22/2024 and 11/29/2024, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM of both lower extremities and PROM of LUE. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. The WS indicated refuse in comments. The WS was reviewed and co-signed by an unidentified nursing staff. During a review of Resident 48's MDS dated [DATE], the MDS indicated Resident 48 had severe cognitive impairments. The MDS indicated Resident 48 did not exhibit any behavior for rejection of care that was necessary to achieve health and well-being. The MDS also indicated Resident 48 required substantial/maximal assistance from staff for oral hygiene, bathing, dressing, personal hygiene, sit to stand, and bed to chair transfers. The MDS indicated Resident 48 had functional limitations in range of motion impairments on one side of the upper extremity and impairments on one side of the lower extremity. During a review of Resident 48's OT JMS dated 12/3/24, the JMS indicated Resident 48 had full range of motion in the right wrist, right hand/fingers, right elbow, and right shoulder. The JMS indicated Resident 48 had moderate loss of motion in the left wrist, left hand/fingers, and left shoulder and minimal loss of motion in the left elbow. The JMS indicated Resident 48 did not have minimal to severe loss of UE passive ROM and had a diagnosis or condition that put Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation was not recommended, and an RNA program was recommended. During a review of Resident 48's 12/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 12/3 - 12/5/24, 12/9/24, 12/10/24, 12/18/24 and refused RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 12/2/24, 12/6/24, 12/16/24, 12/24/24. During a review of Resident 48's 12/2024 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 12/3 - 12/5/24, 12/9/24, 12/10/24, 12/18/24 and refused RNA treatment RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 12/2/24, 12/6/24, 12/11 - 12/13/24, 12/16/24, 12/17/24, 12/19/24, 12/23/24, 12/24/24, 12/26/24, 12/27/24, 12/31/24. According to a review of Resident 48's RNA WS dated 12/3/24, Resident 48 completed RNA treatment 5 times in the last week for AAROM and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's RNA WS dated 12/9/24, 12/16/24 and 12/23/24 the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM, PROM, and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's 1/2025 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment to perform PROM LUE in all planes as tolerated, five times a week on the following days: 1/3/25, 1/6/25, 1/8/25, 1/9/25, 1/13/25, 1/17/25, 1/20/25, 1/24/25, 1/27/25, 1/28/25, 1/30/25, 1/31/25 and did not refuse RNA treatment to perform PROM LUE in all planes as tolerated, five times a week. During a review of Resident 48's 1/2025 RNA DSR, the DSR indicated Resident 48 did not complete RNA treatment RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 1/1/25, 1/3/25, 1/6/25, 1/7/25, 1/8/25, 1/9/25, 1/13/25, 1/15/25, 1/20/25, 1/27/25, 1/28/25, 1/30/25, 1/31/25 and refused RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 1/2/25, 1/14/25. During a review of Resident 48's RNA WS dated 1/2/25 and 1/9/25, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM, PROM, and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's Change of Condition (COC) dated 1/15/25, the COC indicated Resident 48 had a contracture related pressure injury Stage 4 to inferior left middle finger. The COC indicated Resident 48 had pain to left hand middle finger when moved due to contracture. The COC indicated Resident 48 had a Stage 4 pressure wound 1 centimeter (cm) in length, 1.2 cm in width, and 0.3 cm in depth. The COC indicated Resident 48 was in pain when the affected hand was moved. The COC also indicated a CNA informed charge nurse that Resident 48's left hand appeared different than normal and upon assessment of left hand, observed the hand with existing contracture with thumb between middle finger and index finger. The COC indicated per resident facial grimacing and body language, the wound site was painful when moved or manipulated. The COC indicated Wound Consultant Specialist (WCS) visited resident same day and assessed site with measurement of 1 cm x 1 cm x 0.3 cm and classified the wound as Stage 4 with new orders for wound treatment. During a review of Resident 48's WCS's visit note dated 1/15/25, the WCS visit note indicated Resident 48 had a contracture related Stage 4 pressure wound on inferior left middle finger. The visit note indicated WCS performed a procedure to remove devitalized necrotic (dead tissue) subcutaneous (beneath the skin) tissue and muscle tissue to promote healing and a topical spray solution was provided for anesthesia. According to a review of Resident 48's RNA WS dated 1/16/25 and 1/23/25, Resident 48 completed RNA treatment five times in the last week for AAROM, PROM, and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. During a review of Resident 48's OT JMS dated 1/28/25, the JMS indicated Resident 48 had full range of motion in the right wrist, right hand/fingers, right elbow, and right shoulder. The JMS indicated Resident 48 had moderate loss of motion in the left wrist, left hand/fingers, and left shoulder and minimal loss of motion in the left elbow. The JMS indicated Resident 48 did not have minimal to severe loss of UE passive ROM and did not have a diagnosis or condition that put Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation was not recommended, and an RNA program was recommended. During a review of Resident 48's 2/2025 RNA DSR, the DSR indicated Resident 48 missed RNA treatment to perform PROM LUE in all planes as tolerated, 5 times a week on the following days: 2/3/25, 2/4/25, 2/6/25, 2/7/25 and did not refuse RNA treatment to perform PROM LUE in all planes as tolerated, five times a week. During a review of Resident 48's 2/2025 RNA DSR, the DSR indicated Resident 48 missed RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 2/3/25, 2/4/25, 2/7/25 and refused RNA treatment to apply left resting hand splint for 1-6 hours or as tolerated, 5 times a week on the following days: 2/10/25, 2/11/25. During a review of Resident 48's RNA WS dated 2/4/25, the WS indicated Resident 48 completed RNA treatment 5 times in the last week for AAROM and splint for left hand. The WS did not indicate Resident 48 did not tolerate or had a problem with wearing the splint. The WS indicated Resident 48 complained of pain during ROM exercises. During a review of Resident 48's OT JMS dated 2/13/25, the JMS indicated Resident 48 had full range of motion in the right wrist, left wrist, right hand/fingers, right elbow, and right shoulder. The JMS indicated Resident 48 had minimal loss of range of motion in the left shoulder, moderate loss of range of motion in the left elbow, and severe loss (more than 50% loss) of range of motion in the left hand/fingers. The JMS indicated Resident 48 had minimal to severe loss of UE passive ROM and had a diagnosis or condition that put Resident 48 at risk for contracture development. The JMS indicated skilled OT evaluation was recommended, and an RNA program was not recommended. During an observation and interview on 2/10/25 at 1:15 p.m. in Resident 48's room, Resident 48 was sitting up in bed. Resident 48 was able to move the right arm up and down to about shoulder level. Resident 48 was able to lift the left arm up a little, the left wrist was straight, and the left hand was fully bent in a fisted position. The left thumb was opposed across the palm underneath the second finger and the tip of the thumb was above the third middle finger. Resident 48 stated the left hand was no good and stated she could not really move the lower extremities. Resident 48's hip and knees were bent and rotated towards the right side. Resident 48 was not wearing any splints on the upper extremities. During an observation on 2/11/25 at 8:24 a.m. in Resident 48's room, Resident 48 was laying in the bed and the left hand was in a fisted position with the thumb opposed and inside the palm. Resident 48 was not wearing any splints on the upper extremities. During an interview on 2/11/25 at 8:35 a.m., Restorative Nursing Aide (RNA 1) stated he was an RNA and central supply, which included ordering and stacking up supplies. RNA 1 stated on Mondays, he completed RNA treatments for residents in bed A, Tuesdays he completed RNA treatments for residents in bed B, Wednesdays he completed RNA treatments for resident in bed C, and then goes back to residents in bed A on Thursdays, bed B Fridays, and bed C on Saturdays. During an observation on 2/11/25 at 1:53 p.m., Resident 48 was lying on a geriatric chair (a large, padded chair designed to help persons with limited mobility) in the hallway outside Resident 48's room and Resident 48's eyes were closed. Resident 48 was not wearing any splints on the upper extremities. On 2/12/25 at 8:50 a.m. during an observation in Resident 48's room, Resident 48 was laying in bed. Resident 48's right knee was bent, and left ankle crossed over the right ankle. Resident 48 was able to move the right arm to move the gown, the left elbow was bent about halfway and left hand was in a fist. RNA 1 asked Resident 48 to move and straighten the right knee and Resident 48 was able to straighten the right knee. Resident 48 did not want to complete exercises with RNA 1. During an interview on 2/12/25 at 9 a.m., RNA 1 stated when Resident 48 agreed to RNA treatment, RNA 1 performed ROM on BUE and BLE and wore a hand roll, a soft one with a cushion. RNA 1 stated the hand roll was in the laundry. RNA 1 stated he also put on boots for both feet. RNA 1 stated on the right side, he did AROM, and on the left side, both he and Resident 48 moved the arms and legs. RNA 1 stated when Resident 48 refused, he would tell the charge nurse and therapy department. RNA 1 stated Resident 48 refused about two times a week. RNA 1 stated if Resident 48 refused, he would document that Resident 48 refused RNA. During an observation and interview on 2/12/25 at 12:55 p.m. in Resident 48's room, Resident 48 was laying in bed. Resident 48's left wrist was straight and able to move the left arm a little. Resident 48 stated the left hand was hard to move. Resident 48 tried to open the left fingers a little and observed minimal movement in the left fingers, but Resident 48 was not able to open the left hand. Resident 48 stated the left arm was paralyzed. During a record review and concurrent interview on 2/12/25 at 1:32 p.m. in the therapy gym, the Director of Rehabilitation (DOR) reviewed Resident 48's therapy records and stated there were no Occupational Therapy records for Resident 48 since 2022 when the new company started. The DOR stated Resident 48 had not received any skilled OT evaluations or treatments in 2022, 2023, 2024, or 2025. During an interview on 2/12/25 at 1:39 p.m., Licensed Vocational Nurse (LVN 6) stated she was Resident 48's charge nurse. LVN 6 stated she had never received any reports from RNA staff about Resident 48 refusing RNA treatment. LVN 6 stated Resident 48 usually did not refuse and had never received any reports about Resident 48 refusing any kind of care. LVN 6 stated Resident 48's left hand was contracted so it was especially important to perform hand hygiene and nail care, because there could be germs inside the hands. During an interview on 2/12/25 at 2:05 p.m., Certified Nursing Assistant (CNA 3) stated Resident 48's left hand was in a fist now and stated it was about 2 to 3 months when Resident 48's left hand started to be in a fist. CNA 3 stated it was harder to clean the left hand now because it was in a fist. CNA 3 stated Resident 48 could now barely open the fingers (CNA 3 demonstrated a clawed hand) and stated Resident 48 either would not let staff open her fingers more than that or Resident 48 could not open the hand more than that. CNA 3 stated she could not remember the last time she saw Resident 48 wear a hand splint with RNA. During an interview and concurrent record review on 2/12/25 at 2:17 p.m., the Wound Treatment Nurse (LVN 5) stated Resident 48 currently had a contracture related pressure injury on the left middle finger. LVN 5 stated when he first assessed Resident 48 on 1/15/25, the thumb was contracted and underneath the second finger and the thumbnail was digging into the right side of the third middle finger between the large knuckle and middle joint. LVN 5 stated Resident 48's hand was in a fisted position and when LVN 5 opened the thumb out, there was an open wound with slough (layer of dead tissue on surface of wound). LVN 5 stated the Wound Consultant Specialist (WCS) was present and assessed the wound as a Stage 4. LVN 5 stated there were Stages 1 through 4 (4 being worse). LVN 5 stated because Resident 48's hand was in a fist and it was contracted, it put Resident 48 at high risk to develop the wound. LVN 5 stated when LVN 5 completed the wound treatments, Resident 48 could not open the left hand fully. LVN 5 stated Resident 48 was in pain when LVN 5 tried to open the hand. LVN 5 stated to prevent the wound from developing, staff should constantly check Resident 48's hand, keep the thumb from touching the other fingers, and keep the fingernails trimmed. LVN 5 stated a wound was not a condition a resident should have, because when a resident had a wound, there was a risk of infection, risk for further skin breakdown, and it was painful. LVN 5 stated he should have informed the therapy department and included therapy in the wound interdisciplinary team (IDT) because the wound was contracture related and therapy could have offered an alternative other than the splint that Resident 48 had and may have accepted. LVN 5 stated for residents that refuse any type of intervention including RNA and splints, the facility should complete a COC assessment, notify the primary MD, document the refusals and update the care plan. LVN 5 reviewed Resident 48's care plans and stated there were no care plans regarding Resident 48 refusing RNA or splints. During an interview and record review on 2/12/25 at 3:21 p.m., Occupational Therapist (OT 2) stated for residents with contracture, including hand contracture, OT would treat the resident for ROM, assess to see if the resident would benefit from a splint and determine the splint that would work best for that specific resident, monitor and establish splint wear time, and establish an RNA program for splinting and ROM to prevent the contracture from getting worse. OT 2 stated contractures should be prevented because contractures were painful, limit ROM, and limit independence in activities of daily living. OT 2 stated contractures also put residents at risk for skin breakdown, especially if a finger was digging into the palm. OT 2 stated if a resident refused RNA, the facility could train Certified Nursing Assistants (CNA) and RNAs to monitor the resident, reposition the resident if there were redness and make sure nails were trimmed. OT 2 stated if a resident refused to wear splints during RNA, OT could reassess the resident and assess the splint, ask RNA about the splint, and maybe order another type of splint, add a finger separator, try a carrot (finger or hand apparatus shaped like a carrot to position the finger away from palm) or hand rolls. OT 2 stated it would be helpful to have the IDT discuss the resident together. OT 2 stated for example, if Resident 48 had a hand contracture in a fist and you put a carrot inside the palm, the carrot would keep the thumb apart and not touch that part of the finger. OT 2 stated Resident 48 refusing RNA ROM or splinting, and developing a wound because of a hand contracture was something OT would want to be informed about so that OT could assess and see if there were any possible interventions. OT 2 stated OT 2 did not have any knowledge of Resident 48 developing a wound in the left finger due to a fisted position. During an interview on 2/12/25 at 3:37 p.m., DOR stated she attended all the RNA meetings and stated RNAs did not report anything regarding Resident 48 continually refusing to wear the left hand splint. DOR stated to therapy's knowledge, Resident 48 had been wearing the left resting hand splint as ordered with RNA. During an interview on 2/12/25 at 3:40 p.m., Certified Nursing Assistant (CNA 2) stated Resident 48 could only open one hand and the other hand was in a fist. CNA 2 stated she tried to open the left hand, but Resident 48 told her she did not like it. During an interview on 2/12/25 at 3:45 p.m., Licensed Vocational Nurse (LVN 2) observed Resident 48 in the room and stated Resident 48's left hand was in a fist. LVN 2 stated Resident 48 would benefit from something inside her hand to help Resident 48. LVN 2 stated Resident 48 sometimes refused care, but not really. LVN 2 stated if you take time with Resident 48, the resident will do the care. During an interview and concurrent record review on 2/13/25 at 8:24 a.m. with RNA 1, Resident 48's RNA DSR was reviewed. RNA 1 confirmed his initials on the RNA DSR in 9/2024, 10/2024, 11/2024, 12/2024, 1/2025, and 2/2025. RNA 1 stated if the DSR indicated a number, it meant Resident 48 completed RNA that day and the number was how long RNA took to complete RNA as a whole. RNA 1 stated if the box was blank, it meant no RNA was completed that day. RNA 1 stated RR indicated Resident 48 refused RNA that day. RNA 1 stated NA was not applicable and it could mean Resident 48 was not in the facility or Resident 48 was in the activity room and meant Resident 48 did not complete the RNA treatment that day. RNA 1 confirmed [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to protect the resident ' s right to be free from neglect (the failure to provide healthcare services necessary to avoid physical harm, pain, mental anguish, or emotional distress) for one of four sampled residents (Resident 1). On 9/4/2024, Resident 1, who was cognitively impaired (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses), was left unattended with his body partially uncovered, while lying and crawling on the floor of the facility hallway for approximately 59 minutes. This deficient practice resulted in Resident 1 being subjected to neglect while under the care of the facility. On 9/4/2024, Certified Nursing Assistant (CNA) 2, Licensed Vocational Nurse (LVN) 3, Staff 10, CNA 9, Staff 11, Staff 12, Staff 13, Registered Nurse Supervisor (RNS) 2, and Staff 14 watched and allowed Resident 1 to crawl and lay on the floor with Resident 1 ' s body partially uncovered without providing assistance, comfort, and safety to Resident 1. Based on the reasonable person concept (hypothetical [suggested], average person's reaction to the actual circumstances of alleged illegal activities) due to Resident 1 ' s severely impaired cognition (ability to think and make decisions), an individual subjected to neglect has lifetime psychological (mental or emotional) effects including feelings of embarrassment and humiliation. Findings: During a review of the General Acute Care Hospital (GACH) narrative notes dated 8/21/2024 indicated, Resident 1 was confused (not in possession of all one's mental faculties) and had a diagnosis of dementia (a chronic condition that causes a decline in cognitive function, such as thinking, learning, and remembering, to the point that it interferes with daily life). During a record review of the admission record (Face sheet) indicated the Resident 1 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus (DM-a chronic condition that affects the way the body processes blood sugar [glucose]), hypertension (elevated blood pressure), and conversion disorder with seizures (also known as functional neurological system disorder, is a psychiatric condition that can cause seizures [a sudden, uncontrolled burst of electrical activity in the brain that can cause changes in behavior, movements, feelings, and levels of consciousness] as a physical symptom of a mental health issue). During a review of Resident ' s 1 care plan initiated on 9/4/2024, with a focus on Resident with behavior of crawling out bed, indicated the following interventions: Be attentive and responsive to resident's behavior and provide constant supervision that clothing and footwear is clean and appropriate. During a review of Resident ' s 1 Nursing Notes with an effective date of 9/4/2024 at 8:30 pm which was documented on 9/5/2024 at 4:18 pm, indicated LVN 2 was notified about the newly admitted resident (Resident 1) and was in the room at 8 pm. The same note indicated Resident 1 went to the nursing station with unsteady gait (a walking pattern that is abnormal, uncoordinated, or lacks balance) at 9 pm and that the CNA 1 assisted Resident 1 back to the room. During a review of Resident ' s 1 Nursing Notes with an effective date of 9/4/2024 at 10:40 pm which was documented on 9/5/2024 at 3:56 pm by the RNS 2 indicated, Resident 1 was received to the facility at 6:40 pm and re-oriented to his room. Frequent visual checks are needed due to Resident 1 getting up unassisted. The same note indicated all nursing care was rendered and to continue with the same plan of care. During an interview with LVN 2 on 9/16/2024 at 3:10 pm, LVN 2 stated that she was assigned with Resident 1 for the 11 pm to 7 am shift between 9/4/2024 and 9/5/2024. LVN 2 stated that during shift change, the off going LVN stated that Resident 1 likes to get on the floor in the hallway. LVN 2 stated she found Resident 1 sitting on the floor in the hallway and that Resident 1 was helped up and taken back to his room. During an interview with CNA 1 on 9/16/2024 at 2:48 pm, CNA 1 stated that Resident 1 was mostly sitting on the floor and appeared confused. CNA 1 stated that Resident 1 consistently stared at the ceiling and did not make eye contact when asked questions and instead would only mumble incoherently. CNA 1 stated that at 2:30 am while doing rounds, found Resident 1 unresponsive. CNA 1 stated that she immediately called an LVN to the room to assess further. During a concurrent record review of the facility ' s surveillance video footage on 9/19/2024 at 11:09 am with the Administrator, the Administrator stated that both himself and the Director of Nursing (DON) were both newly hired in the facility (four days ago). The video footage indicated that on (time stamp): 1. 9/4/2024 at 10 pm observed Resident 1 ' s hands are seen in the door frame (floor level) of his room. 2. 9/4/2024 between 10:00:10 pm to 10:04 pm, Resident 1 came out of the room crawling, and lying on the floor of the hallway. 3. 9/4/2024 at 10:05 pm, Resident 1 came in video frame outside the hallway sleeping on the floor, belly down with his face on the floor. Resident 1 had a gown which was hanging and dragging on the floor. Gown tied on the neck area. Resident 1 had his upper body exposed and had an incontinence brief that was around his knees and had his private parts exposed in the back. 4. 9/4/2024 at 10:06 pm, Resident 1 turned to his left side (still on the floor) while a female (CNA 2) and male (LVN 3) were observed at nurses ' station talking to each other. Female nurse in navy blue scrubs (CNA2) noted walking from station to other side of the hall wall, within eyesight of Resident 1. 5. 9/4/2024 at 10:07 pm Resident 1 lying on his back with arms stretched out in the hallway floor close to nurses ' station (within eyesight of Resident 1). 6. 9/4/2024 at 10:08 pm Resident 1 tries to get up but then lands on left side of his body. Attempts to get up then gets into fetal position. Another male resident dressed in black (unidentified – Resident 88) with roll aider (walker) observed walking towards resident and (at 10:09 pm) hops over resident (still lying on the floor) while lifting his walker while CNA 2, Staff 11, Staff 12, and Staff 13 were present (within eyesight of Resident 1) and not paying attention to the Resident 1. 7. 9/4/2024 at 10:09 pm LVN in burgundy scrubs (Staff 10) seen working on the medicine cart (a movable piece of equipment used in healthcare settings to transport, store, and dispense medical supplies and medications) [within eyesight of Resident 1] with resident still lying on the floor. 8. 9/4/2024 Between 10:09 pm and 10:14 pm Resident 1 still lying down in the hallway. 9. 9/4/2024 at 10:14 pm LVN in burgundy scrubs (Staff 10) walks away from cart then returns. Moved to the nursing station placing Resident 1 in view of her sight. 10. 9/4/2024 at 10:14 pm, Resident 1 seen crawling back in his room with legs still in hallway and then turns to go back to the hallway in crawling. 11. 9/4/2024 at 10:15 pm, female nurse [CNA] in navy blue scrubs (CNA2) walks over with linen looks at resident then continues to the other side of the hallway. Nurse [CNA] in white scrub (CNA 9) walks over, looks at resident, then continues to other side of the hallway. 12. 9/4/2024 at 10:16 pm, nurse [CNA] in blue scrubs walks (CNA2) in hallway [within eyesight of Resident 1] and ignores Resident 1. Resident 1 lying on the floor. 13. 9/4/2024 at 10:17 pm to 10:19 pm, Resident 1 still lying down in the middle of the hallway with exposed back. 14. 9/4/2024 at 10:20 pm, a female resident (unidentified, Resident 89) who had walked up to the nursing station and was observed saying something to (CNA2) in blue scrubs and pointing at Resident 1 who was turning restlessly on the floor. The (CNA 2) then turned to look at Resident 1 then looked back ahead towards nursing station. 16 seconds later, (CNA2) turns back to look at resident over the shoulder then looks back ahead. Resident still lying on floor in hallway. The same (CNA 2) looks over shoulder again to look at Resident 1. 15. 9/4/2024 at 10:22:35 Resident 1 seen crawling further towards nurse station in hallway then falls to his left side. (CNA2) in blue scrubs (CNA2) turns to look at Resident 1 at 10:22:41 pm, then walks away. 16. 9/4/2024 at 10:23 pm. (CNA2) in blue scrubs comes back in frame and ignores Resident1 who is still lying on the floor with CNA 2 ' s eyesight. 17. 9/4/2024 at 10:23:20 pm, Resident 1 seen crawling towards nursing station and gets within approximately 4 feet of CNA 2 in blue scrubs. Just then the nurse in white scrubs (CNA9) appears in frame and looks at Resident 1. Female nurse in blue scrubs (CNA2) turns towards Resident 1 who was now almost at her feet, then stands on other side of the medication cart, placing resident to her right side, now about 5-6 feet away. Resident 1 continues to wiggle and crawl on the floor. 18. 9/4/2024 at 10:23 pm, female nurse in blue scrubs (CNA2) starts chatting with another staff in blue scrubs with a mask sitting in the nurse ' s station (Staff 11). Resident 1 lying on the floor and looking at the two nurses in the station. 19. 9/4/2024 at 10:24 pm, Resident sits up facing the two staff (CNA2 and Staff 11) at the station who were observed speaking with each other and not paying attention to the Resident 1. 20. 9/4/2024 at 10:24:33 pm, Resident 1 lies down while facing the LVNs and CNA2 looks at resident then continues to chart. Resident 1 at this point sits up against the wall on the floor. 21. 9/4/2024 10:25 pm, nurse in white scrubs (CNA9) and female nurse in peach scrubs (Staff 12) walks in the hallway in full view of Resident 1 struggling on the floor. The two staff look at Resident 1 and left. 22. 9/4/2024 at 10:26 pm, a nurse in blue scrubs (CNA2) looks at Resident 1 again (lying down on the floor), turns to her coworker (Another female nurse in burgundy scrubs, Staff 13) and starts to walk away (Resident 1 was within eyesight). 23. 9/4/2024 at 10:26:36 male nurse in blue scrubs (LVN 3) comes to join the two staff (CNA 2 and Staff 11) in the station. Resident 1 still lying on the floor. 24. 9/4/2024 at 10:27:15 pm, the female nurse in blue (CNA2) and the one in white (CNA9) walk past approximately 2 feet from resident. Female resident dressed in white dress with green palm trees (Unidentified, Resident 90) struggles to walk between Resident 1 and medicine cart while pushing her wheelchair. 25. 9/4/2024 at 10:28 pm, Resident 1 attempted to sit up, lean against the wall, then slips back to the ground mostly starting with his head as though it was heavy. Female nurse in burgundy (Staff 13) observed going to room close to resident. Still no help offered. 26. 9/4/2024 at 10:32:10 pm, Resident 1 crawls back in room, female nurse (CNA 9) in burgundy (Staff 13) observed coming in frame at the medication cart in station 2. CNA9 in white scrubs observed walking past the resident ' s room, pause, then go into the next room. 27. 9/4/2024 at 10:33 to 10:51 pm, Resident 1 continues to be restlessly turning back and forth and crawling on the floor. 28. 9/4/2024 at 10:51 pm, Resident 1 comes back in hallway and the male nurse in blue scrubs (LVN3) as well as the female in burgundy (Staff 10) assist resident up back to room. 29. 9/4/2024 at 10:58:40 pm, Resident 1 came out of the room and laid on his belly down. 30. 9/4/2024 at 11:01 pm, female nurse in gray pants and black top scrubs (Staff 14) walks past Resident 1 with no offer for assistance. 31. 9/4/2024 at 11:03:52 pm, male nurse in burgundy (Registered Nurse Supervisor, RNS2) looks directly at Resident 1, while Resident 1 points at him. RNS 2 looks away with no offer for help. Several nurses (LVNs, RNS, and CNA) walked past Resident 1. 32. 9/4/2024 at 11:05:18 pm, Resident 1 pulls off his gown completely with his diaper still around his knees. Female nurse (Staff 14) that appeared to have been starting her shift gazed at resident with hand under her chin. 33. 9/4/2024 at 11:06:38 pm, male nurse in burgundy (RNS2) speak with Resident 1, then walks away leaving him on the floor. Resident 1 crawled next to medicine cart at nurse ' s station. Female nurse in light blue scrubs (Staff 14) speaks with him for a while then walks away. 34. 9/4/2024 at 11:06:38 pm was the last entry footage seen then skips to 9/5/2024 at 12 midnight. 35. 9/5/2024 at 12 midnight. Resident 1 was no longer seen in the hallway. During a review of the facility ' s surveillance video footage on 9/4/2024 at 11:15 am with the Administrator, the Administrator stated, it is always the same two nurses not helping the resident. During a concurrent interview and record review of the video surveillance with CNA 2 on 9/19/2024 at 3:32 pm, CNA 2 verified that she was one of the nurses who was dressed in blue scrubs and talking to another nurse while the Resident was lying down on the floor close to the nurses ' station. She stated that she was not assigned with Resident 1 but had observed Resident 1 come out in the hallway on several occasions lying down on the floor. She stated that she had helped the assigned nurses bring the resident to his room on one occasion. CNA 2 stated that Resident 1 appeared to be uncomfortable and possibly looking for attention when he crawled to the nurse ' s station. She stated that the residents ' dignity was not preserved. The potential of not helping could result in injury to the resident as well as embarrassment from being exposed. During a concurrent interview and record review of the video footage with CNA 3 on 9/19/2024 at 3:49 pm, CNA 3 stated that she was assigned with Resident 1 and admitted that Resident 1 consistently came out of his room crawling and lying in the hallway. CNA 3 started crying when she saw the footage and stated that she felt bad for Resident 1. She stated that she could have helped him more but was assigned to several other residents and it was impossible to assist him every time. During an interview with the administrator on 9/19/2024 at 5:09 pm, the Administrator admitted that the nurses did see Resident 1 on lying on the floor and crawling while he was exposed multiple times and did not help him. He stated that the nurses should have helped him off the floor. The Administrator stated that his (Resident 1) dignity was not preserved. The Administrator stated that Resident 1 may have benefited from having a 1:1 sitter (a patient care intervention where a staff member is always present with a resident) as a potential intervention he kept coming back out. During a concurrent interview and record review on 9/19/2024 at 5:22 pm, with the Director of Nursing (DON), the facility ' s policy and procedure (P&P) titled Abuse and Neglect – Clinical Protocol, dated 8/15/2024 was reviewed. The P&P indicated under treatment/management that the facility management and staff will institute measures to address the needs of the residents in order to reduce the possibility of abuse and neglect. The same P&P indicated, The physician and staff will address appropriately causes of problematic resident behavior where possible, such as mania (a mental and behavioral disorder that involves a period of abnormally elevated energy, arousal, and affect) psychosis (a severe form of mania that can involve a break from reality), and medication side effects. The same P&P indicated the Medical Director will advise facility management and staff to safeguard the basic needs functionally, medically, and psychosocial (looks at individuals in the context of the combined influence that psychological factors and the surrounding social environment have on their physical and mental wellness and their ability to function) are met thereby preventing or treating conditions that affect function and quality of life are addressed appropriately. The DON stated that the staff in the facility did not know if lying and crawling in the hallway while exposed was Resident 1 ' s baseline behavior (normal behavior for Resident 1). A copy of the facility ' s surveillance video footages for 9/4/2024 and 9/520/24 was requested on 9/19/2024 but was not provided. On 9/20/2024 the facility Administrator informed the Department that the facility ' s surveillance video footages for 9/4/2024 and 9/5/2024 requested was mistakenly deleted and can no longer provide the footages to the Department. During a review of the facility ' s P&P titled Dignity, reviewed 8/15/2024, the P & P indicated, Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem. The same P&P indicated: Staff are expected to treat cognitively impaired residents with dignity and sensitivity, for example: a. addressing the underlying motives or root causes for behavior; and b. not challenging or contradicting the resident's beliefs or statements.

Based on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1), who had diagnosis of schizophrenia (a serious mental illness that affects how a person thinks, feels, and behaves, may have grandiose delusions [strong beliefs of things that are untrue]) and history of wandering was provided with the necessary behavioral health care as indicated in the comprehensive assessment. The facility failed to: -Monitor Resident 1 for schizophrenic behavior each shift, per the Physician's Order. - Evaluate the care plan interventions for their effectiveness and update or revise the interventions based on resident's behavior and needs. -Develop an appropriate care plan for Resident 1's Wandering, and provide supervision, including the frequency. -Anticipate Resident 1's needs and intervene when the resident gets agitated before agitation escalates, per the Potential to Demonstrate verbally / physically Abusive Behaviors care plan related to schizophrenia. As a result, on 6/14/2024, Resident 1 wandered the facility, entered Resident 2's room, and after being told to leave the room, Resident 1 hit Resident 2 in the face causing Resident 2's lip to bleed. Findings: A review of Resident 1's admission Record (Face Sheet) indicated the facility admitted the resident on 5/22/2024, with diagnoses including anxiety disorder (a condition with excessive worry and fear that interferes with daily activities), and schizophrenia. A review of Resident 1's admission / readmission Data Tool dated 5/22/2024, indicated the resident was independently mobile, paced (walk at a steady and consistent speed, especially back and forth and as an expression of one's anxiety), wandered (to walk around slowly in a relaxed way or without any clear purpose or direction), and tried to leave the facility. The form indicated Resident 1 had a history of wandering and was not readily accepting nursing home placement. A review of Resident 1's At Risk of Elopement (leaves the facility, presenting an imminent threat to the resident's health and safety because resident was too impaired to make a decision to leave) care plan initiated on 5/22/2024, indicated the resident was a wanderer due to his impaired (weakened) safety awareness. The care plan interventions indicated to distract Resident 1 from wandering by offering pleasant diversions, structured activities, food, conversation, television, book, to identify types of wandering such as purposeful, aimless (without purpose and direction), or escapist wandering (the state of having wandering and imaginative thoughts in order to escape from reality), and to provide structured activities such as toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. A review of the Physician's Orders dated 5/22/2024, indicated to administer haloperidol (Haldol - a medication used to treat certain mental / mood disorders such as schizophrenia) oral tablet one milligram, three times a day for schizophrenia manifested by constant pacing. A further review of the physician's orders dated 5/22/2024, indicated to monitor Resident 1's schizophrenic behavior during each shift. A review of Resident 1's History and Physical (H&P) dated 5/23/2024, indicated the resident did not have medical decision-making capacity. According to a review of the Minimum Data Set (MDS - a standardized assessment and care screening tool) dated 5/25/2024, Resident 1's cognitive skills (ability to think, remember, express thoughts, and make decisions) for daily decision making was moderately impaired (decisions poor, cues/supervision required). The MDS indicated Resident 1 had schizophrenia diagnosis and was taking antipsychotic medication (the main class of drugs used to treat psychosis [a severe mental disorder in which thought and emotions are so impaired that contact is lost with external reality] and other mental and emotional conditions. The MDS further indicated Resident 1's current behavior, care rejection or wandering was worse when compared to prior assessment. A review of Resident 1's Potential to Demonstrate verbally / physically Abusive Behaviors care plan dated 5/30/2024 indicated this was related to psychosis (a collection of symptoms that affect the mind, with some loss of contact with reality), schizophrenia, ineffective coping skills and poor impulse control (lacking the ability to maintain self-control). The care plan interventions indicated to access and anticipate Resident 1's needs, evaluate for side effect of the medications, give the resident as many choices as possible about care and activity, and to intervene when the resident gets agitated before agitation escalates. A review of the Situation Background Assessment and Recommendation Form (SBAR) dated 6/14/2024, indicated Resident 1 displayed physical aggression towards another resident (Resident 2), and that per Certified Nursing Assistant 1's (CNA 1) report, Resident 1 swung at Resident 2 and struck Resident 2 in the mouth. The SBAR indicated Resident 2 was subjected to physical aggression by Resident 1, and fell. Upon assessment, Resident 2 had discoloration on the inside of his lower lip. The SBAR form indicated Resident 2 asked Resident 1 to leave the room, Resident 1 swung at him and struck him in the lip. Resident 1's physician was informed of the incident and a new order was made to transfer Resident 1 to the emergency room (ER) for psychiatric evaluation. A review of Resident 2's Skin Observation Tool dated 6/14/2024, indicated a cut measuring less than one centimeter (a metric unit of length) on Resident 2's upper lip. A review of Resident 1's Medication Administration Record (MAR) for the month of June 2024, indicated the resident did not display any schizophrenic behavior, such as constant pacing. During an observation on 7/3/2024 at 8:10 AM, Resident 1 was observed walking in the hallway with his walker. Resident 1 appeared confused, did not answer any questions, and continued walking. During a concurrent observation and interview on 7/3/2024 at 9 AM, inside Resident 2's room, Resident 2 was observed sitting on his wheelchair next to his bed. Upon observation, there were no visible injuries or wound to Resident 2's lip. Resident 2 stated, About 2 weeks ago Resident 1 entered my previous room. Resident 1 always walks in the hallways and sometimes entered my previous room. He does not understand. I told him to leave the room. He began swinging his arms and he left the room. The police came and talked to me. Resident 2 stated, I did not press charges against Resident 1. This was the first time that Resident 1 was swinging his arms at me. He did not mean to hit me. His arm might have accidentally struck me on the face. During an interview on 7/3/2024 at 10:57 AM, CNA 1 stated, I was not assigned to either Resident 1 nor Resident 2. I heard commotion in the hallway. I saw Resident 1 swinging his arms and striking Resident 2 on his shoulders. I called for help, and I tried to separate them. I noticed Resident 2 was bleeding at the mouth. CNA 1 stated Resident 2 told her that Resident 1 hit his mouth. CNA 1 stated she always sees Resident 1 walking in the hallways. During a concurrent interview and record review on 7/3/2024 at 2:30 PM, with MDS Coordinator (MDSC), Resident 1's care plans were reviewed. The MDSC stated she revised Resident 1's at risk for elopement care plan today (7/3/2024) because Resident 1 was only wandering in the hallways and not attempting to exit the facility. The MDSC stated Resident 1's risk for elopement care plan did not have any interventions to monitor the resident. The MDSC stated Resident 1 was a wanderer, he sometimes entered other residents rooms and staff were required to perform frequent visual monitoring for him to prevent him from exiting the facility or entering other residents rooms. During a concurrent interview and record review on 7/3/2024 at 2:45 PM, with the facility's Director of Nursing (DON), Resident 1's care plans were reviewed. The DON stated Resident 1's risk for wandering care plan initiated on 5/22/2024, did not include any individualized person-centered interventions for the resident, indicating how and how often staff were monitoring Resident 1. The DON stated Resident 1 was always wandering in the hallways and he needed to be monitored closely by staff. The DON stated Resident 1's care plan intervention of distracting the resident from wandering by offering structured activities was not effective and staff were required to evaluate care plan interventions for their effectiveness and update or revise the interventions based on resident's behavior and needs. The DON stated the potential outcome of not developing a person-centered care plan with effective interventions for a resident who was constantly wandering and pacing was safety issues and harm to other residents. During a concurrent interview and record review on 7/3/2024 at 2:55 PM, with the DON, Resident 1's MAR for June 2024 was reviewed. The DON stated based on licensed staff documentation, it appears that Resident 1 did not display any schizophrenic behavior such as constant pacing during the month of June. The DON stated this documentation was inaccurate because Resident 1 was constantly wandering and pacing. The DON stated licensed staff were required to monitor and document Resident 1's conduct, condition, and behavior and this was an inaccurate reflection of the resident's true condition. A review of the facility policy and procedure titled,Wandering and Elopement, revised March 2019, indicated the facility would identify residents who were at risk for unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety. A review of the facility policy and procedure titled, Abuse and Neglect-Clinical Protocol, revised March 2018, indicated the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. The physician and staff will address appropriate causes of problematic resident behavior where possible, such as mania (extremely elevated and excitable mood usually associated with bipolar disorder), psychosis, and medication side effects. A review of the facility policy and procedure titled, Care Plans, Comprehensive Person-Centered, revised December 2016, indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial (the interrelation of social factors and individual thought and behavior) and functional needs was developed and implemented for each resident. The comprehensive person-centered care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the resident's problem areas and their causes, and relevant clinical decision making. Assessments of residents were ongoing and care plans were revised as information about the residents and the residents' condition change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 66), who had diagnosis of schizophrenia (a serious mental disorder in which people interpret reality abnormally) and had a history of multiple falls, received the care, treatment and services in accordance with professional standards of practice by failing to: -Provide the correct level of assistance for transfers and ambulation, on 7/19/2023, 8/18/2023 and 9/20/2023, per the comprehensive assessment. -Revise and implement the Fall Care Plan to include different fall interventions needed with specific levels of assistance -Complete / Update a fall risk assessment after each fall As a result of this deficient practice, on 12/8/2023, Resident 66 had an unwitnessed fall, hit the back of her head which required transfer to general acute hospital 2 (GACH 2). At GACH 2, Resident 66 had a one-inch laceration treated with staples and hematoma (bruise) on the back of her head, as well as skin tears to her abdomen and back. Findings: A review of Resident 66's admission record indicated the facility admitted the resident on 1/23/2023 with diagnoses including Huntington's Disease (a genetic disease that damages the brain and affects one movement, cognition and mental health), schizophrenia (a serious mental disorder in which people interpret reality abnormally) and anxiety (a mental health condition with feeling of worry, anxiety, or fear interfering with one's daily activities). A review of Resident 66's Minimum Data Set (MDS, a standardized assessment and care screening tool), dated 11/1/2023, indicated the resident's cognition was intact and the resident required supervision (helper provides verbal cues and /or touch /steadying and or contact guard assistance [have one or two hands on the body but provides no other assistance to perform the functional tasks] as resident completes the activity. Assistance may be provided throughout the activity or intermittently) with walking 10 to 150 feet and assistance with transfer. A review of the At Risk for Injury and Falls care plan, revised 4/10/2023, indicated Resident 66 used psychotropic medication (drug taken to exert an effect on the chemical makeup of the brain and nervous system), had poor safety awareness, Huntington's disease, unsteady gait and had impulsive behavior. The care plan interventions included to assist with all transfers as needed, keep bed in lowest position and to maintain safe environment free of hazards. The care plan did not indicate interventions for Resident 66's ambulation. According to a review of the nurse's note, dated 7/11/2023, Resident 66 had a witnessed fall in the hallway and hit the back of her head. The Nurses Note indicated Resident 66 sustained a laceration to the back of her head with bleeding noted. A review of Physician's Order Summary Report dated 7/11/2023 indicated Resident 66 received: - cleanse the resident's occipital (back of head) laceration with normal saline, pat dry and cover with a dry dressing for seven days and - provide the resident with a chest x-ray and skull x-ray after a fall A review of Resident 66's Change of Condition - SBAR form, dated 7/19/2023, indicated the resident had a fall and two staff members assisted the resident to stand and escorted the resident back to bed. A review of Resident 66's Change of Condition - SBAR form, dated 7/28/2023, indicated the resident had a witnessed fall. The form indicated resident was seen on the floor in a sitting position in the hallway. It also indicated the resident was non-compliant with fall precautions provided. The resident was offered a helmet and wheelchair both of which she refused. According to a review of Resident 66's Change of Condition - SBAR form, dated 8/18/2023, the resident had a fall with head and hand injury, as the resident attempted to ambulate (walk) without assistance or supervision. A review of the nurse's note, dated 8/18/2023, indicated Resident 66 returned to the facility from GACH 1, as the resident's imaging results were negative and did not show hemorrhage (an escape of blood from a ruptured blood vessel), or fracture (broken bone) related to fall. A review of the resident's medical chart indicated there was no updated fall risk assessment completed after the 8/18/2023 fall and there was no care plan for Resident 66's non-compliance. A review of Resident 66's Change of Condition - SBAR form, dated 9/20/2023, indicated the resident fell while walking in the hallway. It indicated the resident had a rapid jerking movement and fell backwards hitting her head. It indicated the resident had on her helmet during the fall. A review of the resident's medical chart indicated a fall risk assessment was not completed after the 9/20/2023 fall. According to a review of Resident 66's Change of Condition - SBAR form, dated 12/8/2023, the resident had an unwitnessed fall in her room and the resident was not using an assistive device for ambulation or transferring. A review of the Emergency Services Patient Care Report, dated 12/8/2023, indicated the resident was transferred from the facility to a GACH for the chief complaint of a blunt head injury. The Patient Care Report indicated Resident 66 fell prior to emergency services arrival and hit the back of her head. The Emergency Services Patient Care Report indicated Resident 66 had a one-inch laceration and hematoma (bruise) on the back of her head as well as skin tears to her abdomen and back. A review of the Emergency Department (ED) Physician's Note, dated 12/8/2023, indicated Resident 66 came to the ED with a posterior head laceration after a trip and fall. It indicated while at the facility, the resident lost her balance and hit the back of her head with resultant bleeding. The ED Physician Note indicated Resident 66 received five staples for an occiput (back part of the head) laceration was repaired at bedside without complication. A review of Resident 66's Order Summary Report, indicated on 12/15/2023, the physician ordered the facility to monitor the stapled scalp site for any bleeding, pain or any sign of infection. During an interview on 1/25/2024 at 10:56 AM, Licensed Vocational Nurse 5 (LVN 5) stated that on 12/8/2023 Resident 66 fell in her room. Resident 66 split the back of her head open and there was profuse bleeding. During a concurrent review of Resident 66's care plans related to falls and the medical chart, LVN 5 stated and confirmed Resident 66's care plans were last updated on 7/31/2023. LVN 5 stated that Resident 66's Risk for Fall Care Plan should have been updated (on 8/18/2023 and 9/20/2023) after each fall to reflect new interventions, in order to prevent the resident from repeated falls. Upon further review of the resident's medical chart, LVN 5 stated and confirmed Resident 66's last fall risk assessment was completed on 7/19/2023. LVN 5 stated after Resident 66 fell, a fall risk assessment should have been completed to assess the causes of the fall and generate new interventions to prevent further falls. During an interview on 1/25/2024 at 1:55 PM, the MDS Coordinator (MDSC) stated that on 12/8/2023, Resident 66 had an unwitnessed fall and was transferred via 911 after the fall. The MDSC stated and confirmed Resident 66's fall care plan was last updated on 7/31/2023 and should have been updated after the resident fell on 8/18/2023 and 9/20/2023. The MDSC stated the care plan was to be updated to implement new interventions to prevent further falls. During an interview on 1/25/2024 at 4:37 PM, the Director of Nursing (DON) stated after Resident 66 fell on [DATE], the fall care plan should have been updated on 8/18/2023 and 9/20/2023. A review of the facility's policy and procedure titled, Fall Risk Assessment, dated 3/2018, indicated the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff, and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable. A review of the facility's policy and procedure titled, Falls and Fall Risk, Managing, dated 3/2018, indicated the staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.

Based on interview and record review, the facility failed to provide supervision for one of three sampled residents (Resident 1), who was identified as exhibiting wandering (walking from place to place without any purpose) behavior and verbalized feelings of being afraid inside the facility, by failing to implement the Wandering and Elopements, [an act or instance of a resident leaves the facility independently without notifying anyone] policy to include in Resident 1's care plan strategies and interventions to maintain resident's safety. These deficient practices resulted in Resident 1 eloping from the facility on 7/18/2023. Resident 1 had not been found. Findings: A record review of Resident 1's admission Record indicated the facility admitted Resident 1 on 7/13/2023 with diagnoses including schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), malnutrition (lack of proper nutrition), and depression (a mood disorder that causes a persistent feeling of sadness and loss of interest). A record review of Resident 1's At Risk for Injury/Accidents and Falls care plan dated 7/13/2023, indicated Resident 1 was at risk for injury and falls related to psychotropic medication (medications that affects how the brain works and causes changes in mood, awareness, thought, feelings, or behavior). Resident 1 interventions included to assist resident with all transfers, call light within reach and answer promptly, maintain environment safe and hazard free, remind resident request assistance. A record review of Resident 1's Minimum Data Set (MDS-a standardized assessment and care screening tool) dated 7/18/2023, indicated Resident 1 was cognitively intact and able to make needs known. The same MDS indicated Resident 1 required supervision with bed mobility, transfers, eating and toilet use. Resident 1 required limited one-person physical assistance with dressing and personal hygiene. A record review of Resident 1's Progress Notes dated 7/15/2023 at 8:10 AM, indicated Resident 1 was outside in the smoking area. Resident states, I am fine, I don't feel safe in there Resident 1 was paranoid (unreasonably anxious, suspicious and mistrustful) about going into the building. Resident 1 was unable to state why she did not want to get into her assigned bed. Nurse kept trying to encourage Resident 1 to go inside the facility. Behavior was endorsed to oncoming nurse. A record review of Resident 1's Progress notes dated 7/16/2023 indicated Resident 1 refused the medication Lithium [Oral Capsule 600 MG (Lithium Carbonate) Give 1 capsule by mouth one time a day for Mood Disorder m/b rapid cycling of mood] (a medication used to treat mood disorder). A record review of Resident 1's Progress Notes dated 7/18/2023 at 6:28PM, indicated at approximately 3:30 PM on 7/18/2023, Licensed Vocational Nurse 3 (LVN 3) made rounds and was informed Resident 1 was in the smoking patio. LVN 3 was passing medications around 4:50PM. A staff member received a phone call for Resident 1. LVN 3 did not see Resident 1 in the room or in the bathroom. LVN 3 asked another nursing staff to assist in looking for the resident. Staff was unable to locate Resident 1 on 7/18/2023. Administrator, Director of Nurses, Medical Doctor notified at 5 PM. A thorough search was conducted throughout the facility. Police Department was called to file a missing person report. During an interview with LVN 1, on 7/20/2023 at 2 PM, LVN 1 stated when she worked the night shift on 7/15/2023, she could not locate Resident 1. LVN 1 stated she instructed other nurses to look for the resident. LVN 1 further stated, when Resident 1 was found and asked to come back into the building, Resident 1 was very paranoid and did not want to go back inside the building. LVN 1 stated, Resident 1 stated she does not feel safe inside the building. LVN 1 further stated, Resident 1 refused to go back into her room the whole night. During an interview with the Administrator (ADMIN), on 7/20/2023 at 2:30PM, ADMIN stated she was not aware that on 7/15/2023 Resident 1 verbalized not feeling safe in the facility and exhibiting behaviors of paranoia. The ADMIN further stated a care plan, Interdisciplinary Team (IDT means a group of professional and direct care staff that have primary responsibility for the development of a plan for the care and treatment of a patient) for Resident 1's wandering and change of condition should have been initiated. The ADMIN further stated the facility did not initiate and or implement any of the intervention mentioned. During an interview with Director of Nurses (DON), on 7/20/2023 at 2:40 PM, the DON confirmed and stated Resident 1 left the faciity on 7/18/2023. The DON further stated Resident 1 had left previous facilities against medical advice. DON stated, Resident 1 was not reassessed for wandering and or elopement after Resident 1 verbalized not feeling safe in the facility and not wanting to be here. During a telephone interview with the facility's Medical Director (MD), on 7/21/2023 at 8:21 AM, MD stated he was not aware Resident 1 was missing from the facility. The MD stated the Resident's psychiatrist (a medical practitioner specializing in the diagnosis and treatment of mental illness.) should have been notified regarding when Resident 1 reported feeling unsafe in the facility and the psychiatrist should have been notified regarding the refusal of the medication lithium. Medical Director stated the facility needed to initiate a change of condition for Resident 1 on 7/15/2023. A review of the facility's policy and procedures (P & P) titled, Wandering and Elopements, dated March 2019 indicated the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain a resident's safety.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) was free from physical abuse when Resident 1, with a history of physical aggression, hit Resident 2 on the left eye. This deficient practice resulted in Resident 2 sustaining a bruise (blood or bleeding under the skin due to trauma) under/around the left eye. Findings: A review of Resident 1's admission record indicated the facility admitted Resident 1 on 9/7/2022 and readmitted Resident 1 on 2/13/2023 with diagnoses that included extended spectrum beta lactamase (ESBL - chemicals produced by germs like certain bacteria) resistance, difficulty in walking, anxiety disorder (mental health disorder characterized by feelings of worry or fear that are strong enough to interfere with one's daily activities), type 2 diabetes mellitus (an impairment in the way the body regulates and uses sugar as a fuel), schizoaffective disorder (a serious mental disorder in which people interpret reality abnormally), bipolar disorder (disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and Parkinson's disease (a brain disorder that causes unintended or uncontrollable movements, such as shaking, stiffness, and difficulty with balance and coordination). A review of Resident 1's Minimum Data Set (MDS - a standardized assessment and care-screening tool) dated 2/16/2023, indicated Resident 1's cognitive skills (the mental core skills to think, read, learn, remember, reason, and pay attention) for daily decision making was severely impaired (when a person has trouble remembering, learning new things, concentrating, or making decisions). A review of Resident 1's physician order summary dated 1/17/2023, indicated staff to monitor Resident 1 for schizoaffective disorder manifested by persistent delusion (having false or unrealistic beliefs or opinions) that people are out to harm her and hold her against her will and for physical aggressive behavior every shift for the use of Abilify (a medication to treat schizophrenia), and monitor anxiety manifested by restlessness. The physician order summary further indicated Resident 1 was on: -Abilify Tablet five milligrams (mg - unit dose measurement) give one tablet two times a day for aggressive behavior related to bipolar disorder, -Lorazepam (medication used to treat anxiety disorders) tablet one mg give one tablet by mouth every 24 hours as needed for anxiety related to bipolar disorder effective 1/16/2023: and -Risperidone (medication used to treat certain mental/mood disorders) tablet one mg, give one tablet by mouth two times a day for schizophrenia effective 1/16/2023. A review of Resident 1's Medication Administration Record (MAR) for the month of 2/2023, indicated to monitor Resident 1 for schizoaffective disorder manifested by persistent delusion of people out to harm her and hold her against her will and monitor behaviors of physical aggressive behavior every shift for use of Abilify. The MAR further indicated the facility did not administer Abilify or Risperidone to Resident 1 on 2/6/2023 and 2/7/2023. A review of Resident 1's care plan for physically aggressive to staff and throwing ice in the room dated 10/24/2022, indicated the goals included Resident 1, will demonstrate effective coping skills through review date. Interventions included to analyze key times, place, circumstances, triggers and what de-escalates behavior and document for Resident 1. The interventions also included to assess, and address contributing sensory deficits (shortages), assess and anticipate resident's needs such as food, thirst, toileting needs, comfort level, body positioning, pain etc. The interventions included to provide Resident 1 with physical and verbal cues to alleviate anxiety, give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated . intervene before agitation escalates, and guide away from source of distress. A review of Resident 1's care plan for behavior of hitting staff dated 10/25/2022, indicated the goals included Resident 1 will demonstrate positive coping mechanisms. The interventions included staff to be attentive and responsive to resident's behavior, check for unmet needs, identify and remove triggers for the behavior, and if possible, minimize changes to resident's environment. A review of Resident 1's care plan for potential demonstrate abusive behaviors dated 9/21/2022, indicated the goals included Resident 1 will demonstrate effective coping mechanism. The interventions included to monitor/document observed behavior and attempted interventions in behavior log. A review of Resident 1's Psychiatry (a branch of medicine that deals with mental, emotional, or behavioral disorders) consult note dated 10/28/2022, indicated Resident 1 was anxious, perplexed and internally preoccupied (lost in thought), not with cognitive impairment, and denied any psychiatry complaints. The plan of care included to continue to monitor Resident 1's symptoms and behavior. A review of Resident 1's Psychiatry consult note dated 11/10/2022, indicated Resident 1 is anxious and the plan was to continue current management, continue to monitor symptoms and behavior. A review of Resident 1's progress note documented by Licensed Vocational Nurse 1 (LVN 1) dated 2/7/2023 at 6:47 PM, indicated Resident 2 was noted with bruising on 2/7/2023 at approximately 6:30 PM. The progress note indicated Resident 2 said Resident 1 hit her because Resident 2 called Resident 1 the N word. The progress note further indicated Resident 1 had no injuries and a Nurse Practitioner (NP - a registered nurse who has additional education and training to diagnose and treat disease) was notified at 6:54 PM on 2/7/2023. The NP ordered to monitor Resident 2's behavior for 72 hours and to make sure resident took her routine medications as ordered. A review of Resident 2's admission record indicated the facility admitted Resident 2 on 1/12/2023 with diagnoses including metabolic encephalopathy (an alteration in consciousness caused by diffuse or global brain dysfunction), peripheral vascular angioplasty (a procedure to help blood flow), dysphagia (difficulty with swallowing), depression (group of conditions associated with the elevation or lowering of a person's mood), anxiety disorder, and embolism (a blocked artery typically from a blood clot) and thrombosis (the formation of a blood clot), of arteries (blood vessel) of the lower extremities. A review of Resident 2's History and Physical dated 1/24/2023, indicated Resident 2 had the capacity to understand and make decisions. A review of Resident 2's MDS dated [DATE], indicated Resident 2's cognition was intact. The MDS indicated Resident 2 required one person assist with bed mobility, transfer, dressing, toilet use and personal hygiene. A review of Resident 2' progress note documented by LVN 1 dated 2/7/2023 at 6:47 PM, indicated at approximately 6:30 PM on 2/7/2023, . Resident 2 was assessed and noted with bruising on the left cheek. Resident 2 denied pain or tenderness, and no changes in level of orientation. Resident 2 was offered ice pack for the left cheek but refused. On 2/23/2023 at 4:45 PM, during an interview, LVN 1 stated she was on duty on 2/7/2023 and remembered the incident between Residents 1 and 2. LVN 1 stated another nurse told her to go and look at Resident 2's face because Resident 2 had a black eye. LVN 1 stated Resident 1 (Resident 2's roommate) had a history of aggressive behavior and mental illness and nobody saw her hit Resident 2. LVN 1 stated she notified the facility's Acting Administrator (ADM-Abuse coordinator) who told her (LVN 1) not to report until we (facility) can confirm what happened. On 2/28/2023 at 1:30 PM, during an interview, the Social Services Director (SSD) stated Resident 1 had a history of mental illness, was confused most of time, was aggressive at times, and was verbally and physically abuse. The SSD stated Resident 2 told her we (Residents 1 and 2) hit each other. The SSD stated, that would be considered a resident to resident abuse. The SSD stated she contacted and informed the psychiatrists of what had happened between Residents 1 and 2. The SSD stated Resident 1 was sent to a hospital for higher level of care and Resident 2 told SSD that she was okay. On 2/28/2023 at 3:13PM, during an interview, the Director of Nursing (DON) stated, I was informed that Resident 2 had discoloration under the left eye The DON stated Resident 2 was unable to say how her (Resident 2's) left eye got decolorization. The DON stated Resident 2 stated denied pain or blurred (unclear) vision. On 3/2/2023 at 12:45 PM, during an interview, Resident 2's Responsible Party (RP) stated, when I spoke with Resident 2 about the bruising (left eye), her (Resident 2) exact words were, that woman (Resident 1) beat me, and her voice sounded funny, like she had just come from the dentist. RP 1 stated the SSD contacted and told her there is nothing wrong with her (Resident 2) mouth .The next day I called and spoke with the SSD who told me Resident 2 has bruising around her eye. We (facility) are doing an investigation and it may be possible that it (bruising) was caused by medication. FM 1 stated, I received a call a few days later (unsure who called) and they told me, they found out that Resident 2 and Resident 1 got into a fight. RP stated, I asked Resident 2 what happened, and she (Resident 2) said that woman (Resident 1) beat me. RP stated Resident 2 was at a General Acute Care Hospital (GACH) for an unrelated medical concern and did not want Resident 2 to return to the facility. RP stated she was upset with the care at the facility and the aforementioned incident between Resident 1 and Resident 2. On 3/2/2023 at 3:45 PM, during an interview, the ADM stated she was the facility's acting Administrator on 2/7/2023. The ADM stated she remembered Resident 2 and that Resident 2 had decolorization around the left eye. On 3/3/2023 at 12:15 PM, during a follow up interview and concurrent record review with the DON, Resident 2's nursing progress notes were reviewed. The DON stated the nursing progress notes indicated Resident 2 said Resident 1 hit Resident 2. The DON stated the aforementioned incident should be considered as a resident to resident abuse. The DON stated resident to resident abuse should be reported to the authorities (CDPH). A review of the facility's policy and procedures titled Abuse Prevention Program dated December 2016, indicated our residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary, seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms . As part of the resident abuse prevention the administration will: Protect residents rom abuse by anyone including, but not necessary limited to facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors or any other individual . Identify and assess all possible incidents of abuse . Investigate and report any allegations of abuse within timeframes as required by federal requirements . Protect residents during abuse investigations.