**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews, and facility policy review, the facility failed to ensure residents were free from physical abuse from: 1. one resident (Resident (R) 95) who demonstrated repeated acts of physical violence towards multiple other residents to include residents R24 and R109; and 2. R128's wandering behavior resulted in a resident-to-resident abuse between R128 and R6. The facility's Administrator was informed on 02/29/24 at 3:40 PM that Immediate Jeopardy (IJ) existed at F600-K Freedom from Abuse and Neglect when the facility failed to implement effective interventions to ensure residents were free from abuse from R95. The facility provided an acceptable removal plan for the Immediate Jeopardy on 03/01/24 at 12:21 AM. The survey team validated that the Immediate Jeopardy was removed on 03/01/24 at 1:45 PM. The removal was validated by observations, interviews, record review, and review of training records. The removal plan included training for all disciplines recognizing signs and symptoms of abuse and neglect, along with reporting and preventing abuse and neglect. All residents with known behaviors were reviewed and care plans were reviewed for effectiveness. Abuse policies were reviewed and updated to include resident to resident interactions. After removal of the Immediate Jeopardy, the deficiency remained at an E scope and severity for pattern with a potential for more than minimal harm. Findings include: 1. a. Review of R95's admission Record, located in the Profile tab of the electronic medical record (EMR) revealed admission to the facility on [DATE] with diagnoses of traumatic subdural hemorrhage, irritability and anger, delusional disorders, and anxiety disorder. Review of R95's quarterly Minimum Data Set (MDS) under the MDS tab of the EMR with an Assessment Reference Date (ARD) of 08/31/23, revealed a Brief Interview for Mental Status (BIMS) score of 13 out of 15 which indicated the resident was cognitively intact. Further review revealed R95 had physical behavior symptoms directed at others. Review of R95's Care Plan, located under the Care Plan tab of the EMR and dated 06/09/23, revealed The resident has the potential to be physically aggressive related to poor impulse control as evidenced by swinging fist at others. Interventions in place were to calmly explain or reinforce why behavior was inappropriate or unacceptable. Intervene as necessary to protect the rights and safety of others. Provide programs of activities that were of interest and accommodated the resident's status. Review of a Nurse's Note, located under the Notes tab in the EMR and written by Registered Nurse (RN) 2, dated 08/24/23 at 1:46 AM, indicated R95 was combative and verbally aggressive toward staff who were unable to redirect him. R95 became verbally aggressive toward both of his roommates waking them both up. Staff were unsuccessful at redirecting R95 out of the room and R95 attempted to hit staff. Staff offered snacks but R95 refused and wheeled (himself) to a different unit. Review of a Nurse's Note, located under the Notes tab in the EMR and written by Assistant Director of Nursing (ADON), dated 08/24/23 at 3:15 AM (one and a half hours later) indicated R95 was found in R24's room swinging his arms at R24. R95 told staff he hit R24 in the face. Coffee was provided to R95 as requested which calmed him down for a short period of time but R95 became more aggressive and difficult to redirect by the staff. The physician was notified and R95 was sent out to the emergency room (ER). Review of a Nurse's Note, located under the Notes tab in the EMR and written by RN9, dated 08/24/23 at 1:09 PM, indicated R95 returned from the ER at 9:00 AM and was moved to another unit and the Psychiatrist (PSYD) reviewed R95's medications and there was a new order for Ativan (anti-anxiety medication) 0.5mg (milligram) tab one dose and for Ativan IM (intramuscular) 1mg every six hours PRN (as needed). During an interview on 02/28/24 at 5:39 AM, RN2 stated R95 was combative and noncompliant towards both staff and other residents. She stated staff tried redirection, keeping him by the nurse's station, offering fluids, snacks, and general safety checks every two hours. RN2 stated R95 was moved to another unit after hitting R24 in the face but she was unsure of any changes to his care plan for aggressive behaviors. During an interview on 02/29/24 at 9:24 AM, RN7 stated R95 was very aggressive, and staff tried calming him down and were aware of some things that worked such as offering coffee or Pepsi. RN7 stated was not aware of changes made to his plan of care when he was readmitted . During an interview on 02/29/24 at 10:17 AM, the Social Services Director (SSD) 1 stated R95 was very authoritative, and thought he was the boss. SSD1 stated it was best for them to walk away and reapproach later. She stated the interdisciplinary team (IDT) met a lot to discuss him and tried to have consistent staff provide care since he liked consistency. b. Review of a Nurse's Note, located under the Notes tab in the EMR and written by Licensed Practical Nurse (LPN) 1, dated 09/27/23 at 1:26 AM, indicated R95 was exhibiting very aggressive behaviors and went into a female residents' room and was touching their feet and both residents yelled at R95 to get out of the room. R95 got up off his wheelchair and sat down on one of the female resident's wheelchairs. R95 could not be redirected and started kicking and punching at female staff members. A male nurse from another unit came and picked R95 up and placed him in his own wheelchair and he eventually self-propelled to another unit. No change in plan of care. During an interview on 02/28/24 at 10:58 AM, LPN1 stated R95 was very aggressive and argumentative to staff, but he was much more aggressive towards other residents at the facility. She stated staff tried to keep him away from other residents and he was moved to other areas of the facility, but staff were unable to redirect him during the 11:00 PM to 7:00 AM shift. LPN1 stated staff tried to stay out of his range. LPN1 stated they would provide fluids, and sometimes he accepted but there was a skeleton crew at nighttime which made it more difficult to redirect or intervene. On 09/27/23, she stated she remembered R95 very inappropriate and calling out racial names and attempting to hit staff before he went into a female resident's room and was touching their feet c. Review of a Nurse's Note, located under the Notes tab in the EMR and written by LPN1, dated 10/19/23 at 7:53 PM, indicated R95 became physically aggressive throwing punches and kicking at staff and struck R109 on the arm. No change in plan of care. Review of a Nurse's Note, located under the Notes tab in the EMR and written by LPN1, dated 10/22/23 at 3:38 AM, indicated R95 continued with behaviors and wandering in and out of female resident rooms and calling two female aides [derogatory language]. R95's roommate complained that R95 kept purposely running into his bed with his wheelchair to wake him up. At 3:45 AM, R95 continued being aggressive and kicked a nurse in the leg twice and hit her in the face. During an interview on 02/28/24 at 10:58 AM, LPN1 stated that on 10/19/23, R95 was in the hallway in his wheelchair and when R109 passed by and attempted to speak to R95, R95 punched R109 in the face. LPN1 stated she witnessed R95 hit R109 in the face.LPN1 stated a few days later, on 10/22/23, R95 could not be redirected and went into another room of female residents. and while attempting to redirect R95, he kicked her in the knees multiple times and punched her in the face. She stated R95's medications were changed, and he was moved off her unit to another unit, but she was unsure what, if any additional changes in his plan of care were put into place after these incidents. d. Review of a Nurse's Note, located under the Notes tab in the EMR and written by the ADON and dated 10/23/23 at 1:46 PM, indicated the IDT team met and requested a room change and another psychological evaluation to be completed for R95. The resident was moved to another unit. Review of a Nurse's Note, located under the Notes tab in the EMR and written by LPN10, dated 10/26/23 at 4:25 PM, indicated at 4:25 PM, a psychological evaluation was completed on R95. Medications were reviewed and new orders for Depakote (mood stabilizer) 125mg BID (twice a day) one day, Ativan 0.5 mg tab BID and discontinue mirtazapine (anti-depressant medication). On 10/27/23, a new order for Depakote 250 mg QD (once a day). During an interview on 02/28/24 at 2:00 PM, the Administrator stated there were no psychological evaluations completed on R95, but the PSYD completed a medication review. e. Review of a Nurse's Note, located under the Notes tab in the EMR and written by RN7, dated 10/31/23 at 5:53 AM, indicated R95 was physically aggressive throwing punches, kicking at staff and attempting to hit a fellow resident, but staff intervened and redirected the resident away from the other resident. R95 continued to be aggressive and attempted to hit any staff that passed by. The staff's attempts to redirect were unsuccessful. R95 had another room change and was moved to a different unit. No other changes in the plan of care. During an interview on 02/29/24 at 9:24 AM, RN7 stated she did not remember who the resident was that R95 tried to hit on 10/31/23, but that R95 had multiple behaviors during that time. She stated R95 was sitting in his wheelchair and tried to punch the nurse and the staff were attempting to calm him down, but he could not be redirected. RN7 stated he was kicking at staff who tried offering him coffee or snacks, but he continued to refuse that along with his medications f. Review of a Nurse's Note, located under the Notes tab in the EMR and written by RN1, dated 11/03/23 at 10:28 PM, indicated R95 was being resistive to care, and staff attempted to provide reassurance to R95 who appeared to calm down. However, after care was provided R95 punched a nurse on the cheek and struck another nurse in the left eye. R95 was sent out to the ER for further evaluation. He came back to the facility on [DATE] at 1:27 AM. At 11:10 AM, the physician gave an order for one time Ativan 0.5mg by mouth. No other changes in the plan of care. During an interview on 02/27/24 at 4:25 PM, RN1 stated R95 would wander the halls and staff tried to redirect by offering coffee or food. But she was unsure if there were specific interventions on R95's care plan that listed things staff should do to effectively redirect or engage him. During the incident that occurred on 11/03/23, she stated R95 punched one of the nurses in the head and she called 911 and she thought R95 was transported to ER. RN1 stated when he returned, he was moved to another unit, but she was unsure if there were any changes made to his plan of care. Review of a Nurse's Note, located under the Notes tab in the EMR and written by RN5, dated 11/04/23 at 2:37 PM, indicated R95 continued to be agitated and running into other residents with his wheelchair and kicking door of nurse's station. Re-direction unsuccessful but staff continued to re-direct. Review of a Nurse's Note, located under the Notes tab in the EMR and written by the Director of Nursing (DON), dated 11/06/23 at 1:18 PM, indicated the IDT team met and R95 medications were reviewed and there was a new order to discontinue Lorazepam (anti-anxiety medication) and start Ativan gel. During an interview on 02/29/24 at 9:24 AM, ADON stated R95 could be very aggressive, and at times redirected. The ADON stated they sent him out to the ER to get him psychiatric treatment, but the ER would send him right back to the facility. She stated they tried to address his aggressive and violent behavior by moving him to other rooms but that was only effective for a short period of time. She stated that the facility was not protective of other residents since R95 was able to physically assault other residents on multiple occasions She stated his behavior only stopped due to his physical decline. During an interview on 02/29/24 at 10:36 AM, the PSYD stated he was at the facility every Thursday seeing residents. He stated when he made rounds, he physically saw each resident and reviewed their medical record along with their medications. He stated R95 had some behaviors and was on every Thursday list to be seen. anytime there was physical altercation the residents' medications were reviewed and adjusted and he followed-up within a week He stated R95 was a chronic patient, but he did not document that anywhere in the EMR because he kept his own notes. During an interview on 02/29/24 at 10:36 AM, the DON stated R95's behavior depended on the day. She stated staff tried redirecting him. She stated they offered him coffee or activities of his choice like football, which he liked. The DON stated there were some staff he really took to, so they tried assigning those staff to provide his care. She stated they tried finding the right room/unit in the facility and PSYD made several medication adjustments. During an interview on 03/01/24 at 10:08 AM, the Administrator stated staff attempted to address R95's aggressive behaviors by sending him out to the ER in hopes the hospital would send him for psychiatric treatment. But she stated they would send him back to the facility. She stated staff tried redirection, offering coffee, putting on football. But R95's aggression was out of control no matter what staff did. Further review of the Care Plan revealed no updates to the care plan since it was implemented on 06/09/23 despite R95's multiple abusive behaviors towards other residents. One intervention, not documented on the care plan, was to transfer R95 to different units of the facility where the abusive behaviors continued. 2. Review of R6's admission Record located in the EMR under the Profile tab, indicated the resident was admitted to the facility on [DATE]. Diagnoses included dementia, psychotic disturbance, mood disturbance, and anxiety. Review of R6's MDS with an ARD of 04/05/23, revealed a BIMS score of ten out of 15 which indicated moderate cognitive impairment. R6 was independent with ambulation and was documented as wandering for one to three days of the assessment period. Review of R6's Care Plan located in the EMR under the Care Plan tab, dated 04/25/23, indicated Resident is/has potential to be verbally aggressive r/t [related to] Dementia. Interventions were revised 07/28/23, STOP sign initiated at the door. Review of R128's admission Record, located in the EMR under the Profile tab, indicated the resident was admitted initially to the facility on [DATE]. Diagnoses included dementia with behavioral disturbances, restlessness and agitation, schizoaffective disorder, mood disorder, and generalized anxiety. Review of R128's MDS with an ARD of 05/30/23 revealed a BIMS score of 99 which indicated severe cognitive impairment. R128 required one person supervision for ambulation and was documented as wandering daily. R128 expired on 09/14/23. Review of R128's Care Plan, located in the EMR under the Care Plan tab, dated 06/09/23, indicated resident had Socially inappropriate behavior: inappropriate touching AEB [as evidence by]: touching other's hair and/or rubbing others' head. Interventions were revised on 08/01/23 to include, Intervene and redirect when inappropriate behavior is observed. Review of the Investigation Report of resident-to-resident physical abuse provided by the facility, dated 07/23/23, revealed on 07/23/23 at 12:10 PM, RN10 and CNA9 heard R6 yelling for help and immediately responded to the resident. R128 was observed by CNA9 trying to grab and swing at R6, and R6 was trying to push the resident out of her room. CNA9 separated the residents. RN4 documented that R6 told the nurse that R128 had come into her room, and she told him to get out, but R128 continued and then grabbed her on the shoulder. R6 then told RN10 that R128 hit her on the left side of her face, but not hard. R128 sustained a small skin tear to the left upper arm, right forearm, and chest. R6 had no visible injuries. R128 was difficult to redirect. Upon the facility becoming aware of the incident on 07/23/23, the facility placed a stop sign on R6's room doorway to redirect R128 away from her room. During an interview on 02/28/24 at 10:10 AM, CNA9 stated that she could not recall the incident but did recall R128 wandered up and down the hallway with his walker and was difficult to redirect. She stated that he did not like to stand still and would wander into other residents' rooms. She stated R6 preferred to stay in her room and could be easily agitated when someone tried to come in. During an interview on 02/28/24 at 10:45 AM, ADON stated that R128 was a wanderer and had behaviors with touching other people. During an interview on 02/28/24 at 12:50 PM, RN10 stated that R128 had entered R6's room and she only saw that R6 had pushed R128. She stated that R128 was a wanderer and liked to get into the personal space of other residents. She stated that he had not shown signs of aggressive behavior, but due to his constant shadowing of other residents and getting into their space, the other residents would become upset and that would lead to altercations. She stated they continued to try new interventions such as one on one, keeping him in the dining room with activities, and adjustments to his medication. During an additional interview on 02/28/24 at 1:33 PM, the ADON stated the facility had used stop signs to keep him from visiting other resident rooms and had also tried to keep him engaged. Further review of R6's Care Plan located in the EMR under the Care Plan tab, revealed interventions were revised on 07/28/23 to place STOP sign initiated at the door. Review of the facility's policy titled, Abuse, Neglect, and Exploitation, dated 04/01/22 and 07/25/22, revealed It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The policy revealed appropriate corrective action should be done once abuse was identified and the care plans should be revised.