**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews the facility failed to protect the residents' right to be free from neglect for 1 (Resident #999) of 4 sampled residents by failing to ensure staff follow safety precautions while providing care to prevent avoidable falls and fall related major injury. The findings included: Review of the facility's neglect investigations revealed on 4/1/25 at approximately 6:40 p.m., Certified Nursing Assistant (CNA) Staff A was providing care to Resident #999. The CNA turned the resident on his left side to remove his brief. The resident moved more off the bed as she placed her hand on his side to hold him he went falling. The incident investigation noted Resident #999 sustained a red discoloration to the right side of his face and a skin tear on his right hand. Resident #999 was transferred to a local hospital and diagnosed with an acute intra-axial hemorrhage (bleeding) within the left frontal lobe (front of the brain) measuring 2.0 by 1.07 by 2.4 centimeters. The investigation noted CNA staff A turned Resident #999 on his left side to remove his incontinent brief and bed sheet. As she was placing the fitted sheet on the bed she saw the resident moving more off the bed so she placed her hand on his side to hold him. The resident fell off the bed because his weight was too heavy on one side. Once the resident the floor she went out into the hallway to get help. The investigation noted the nurse arrived in the room, observed Resident #999 on his right side with a hematoma (collection of blood outside the blood vessels) on the right side of the face. As part of the investigation, on 4/2/25 CNA Staff A demonstrated she had the resident centered and as she turned him, he was more toward the other side, away from her which resulted in the resident's falling as he moved. The facility verified the allegation of neglect and noted CNA Staff A would be terminated for failure to follow the facility's policy and procedures related to reviewing residents [NAME] (System of communication and organization used in nursing that helps long term care facilities document resident care summaries). Review of the [NAME] revealed to turn and reposition Resident #999 every two hours and as needed. The [NAME] did not specify that the resident required the physical assistance of two persons for bed mobility, including turning and repositioning as per the Nursing admission evaluation. Review of the staff education dated 4/2/25 noted Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. Review of the facility new employee education and in-service training revealed, At the start of the shift, read the [NAME] for updated changes such as interventions in place for bed mobility, transfer status, falls, behaviors. Review of the clinical record revealed Resident #999 was a [AGE] year-old male with an admission date of 2/14/25. Diagnoses included right side hemiparesis (weakness on one side of the body) and hemiplegia (paralysis of one side of the body) related to Cerebral Vascular Accident, Osteoporosis, and a history of falls. The admission Minimum Data Set (MDS) assessment (standardized tool that measures health status in nursing home residents) with an assessment reference date of 2/21/25 documented Resident #999 was dependent for bathing, toileting, personal hygiene and bed mobility (Helper does all of the effort, Resident does none of the effort to complete the activity). The MDS noted Resident #999's cognitive skills for daily decision making were severely impaired. Resident #999 was rarely/never understood. Review of the New admission re-admission Evaluation form dated 2/14/25 revealed Resident #999 required the physical assistance of two persons for bed mobility. Resident #999 scored 18 on the fall risk evaluation upon admission indicating the resident was at high risk for falls. The care plan initiated on 3/21/25 identified Resident #999 had activity of daily living self-care performance deficit due to, Confusion/decreased cognition, musculoskeletal impairment, stroke, and weakness. The interventions noted the resident had an air mattress to his bed and was, dependent with rolling left to right. The care plan did not specify the resident required the physical assistance of two persons for bed mobility as per the admission MDS assessment. The care plan initiated on 3/21/25 noted Resident #999 was at risk for falls related to decreased cognition and decreased mobility. The goal was, The risk for falls will be minimized through the next review. The interventions included to be sure the resident's call light is within reach and encourage the resident to use if for assistance as needed and evaluate the resident's environment to identify factors known to increase risk of falls. On 4/7/25 at 8:40 a.m., in an interview Unit Manager Registered Nurse (RN) Staff B said, I was in [NAME] Garden secured unit when [Resident #999] fell. I applied ice and printed the paperwork to send him to the hospital. He went to the hospital and did not return. He was a two person assist with care. [CNA Staff A] said she did not have another person with her. On 4/7/25 at 8:48 a.m., in an interview RN Staff C said she works the 11:00 p.m. to 7:00 a.m., shift on the North Unit. She said, We regularly keep the [NAME] up to date. The Unit managers and the nurses can do it. If the CNA notices any changes they tell us. If the resident has had any changes we update the [NAME]. On 4/7/25 at 8:52 a.m., in an interview North Unit Manager Licensed Practical Nurse Staff C said the CNAs and nurses get resident information from the [NAME] and report from the nurse. Unit Managers and MDS nurses mostly update the [NAME]. We received recent education to ensure the [NAME] is updated and reviewed at the beginning of every shift. On 4/7/25 at 11:05 a.m., in a telephone interview CNA Staff A said, I was working the 3:00 p.m., to 11:00 p.m., shift on 4/1/25. I had worked with Resident #999 before. I went to do my last rounds to see if he needed to be changed. I had him positioned in bed to the left side facing the door. I realized he did not have a fitted sheet on the bed, and I went to get one. Before I turned him on his back, flat on his back in bed. He had an air mattress. I did the upper part of the sheet first. I had all the soiled linen and brief rolled up and against him. I went to place the bottom of the fitted sheet on the bed and he began to roll out of the bed. I tried to stop him but I did not make it. He fell out of bed. I saw him and I did not see any blood, so I ran to get the nurse. When we got back to the room, there was blood everywhere. He had a skin tear to his right arm and it was bleeding. What I did wrong was I did not roll him toward me like I should have. I always did him by myself and no one ever told me he was a two person assist. I never knew about the care [NAME]. They told me about the [NAME] after the fact. I know you need to have two people with a mechanical lift, but he was already in bed, I just wanted to change him. They gave education after the fact. If I had known before, I would have had help, but no one ever told me anything about him. It all happened so fast. Review of the Certified Nursing Aide, Competency Checkoff List revealed Staff A completed Review [NAME] on 1/13/25. On 4/7/25 at 11:45 a.m., in an interview the Administrator said Resident #999 was always a two person assist. From the re-enactment with CNA Staff A, using a pillow to demonstrate, she stood at the bed and he was in the center of the bed, she rolled him away from her and he was at the edge of the bed. I educated her the resident needs to be closer to you so when you turn him he is not so close to the edge, do not center the resident. On 4/7/25 at 11:55 a.m., in an interview Occupational Therapist (OT) Staff G said Resident #999 was on caseload when he was first admitted and he required two persons assist with all his care needs. He said Hospice got involved and had their own therapy seeing the resident but the resident was always two persons assist with his care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure the safety interventions were documented in the care plan and failed to ensure staff used safe repositioning technique to prevent avoidable fall and fall related serious injury for 1 (Resident #999) of 4 dependent residents reviewed. The findings included: Review of the clinical record revealed Resident #999 was a [AGE] year-old male with an admission date of 2/14/25. Diagnoses included right side hemiparesis (weakness on one side of the body) and hemiplegia (paralysis of one side of the body) related to Cerebral Vascular Accident, Osteoporosis, and a history of falls. Review of the New admission Evaluation form dated 2/14/25 revealed Resident #999 required the physical assistance of two persons for bed mobility. The care plan initiated on 3/21/25 identified Resident #999 was at risk for falls related to decreased cognition and decreased mobility. The resident had activity of daily living self-care performance deficit due to, Confusion/decreased cognition, musculoskeletal impairment, stroke, and weakness. The interventions noted the resident had an air mattress to his bed and was, dependent with rolling left to right. The care plan did not specify the resident required the physical assistance of two persons for bed mobility as per the admission evaluation. The Significant Change in Status Minimum Data Set (MDS) assessment (standardized tool that measures health status in nursing home residents) with an assessment reference date of 3/5/25 documented Resident #999's cognitive skills for daily decision making were severely impaired. Resident #999 was rarely/never understood. The resident's range of motion was impaired on one side of the upper extremities and both sides of the lower extremities. Resident #999 was dependent on staff for activities of daily living, including bed mobility, rolling left and right (Helper does all of the effort, Resident does none of the effort to complete the activity). Review of the progress notes revealed on 4/1/25 Resident #999 had a fall resulting in a hematoma (collection of blood outside of the blood vessels) to the right cheek and a skin tear to the right hand. Resident #999 was transferred to the local hospital for evaluation. Review of the hospital documentation for 4/1/25 revealed Resident #999 had a CT scan (Computerized Tomography) of the head with findings of acute intra-axial hemorrhage (bleeding) within the left frontal lobe (of the brain) measuring 2.0 by 1.7 by 2.4 cm (centimeters). Review of the fall investigation initiated on 4/1/25 revealed Certified Nursing Assistant (CNA) Staff A was changing Resident #999. She turned the resident to the left side to remove the incontinent brief and change the fitted sheet on the bed. As she was placing the fitted sheet on the bed she went to tuck it under and saw the resident move more off the bed. She placed her hand on his side to hold him, he went off falling off the bed because his weight was too heavy on one side. Once the resident hit the floor CNA Staff A went into the hallway to get help from a CNA or a nurse. A nurse on duty documented CNA Staff A call to her and said Resident #999 fell. Upon arrival to the resident's room, she observed the resident on the floor on his right side. Resident #999 had a hematoma to the right side of the face. Unit Manager Registered Nurse (RN) Staff B obtained a statement from CNA Staff A who said she always cared for Resident #999 and has not had a problem with caring for him. She was changing the resident and the sheets. She rolled the resident over and saw him begin to move and when she went to hold/grab him, he fell. CNA Staff A said no one ever told her she needed two people to care for the resident. She had taken care of him several times and had no problem. CNA Staff A said it just happened so fast. The facility's investigation noted on 4/2/25 CNA Staff A demonstrated how she had Resident #999 centered and as she turned him, he was more toward the other side, away from her which resulted in him falling as he moved. The facility's investigation noted CNA Staff A was given one to one education on proper positioning and following the [NAME] (System of communication and organization used in nursing that helps long term care facilities document resident care summaries) for transfer status. Review of the [NAME] failed to reveal documentation Resident #999 required two persons assistance for bed mobility. Review of the Education/Training provided to CNA Staff A on 4/2/25 noted, When providing care for patients in the bed and turning patient away from you ensure patient is positioned on the side of the bed closest to you to minimize risk of fall from the bed and maintain safety. Start of shift, review [NAME] for each patient to follow plan of care and transfer status. On 4/7/25 at 8:40 a.m., in an interview Unit Manager Registered Nurse (RN) Staff B said, I was in [NAME] Garden secured unit when [Resident #999] fell. I applied ice and printed the paperwork to send him to the hospital. He went to the hospital and did not return. He was a two person assist with care. [CNA Staff A] said she did not have another person with her. On 4/7/25 at 8:48 a.m., in an interview RN Staff C said she works the 11:00 p.m. to 7:00 a.m., shift on the North Unit. She said, We regularly keep the [NAME] up to date. The Unit managers and the nurses can do it. If the CNA notices any changes they tell us. If the resident has had any changes we update the [NAME]. On 4/7/25 at 11:05 a.m., in a telephone interview CNA Staff A said, I was working the 3:00 p.m., to 11:00 p.m., shift on 4/1/25. I had worked with Resident #999 before. I went to do my last rounds to see if he needed to be changed. I had him positioned in bed to the left side facing the door. I realized he did not have a fitted sheet on the bed, and I went to get one. Before I turned him on his back, flat on his back in bed. He had an air mattress. I did the upper part of the sheet first. I had all the soiled linen and brief rolled up and against him. I went to place the bottom of the fitted sheet on the bed and he began to roll out of the bed. I tried to stop him but I did not make it. He fell out of bed. I saw him and I did not see any blood, so I ran to get the nurse. When we got back to the room, there was blood everywhere. He had a skin tear to his right arm and it was bleeding. What I did wrong was I did not roll him toward me like I should have. I always did him by myself and no one ever told me he was a two person assist. I never knew about the care [NAME]. They told me about the [NAME] after the fact. I know you need to have two people with a mechanical lift, but he was already in bed, I just wanted to change him. They gave education after the fact. If I had known before, I would have had help, but no one ever told me anything about him. It all happened so fast. On 4/7/25 at 11:45 a.m., in an interview the Administrator said Resident #999 was always a two person assist. From the re-enactment with CNA Staff A, using a pillow to demonstrate, she stood at the bed and he was in the center of the bed, she rolled him away from her and he was at the edge of the bed. I educated her the resident needs to be closer to you so when you turn him he is not so close to the edge, do not center the resident. The Administrator added she thought the placement of the resident in the center of the bed was the root cause of the fall but she had 15 days to determine that.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's abuse and neglect policy and procedure, resident and staff interviews, the facility failed to protect residents' rights to be free abuse for 1 (Resident #900) of 3 sampled residents. The facility also failed to implement adequate supervision to prevent resident to resident physical abuse of 2 (Resident #850 and #700) of 3 sampled residents from Resident #900 with known aggressive behaviors. The findings included: The facility policy Abuse, Neglect and Exploitation, documented It is our facility policy to prohibit the mistreatment of residents. All residents have the right to be free from verbal, sexual, physical, and mental abuse. Corporal punishment and involuntary seclusion by facility staff, other residents, consultants or volunteers, staff or other agencies serving our residents, family members or legal guardians, friends, or other individuals. 1. Clinical record review revealed Resident #900 was admitted to the secured memory care unit of the facility on 9/9/21 with diagnoses including unspecified dementia with behavioral disturbance, and brief psychotic disorder. The Quarterly Minimum Data Set (MDS) (standardized assessment tool that measures health status in nursing home residents) with an assessment reference date of 2/4/23 documented Resident #900 required supervision with ambulation on the unit. Resident #900 scored 00 on the Brief Interview for Mental Status (BIMS) indicating severe cognitive impairment. Resident #900's current care plan included a focus on physical and aggressive behaviors towards his wife (per admission records). Has paranoid behavior, diagnosis of dementia with behaviors. Resident #900 had episodes of verbal and physical aggression, anger and crying. The interventions included administering medications as ordered, observing for effectiveness and side effects. Approach resident in a calm manner and explain actions. Update physician of increased presence or severity of behaviors as indicated. Request psychiatric consult as needed. The plan of care did not document specific interventions to address Resident #900's behaviors when he was verbally or physically aggressive. The target behavior monitoring included agitation, anger, crying, restlessness. January 2023 documented behaviors included anger and crying occurred one time on the day and night shift on 1/6/23, 1/18/23 and two times on the night shift on 1/20/23. Agitation was documented as occurring twice on the day and night shift on 3/6/23 and twice on the night shift on 1/19/23 and 1/20/23. Restlessness was documented twice on the night shift on 1/20/23. February 2023 documented agitation occurred three times on 2/8/23 on the night shift, one episode on night shift on 2/9/23, five episodes on the night shift on 2/22/23, more than five episodes on the night shift on 2/25/23 and more than five episodes on day shift 2/26/23. Restlessness was documented five times on the night shift on 2/22/23. The behavior anger/crying was documented three times on night shift on 2/8/23 and once during the night shift on 2/9/23, and four times on the night shift on 2/22/23. March 2023 documented the behaviors of anger/crying one time on 3/14/23 day shift, and one time on 3/13/23 night shift. Restlessness was documented one time on the night shift on 3/15/23, and one time on the day shift on 1/16/23. Agitation was documented as occurring one time on the night shift on 3/10/23, four times on day shift on 3/12/23, one time on day shift on 3/14/23 and one time on night shift on 3/13 and 3/14/23. Review of the nurses' notes revealed: On 1/18/23 at 12:33 p.m., Resident #900 was verbally and physically aggressive during lunch. Using profanity towards other residents, using his walker to attempt to hit other residents. Accusing residents of stealing his car. Problem solving technique was attempted to de-escalate the situation. Resident #900 became violent towards the nurse and was removed from the dining area. On 1/22/23 at 7:30 a.m., Resident #900 has had two sleepless, restless, and agitated nights. Threatens staff and refused multiple redirections. Spent most of the night going into other rooms despite the assistance to find a room. Additional behavior included verbal aggression, refusal to use walker, leaving walker and walking in hallway. On 1/23/23 Resident #900 continues to be sleepless, displays combativeness, non-compliant with walker, entering other rooms despite assisted to his room. Implementations included redirection, snacks television. Evaluation shows ineffectiveness. On 2/6/23 at 11:12 a.m., the nurse documented Resident #900 was acting up, showing signs and symptoms of increased agitation, wants to fight peers and staff and attempting to hit them with his wheelchair. Not able to be redirected verbally. On 2/6/23 at 12:04, the nurse documented Resident #900 with increased agitation using walker to hit doors attempting to open doors, wandering in other resident's room calling it his own room, attempting to hit staff with walker. The resident was unable to be redirected. The resident's spouse called to assist with redirection with no success. The physician was notified and gave orders to administer medications with positive response. On 2/7/23 the psychiatric Advanced Practice Registered Nurse (APRN) documented Resident #900 presented alert/awake, blank stare, depressed mood and anxious. Per nursing staff patient displays intermittent periods of disruptive, aggressive behavior and uncooperative resistance with care at times. The treatment plan specified monitor mental status for any acute change in mood or behavior, promote a safe environment and continue with current pharmacological regiment and start Seroquel (antipsychotic) 25 milligrams (mg) twice a day, Buspar 5 mg three times a day and Lexapro 10 mg daily (medications used to treat mood disorders). On 2/8/23 at 10:58 p.m., the nurse documented in a behavior note the resident woke up from a nap very agitated during this shift. Resident yelling at others Go to your room, now banging his walker on the floor multiple times. On 2/25/23 at 10:32 p.m., the nurse documented Resident #900 was noted with increased anxiety, agitation and several episodes of crying. The resident required frequent redirection back to his room. The physician's orders as of 10/21/22 included to administer Lorazepam 0.5 milligram by mouth at bedtime for anxiety. The nursing progress noted dated 3/7/23 at 6:42 a.m., noted behavior was noted. The Lorazepam was not administered. The nurse documented, Medication not available on hand. On 3/7/23 at 10:06 p.m., the Lorazepam was not administered for anxiety. The nurse documented, Not available. On 3/8/23 at 8:11 p.m., the nurse documented the Lorazepam was not administered. The nurse documented the resident needed a new script. The physician was called with no answer. On 3/9/23 at 8:05 p.m., the Lorazepam was not administered. The nurse documented Resident needs new hard script per pharmacy. Awaiting new script. On 3/10/23 at 7:00 a.m., the nurse documented, I visually observed resident holding onto roommates (Resident #850) arm trying to push him out of his bed. I was unable to redirect resident. I called for nurses aide to come assist me in getting the residents apart. 3 nurses aides assist me in getting [Resident #900] hands off of his roommate arm and assist [Resident #900] into his bed. [Resident #900] was using profanity towards staff. [Resident #900] got out of his bed and walked across the hall into another resident's room. I last saw [Resident #900] approx. 5:15 am when I gave him his morning medications, both residents were laying in bed. No behaviors observed at that time. Licensed Practical Nurse Staff A assessed both residents and no injuries were noted. The physician was notified, and no new orders were received. Resident #850 was moved to a different room. Review of the clinical record revealed Resident #850 was a vulnerable resident admitted to the secured memory care unit on 3/11/22 with diagnoses including dementia, anxiety, mood disturbance, and hypertension. The annual MDS dated [DATE] documented the resident's cognition was severely impaired. On 3/20/23 at 1:30 p.m., Resident #850 was observed in his room in bed. He was pleasantly confused responding to simple greeting but not able to recall the incident with resident #900. On 3/21/23 at 9:00 a.m., in a telephone interview CNA Staff F said she works both the 3-11 and 11-7 shift. She said she was there in the morning on 3/10/23. She went into Resident #900 and #850's room when she heard the nurse yelling. She saw Resident #900 trying to push Resident #850 out of the bed. Resident #900 was trying to get him out of the room but they both lived there. Resident #900 had a hold of Resident #850's arm, pushing him. They separated the residents. On 3/21/23 at 9:45 a.m., in a phone interview, LPN Staff A said she was working on the memory care unit on 3/10/23 passing medication in another room. She heard someone yelling for help, so she went to look. She knocked and went into Resident's #900 and #850's room. She saw Resident #900 trying to push Resident #850 out of bed. He had his arm and was tugging on it but Resident #850 did not fall out the bed. She tried to separate them but Resident #900 can be really strong. She called for help. The CNAs came and helped to separate them. They both have dementia. They moved Resident #850 to another room. They were not hurt. LPN Staff A said Resident #900 has days when he yells and curses and will push things around in the dining room. He can try and hit staff, but you can calm him down easily. On 3/21/23 at 8:00 a.m., the Administrator said the last allegation of resident to resident involving Resident #900 was on 9/15/21. She said Resident #900 wanders and has behavior outbursts that is why he was on a memory care unit. She said staff watch him and keep an eye on him. Further review of the progress notes revealed on 3/10/23 at 9:03 p.m., the nurse documented the Lorazepam 0.5 mg was not available to be given to Resident #900. The nurse noted, Medication not available, script needed. The Medication Administration Record for March 2023 did not contain documentation the Lorazepam was administered as ordered on 3/10/23 ,3/11/23 and 3/12/23. On 3/12/23 at 12:20 p.m., the nurse documented in a progress note at 9:20 a.m., she was passing medications when she heard a commotion. Upon investigation, she looked to the dining room next to the patio. Resident #900 was seen with walker in both hands shoving towards dining room door, yelling and screaming as he was being assisted away from the door. Another resident (Resident #700) was seen on the floor in a sitting position. Resident #900 continued to be verbally abusive with profanities and threats. Review of the clinical record showed Resident #700 was admitted to the facility on [DATE] to the secured memory care unit with diagnoses including cirrhosis of the liver, dementia, depression, Alzheimer's disease, schizoaffective disorder, anxiety, and bipolar disorder. Review of the Quarterly MDS dated [DATE] documented resident #700 was independent with ambulation, Resident #700 scored a 12 on the BIMS score indicating mild cognitive impairment. On 3/16/23 at 10:08 a.m., the psychiatric APRN documented the resident was seen today for increased agitation and disruptive behavior, as patient is exhibiting disruptive/aggressive behavior and elevated mood. Per nursing staff patient is uncooperative with care, medication adherence and very aggressive with staff, and other patient within the unit. On 3/20/23 at 1:00 p.m., Registered Nurse (RN) Staff C said Resident #900 was a very violent man, and they keep an eye on him because he wanders. The residents on the memory care unit have behaviors and most wander, it is why they are here. The RN said with Resident #900 sometimes all you do is talk to him and he can start yelling and cursing, and it does not matter. The CNAs come and say Resident #900 is cursing and trying to hit them. All he can do is try and redirect him and if that does not work, he gives him medication. RN Staff C said, You don't want to keep talking to him sometimes when he is angry because it makes him worse, he is not a nice man. On 3/20/23 at 1:45 p.m., Resident #700 said Resident #900 was in the dining room and closed the dining room door on her as she was waiting in the hall to go outside to the smoking area. Resident #700 said she opened the dining room door and told Resident #900 to leave it open and, he pushed the door into me, and I fell backwards. I was on the floor and the nurse found me and helped me to get up. Resident #700 said she fell onto her buttocks and scratched her right knee. She said Resident #900 wanders and he tries to come into her room and the nurse has to come and get him. Resident #700 said Resident #900 scares me. On 3/21/23 at 9:30 a.m., CNA Staff G said she was working on 3/12/23. Residents #900 and #700 were in the dining room. Resident #700 was waiting to go out and smoke around 9:00 a.m. Resident #900 likes to sit in the dining room and be by himself. It was noisy, so he got up and shut the door from the hall to the dining room. Resident #700 was standing on the other side of the door. She got upset because she wanted the door open, so she pushed the door open. Resident #900 pushed it back toward her and Resident #700 fell backwards. One wanted the door open and the other wanted to close it so they both pushed on it. She said she was in the dining room at the time it happened. Resident #900 gets verbally aggressive. He will curse you up and down and yells at you. He just likes to sit in the dining room by himself. She gives him a snack and a drink and he is ok. On 3/20/23 at 1:15 p.m., observed Resident #900 sitting in the dining room on the secured unit. He was not able to answer any questions regarding the incidents with Resident #700 or Resident #850. On 3/21/23 at 8:20 a.m., LPN Staff D said she works the night shift on the secured unit. Resident #900 gets up at night sometimes and tries to wander into other residents' rooms. She has a CNA follow him from a distance to make sure he is safe and everyone else too. LPN Staff D said resident #900 has some ugly days. He will try to hit you, yell, curses and will tear up the dining room. She tries to talk with him calmly. Sometimes he cries, shouts, and just wants his wife. She would call his wife to talk to him on the phone. her and she will talk to him on the phone. She says Resident #900 would try to hit staff, not residents. On 3/21/23 at 12:30 p.m., the Director of Nursing (DON) said Resident #900 was assessed by Psychiatry services on 3/16/23 after the incidents. She said they keep an eye on all the residents in the secured unit because they all have behaviors which are documented in the behavior monitoring sheets. She staffs the unit with three CNAs each shift and a nurse to keep a close eye on the residents. The DON said she did not implement increased supervision or one to one supervision for Resident #900 after the incidents with Resident #850 and #700. She said they could not predict when a resident on the secured unit is going to have a behavior. On 3/21/23 at 12:45 p.m., the Assistant Director of Nursing said they did not implement one to one supervision for Resident #900. She said they have staff softly monitor him, keeping a distance but still observing as not to make him more agitated. She said they could not predict his behaviors, there were no real triggers. It could be anytime or anything that sets him off. Staff has been trained to de-escalate the situation. On 3/21/23 at 2:15 p.m., in a phone interview the Psychiatric Advanced Practice Registered Nurse (APRN) said there was no way to predict when Resident #900 was going to have a behavior, that is the problem. We are working to find his triggers. I get a call when he is acting up but by the time, I get to the facility he is calm. I'm at the facility twice a week. Any resident could use more supervision, it would help. If you are asking me do I think we can tell when Resident #900 is going to have an episode, no I can't. I changed his medication, so now we wait and see if it was effective. If I give too much medication then he can fall or he becomes sedated, that is not the answer either. 2. Review of Resident #999's clinical record revealed an admission date of 10/12/21 with diagnoses including acute respiratory failure, anxiety, alcohol abuse, multiple rib fractures, and adjustment disorder. The Quarterly MDS with an assessment reference date of 12/15/22 documented Resident #999 required extensive assistance from staff with transfers, toileting, and dressing. The MDS indicated Resident #999's cognitive skills for daily decision making were severely impaired. The plan of care identified Resident #999 exhibited behaviors of physical aggression, including striking out, hits, kicks, throws things, abrasive outburst towards staff and others, and uses inappropriate language, yelling and cursing at other resident, and verbally and physically aggressive toward staff. The interventions instructed staff to redirect, administer medications as ordered and observe for effectiveness. Approach resident in a calm manner and explain actions. Intervene as needed to protect the rights and safety of the resident, and others and remove from situation as able. On 3/5/23 at 12:35 p.m., the Manager on Duty Registered Nurse (RN) Staff I documented she observed CNA Staff H grab Resident #999 by the left arm while he was seated in the wheelchair. RN Staff I yelled from the South Unit Nursing station at the CNA to get away from the resident. CNA Staff H told the RN Resident #999 had tried to scratch her. The RN told the CNA to leave the facility and she assessed the Residents left arm. No injuries were observed by the RN. The RN then contacted the NHA who filed a report with the police. On 3/20/23 at 10:45 a.m., in a telephone RN staff I said she was the manager on duty on 3/5/23 and was standing at the South Unit nursing desk after dinner time and was looking down the hallway toward the Nort Unit. RN Staff I said CNA Staff H had Resident #999 by the left arm, yanking on him like she was about to pull him form the wheelchair. She said, I could see it very clearly, they were yelling. I screamed from the hall get away from him, because I knew I was not going to get there that fast. She let him go right away when she heard me scream. RN Staff H said she got to them, the CNA kept yelling he was fitting to scratch me, I ain't fitting to let anyone scratch me. She said CNA Staff H kept yelling, I ain't fitting to let anyone scratch me. She said she escorted the CNA out of the building and notified the Administrator who is the abuse coordinator right away. She assisted Resident #999 to his room and checked him to make sure he wasn't hurt. He didn't have anything on him, no bruises or anything. She said Resident #999 was confused and couldn't tell her or recall the incident. On 3/20/23 at 3:10 p.m., in a telephone interview LPN, Staff J said she was on duty on 3/5/23 the day of the incident with Resident #999 and CNA Staff H. She was sitting at the desk charting and could hear Resident #999 in the dining room yelling and cursing and threatening to hit residents and staff which was normal behavior for him. He was always yelling and cursing. I told CNA Staff H to take him to his unit. She said Resident #999 was very combative and you can't touch his wheelchair when he is in it. He is very aggressive all the time. She said she did not witness the incident but heard RN Staff I scream Get away from him. On 3/20/23 at 12:00 p.m., Resident #999 said he did not remember a CNA hurting him. On 3/20/23 at 10:10 a.m., the Administrator said CNA Staff H was immediately suspended after the incident. She was not permitted to return to the facility and her employment terminated.