**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, facility document review, and review of the facility's policy titled, Prevention of Patient, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, the facility failed to ensure residents were free from physical abuse from Resident (R) (#79) for three of seven sampled residents reviewed for abuse (R13, R19, and R6). An altercation between R79 and R13 resulted in actual harm to R13 when he sustained an eyebrow laceration requiring repair and an orbital floor closed fracture. Findings include: Review of the facility's policy titled, Prevention of Patient, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Property, revised 10/27/20, indicated, It is the policy . to actively preserve each patient's right to be free from verbal, sexual, physical and mental abuse . 1. Review of the Face Sheet found in the electronic medical record (EMR) revealed R79 was admitted to the facility on [DATE] with diagnoses including schizophrenia, bipolar, fetal alcohol syndrome, and traumatic subdural hemorrhage (bleeding into the brain) with loss of consciousness of 30 minutes or less. Review of the Against Medical Advice [AMA] Release from Responsibility for Discharge indicated R79 left the facility AMA on 12/29/21. Review of R79'S Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 9/15/21 revealed R79 had a Brief Interview for Mental Status (BIMS) score of 13 out of 15, which indicated the resident was cognitively intact. The MDS indicated R79 exhibited physical behavioral symptoms toward others that occurred one to three days in the assessment period. Review of the Care Plan, located in EMR under the Care Plan tab, revealed a Psychosocial Wellbeing care plan with a start date of 6/11/21 that indicated, Monitor for psychosocial changes. Observe and report any changes in mental status, mood, behavior, caused by situational stressor. A Behavioral Symptoms care plan with a start date on 9/9/21 indicated, Encourage [R79] to utilize acceptable coping mechanisms if feeling stressed. [R79] will accept medication as ordered . [R79] will verbalize his frustration to staff when feeling frustrated . An update to the Behavioral Symptoms care plan with a start date of 12/3/21 indicated, Resident exhibited socially inappropriate disruptive behavioral symptoms. 12/2/21- physical altercation with another resident, hitting head against wall, refusing care . Approaches indicated, Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Divert resident's behavior. When resident becomes physically abusive, keep distance between resident and others. When resident becomes physically abusive, move resident to a quiet, calm, environment. 2. Review of R13's Face Sheet, located under the Face Sheet tab in the EMR revealed an admission date of 3/11/21 with diagnoses of blindness in both eyes, diabetes mellitus, seizure disorder, major depression, and schizophrenia. Review of R13's Quarterly MDS with an ARD of 10/8/21 revealed R13 had a BIMS score of 11 out of 15, which indicated the resident was moderately cognitively impaired. The MDS indicated R13 didn't exhibit any physical or verbal behavioral symptoms toward others. Review of the facility's Incident Report Form, dated 9/9/21 and provided by the facility, revealed On 9/9/21 at 11:50 a.m., [R13] pushed [R79] because he was talking bad about some of the female residents. In the process of [R79] being pushed, [R79] took a swing and hit [R13] by his eye. [R13] was sent to the ER [emergency room] for stitches. Review of the Situation Background Communication Form dated 9/9/21 revealed the physician was notified that R13 was involved in an altercation with another resident and sustained a laceration above the left eye that may require suturing. Emergency medical transport was initiated. Review of the Emergency Department Provider Report dated 9/9/21 revealed chief complaint: assault victim, nursing home pt (patient) was punched by another resident, lac (laceration) above left eye. Clinical impression included closed injury of head, eyebrow laceration (with repair), and orbital floor (blow-out) closed fracture. Interview with R13 on 1/17/22 at 11:29 a.m. revealed R79 hit him in the face in the day room which resulted in a laceration over his left eye after he stood up to tell R79 to stop talking about his girlfriend. R13 also stated he was sent to the ER and stitches were placed above his left eye. R13 indicated R79 no longer resided in the facility. 3. Review of the Resident Face Sheet, undated and located in the EMR under the Home tab, revealed R19 was admitted to the facility on [DATE]. R19's diagnoses included unspecified psychosis, dementia, paranoid schizophrenia, major depressive disorder, and schizoaffective disorder. Review of the MDS with an ARD of 10/13/21 revealed R19 was moderately impaired in cognition with a BIMS of eight out of 15 (score of eight - 12 indicates moderate cognitive impairment). R19 exhibited verbal behavioral symptoms towards others four to six days out of the seven-day assessment period. R19 required extensive assistance of one person for transfers, dressing, and hygiene. R19 had not walked during the assessment period and used a wheelchair for mobility. Review of the Care Plan, dated 11/27/19 and located in the EMR under the Resident Assessment Instrument (RAI) tab, revealed a problem of, Behavioral Symptoms. [R19] has verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) . verbal altercation leading to physical aggression with injury from another resident on 12/3/21. The goal was for R19 to not threaten, scream at, or curse at other residents, visitors, and/or staff . Interventions included, Notify the MD [Medical Doctor] as needed . psych services . Assess whether the behavior endangers the resident and/or others. Intervene if necessary . Convey an attitude of acceptance toward the resident . Follow familiar routines with resident . Maintain a calm environment and approach to the resident . Review of the Nurse's Note, dated 12/3/21 at 1:10 p.m. and located in the EMR under the Progress Notes tab, revealed Resident was involved in altercation in the day room. Resident [R19] was attacked by another resident [R79] after a verbal altercation. The other resident [R79] punched him [R19] in the head and neck area several times. He [R19] was knocked out of his wheelchair and landed on the floor on his right side. Staff assisted resident [R19] off floor. Resident [R19] assessed for pain and injuries. Resident [R19] had a skin tear to right lower leg. Bleeding stopped, and dressing applied. 911 and MD [Medical Doctor] notified. [R19's family] called and aware. Review of the Follow-up for [number of incident], undated paper document provided by the facility, revealed The incident on 12/3/21 took place between [R19] . male age [AGE] BIMS score of 8 and [R79] [AGE] year-old . male who has a BIMS of 13 . [R19] rolled his wheelchair by [R79] and asked him what time smoke break was. [R79] replied it's the same time it is every day why are you asking me that. [R19] replied back it's just a stupid f (---) ing question cracker. This upset [R79] and he stood up and took a swing at [R19] and pushed him out of his wheelchair. There was some commotion and yelling in the common ground until staff rushed in and separated the two men. [R79] was standing over ([19] on the ground in an attack like position and was separated, the [name] sheriff's office was notified, the physician notified and both responsible parties . The decision was made to 1013 [initiate transportation to an emergency receiving mental health facility due to imminent risk] [R79] . He [R79] was sent to a behavior health center for stabilization (resident was hospitalized from [DATE] through 12/14/21 at inpatient psychiatric facility) . [R19] was evaluated for any injuries and had none to report. [R19] has returned back to his normal baseline routine. During an interview on 1/18/22 at 6:56 p.m., the Administrator stated R79 was sent out on a 1013 after he punched R19 in the head and neck. The Administrator stated R79 hit R19 after R19 called R79 a cracker. During an interview on 1/19/22 at 10:31 a.m., the Social Services Director (SSD) stated R19 was sporadically verbally aggressive towards residents and staff. She stated there were no patterns to this behavior and indicated the incident between R19 and R79 was started by R19. The SSD indicated R19 had used a derogatory name towards R79 on 12/3/21; R79 then punched R19 in the face two or three times. The SSD stated R19 had a history of sustaining a head injury when he was in prison prior to admission and indicated his cognition was delayed. The SSD stated R19 did not have a history of being physically abusive towards other residents. During an interview on 1/20/22 at 12:53 p.m., Licensed Practical Nurse (LPN) 9 stated R19 upset other residents by cussing and fussing at them. R19 had to be redirected by staff. LPN9 stated anything could tick R19 off. During an interview on 1/20/22 at 1:34 p.m., the Medical Director, also R19's physician, stated R19 had dementia. He stated R19 was usually calm, he had not witnessed any verbally aggressive behaviors, and in general R19 was doing well. The Medical Director stated he was notified of the incident on 12/3/21. He stated staff should be monitoring residents on a one-to-one basis after aggressive behaviors were exhibited for 24 to 48 hours. He stated residents were sent on a 1013 if they were at risk of harming themselves or others. 4. Review of R6's Face Sheet, located under the Face Sheet tab in the electronic medical record (EMR) revealed an admission date of 2/18/13 with diagnoses that included cerebrovascular accident (CVA-stroke), aphasia (difficulty speaking), vascular dementia with behavioral disturbance, depression, bipolar disease, and anxiety disorder. Review of R6's Quarterly MDS with an ARD of 10/8/21 revealed a BIMS score of 10 out of 15, which indicated R6 was moderately cognitively impaired. The MDS indicated R6 exhibited verbal behavioral symptoms toward others that occurred one to three days during the assessment period. Review of the facility's Incident Report Form, dated 12/27/21 and provided by the facility, revealed On 12/27/21 at 5:00 p.m., [R6] was rolling by in her wheelchair and mumbled something to [R79] calling him a bastard and [R79] called [R6] a whore then according to witnesses stood up and kicked [R6] and [R6] fell out of her wheelchair. Staff were notified [and] separated the two and did an injury assessment on [R6]. The police department was called for assistance. They called back after an hour saying they couldn't do anything and to call back to dispatch if further assistance was needed. Review of the facility's Follow Up Report, undated and provided by the facility revealed The incident that took place on 12/27/21 between [R6 and R79] .[R79] was watching [television] and [R6] who is verbally impaired rolled by [R79] who was blocking the view of the TV [television]. [R6] mumbled to [R79] get out of the way you bastard. [R79] proceeded to stand up and yelled back at [R6] shut up your [sic] whore. Then [R79] kicked [R6's] wheelchair and [R6] slid out of the chair. Staff rushed in and separated the residents and cleared out the common area. A pain assessment was done on [R6] and the physician and family was [sic] notified. After the incident took place [R79] went and spoke with the social services director and told them he wanted to leave the facility and go back to his brother's home in [city]. [R79's] brother was working on finding a room for him to rent prior to this incident. Later that evening an uber was called and [R79] signed himself out AMA [against medical advice] to return back to his home in [city] GA. [R6] has since returned back to her normal routine. Interview with R6 on 1/18/22 at 9:49 a.m. revealed R79 kicked her wheelchair and she slid out of it in the dayroom. R6 also stated staff assessed her and she didn't have any injuries. R6 indicated that R79 didn't reside in the facility any longer. Interview with the Administrator on 1/20/22 at 5:34 p.m. revealed he protected the residents from abuse per the facility's abuse policy by clearing the common area where the incident took place, sending R6 and R79 to their rooms. The Administrator also stated he paused the smoke break temporarily and R79 signed out AMA on 12/29/21. Interview with the Nurse Consultant, along with the Administrator, Director of Nursing (DON), and Social Worker on 1/18/22 at 6:00 p.m. revealed the facility would not accept the resident back if he wanted to come back. The Nurse Consultant stated the resident was not a good fit for the facility and that he was danger to himself and others. Interview with the Administrator on 1/18/22 at 6:44 p.m. revealed that he didn't know R79's medical history and would not have admitted him if had known about his violence. Regarding R79, the facility got a referral from the hospital, prior history of behaviors was not known. The Administrator stated after admission they learned R79 had been living with his brother in the past and the brother kicked him out due to drug abuse. R79 had been shot multiple times and had a history of fighting. Record review for R79, R13, R19, and R6 from 9/9/21 through 1/20/22 revealed residents were receiving appropriate behavioral health services when indicated.