Based on interviews and record reviews, the facility failed to protect a residents' (R2, R11, and R12) right to be free from verbal and physical abuse form another resident (R1) for three out of 13 residents reviewed for abuse. This failure resulted in staff not providing needed supervision for an aggressive resident causing R1 to get into a verbal altercation with R12, R11 having to physically stop R1 from striking R11 with a cane and R1 punching R2 in the face. Findings include: R1's admission Record, Order Summary Report, and care plan documents in part diagnoses including but not limited to schizophrenia and bipolar disorder. R1's Brief Interview for Mental Status (BIMS) dated 9/09/2024 documents in part that R1 was moderately cognitively impaired. R1's care plan documents in part that R1 displays impaired decision-making ability as evidence of inattention, disorganized thought content, and hallucinations (date initiated 3/12/2024). Care plan does not contain a focus for potential/risk for abuse. R1's progress notes document in part that on 9/26/2024, R1 experienced aggressive and noncompliant behaviors. V21's (Former Licensed Practical Nurse/LPN) progress note dated 9/26/2024 2:55 AM documents in part: Resident is displaying aggressive and abusive behavior. Resident continues to walk the floor, not easily directed. Resident refused to go to [R1's] room. Resident is trying to fight another resident and stated, 'somebody is going to get hurt.' [R1] continues to verbally abuse [R1's] roommate. Noncompliant behavior continued throughout the day and needed multiple re-direction from staff. Facility sent R1 to the hospital for psychiatric evaluation and returned on 9/27/2024. V10's (Nurse) progress note dated 9/27/2024 2:25 AM documents in part that R1 returned to the unit argumentative and noncompliant. V22's (Nurse) progress note dated 9/27/2024 7:36 AM documents in part: Resident at nurses' station verbally aggressive unable to redirect. Verbally threatening staff and peers. On 10/23/2024 at 11:25 AM, V27 (Medical Records Director) stated during that Friday morning, facility assigned V27 to work as receptionist at the front lobby. R12 ran out the front door in the lobby with shirt off like R12 was getting ready to fight. V27 stated R1 and R12 were having a verbal altercation. R12 was inviting R1 to join R12 outside for a physical altercation. Social services stood outside with R12 to settle R12 down. V27 stated staff directed R1 back to the first-floor nurses' station. V27 described R12 as a resident that 'gets into moods where [R12] can be confrontational.' V27 stated I guess that morning, [R1] was feeling confrontational as well and it spear headed the whole thing. Both showed signs of agitation and when those personalities met, it wasn't good. On 10/23/2024 at 12:25 PM, R12 stated a resident put their fists up to R12 so R12 put their fist up in response. R12 stated (R1) did it first. I was outside. (R1) didn't follow me outside cause (R1) was scared. I said come outside and fight me but (R1) didn't. (R1) was too scared. I had to protect myself then. R12's admission Record, Order Summary Report, and care plan documents in part diagnoses including but not limited to unspecified psychosis not due to a substance or known physiological condition; schizoaffective disorder, bipolar type; anxiety disorder; unspecified symptoms and signs involving cognitive functions and awareness; and unspecified intellectual disabilities. R12's BIMS dated 8/25/2024 documents in part that R12 was moderately cognitively impaired. R12's care plan documents in part that R12 has impaired cognitive function or impaired thought processes related to comorbidities (initiated 5/14/2024). It does not contain a focus for potential/risk for abuse. During same interview with V27 on 10/23/2024 at 11:25 AM, V27 continued with the morning's events. After staff separated R1 and R12, V27 looked outside towards R12 and social services to make sure R12 was doing okay. When V27 turned around towards the first-floor nurses' station, V27 saw R1 having another altercation with R11 fighting over a cane. V27 stated [R1] was trying to attack R11 with the cane. V27 stated R11 had two hands on the cane stopping R1 from striking R11 with it. V27 took the cane, headed back to the front lobby, and staff separated R1 and R11. R11's admission Record, Order Summary Report, and care plan documents in part diagnoses including but not limited to abnormal posture; chronic angle-closure glaucoma, bilateral; blindness, one eye, low vision other eye; abnormalities of gait and mobility; muscle wasting and atrophy; and lack of coordination. R11's BIMS dated 8/25/2024 documents in part that R11 was cognitively intact. R11's care plan documents in part that R11 has history of aggressive behavior towards others. R11 has displayed physical aggression toward staff and peers (initiated 11/21/2023). It does not contain a focus for potential/risk for abuse. During a telephone interview with V21 (Former LPN) on 10/23/2024 at 10:22 AM, V21 stated when V21 arrived for work that morning, R1 was already irate and fighting another resident at first. V21 saw R1 and R11 tussling back and forth over a cane. V21 stated R11 struck R1 twice in the face with a closed fist. V21 stated facility called a code to have additional staff assist with the incident. R11 went back to the bedroom and R1 went into the Parlor. V21 stated leaving the facility afterwards and when V21 returned, staff informed V21 that R1 hit R2 across the face. V21's progress note for R2 dated 9/27/2024 9:30 AM documents in part: Upon arrival nurse was told by the nurse that resident was struck in the face by (R1) peer. The resident noted with facial redness and slight swelling to the left eye. No cuts or scrapes noted. Asked resident was (R2) in pain, resident pointed to [R2's] nose. Resident face was red, and the nose is slightly swollen. Patient was given Tylenol for the pain, and ice pack for the swelling. During a telephone interview with V22 on 10/23/2024 at 1:03 PM, V22 (LPN) stated seeing V21 walk out of the facility. When V22 made it to the front desk, V22 heard staff say, 'Hey they are trying to fight.' V22 went to the first-floor nurses' station where staff informed V22 that R1 got into two altercations. V22 stated separating R1 and R1 went into the Parlor by self. Staff later informed V22 that R1 punched another resident in the face (R2). V22 did not witness it but was told by staff because they saw it through the Parlor's window. V22 stated a Certified Nurse Aide (CNA) was looking at the Parlor and said 'hey [R1] just hit [R2].' Staff went to the Parlor and separated the residents. V22 stated R2 was crying and saying that R1 had hit R2 in the eye. R1 was cursing a lot and stated R1 got hit with the cane and that R1's finger was hurting. When V22 interviewed R2, R2 repeatedly stated getting hit in the eye. V22 contacted the provider and received orders for an x-ray of R1's face, which showed no fractures. V22 stated I do believe that [R1] hit [R2]. V22 stated ever since R1 returned from the hospital, R1 has been aggressive and purposely getting into it with other residents. V22's (Nurse) progress note for R1 dated 9/27/2024 8:14 AM documents in part: Resident pacing back fourth throughout unit attempting to go in other peers' room. Resident shouting and pointing finger in staff face. Resident unable to redirect [Social Service] call and administrator [psychiatric service company] made aware PRN (as needed) offer but decline. V22's following progress note (time stamp 8:34 AM) documents in part: Writer made aware by staff resident was walking pass and struck another resident in the face. On 10/22/2024 at 1:11 PM, V9 (CNA) described R1 as being loud and bossy during last days at the facility. R1 would get upset if staff and residents didn't do what R1 told them to do. V9 stated sometimes R1 would get confrontational and exchange words with other residents. V9 stated working during R1 and R2's incident. R1 and R2 were in the Parlor room. V9 stated R1 was already loud and then V9 heard R2 yell '(pronoun/R1) hit me.' When V9 turned to look, R1 was bent over in front of R2 picking something off the floor and R2 was screaming. V9 stated facility assigned V9 to watch the Parlor room but V9 went out to get coffee and did not see the incident. When V9 returned and asked R2 what happened, R2 stated '[pronoun/R1] hit me.' V9's typed and signed statement dated 9/27/2024 documents in part that V9 was at the nurses' station and did not observe the incident. State Report documents in part a reportable incident on 9/27/2024 at 9:00 AM involving R1 and R2 for an alleged peer-to-peer altercation. Under Analysis and Conclusion, it documents in part When [R1] was asked what happened, all [R1] would say is 'I got [pronoun].' [R1] would not elaborate. [R2] was rubbing [R2's] right eye and cursing, not able to be redirected to the questions at hand. R2's admission Record, Order Summary Report, and care plan documents in part diagnoses including but not limited to bipolar disorder; difficulty walking; hemiplegia and hemiparesis affecting the left non-dominant side; muscle weakness; traumatic brain injury; muscle wasting and atrophy; weakness; lack of coordination; and disorder of bone density and structure. R2's BIMS dated 3/17/2024 documents in part that R2 has severe cognitive impairment. R2's care plan documents in part that R2 may be at risk for potential abuse related to physical and/or communication challenge as evidenced by unable to propel wheelchair safely, severely limited range of motion and severe frailty/weakness (initiated 6/06/2023). Goal was for R2 to be free from harm through the next review. Additional focus documents in part that R2 may be at risk for potential abuse related to mental/emotional challenges (initiated 6/06/2023). Goal was for R2 to be free from harm through the next review. Intervention included to assure R2 that they are in a safe and secure environment with caring professionals (initiated 6/06/2023). R2's care plan also documents in part that R2 demonstrates behavioral distress related to ineffective coping mechanisms; poor verbal skills and inability to express self in a more appropriate language; poor self-esteem; feelings of inadequacy; and feeling powerless (initiated 6/06/2023). On 10/23/2024 at 11:00 AM, surveyor interviewed V3 (Assistant Director of Nursing) who was in charge during R1's altercations between R2 and R11 per V2 (Director of Nursing) and V21 (Former Nurse). V3 stated [V3] was not involved in the incidents and found out about it during morning meeting. V3 instructed survey team to refer questions to the morning staff and to V1 (Administrator). On 10/23/2024 at 1:52 PM, V2, stated the facility tries to ensure that the environment and residents are safe and free from abuse. If staff can identify early on and be proactive, the facility can get appropriate parties involved to prevent any incident from occurring. If a resident is irate and aggressive, the facility must make sure there is no immediate threat or anything to cause to escalate the situation. Staff must make sure the resident is free from other residents and there is no potential for harm to self and others. Facility will try to give the resident an opportunity for them to voice any concerns and work through it. V2 stated during R1 and R12's incident, after the staff separated the two residents, one staff should have stayed with R1 and another staff with R12. V2 stated staff should have directed R1 to another location such as to the bedroom or the office. V2 stated after R1 and R11's incident, staff should have put R1 on one-to-one monitoring. V2 stated facility has social services or psychiatric services aide to monitor one-to-one while the nurses handle the clinical portion. V2 stated if a resident is experiencing behaviors, then the staff must try the least invasive interventions first. If that doesn't work, then staff must notify the provider to get orders either for an as needed anti-psychotic medication or hospital evaluation. If the resident declines the medication, then staff are to follow-up with the ordering provider to retrieve further instruction. On 10/23/2024 at 2:40 PM, V1 (Administrator) stated staff should have informed V1 regarding R1 and R11's incident and documented it. Staff should have de-escalated the situation and kept R1 under close supervision and monitoring. They should have had the nurse evaluate and the nurse should have documented what they done. V1 stated if a resident is irate, staff needs to try to speak with the resident to try to get them to focus on the issue at hand. Staff need to call social service and nursing to speak with the resident to get clinical perspective. If needed, nursing will then call psychiatrist or primary provider to get further instructions. Facility's Policy & Procedure Supervision Policy (01/24) documents in part: additional supervision may be required in order to meet the specialized needs of residents. Additional supervision may be but not limited to 1:1 supervision, 15-minute checks, 30 minute and so forth. Purpose: to ensure resident safety. Responsibility: All staff. Facility's Abuse Prevention Program Facility Policy and Procedure (1/04/2018) documents in part: Abuse is the defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse and mental abuse including abuse facilitated or enabled through the use of technology. This facility desires to prevent abuse, neglect, exploitation, mistreatment and misappropriation of resident property by establishing a resident sensitive and resident secure environment. As part of the resident social history evaluation and MDS [Minimum Data Set] assessments, staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment or misappropriation of resident property or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals and approaches, which would reduce the chances of abuse, neglect, exploitation, mistreatment or misappropriation of resident property for these residents. Supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling or impersonal care will be corrected as they occur.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon observation, interview, and record review the facility failed to follow the abuse prevention policy, failed to implement interventions, failed to acknowledge (R4's) behaviors, failed to immediately remove (R4) from resident contact to ensure safety, and failed to ensure that one of four residents (R5) reviewed for abuse remained free from abuse. On (11/25/23) R5 sustained blunt head trauma during physical altercation with (R4) resulting in left frontal scalp contusion/hematoma and age indeterminate mildly displaced right nasal bone fracture. R5 also reported enduring chronic dizziness and headaches subsequent the altercation. Findings include: R4 is [AGE] years old with diagnoses which include bipolar disorder and paranoid schizophrenia. R4 resides on 1st floor. R4's (12/20/23) BIMS (Brief Interview for Mental Status) determined a score of 12 (moderate impairment). Inattention and disorganized thinking present, fluctuates. R4's care plan includes (6/14/23) resident may be at risk for potential abuse related to behavior problem as evidenced by history of verbally threatening/obnoxious behaviors, offensive antisocial habits and wandering. Intervention: monitor resident behaviors. (6/27/24) Resident has a diagnosis of schizoaffective disorder, bipolar disorder and is at risk for changes in mood, energy, and depression. Intervention: watch for behavior changes such as talking very fast, racing thoughts, easily distracted, overly restless, being impulsive. Notify physician if these changes are seen. R4's progress notes include the following behaviors (6/19/23) resident presented with physical and verbal aggression toward staff and peers stating that he was going to Kill all of the black people. (10/20/23) Resident began threatening nurse saying, I will f*** you up, come on, right here, right now. Resident threw his fist up in the position to fight. (11/25/23) Resident was standing in front of the nurse's station and another resident asked him to stay out of his room. Resident turned and looked at this person and put his face close to this person and this person reacted by putting his hand to resident's upper chest area, that's when resident hit this person with full strength (twice) to the face, knocking this person (who is elderly) to the floor. (2/10/24) Resident is verbally aggressive, calling writer profane words. Resident is delusional, thinking writer said she was going to shoot him. Writer did not say anything to him. Resident has been refusing his medications and his Haldol decanoate this month and is observed to be growing increasingly aggressive and delusional. The (11/25/23) initial state report includes incident time: 12:45am, (R4) was allegedly physically aggressive towards (R5). The (11/25/23) final state report states (R4) befriended a roommate of (R5). (R4) went into (R5's) room later in the evening on 11/24/23. (R5) came to the nursing station a little after midnight to talk to the nurse. As (R5) was talking to the nurse, (R4) came over to the nurse's station. (R5) can be hard to understand as he speaks with a thick accent. (R4) came over to (R5) and leaned in, towards (R5) as if to hear and understand what (R5) was saying. It was in that moment that (R5) pushed (R4) back, in a manner to state you are too close. As a reflex, (R4) hit (R5) and (R5) lost his balance and fell to the floor. This was an isolated event for (R4). (R4) has been with us since June 2023 and has never shown aggression towards residents or staff. The staff have never seen this behavior from (R4) nor was it ever anticipated [R4's progress notes affirm history of verbal and physical aggression towards staff and residents]. Both residents feel safe in the building [R5's subsequent interview affirms otherwise]. On 2/27/24 at 12:01pm, R4 was observed pacing (briskly) in the hallway. Surveyor(s) attempted to speak to R4, he (R4) proceeded to walk by surveyor(s), entered the room and closed the door immediately. Surveyor subsequently knocked on R4's door, R4 did not open the door and/or verbally respond. As surveyor(s) were standing in the hallway (approximately 1 minute later) R4 exited the room, walked (briskly) towards the nurse's station then wandered aimlessly about the unit. [Staff were present however failed to acknowledge R4's behavior at this time]. R5 is [AGE] years old with diagnoses which include Alzheimer's disease and bipolar disorder. R5 resides on 1st floor. R5's care plan includes (7/10/23) Resident has hearing deficit. (7/18/23) Resident presents with moderate to extreme anxiety related to persistent worry that something terrible is about to happen and verbal expressions of distress. Intervention: evaluate the potential causal factors contributing to feelings of anxiety. Work with the resident to eliminate causes whenever possible. R5's Nurse Practitioner progress notes state (11/25/23) seen in room today following a short ER (Emergency Room) visit from blunt head trauma. Patient was hurt by another resident. (12/4/23) Still complaint of residual pain on the left jaw area. X-ray were negative for fracture however R5's (11/25/23) CT (Computed Tomography) scan affirms otherwise. R5's (11/25/23) history & physical states patient here due to being hit in face by resident at the facility. Computerized Tomography (CT) Head: left frontal scalp contusion. CT Maxilofacial: small soft tissue contusion/hematoma anterior to the mandible extending to the left facial soft tissues. There is an age indeterminate mildly displaced right nasal bone fracture. [R5's 10/29/23 facial x-ray states no fractures were identified therefore considering reasonable person concept the fracture likely occurred during 11/25/23 altercation]. R5's (1/13/24) BIMS determined a score of 13 (cognition intact). On 2/27/24 at 12:05pm, surveyor inquired about the (11/25/24) altercation involving R4. R5 stated I got hit and fell down, he (R4) broke my nose. He (R4) came from behind and hit my face. Surveyor inquired if R5 has encountered any problems since the (11/25/24) incident. R5 responded Because of this guy (R4) I'm still not recovery, I have headaches, dizziness I need to see the doctor, it's been more than 3 weeks (months), it's an emergency. Surveyor inquired if R5 feels safe residing in the facility R5 replied It's not safe, I'm scared for my life right now. The guy (R4) who hit me came up behind me (R5), I'm 76 and he's about [AGE] years old [R4 is 32]. Three days ago, he walked in front of me, I can't say nothing cause he gonna hit me. I need to leave from here! On 2/27/24 at 12:12pm, surveyor inquired about the regulatory requirements for abuse V1 (Administrator) stated in part We immediately separate the alleged victim and the alleged aggressor. If it's residents, we involve psych (Psychiatric) and medical doctors immediately. The victim should be assessed by nursing and medical staff and psych to address their needs. The aggressor should be separated from the individual. Surveyor inquired about the current location of R4 and R5 [both reside on 1st floor - in the same hallway]. V1 responded (R5) is in room (room #) at the end of the hall and (R4) is at the other end of the hall. Surveyor inquired why R4 and R5 reside on the same unit if the aggressor (R4) should be separated (from R5) V1 replied Because at the time that this happened after speaking with them and watching the video it seemed as if (R5) instigated it. (R4) acted to be scared and protect himself. It was my belief that there was some misunderstanding between them. There's never been issues in the past with them. Once they calmed down it wasn't like he (R4) came out of nowhere and punched the guy (R5). It was (R5) getting into (R4) face and (R4) trying to get away from him (R5) [documentation affirms otherwise]. Surveyor inquired about R4's behaviors V1 stated He's (R4) much better since we got him (R4), he was erratic in his behavior. According to his (R4) history he's a nursing home hopper. He's (R4) pretty stable right now. Surveyor relayed concerns regarding R4's current behavior (response towards surveyors, rapidly wandering aimlessly about the unit), lack of staff acknowledgement and/or redirection for R4's behaviors V1 responded I'm gonna have nursing call psych right now if he's erratic and not acknowledging that people are speaking to him, that's not his baseline. On 2/27/24 at 12:25pm, R4 yelled down the hallway (while standing at his doorway) at surveyor(s) stating Hey! If you're wanting to talk to me about my apartment, I'll talk to you. If no, skip it then! however staff failed to acknowledge that R4 was yelling. On 3/4/24 at 11:15am, surveyor inquired about the (11/25/23) incident V9 (RN/Registered Nurse) stated I was the 4th floor nurse, and the 1st floor nurse (V8/RN) asked me to come down to assist him (V8). When I (V9) came down he (R5) was rubbing the right side of his face like around the jaw. He (R5) complained of pain, he just said it hurt bad. Surveyor inquired about R4's behaviors V9 responded He's like all over the place, hard to redirect and non-compliant. Surveyor inquired about R5's behaviors V9 replied He's (R5) not aggressive at all. On 3/4/24 at 12:31pm, surveyor inquired about potential harm to a resident that gets hit in the face (twice) and falls to the ground V10 (Medical Director) stated A fracture could happen if someone is hit in the face, a nasal bone fracture, bruising those are the type of things that could happen. Surveyor inquired if R5's x-ray affirmed no nasal fracture a month prior to 11/25/23 incident would you suspect the nasal fracture occurred during the 11/25/23 incident? V10 responded Its possible it could have happened from that. R4's (2/27/24) progress notes state 1:34pm, (after surveyor concerns were reported) resident is intimidating other resident and also provoking other resident in behaviors. Resident cannot be redirected at this time. Order received for resident to be sent out involuntary for psych evaluation. The abuse prevention policy (reviewed 1/4/18) includes IV.) Establishing a Resident Sensitive Environment: this facility desires to prevent abuse, neglect, exploitation, mistreatment, and misappropriation of resident property by establishing a resident sensitive and secure environment. This will be accomplished by a comprehensive quality management approach involving the following: Resident Assessment: staff will identify residents with increased vulnerability for abuse, neglect, exploitation, mistreatment, or misappropriation of resident property or who have needs and behaviors that might lead to conflict. Through the care planning process, staff will identify any problems, goals, and approaches, which would reduce the chances of abuse. Staff Supervision: supervisors will monitor the ability of the staff to meet the needs of residents, including that assigned staff have knowledge of individual resident care needs. Situations such as inappropriate language, insensitive handling or impersonal care will be corrected as they occur. VI.) Protection of Residents: the facility will take steps to prevent potential abuse while the investigation is underway. Residents who allegedly abused another resident will be removed from contact with other residents during the course of the investigation. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to supervise a resident and provide individualized fall prevention interventions, for a cognitively impaired resident, who had four repeated falls. This failure affected one resident (R1) of three residents, reviewed for falls. As a result, R1 was sent to the hospital three times within seven weeks. The last fall incident of R1 resulted in an open fracture of the nasal bone. Findings include: R1's Hospital Records written by V20 (emergency room Physician), dated 12/13/23 at 11:44am documented on page 83 Patient was seen one day ago for concerns of a mechanical fall and had findings for an open fracture of the nasal bones, and was discharged with Augmentin for 7 days. On 1/10/24 at 11:02am, R1 was observed in the dining room sitting in a wheelchair that was not locked, with oxygen nasal cannula prongs on the head, and moving the wheelchair slightly forward and backward. V6 (RN/Registered Nurse/Restorative Nurse) was asked about R1's portable oxygen tank and V6 came to the dining room and put a new portable oxygen tank. At this time, V6 also locked R1's wheelchair, stating that the wheelchair should be locked. On 1/11/24, the following were observed on the fourth floor: At 9:53am, R1 was observed in the wheelchair in the dining room with eight other residents; no staff was present in the dining room to supervise all 9 residents. The surveyor stayed in the dining room for about 10 minutes and then went to the nursing station and asked V15 (RN/Registered Nurse) about who was supposed to be watching the residents in the dining room. V15 stated No one is watching them right now; I will have to call down to see what time Activities will get here. V15 made a phone call and then stated, Someone will come soon. Inquired from V15 what time the activities staff is supposed to get here to watch the residents. V15 stated Activity gets here sometimes at 10am, depending on who. At 10:02am, V6 (RN) also was at the nursing station, and the surveyor asked V6 about who was supposed to watch the residents in the dining room; V6 stated I'm not working up here today, I don't know when someone will be available, you can talk to the nurses working here. At 10:22am, V16 (Psychosocial Director) came into the dining room and stated, I will stay here and watch the residents. At 10:19am, V7 (CNA/Certified Nurse Assistant) who is the assigned CNA for R1, was asked about how many of her assigned residents still needed to be cleaned; V7 stated I have a total of five residents to get up; So far, I have done three residents. I did not get (R1) up, the night shift usually gets him (R1) up. At 10:25am, the surveyor left the dining room with V16 watching the residents (including R1) in the dining room, no Activity Staff arrived on the floor yet. On 1/10/24 at 12:40PM, V2(Director of Nursing) presented the facility's incident reports of R1's fall events dated as follows: 10/21/23 - R1 had an unobserved fall in the room with no injury. 10/26/23 - R1 observed on the floor in the dining room; R1 was sent to the hospital by ambulance. 12/11/23 - R1 fell and hit his head in the dining room and was sent to the hospital by ambulance. 12/12/23 - R1 fell and hit his head in the dining room and was sent to the hospital by ambulance. On 1/10/24 at 12:30pm, V4 (Fall Nurse/LPN/Licensed Practical Nurse) was interviewed about R1's fall prevention interventions. V4 stated that R1 is a high risk for falls because he thinks he can get up by himself and he is weak and has Dementia. V4 added, We have interventions in place, to make sure he stays in a supervised area when awake, and to monitor him. R1's records reviewed include but are not limited to the following: Face sheet shows that admission diagnoses include but are not limited to Weakness, Multiple Sclerosis, Reduced Mobility, Dementia, And Disorganized Schizophrenia. Fall Risk Review forms dated 12/12/23 and 12/29/23 both show that R1 is at risk for falls. MDS (Minimum Data Set) section GG shows that R1 requires moderate assistance for functional ability activities and transfers. MDS section C dated 10/1/23 shows BIMS (Basic Interview for Mental Status) score of 4 out of 15(severe cognitive impairment). Care plan Intervention dated 12/4/23 states: Staff will encourage participation in activities when up in chair in dining room. Care plan Intervention dated 12/12/23 states: Observe frequently and place in supervised area when out of bed. Care plan Intervention dated 12/4/23 states: Gather information on past falls and attempt to determine the root cause of the fall(s). Anticipate and intervene to prevent recurrence. R1's progress notes dated as follows documents: On 10/21/23 at 10:41am, V13 (LPN/Licensed Practical Nurse) wrote in part: Writer called by CNA to resident's room, resident noted on floor next to wheelchair. Resident denied hitting head and stated he slipped. Resident assessed head to toe no injuries noted, resident denies any pain/discomfort. On 10/26/23 at 12:11pm, V13 (LPN) documented in part: Writer's attention called to the dining parlor, resident observed on the floor lying on back. Resident stated he was going to the other spot. Head to toe assessment done, no noted injuries/bruising at the time, able to perform from upper and lower extremities at baseline. NP (Nurse Practitioner) in facility, order given to send to the Hospital. On 12/11/23 at 12:14pm, V13 documented in part: Writer's attention was called to the dining room, resident lying flat on back with nonskid footwear on. Resident stated I was getting up. Head to toe assessment done, resident hit his head but denies any pain, no swelling or bruising noted at this time. (Ambulance contacted for transportation to the hospital). On 12/12/23 at 5:47pm, V14 (LPN) wrote: Writer was called to dining room. Upon entering, writer observed resident on floor lying on his side next to his wheelchair. Staff assisted with transfer. Tolerated transfer well. Resident noted A&Ox1 (Alert and Oriented times 1). Head to toe assessment performed. Writer noted light bleeding to nose, top lip, and mouth. Vital signs obtained. Team Health phoned and spoke with NP with orders to transfer resident to the Hospital for further evaluation. On 12/13/23 at 1:36am, V21 (RN) documented in part: Resident returned to facility from ER (Emergency Room) with a diagnosis of Open Fracture of Nasal Bone. On 1/11/24 at 10:30am, V13 (LPN) was interviewed regarding how R1's falls happened during three out of four incidents that V13 was R1's nurse. V13 stated that she (V13) was R1's nurse when the falls dated 10/21/23, 10/26/23, and 12/11/23 happened. V13 explained that activity staff was present in the parlor (dining room) when R1 fell on [DATE], but the staff could not catch R1 in time to prevent the fall, and it was lunch time. V13 stated I cannot remember the staff, but I remember someone was there with the residents in the dining room when it happened. For the fall of 12/11/23, I don't remember if staff was present during the fall of 12/11/23, because staff were all passing trays at that time. On 1/11/24 at 10:34am, V17 (Activity Director) was interviewed and stated It is the responsibility of nursing to watch the residents in the dining room. Activity staff usually gets to the day room at 10:00 AM, but this staff has a day-off today. On 1/11/24 at 12:01pm, V2 (Director of Nursing) was asked why there was no staff watching residents in the dining room on the 4th floor (a total of nine residents sitting there without supervision). V2 stated Formal activity programs starts at 10am, but activity staff is supposed to be on the units before then, during breakfast and after breakfast. It's not okay to have residents in the dining room without any staff watching them. It's for safety reasons; there should be someone in there. On 1/11/23 at 1:52pm, V19 (NP/Nurse Practitioner) was interviewed regarding R1's frequent falls and why the nursing staff should follow the care plan for fall prevention, especially for a resident like R1 whose fourth fall resulted in a fracture. V19 stated the reason for a fall care plan is to help reduce the incidents of falls for residents, and the interventions stated in the care plan should be followed. V19 added that residents at risk for falls should be supervised more closely by staff. Regarding R1's last fall incident that involved hospitalization and a nasal fracture, V19 stated that the ENT (Ear, Nose, and Throat) doctor saw R1 in the hospital and there is no need for surgery on R1's nose. V19 added that nasal fractures usually heal within 6-8 weeks. On 1/16/2024, at 9:50am, R1 was observed in a different room closer to the nursing station. Inquired from V15(RN) why R1's room was changed; V15 stated After you left that day, we moved him (R1) to room [ROOM NUMBER], closer to the nursing station, so we can keep a closer eye on him. On 1/16/24 at 10:32am, V4 (Fall Nurse) stated I spoke to the nurses on the fourth floor about the fall prevention interventions for (R1) and that was when they decided to move him closer to the nursing station because his room was all the way at the back. Facility's Fall Prevention Program dated 2/28/14 states: It is the policy of this facility to have a fall prevention program to ensure the safety of all residents in the facility when possible. The program will include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. #3 states: Safety interventions will be implemented for each resident identified at risk using a standard protocol. Facility's document CNA Job Description states in part: Ensure that residents who are unable to call for help are checked frequently. Check each resident routinely to ensure that his/her personal needs are being met in accordance with his/her wishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to provide adequate supervision for a dementia resident (R1) who is a fall risk. This failure resulted in R1 falling in the hallway, sustaining a laceration to his forehead, requiring emergency department evaluation and receiving eight sutures. Findings Include, R1's clinical record documents in part: R1 is a [AGE] year-old with the medical diagnosis of dementia, vascular dementia, muscle weakness, history of falling, cognitive communication deficit, unsteadiness on feet, metabolic encephalopathy, dysphagia, weakness, and reduced mobility. Minimum data set [MDS] Brief Interview Mental Status Score indicates R1 is cognitively impaired. R1's Care Plan documented in part five falls. Two falls 5/24/23 and 9/20/23 resulted in injury. -R1 is at risk for falls due to co-morbidities: Fall 10/17/23: Resident stated, I was getting money out the drawer for a soda, no injuries. Intervention: Fall 10/17/23: When up out of bed, resident will be monitored in supervised common areas. Fall 09/20/23 observed lying face down in hallway, facial laceration Rt Forehead Intervention: Fall 09/20/23: wear safety helmet at all times Fall 06/19/23 observed sitting on floor near bathroom door, no injuries. S/P Fall res observed sitting on bathroom floor, no injuries. Intervention: Refer to Therapy for screen and treat Fall of 05/24/23 resident stated, I was going to restroom and lost my balance, laceration to Lt hand 4th digit. Intervention: Ensure proper footwear 5/24/2023 06:57-Health Status/Progress Note Note Text: Resident return from hospital. R1's left hand 4th digit 3 sutures intact no bleeding noted to site. Fall of 01/02/23 res stated, I fell trying to go to the bathroom, no injuries. S/P Fall 01/14/23 observed sitting on buttocks in front of bed (laceration to forehead Intervention: Offered and placed Urinal at bedside. R1's Progress notes documented in part: On 9/20/2023 11:00- Nursing Progress Note Note Text: Writer heard loud noise in hallway noted R1 lying face down. Noted swelling of nose open area to forehead moderate amount of blood noted ice pack applied with pressure dressing. On 9/20/2023 23:34-Health Status/Progress Note Note Text: Received a call from hospital stated that all CT scans to cervical spine, facial bones, and head/brain read negative. On 9/20/2023 22:25-Health Status/Progress Note Note Text: R1 returned to the facility from Hospital alert and oriented x1. R1 Returned with approximately 6-7 sutures noted to laceration on face. On 11/15/23 at 11:02 AM, surveyor and V9 [Licensed Practical Nurse] observed R1 was resting in bed without his soft helmet in place. V9 stated, R1 always needs his soft helmet on, even when in bed, to prevent a head injury incase R1 falls. I last saw R1 around 9:30 AM. [Surveyor observed V9 look for R1's helmet for several minutes. V9 located R1's helmet underneath R1's bed, near the foot of the bed.] On 11/15/23 at 12:42 PM, V17 [Certified Nurse Assistant] stated, I been working with R1 for months. R1 is alert only to himself. R1 need complete assistance with ADL care. R1 needs to be spoon fed one to one. R1 tries to stand up out his bed or wheelchair often, R1 constantly needs supervision. R1 is supposed to always wear his soft helmet even while in bed. I placed on R1's helmet this morning, but I'm not sure why it was off around 11:00 AM. On 11/15/23 at 11:53 AM, V9 stated, I was R1's nurse on 9/20/23, the day R1 feel and sustained a laceration to his forehead. I was at the nursing station and heard a loud noise. I observed R1 laying in the hallway, bleeding from his forehead. I applied a pressure dressing and called 911. R1 received several sutures and returned back to the facility. R1 is alert to himself only and needs constant supervision because he is very impulsive. R1 will stand up and start to walk and needs verbal queuing and redirection. On 11/16/23 at 11:44 AM, V2 [Director of Nursing] stated, R1 is confused and impulsive. R1 uses a wheelchair to ambulate the unit. R1 needs supervision, frequent queuing, extensive assist with all areas of care, and one to one feeding. On 9/20/23, R1 was observed on the floor in the hallway. The nurse controlled R1's head bleeding. R1 returned with several sutures to forehead. Intervention was to wear the soft helmet at all times. R1 should wear the helmet at all times to prevent further head injuries from occurring. Policy documents in part: Fall Prevention and Management Policy - Facility is committed to providing a safe and secure environment for residents, staff, and visitors. -. Individualized fall prevention care plans will be developed based on the resident's risk assessment. - The fall prevention care plan will be communicated to all staff members involved in the resident's care - The environment will be routinely assessed for potential hazards, and necessary modifications will be made promptly. - All staff members will receive regular training on fall prevention strategies, resident-specific care plans, and the proper use of assistive devices - Ongoing Monitoring: a. Staff will continually monitor residents for signs of increased fall risk and report changes promptly. - Communication among staff members, including handoffs during shifts, will emphasize fall prevention strategies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow its policy and procedures for Fall Prevention for one (R2) of three residents reviewed for falls. This failure resulted in R2 sustaining a fall resulting in fractures to the Humerus and finger of R2's left hand. Findings include: On 09/21/2023 at 2:16pm, R2 was observed sitting on her wheelchair smoking on the outside patio. R2 was observed wearing a sling on her left hand and left middle finger. R2 said she fell last Wednesday (09/13/2023), while standing up, after putting on the call light and no staff come to her assistance. R2 said her pants went down, and R8, who was her room mate come to assist her pull her pants up. R2 said as she was trying to pull her pants up, she fell. R2 said she was using her cane to support herself, but she lost her balance and fell. R2 said after she fell and shouted for help, and two staff members came to help her, then she was taken to the hospital. R2 is a [AGE] year old individual admitted to the facility on [DATE]. R2's diagnosis includes but not limited to: hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, other reduced mobility, muscle wasting and atrophy, not elsewhere classified, multiple sites. R2's BIMS (Brief Interview for Mental Status) dated 8/2/2023 documents R2 has a BIMS score of 13/15, indicating R2 has intact cognition. R2's MDS(Minimum Data Set) dated 8/4/2023 documents R2 needs supervision with Bed mobility, transfer, walk in room, walk in corridor, Locomotion on/off unit, and need limited assistance with dressing, and further documents that R2 needs supervision or touching assistance with eating, Oral hygiene, Toileting hygiene: Shower/bathe self: Upper body dressing, Putting on/taking off footwear, Roll left and right, Sit to lying, Lying to sitting on side of bed, Sit to stand, Chair/bed-to-chair transfer, Toilet transfer, Walk 10 feet, Walk 50 feet with two turns. On 09/21/2023 at 2:22pm, R8 was observed on the outside patio sitting on her wheelchair smoking a cigarette. R8 said when R2 fell, she, R8 was tying to help R2 pull her pants up after they fell when R2 got up from her bed. R8 said R2 said she had put the call light on and no one came to help R2. R8 said R2 fell next to the bed. R8's BIMS dated 08/ 14/ 2023, document R8 has a BIMS score of 13/15, indicating R8 has intact cognation. On 09/21/2023 at 2:34pm, R2 was observed in bed being assisted with repositioning by V30(R2's family member). R2's bed was observed to be moving from side to side when V30 was assisting R2 to reposition. Surveyor called V13(registered Nurse) and asked her to observe R2's bed. V13 said the bed was not not stable and was moving around, and may not be locked. V13 said R2's type of bed was new, and she did not know where the wheels of the bed are locked at. V13 looked for the bed lock and found it by the bed wheels, then V13 locked the bed. V13 said the bed is supposed to be locked for safety, so that the bed does not move when R2 getsin and out of bed, to prevent R2 from falling and hurting herself. V13 said it is every staff's responsibility to make sure residents beds are in locked potion to prevent falls. On 09/22/2023 at 10:33am, V4(Falls Nurse-LPN) said when a resident first comes to the facility, the nurses perform the fall risk assessment, then the falls nurse/restorative nurse(V4) does the restorative assessment note and restorative program tracker, which tells what the resident is able to perform for ADLs, and assists in putting the resident in the right program for Activities of Daily Living(ADLs), and helps the facility know what therapy or assistant the resident will need with ADLs. The CNAs then carry out care based on the assessment. V4 said R2's Functional Abilities and Goals, dated [DATE], documents R2 needs Supervision or touching assistance with ADLs, where the helper provides verbal cues and/or touching/steadying and/or contact, guarding assistance as R2 completes activity. V4 further stated that assistance may be provided throughout the activity or intermittently. V4 further said R2's bed should be locked and in lowest position at all time, as a safety precaution to prevent falls. V4 said all staff know all residents fall precautions should be on beds that are locked and in lowest position when the resident is in bed. V4 said R2 uses a quad cane because her left side hand is impaired related to a stroke, and R2 wears a splint on the left arm, and was wearing it even before the fall, and she was using a quad cane for support. V4 said R2 is ambulatory but may require additional assist and support from staff. On 09/22/2023 at 11:50am, V2(Assistant Director of Nursing-ADON) said R2 sustained a fracture on the left shoulder and finger after R2 fall on 9/13/2023. V2 said the call light system has not been working or over a week now, and maintenance has been working on it and it is still not working. V2 said if the call light system is not working, residents cannot make their needs known in a timely manner. On 09/26/2023 at 1:32pm, V14(Director of Nursing- DON) said she was coming down the hallway when she heard R2 say she needed help. V14 said she went into R2's room and and saw R2 sitting on the floor on her buttocks, and V14 said she knew R2 had fallen, and had landed on her left side. V14 said she did Range of Motion (ROM) checks with R2 and noticed that R2 could only perform passive/limited range of motion exercises with the left hand. V14 said R2 was sent to the hospital for further evaluations, and facility was later notified that R2 had suffered fractures on her left shoulder and middle finger from the fall. Records from community hospital dated 09/13/2023-09/16/2023 document: -R2 was admitted to the community hospital because she suffered a fracture to her left humeral head and left finger due to a fall, and R2 was recommended to keep her hand in a splint -Facility incident report dated 09/13/2023 documents : R2 fell on [DATE] and suffered fractures to the Humerus and finger. Fall prevention policy, no date, documents: STANDARD FALL/SAFETY PRECAUTIONS FOR ALL RESIDENTS: -The bed locks will be checked to assure they are in locked position at all times. -Call lights are kept within reach and answered promptly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to follow its policy and procedures for Fall Prevention & Post Fall Assessment by a.) not providing individualized preventative fall risk measures, b.) not following fall risk care plan interventions prior to fall, c.)failed to complete new or updated fall risk assessment post fall, d.) failed to update care plan with any new fall interventions after fall incident for one (R3) out of three residents reviewed for falls. This failure resulted in R3 sustaining a fall resulting in a laceration requiring five sutures with risk for falls ongoing for lack of interventions. Findings include: R3 is a [AGE] year-old female, admitted to the facility 12/07/15 with diagnosis not limited to Dementia, Muscle Weakness, Reduced Mobility, Lack of Coordination, Muscle Wasting And Atrophy, Weakness, Arthritis, Peripheral Vascular Disease, Chronic Ulcer Of Other Part Of Unspecified Foot With Unspecified Severity, Osteomyelitis. R3's MDS (Minimum Data Set) dated 07/19/23 document R3's BIMS (Brief Interview of Mental Status) score of 14/15 indicating intact cognition. R3's Activities of Daily Living (ADLs) Assistance documents that R3 requires supervision with bed mobility, limited assistance with one-person physical assist with transfer and extensive assistance with one-person physical assist with toilet use. R3's MDS (Minimum Data Set) dated 07/19/23 documents that walking did not occur. Activity with balance during transitions and walking, moving on and off toilet, surface to surface transfer between bed and chair or wheelchair is not steady, and R3 is only able to stabilize with staff assistance. R3's care plan dated 06/25/23 documents in part R3 is at risk for falls related to co-morbidities with interventions including but not limited to staff will ensure resident has on appropriate footwear at all times (06/25/23), and to keep resident's immediate environment clutter free (06/25/23). On 09/13/23 at 1:16 PM, observed R3 lying in bed not in the lowest position, and R3's feet were bare. Did not observe any type of footwear nearby. R3's side table was close to R3's bed and covered in 6 cans of soda pop and papers. R3 stated that R3 does not know what caused the fall. R3 said, they got my program mixed up with the football players program and the weights from Weight Watchers. R3 then stated I was trying to use the bed pan. I went to stand up and didn't know I couldn't stand up. I was off balanced, and my legs twisted. R3 then stated that the football players injuries was messed up with my injuries and the fall was related to them wanting to weigh me. R3 then stated, I don't know what happened. On 09/13/23 at 1:20 PM, R17 (R3's Son) who is also a resident at the facility and is R3's roommate stated that R17 was lying in bed on 07/11/23 listening to music and R17 heard a loud thud when R3 fell on the floor. R3's progress notes dated 07/11/23, 2:45 AM and 4:25 AM by V11 (Registered Nurse) documents in part R3 was observed lying on her back near the bed while using the bed-pan in bed and sustained a moderate laceration on her forehead and R3 was transferred to the emergency room for CT scan of head and stitches related to fall. R3's hospital emergency room record dated 07/11/23, 3:05 AM documents in part R3 brought in with laceration to forehead after fall. (R3) states she was trying to go to the bathroom and fell hitting her forehead on floor. (R3) stated she stepped on her bed sheets causing her to slip and strike her head. (R3) has a 3 centimeter (cm) by 2 cm wound on her forehead. Radiology results of CT Head documents in part left forehead laceration with small amount of soft tissue gas and trace hematoma. R3 received five sutures in the emergency room and was discharged back to the facility. R3's progress note dated 07/12/23, 12:50 PM by V29 (Fall Nurse/Licensed Practical Nurse) documents in part R3 had a fall on 07/11/23 at 3:51 PM, observed lying on the floor on her back near the bed, requires limited assist x1 with transfers and care plan updated with interventions. R3's care plan dated 06/25/23 documents in part R3 is at risk for falls related to co-morbidities with the goal for R3 to have no falls with major injuries over next review period. All interventions in R3's fall risk care plan are dated 06/25/23 and include but not limited to staff will ensure resident has on appropriate footwear at all times, and to keep resident's immediate environment clutter free. There is no mention of low bed position in R3's fall risk care plan and R3's fall risk care plan has not been updated since 06/25/23. R3's Fall Risk assessment dated [DATE] documents R3's score at 13 indicating moderate fall risk. A new or updated Fall Risk Assessment was not completed after 07/11/23 fall. On 09/14/23 at 11:00 AM, V22 (R3's Nurse Practitioner) stated via phone interview that R3 has diagnoses that place her at risk for falls including lack of coordination, weakness, muscle wasting and atrophy. On 09/13/23 at 2:18 PM, V29 stated V29 is responsible for investigating falls and updating the fall care plan. V29 stated if a fall occurs the fall would be dated and documented in the resident's care plan and new interventions would be added to the fall care plan. V29 stated that new interventions would need to be added because something would need to change since the old interventions were not effective in preventing the resident from falling. V29 stated that these new interventions would be put in the resident's care plan immediately to prevent or combat another fall from happening. V29 stated that all care plan updates are done directly on the resident's electronic health record (EHR), no paper copies are kept. V29 stated that up until an actual fall occurs there are standard interventions that are in place for everyone who is at risk for a fall. V29 stated that once a fall occurs then this is when V29 would then adjust or add interventions to individualize the interventions in the care plan based on the root cause analysis of the fall. V29 stated, I don't change the standard interventions for fall risk care plan unless a resident has a fall. V29 stated that prior to R3's fall on 07/11/23 it was determined that R3 was at risk for a fall and therefore R3 had standardized fall risk care plan in place which included interventions such as having the call light within reach and the bed in the lowest position. V29 stated that all residents who are at risk for falling should have their bed in the lowest position for safety preventive measures, so if a fall does occur the resident will not be falling from a high place to a low position, there is less of a distance to fall. V29 stated that after R3 fell on [DATE] the intervention of using non-skid socks was added because the root cause analysis investigation determined that R3 had slipped on a sheet on the floor when R3 was using the bed pan in the middle of the night. Surveyor asked V29 to review R3's fall risk care plan and V29 acknowledged that R3's fall on 07/11/23 was not documented on R3's care plan, and interventions had not been updated since 06/25/23. V29 acknowledged that R3 did not have an intervention for R3's bed to be in the lowest position before or after the fall on 07/10/23. V29 stated having the bed in the lowest position when resident is in bed is not included in R3's care plan because it is a standard for all residents at risk for falls and that the staff knows R3's bed should be kept in the lowest position. V29 also acknowledged that care plan already had intervention that staff will ensure resident has on appropriate food wear at all times dated 06/25/23. On 09/13/23 at 3:12 PM, surveyor went to R3's room with V29 and V30 (Restorative Nurse) and observed R3 lying in bed in bare feet. V30 stated that R3's bed was in the lowest position. Surveyor asked V30 to check and V30 picked up the bed controller at the foot of the bed and was able to lower R3's bed further by at least 5-6 inches until R3's bed was in the lowest position. R3 did not protest or complain about the bed being in the lowest position. V30 stated R3's bed was not in the lowest bed position when we entered R3's room but R3's bed is now in the lowest position. V30 stated R3 does not like her bed to be in the lowest position and then stated to R3 you don't like the bed like this, right? On 09/13/23 at 3:18 PM, V31 (Licensed Practical Nurse) viewed R3's fall risk care plan and stated that V31 does not see that the bed being in the low bed position is included as an intervention or that R3's fall on 07/11/23 was documented in R3's fall risk care plan or that there were any changes made to R3's interventions relate to R3's fall. V31 stated V31 would like for R3's bed to be in the lowest bed position because she is a fall risk, and she spends all her time in the bed. V31 stated if the bed is in the lowest position R3 wouldn't have as much of a distance to fall if R3 did have a fall. V31 stated V31 cannot recall trying to lower R3's bed and R3 not letting V31 lower it. Facility policy and procedure titled, Fall Prevention Program undated, documents in part the policy is to assure the safety of all residents in the facility and to include measures which determine the individual needs of each resident by assessing the risk of falls and implementation of appropriate interventions to provide necessary supervision and assistive devices are utilized as necessary. A Fall Risk Assessment will be performed after any fall incident and care plan incorporates preventative measures and interventions are changed with each fall as appropriate. Facility policy and procedure titled, Fall Risk and Post Fall Assessment undated, documents in part the purpose it to improve quality of life for resident, conduct appropriate assessment prior to and after falls and procedure includes if fall prevention plan failed initiate an immediate new intervention, complete or update Fall Risk Assessment, revise resident care assignment according to fall risk type with new interventions, revise the care plan to include all new fall interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and review of records facility failed to protect resident right to be free from accidents, falls, hazards, and injury. And failed to follow safe resident policy to a resident with multiple falls, that needs 1-person extensive assistance but was left by nursing staff to be independent. Failures apply to 1 out of 3 residents (R4) for a total of 3 residents reviewed for accidents and hazards. These failures resulted to 1 resident (R4) sustaining right hip fracture and undergone surgery as a result of the fall. Findings include: R4 is [AGE] years old during review, with medical diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting right dominant side diagnosed on [DATE], seizure diagnosed on [DATE] and displaced intertrochanteric fracture of right femur diagnosed on [DATE] after the R4 had a fall on 04/22/2023. R4's cognition is impaired with brief interview of mental status score of 0 which indicates R4 is rarely or never understood. Incident Report initial and final was dated 04/22/2023. R4 was left in the toilet by himself. R4 transferred by himself and fell. Per Minimum Data Set (MDS) on functional status dated 04/13/2023, documents that R4 needs 1-person extensive assistance on bed mobility, transfers, and toileting. On 05/23/2023 at 04:32 PM, V11 (Certified Nursing Assistant) who was assigned to R4 during incident of fall on 04/22/2023 said, It was during dinner time, and we are busy. The nurse was passing medicine. And I was collecting trays, I was across the room of R4. When I looked up, R4 was on the floor. I cannot remember what happened if R4 was on the toilet or on his wheelchair. The first shift should have not transferred R4 on his chair. Yes, now I remember, I placed R4 on the toilet. But R4 is independent, R4 can transfer on his own, R4 is pretty much independent when he is on the toilet. The only thing R4 needs assistance or help was when I put him on the bed. I wiped him and helped him on the bed. Besides that, R4 is mostly independent. R4 ' s progress notes related to fall are as follows: - V3's (Registered Nurse) notes dated 04/22/2023 documents: R4 was observed on the floor of his bathroom. R4 fell in bathroom while transferring on or off the toilet. Order for right hip and leg X-Ray with neurological checks. During this fall R4 sustained right hip fracture and undergone ORIF (Open Reduction Internal Fixation) surgery. - V25's (Licensed Practical Nurse) notes dated 04/07/2023 documents: R4 had a fall on 04/06/2023 at 07:30 PM. R4 observed on bathroom floor fell attempting to transfer from toilet to chair. R4 requires supervision with transfers. R4 is alert and oriented times 1-3. - V3's notes dated 04/06/2023 documents: R4 was trying to transfer from the toilet to the wheelchair located in his room and fell while transferring. - V26's (Registered Nurse) notes dated 03/21/2023 documents: R4 ' s roommate notified her (V24) that R4 has fallen in the bathroom. R4 was on the floor in front of the toilet. - V27's (Licensed Practical Nurse) notes dated 03/16/2023 documents: R4 had a fall was observed laying on the floor on his right side of the bed facing his wheelchair. V3 (Registered Nurse) was assigned to R4 during the incident per V2 (Director of Nursing) and was called on the phone multiple times but did not answer. On 05/23/2023 at 02:04 PM V2 provided complete plan of care for R4 that does not include dates. After further review of R4's care plan, it was found out that V9 made multiple additions and modifications of R4's care plan although R4 was already discharged on 05/17/2023. On 05/24/2023 at 10:46 AM. V9 (Minimum Data Set Coordinator) said, Yes, I do some of the care plan for the residents. Care plans are reviewed when things come up as needed and also quarterly as scheduled. When a problem was identified it should be reviewed because you want it to reflect current condition. R4 does not have care plan for his right hip fracture and should have care plan on the day it was identified. Yes, I added R4 ' s right hip fracture in the care plan yesterday. I should have not done that because it should have been done when the incident happened. Or it must be added at the time of occurrence. I know that those care plan I just added does not reflect care that really happened because I just added it. But I cannot answer why I added it. V9 admitted that R4 does not have care plan for right hip fracture related to the fall. V9 presented documentation that R4 ' s care plan for alteration in musculoskeletal status related to fracture of the right hip with goals and interventions were all added on 05/25/2023 after R4 was already discharged on 05/17/2023. On 05/24/2023 at 11:15 AM. V2 (Director of Nursing) stated, R4 needs staff assistance for ADLs (Activity of Daily Living) like transfer, and toileting. Typically, staff needs to stay with the resident during toileting. Nursing staff needs to know care needs of resident. There is a care cards used in the floor that shows each resident needs. It is restorative department that provides those care cards. CNAs (Certified Nursing Assistants) needs to identify and follow up with the nurse and review Care Cards. Yes, V11 obviously does not know what R4 needs and should be guided. R4 is not independent or supervision, because he (R4) needs assistance. As shown in R4'ss assessment that he is rarely or never understood. Then any instructions not to get up may not be understood or followed by R4. V2 was asked that many nursing staff documents in their progress notes that R4 alert and oriented and requires supervision instead of assistance. V2 said, R4 has right-sided weakness due to hemiplegia and needs assistance not only supervision. Yes, I understand that nursing staff should direct care and assistance to residents in choosing safer side. V2 was asked about V9 modifying care plan of R4. Yes, I was informed about modification of care plan of R4. R4 is not here in the facility, and it should not have been done. On 05/24/2023 at 12:59 PM. V17 (Restorative Nurse / LPN) presented Care Alert Cards (CAC) for R4 dated 02/13/2017 and 04/28/2023. CAC dated 02/13/2017 documents that R4 needs 1-person limited assistance during transfers. V17 said that R4 does not have CAC between 02/13/2017 and 04/28/2023 because there was no change of R4 status between those dates. MDS assessment of R4 was presented to V17 that shows R4 needs extensive assistance which requires weight bearing compared to limited assistance that does not require weight bearing assistance. V17 said, Yes, R4 has right-sided weakness and needs weight bearing assistance on his right side. Comparing CAC of 02/13/2017 from CAC 04/28/2023, because of the fall that resulted to fracture of hips and surgery. R4 now requires mechanical lift (sit to stand) with 2-person assistance. V17 said, R4 never was independent in toileting and transfer. R4 needs assistance, staff needs to stay with R4 during toileting. Again, R4 has one side weakness that needs assistance during transfer because R4 cannot bear weight on that side. Minimum Data Set (MDS) of R4 dated 04/13/2023 prior to fall (04/22/2023) on cognitive patterns documents that R4 score was 0 or R4 rarely/never understood. On functional status, R4 needs 1-person extensive assists on bed mobility, transfers, and toileting. On health conditions, R4 had multiple falls since admission. Plan of Care for R4 on ADL (Activity of Daily Living) with multiple dates, documents as follows: R4 has an ADL self-care performance deficit due to hemiplegia diagnosis. R4 requires 1-person assist with toileting, transfers, bed mobility, bathing, and personal hygiene. R4 ' s hospital record dated 04/24/2023 to 04/28/2023 documents the following: R4 sustained closed comminuted fracture of the hip, other diagnosis includes impaired functional mobility and activity intolerance and right-sided weakness. Sudden fall or accident can be a life-changing event often need surgery or repair the fracture. R4 undergone a procedure Intramedullary Nail Femur, Antegrade (Right) or right femoral ORIF (Open Reduction Internal Fixation) on 04/25/2023 due to his fracture related to fall on 04/22/2023. On 05/26/2023 at 10:13 AM. Called V28 (Medical Doctor) and left a message with call back number. Safety Resident Policy not dated, in part reads: Resident transfer status will be reviewed via resident care plan time frame and on an as needed basis. Resident transfer status will be properly communicated with a resident individual Care Service Plan in Electronic Medical Record, coding system or on a Care Card or [NAME].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation and record review, the facility failed to protect residents right to be free from physical abuse. This deficient practice affected 4 residents (R2, R7, R8, R13) in a sample of 8 residents (R1, R2, R3, R4, R6, R7, R8, R13) reviewed for abuse. This failure resulted in a.) R8, a cognitively impaired male resident being slapped on the hand by a staff member; b.) R7, a female resident who is non-ambulatory using a wheelchair (R7) being slapped on the face by an ambulatory male resident (R6) who has a history of physically aggressive behavior(s); c.) R1 punching R2 on the back; and d.) R7 hitting and scratching R13's wrist. Findings include, Facility's Final Incident Investigation Report dated (12/24/22) regarding incident which occurred on 12/21/22 between R8 and a staff member documents in part: R8 took a cup of juice from the food cart and V3 (Certified Nursing Assistant) grabbed R8's arm and took the cup away from R8. V3 stated that R8 took a cup of juice from the food cart and spit in it, V3 then grabbed R8's arm and took the juice from R8. R8 has diagnosis not limited Cognitive Communication Deficit, Unspecified Dementia without Behavioral Disturbances, Psychotic Disturbance, Mood Disturbance and Anxiety, Major Depressive Disorder, Schizoaffective Disorder, Hypertension, Personal History of COVID-19, Glaucoma, Gastro-Esophageal Reflux Disease with Esophagitis, Type 2 Diabetes Mellitus with Hyperglycemia. R8's Brief Mental Status Interview (BIMS) dated 12/18/22 documents that R8's cognition is severely impaired. R8's care plans dated 12/23/22 documents in part R8 is at risk for potential abuse related to behavior problems, and mental/emotional challenges. R8's progress note dated 12/21/22 at 12:40, completed by V19 (Licensed Practical Nurse), documents in part, R8 reported to writer (V19) that R8 (was) trying to get some juice off of the cart when a CNA grabbed his (R8)'s hand and hit the cup of juice to the floor. Writer (V19) took R8 to R8's room and assessed R8 for injuries (none noted). R8 denied pain. Writer (V19) reported immediately to Abuse Coordinator. On 02/14/22 at 10:57 AM, V1 (Administrator) stated that V1 did not witness the altercation between R8 and V3 (Certified Nursing Assistant) but was aware of the incident. V1 stated that it was reported to V1 that R8 was reaching for juice after R8 was told not to get the juice by V3 who was preparing the juice for lunch, and then R8 proceeded with trying to grab the juice and that V3 tapped the juice cup out of R8's hand causing the juice to fall on the floor. V1 stated that R8 was immediately separated from V3 by the unit staff and the Abuse Coordinator & V1 were notified. V1 stated at the time of the event V1 was the Social Service Director, not the Administrator. V1 met with R8 for a well-being follow up and R8 told V1 that V3 knocked the juice out of R8's hand. V1 stated that R8's care plan was updated with appropriate interventions. V1 was not sure of what steps the Administrator (V22) took with the CNA (V3) involved but V1 stated that V1 knows V3 is no longer working at the facility. V1 stated that there was a video recording of the incident however stated that after 30 days the recording is deleted. V1 stated that V1 did not view the recording of the incident but that the former Administrator (V22) did watch the video. On 02/14/22 at 1:22 PM, V1 stated to surveyors, residents have the right to be free from abuse. On 02/14/23 at 2:05 PM, V19 (Licensed Practical Nurse) stated that V19 did not witness the event on 12/21/22 between R8 and V3 but after the fact R8 told V19 that V3 had hit R8's hand during lunch pass. V19 stated that R8 will try to grab juice but when told to wait his (R8) turn, R8 responds well to verbal redirection and is cooperative. V19 stated that V19 called the administrator to report the abuse and R8 was separated from V3. V19 stated that V22 (Administrator) removed V3 from the unit immediately to interview V3 and that V3 never returned to the floor again. V19 stated that R8 was monitored for signs or symptoms of abuse and assessed for injury, harm and that no injuries were noted, R8 denied any pain. On 02/14/23 at 2:11 PM, R8 stated that R8 was thirsty and wanted something to drink so R8 took a cup of juice from the beverage cart during lunch time. R8 stated that one of the CNAs smacked my hand hard, and yelled, don't do that! R8 stated that R8 has not seen that CNA for a while, and said, I don't think she works here anymore. R8 stated that R8 feels safe at the facility and that there have been no other times that a staff member or resident has hit him (R8). On 02/15/23 at 11:56 AM, V22 (Former Administrator) stated that on 12/21/22 V30 (Activity Aide) came down to V22's office tearful and upset. V22 stated that V30 reported that V30 saw a resident being abused. V22 stated that V30 reported that V30 saw V3 slap R8's hand. V22 immediately went to the floor and separated R8 from V3 and made sure R8 was assessed to make sure R8 did not have any injuries and R8 was monitored by social services. V22 stated that V22 had V3 go down to the office to get V3's statement or version of what happened. V22 stated that initially, V3 denied touching R8 but, then V3 stated that V3 saw R8 spit into a cup of juice and that V3 asked R8 to put down the glass of juice but that R8 did not listen and that R8 tried to put the cup of juice back on the cart and that is when V3 tried to knock the cup away from R8. V22 stated that V22 watched the video recording of the event and that what V22 saw on the video did not correlate with V3's report of the event. V22 stated that video showed that R8 did not spit into the cup of juice and that V3 very aggressively made contact with V3's hand against R8's hand which was holding the juice causing the contents of the juice to fall on the floor. After V3 watched the video V3 admitted to trying to snatch the cup out of R8's hand. V22 stated V3 then got up and said, I resign and then V3 left the building and has not been in the building since. V22 stated that this event was substantiated as abuse. On 02/15/23 at 01:54 PM, surveyor spoke with V30 (Activity Aide) via phone. V30 stated that V30 did not see the altercation between R8 and V3 on 12/21/22 but that V30 heard the commotion in the hallway. V30 stated that V30 heard V19 (LPN 2nd floor) say to V3, why did you slap that juice out of his hand? V30 stated that V19 was referring to R8. V30 stated that there was juice spilled all over the floor. V30 stated the juice was just sitting there, I don't know why the CNA wouldn't let R8 have it. On 02/17/23 at 11:54 AM, surveyor spoke with V36 (Psychiatric Nurse Practitioner) over the phone. V36 stated that V36 was not aware of the altercation between R8 and a staff member. V36 stated that it is never appropriate for a staff member to hit a resident. V36 stated that the staff members should be trusted to take care of the residents and that staff members do not have any conditions and should be able to control themselves. V36 stated that if a staff member hit a resident, it was intentional and therefore would be considered abuse. Surveyor left voice mail messages for V3 the following dates/times with no response: 02/15/23 at 9:38 AM, 02/15/23 at 10:45 AM, 02/15/23 at 12:30 PM, and 02/17/23 at 1:42 PM. Facility's Final Incident Investigation Report dated (12/24/22) regarding incident which occurred on 12/20/22 between R6 and R7 documents in part: R6 went into R7 room to retrieve R6's jacket which had been taken by R7 from R6's room while R6 was sleeping. R6 stated that R6 went into R7's room and grabbed R6's jacket from R7's hands. At that time both R6 and R7 denied any physical altercation. R7's roommate reported witnessing R6 slap R7, which R7 later confirmed. R6 has diagnosis not limited Cognitive Communication Deficit, Major Depressive Disorder, Epilepsy, Type 2 Diabetes Mellitus, Hypertension, Hyperlipidemia, Vitamin D Deficiency, Nicotine Dependence. R6's Brief Mental Status Interview (BIMS) dated 11/25/22 documents that R6's cognition is moderately impaired. R6's care plan documents in part R6 has been physical aggressive toward peers when angry and displays poor impulse control. R6's MDS section G (Functional Status) documents R6 is able to walk in room and corridor with supervision (oversight, encouragement, cueing). R7 has diagnosis not limited to Bipolar Disorder, Anxiety Disorder, Disorder of Adult Personality and Behavior, Schizophrenia, Adult, Chronic Obstructive Pulmonary Disease, Difficulty Walking, Lack of Coordination, Weakness, Type 2 Diabetes Mellitus, Epilepsy, Diastolic (Congestive) Heart Failure, Anemia, Insomnia. R7's Brief Mental Status Interview (BIMS) dated 12/02/22 documents that R7's cognition is moderately impaired. R7's care plan documents in part R7 may be at risk for potential abuse related to mental/emotional challenges, secondary to behaviors displayed as evidenced by going into peers' rooms and not respecting peers' boundaries. R7's MDS section G (Functional Status) documents R7's ability to walk in room and corridor did not occur 100% of the time. R9 has a diagnosis not limited to Schizoaffective Disorder, Morbid Obesity, Weakness, Lack of Coordination, Difficulty Walking, Alcohol Abuse, Osteoarthritis, Adult Failure to Thrive, Need for Assistance with Personal Care. R9's Brief Mental Status Interview (BIMS) dated 01/11/23 documents that R9 is cognitively intact. R7's progress note dated 12/20/22 at 06:16 completed by V32 (11-7 Registered Nurse) documents in part, R6 wandering the hall all night going in peers room taking their belongings. R9's progress note dated 12/20/22 at 06:33, completed by V32 documents in part, R9 complained of R9's roommate (R7) was slapped by a male resident in R9's room. R7's progress note dated 12/20/22 at 06:40 completed by V32 documents in part, R7's roommate informed nurse that R7 had been slapped by a male resident, R7 denied being slapped but later when questioned R7 stated that R7 took R6's coat and gloves looking for money and R6 came into R7's room and snatched R6's coat out of R7's hands and the coat sleeve hit R7. R6's progress note dated 12/20/22 at 06:48, completed by V32 documents in part, R6 stated R6 went to R7's room and snatched R6's coat out of R7's hand that's all, denied striking R7. R6's progress note dated 12/20/22 at 14:33, completed by V1 (Administrator, Former Social Service Director) documents in part R6 hit peer because R6 stated peer (R7) stole R6's jacket and R6 stated, so what. On 02/14/23 at 1:20 PM, surveyor observed R7 in R7's room sitting in a wheelchair. R7 stated that R6 was in R7's room but R7 did not know why. R7 denied taking R6's jacket. R7 stated, he (R6) hit me in the face, here and as R7 made this statement R7 took R7's hand and covered R7's face with R7's hand. R7 stated R6 has not been in R7's room since R6 hit R7. R7 stated, he's a nice guy. On 02/14/23 at 1:24 PM, R9 stated that R6 barged into R7 and R9's room early one morning and asked for R6's jacket back. R9 stated that R7 gave R6 his jacket back and then R6 slapped R7 across the face really hard. R9 stated that R9 told R6 to get out of their room and that R6 left the room at that time. R9 stated that R9 reported what R9 had witnessed to the nurse on duty. On 02/14/23 at 1:32 PM, R6 stated that R7 came into R6's room when R6 was in the washroom and took R6's jacket. R6 stated that one of R6's roommates told R6 that R7 took R6's jacket. R6 stated that R6 went into R7's room to get R6's jacket back. R6 stated that R7 tried to make it like she (R7) didn't have it. But, I saw my jacket on her (R7)'s bed as she (R7) was going through the pockets of my jacket. R6 stated that R6 snatched R6's jacket from R7's bed. R6 stated that R6 did not hit or slap her. R6 stated, I don't hit ladies. Men aren't supposed to hit ladies. R6 stated that R7's roommate told R6 that R6 should not be in the room and told R6 to leave. R6 stated that R6 then left the room with R6's jacket in hand, and said, that was all, I did not touch her. R6 stated that R7 has taken other things from R6's room before but not able to specify what items. On 02/14/22 at 11:15 AM, V1 (Administrator) stated that V1 did not recall or witness the incident between R6 and R7 that occurred on 12/20/22. V1 stated that R7 has a known history of roaming into other resident rooms and taking items from them. V1 stated that initially R7 denied being touched by R6, however later R7 did confirm that R7 was slapped by R6. V1 stated that the facility confirmed abuse had occurred. On 02/14/22 at 1:22 PM, V1 stated to surveyors, residents have the right to be free from abuse. On 02/14/23 at 1:44 PM, V17 (4th Floor Social Worker) stated that R7 constantly goes into other resident's rooms uninvited and takes their things without their permission. V17 stated that R7 took R6's jacket from R6's room and that R6 went into R7's room to get R6's jacket back. V17 denied being aware that R6 hit or slapped R7 when R6 was in R6's room retrieving R6's jacket. V17 stated R6 and R7 continue to reside in the same room on the same unit but that R6 and R7's rooms are on opposite sides of the unit from each other. V17 stated that R6 and R7 don't socialize and that R6 keeps to himself except to participate in smoke breaks and activity functions. V17 stated that staff continue to monitor R7 for roaming behavior as this is an ongoing behavior and try to redirect R7 back to R7's room. On 02/14/23 at 1:54 PM, V18 (Certified Nursing Assistant) stated that V18 has been working at the facility for 6 years. V18 stated that R7 is constantly taking other resident items and selling or trading them to other residents for money or cigarettes. V18 stated that this is R7's long standing behavior and is something R7 is constantly doing including all night and throughout the day. V18 stated that R7 also wanders to the other floors looking for money and cigarettes. V18 stated R6 stays in R6's room and does not wander or roam into other resident's rooms. V18 was not aware of incident between R6 and R7. On 02/15/23 at 11:56 AM, V22 (Former Administrator) reported that on 12/20/22 R7 had taken R6's jacket from R6's room and R6 went into R7's room to retrieve the jacket. V22 stated that R6 grabbed the jacket from R7's hand and that initially, R7 denied being hit by R6 however R7's roommate (R9) reported seeing R6 slap R7 on the face. V22 stated that R7 has a history of denying physical abuse even if it has occurred because R7 would then have to admit to taking items from other residents (for example R6's jacket) which R7 knows R7 is not supposed to do. V22 stated that after facility investigation was conducted the allegation of theft and abuse were both substantiated. On 02/16/23 at 10:21 AM, surveyor spoke with V32 (11-7 Registered Nurse) via phone. V32 stated that V32 has been working at the facility since June 2020 and that V32 works on the 4th floor (11-7 shift). V32 stated that V7 has a long-standing behavior of entering other resident's rooms looking for money, cigarettes or food and taking other resident's belongings. V32 stated that R7 wanders all light long into and out of other resident rooms and that most of the time R7 will respond to redirection provided however sometimes if R7 has drank a lot of soda R7 can get hyped up and in those instances R7 does not respond to redirection. V32 stated that 12/20/22 was one of those nights, R7 was in constant movement all night long, going in and out of other resident's rooms and was not responding to staff redirection. V32 stated that V32 did not see R7 go into R6's room or see R7 take R6's jacket. V32 stated that on 12/20/22 early in the morning, toward the end of V32's shift V32 was passing medications when R7's roommate (V9) approached V32 and told V32 that R6 had entered R7 and R9's room and R9 saw R6 slapped R7 in the face. V32 stated that V32 separated R6 and R7 and went to R7's room to assess R7 for injury. V32 stated R7 had no signs or symptoms of injury and denied pain. V32 state that R7 denied being hit by R6 and that R7 felt safe. V32 notified the nursing supervisor who came to the floor to interview R6 and R7 and the Administrator was notified. On 02/16/23 at 1:06 PM, V21 (Restorative Aide/Certified Nursing Assistant) stated V21 has been working at the facility for 8 years. V21 state that R7 is non-compliant with wandering and stealing behavior and that R7 is constantly wandering around the facility looking for money or cigarettes. V21 stated this is a long-standing behavior. V21 stated that R7 does have the ability to walk however R7 only uses R7's wheelchair when R7 is out of R7's room. On 02/16/23 at 1:10 PM, R9 stated that R7 goes room to room looking for items all day and night and that R7 steals things so R7 can trade them or sell to other residents in the facility. R9 stated that R7's behavior makes the other residents mad and that the residents whose stuff R7 has stolen then come looking for their items in R7 and R9's room and that those residents are very, very angry. R9 stated that R6 burst into their room early one morning when still dark outside and started arguing with R7. R9 stated that R9 got up because of the commotion and that is when R9 saw R7 slap R6 real hard across the face. On 02/16/23 at 3:05 PM, surveyor spoke with V36 (Psychiatric Nurse Practitioner) via phone. V32 stated that V36 provides care to R6 and R7 and that V36 has been covering the facility since the fall of 2022. V36 stated that R6 has a history of being verbally and physically aggressive and that those types of behaviors are usually exhibited when R6 is triggered by something. For example, by the way people talk to R6, or if R6 is told to do something R6 does not want to do. V32 stated that verbal and physical aggression are not new behaviors for R6. V36 stated that R7 displays a lot of aggression and agitation toward staff and other residents. V36 described R7 as being very manipulative, non-compliant with care and roams around R7's unit, and other resident floors within the facility looking for money, or cigarettes constantly. V32 stated that R7's wandering, hoarding, and stealing behaviors are not new behaviors. V36 always sees R7 sitting in R7's wheelchair but has seen R7 transfer herself from R7's wheelchair to the R7's bed when in R7's room. V36 stated that V36 was aware of the altercation between R6 and R7 in terms of R7 stealing R6's jacket but did not realize R6 had slapped R7 on the face when R6 had gone into R7's room to retrieve R6's jacket. V36 stated, that should not be happening at the facility and that physical aggression toward another resident could be triggering for that resident (R7) and for all of the other residents on the unit. V36 stated it is not a safe environment if there is physical aggression between residents. V36 stated that R7 is a high risk of this happening again because of R7's wandering and stealing behaviors are ongoing. V36 stated that the facility needs more people to make sure the residents are safe in their rooms and provide more re-direction as needed to intervene quickly. Surveyor left voice mail messages for V37 on 02/17/23 at 9:40 AM, 10:21 AM, and 12:12 PM with no response. Policy: Abuse Prevention Program - Policy undated, documents in part, Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. Residents' Rights undated, documents in part, your (residents') rights to safety: you must not be abused, and the facility must ensure that you are free from retaliation. R1's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: HYPERLIPIDEMIA, UNSPECIFIED, MAJOR DEPRESSIVE DISORDER, SINGLE EPISODE, UNSPECIFIED, SCHIZOAFFECTIVE DISORDER, UNSPECIFIED, MILD COGNITIVE IMPAIRMENT OF UNCERTAIN OR UNKNOWN ETIOLOGY, FOURTH [TROCHLEAR] NERVE PALSY, LEFT EYE, DIPLOPIA, ALCOHOL DEPENDENCE, UNCOMPLICATED, HOMONYMOUS BILATERAL FIELD DEFECTS, LEFT SIDE, PRESENCE OF INTRAOCULAR LENS, OTHER VISUAL DISTURBANCES. Final Incident Investigation Report (fated 01/13/2023) documents On 01/13/2023 at approximately 8:15am, AM nurse reported that she witnessed R1 hitting R2 in the back. Both residents were immediately assessed for injuries. No injuries observed. Staffed confirmed that R1 repeatedly asking R2 to leave her room as she was getting dressed. Upon further investigation of this incident, physical abuse was founded. Upon the conclusion of this investigation, it is believed that abuse is substantiated. R1's Care Plan (dated 10/24/2020) documents that R1 presents with verbal/physical act out with peers, easily agitated, poor impulse control. R1's Care Plan (revised on 01/15/2023) documents that R1 may be at risk for potential abuse r/t behavior problem as evidenced by verbally and physically acting out when agitated. R1's Minimum Date Set assignment dated 12/30/2022 indicated R1 has a Brief Interview for Mental Status (BIMS) score of 14, which indicates resident has intact cognitive response. R2's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: OTHER ASTHMA, UNSPECIFIED SEVERE PROTEIN-CALORIE MALNUTRITION,IRON DEFICIENCY ANEMIA SECONDARY TO BLOOD LOSS (CHRONIC), UNSPECIFIED DEMENTIA, UNSPECIFIED SEVERITY, WITHOUT BEHAVIORAL DISTURBANCE, PSYCHOTIC DISTURBANCE, MOOD DISTURBANCE, AND ANXIETY, SCHIZOPHRENIA, UNSPECIFIED, INSOMNIA, UNSPECIFIED, DYSPHAGIA, ORAL PHASE, RESIDUAL HEMORRHOIDAL SKIN TAGS. R2's Minimum Date Set assignment dated 11/20/2022 indicated R2 has a Brief Interview for Mental Status (BIMS) score of 11, which indicates resident has moderately impaired cognitive response. R2's Care Plan (dated 06/24/2022) documents that R2 may be at risk for potential abuse r/t behavior problem, communication issues/deficits as well as poor impulse control, secondary to mental and emotional challenges. Abuse Prevention Policy (dated 11/22/2017) states: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. On 02/14/2023 at 9:15am, R1 stated, On 01/13/2023, I was sitting on my bed, and I was getting dressed. Suddenly, R2 just barged into my room and stood there and was staring at me. I asked R2 to leave my room, but he did not leave. R2 just stood there and was looking at me getting dressed. So, after I asked him several times to leave, I pushed him out of my room and hit him on his back to get him out. I don't know why R2 came in here in the first place, maybe R2 was confused because R2 just stood there. R2 did not say anything to me when I asked him to leave. R2 just stood there. Finally, I became agitated and pushed R2 out of my room and hit him on his back so that R2 would leave. I didn't hit R2 hard and R2 did not sustain any injuries. I wasn't trying to hurt R2, I just wanted him to leave. I feel safe here, I just wanted some privacy so that I can get dressed. On 02/14/2023 at 9:23am, R2 stated, I don't remember what happened. I don't remember going into anyone's room. On 02/14/2023 at 1:43pm V15 (licensed practical nurse) stated, R1 is not aggressive. R1 is calm and cooperative and keep to herself. R2 is not aggressive and has not been physically aggressive towards other residents. R2 has periods of confusion and during those periods of confusion, R2 can wonder into other resident rooms. R2 wondered into R1's room because R2 was confused at the time. R1 got upset that R2 entered R1's room. On 02/15/2023 at 12:33pm, V1 (administrator) stated, On 01/13/2023, a nurse reported that R1 hit R2 on the back. Both of the residents were separated. I met with R1 first and R1 said that R2 came into her room while R1 was getting dressed. R1 said that R1 asked R2 to leave and R2 refused to leave and R1 hit R2 on the back because R2 would not leave. R1 admitted that R1 hit R2 on the back. R1 said that R2 did not take anything from the room, it was just that R1 was trying to get dressed and R2 would not leave. I asked R2 what happened and R2 indicated that R2 did not know. R2 did not remember the incident. We did a potential for abuse form for R2. R1 was encouraged to seek staff assistance when she becomes triggered. The incident between R1 and R2 was substantiated, and abuse was founded. The resident has the right to be free from abuse. On 02/16/2023 at 10:05am V21 (certified nursing assistant) stated, On 01/13/2023, I was working on the 4th floor, and I heard someone yelling get out of my room. I recognized the voice to be of R1. I immediately stopped what I was doing, and I went to R1's room. When I walked in to R1's room, I saw R1 screaming at R2 telling him to get out of her room. R2 was just standing there, and I asked R1 to calm down. I asked R2 to leave R1's room. R2 just stood there and was staring at me but he didn't move. When I was talking to R2 telling him to leave R1's room, that's when R1 became more agitated and came from behind and hit R2 in the middle of R2's back. I was in between R1 and R2, and R1 came from behind and punched R2 in the middle of his back. After R1 hit R2 on the back, R2 left R1's room and went to his room. R2 did not appear to be injured. R2 just walked to his room. R2 did not scream from pain or anything like that, R2 just left R1's room and went to his own room. After the incident, the nurses assessed R1 and R2 and both residents were immediately separated. R1's Progress Note (dated 01/13/2023) documents, Staff reported to writer co-resident entered res room while res was dressing. Res asked co-resident to leave room three times. Co-resident res did not leave room so res punched co-resident in back. Residents were immediately separated. NP notified. DON notified. POA notified. No s/s of bruising or pain noted. vitals within normal range. No further behaviors noted at this time. 72 hr behavior charting initiated at this time. Will continue to monitor. R1's Social Service Note (dated 01/13/2023) documents, Wellbeing check/ Behavior monitoring 1/3: Writer was made aware by nursing staff that resident initiated physical aggression towards peer. Resident presents to be aox3 and can verbalize her wants and needs with no issues. Resident stated He was in my room while I was changing my clothes, when I asked him to leave. I punched him because he wouldn't leave my room after I asked 3x. Writer encouraged resident to seek staff assistance when needed. Writer encouraged resident to maintain appropriate boundaries. Writer reassured resident that she resides in a safe place. Psychiatrist made aware. Appropriate departments made aware. Resident was able to be redirected and complaint. No reported aggression. Staff to continue to monitor resident accordingly. R2's Progress Note (dated 01/13/2023) documents, Staff reported to writer res was seen in co-residents' room. co-resident stated res was asked to leave room three times. res did not leave room so co-resident punched res in back. residents were immediately separated. NP [NAME] notified. POA [NAME] notified. no s/s of bruising or pain noted at this time. vitals within normal range. no further behaviors noted at this time. 72 hr behavior charting initiated at this time. will continue to monitor. R7's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: BIPOLAR DISORDER, CURRENT EPISODE MIXED, MODERATE, UNSPECIFIED INJURY OF RIGHT ANKLE, INITIAL ENCOUNTER, GENERALIZED ANXIETY DISORDER, TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, EPILEPSY, UNSPECIFIED, NOT INTRACTABLE, WITHOUT STATUS EPILEPTICUS, UNSPECIFIED DIASTOLIC (CONGESTIVE) HEART FAILURE, DIFFICULTY IN WALKING, NOT ELSEWHERE CLASSIFIED, WEAKNESS, EDEMA, UNSPECIFIED. Final Incident Investigation Report (01/03/2023) states: On 12/30/2023 at approximately 3:40pm, both residents were observed getting off the elevator together on the 4th floor. R7, then suddenly physically hit R13 while at the nurse's station unprovoked. Both residents were immediately assessed for injuries. No injuries observed. Staff confirmed that R7 hit resident in front of the nurse's station. Upon the conclusion of this investigation, it is believed that abuse is substantiated. R7's Minimum Date Set assignment dated 12/02/2022 indicated R7 has a Brief Interview for Mental Status (BIMS) score of 12, which indicates resident has moderately impaired cognitive response. R7's Care Plan (dated 11/15/2021) documents that R7 presents with behavioral concerns as evidenced by being physically aggressive towards peer. R13's Face Sheet documents resident is a [AGE] year-old with diagnoses including but not limited to: SCHIZOAFFECTIVE DISORDER, BIPOLAR TYPE, TYPE 2 DIABETES MELLITUS WITHOUT COMPLICATIONS, DYSPHAGIA, OROPHARYNGEAL PHASE, PNEUMONIA, UNSPECIFIED ORGANISM, DEHYDRATION, HYPO-OSMOLALITY AND HYPONATREMIA, ABDOMINAL RIGIDITY, UNSPECIFIED SITE, REPEATED FALLS, LONG TERM (CURRENT) USE OF ASPIRIN, CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED, DYSPHAGIA, ORAL PHASE. R13's Minimum Date Set assignment dated 01/10/2023 indicated R13 has a Brief Interview for Mental Status (BIMS) score of 10, which indicates resident has moderately impaired cognitive response. R13's Care plan (dated 07/10/2022) documents that R13 may be at risk for potential abuse r/t behavior problem as evidenced by verbally and physically acting out when agitated and R13 was involved in a physical altercation in which R13 received physical aggression. Abuse Prevention Policy (dated 11/22/2017) states: Residents have the right to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This includes but is not limited to corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the resident's medical symptoms. On 02/15/2023 at 1:20pm, R7 stated, I don't remember hitting anybody. I don't remember it at all. On 02/15/2023 at 10:49, R13 stated, R7 and I were on the elevator together. We got off the elevator and all of a sudden R7 grabbed my arm and scratched my wrist. I don't know why R7 attacked me this way. I didn't do anything to R7. There was no verbal altercation or any issues and R7 just attacked my arm for no reason and scratched me. On 02/15/2023 at 11:33am V1 (administrator) stated, On 12/30/2023, both residents were getting off the elevator, and that's when R7 suddenly hit R13 without being provoked. R7 hit his arm. R13 did not report any injuries after the incident occurred, but later we learned that R7 scratched R13's arm. R7 was not provoked and hit R13 without any reason. Both residents were separated. We spoke to R7 and R7 did not recall what happened. We spoke to R13 and R13 stated that R7 hit him for no reason, but that he was fine and had no injuries. R7 dos not have a history of aggressive behavior towards other. R7 has a lot of behaviors, however, it is not of norm for R7 to hit other residents without a reason. After the incident, we did an abuse assessment on R13. R7 was encouraged to utilize her positive coping skills in the milieu. R7 was encouraged to refrain from any confrontation with a peer and to refrain from being aggressive towards other. The final investigation of the incident between R7 and R13 was substantiated for abuse. The resident has the right to be free from abuse. R7's Social Service Note (dated 12/30/2022) documents, Writer was made aware that resident was involved in an altercation where she initiated physical aggression towards peer. Resident presents to be aox3 and can verbalize her wants and needs with no issues. W[TRUNCATED]