Based on observation, record review and interview, the facility failed to ensure a cognitively impaired resident who wandered (Resident D) was free from resident-to-resident physical abuse perpetrated by a resident known to be physically abusive towards others when approached (Resident C) for 1 of 3 residents reviewed for abuse. This deficient practice resulted in Resident D sustaining a head laceration and required emergent treatment at the hospital with six sutures to repair. Findings include: Review of an Incident Report sent to the Indiana Department of Health's reporting system indicated, on 8/15/24 at 9:01 p.m., Resident D was found lying on the floor in Resident C's room. Resident D had a laceration on the left side of his head and bruising to his chest and head. Resident C indicated there had been an altercation. A local police department's case report, dated 8/15/24 and provided by the Director of Nursing (DON) on 8/21/24 at 10:25 a.m., indicated as the officer got to the door of Resident C's room, blood was observed on the floor inside the entryway. Resident C was asked about what happened and he advised that Resident D had walked into his room while he was asleep. Resident C was unsure how many times he stomped on Resident D's head. Resident C also stated that he had thoughts of harming others. An employee had indicated to the officer they had not seen the incident, but witnessed Resident C standing over the top of Resident D while yelling. Resident C's clinical record was reviewed on 8/19/24 at 11:28 a.m. Diagnoses included mild cognitive impairment, alcohol use, history of cerebral infarction, mood disorder, cocaine abuse, and epileptic syndrome. A current care plan, revised on 5/3/24, indicated the resident had potential to be verbally aggressive and had threatening behaviors when others were loud, repetitive, or when there lacked space at a dining room table he wanted to sit. An intervention indicated the resident's triggers for verbal aggression were when others come too close to him. The behaviors were de-escalated by keeping wanderers away from him. The most recent quarterly Minimum Data Set (MDS) assessment, dated 6/6/24, indicated resident was cognitively intact, had verbal behaviors directed at others on one to three days during the assessment period and physical behaviors directed towards himself on one to three days during the assessment period. A current care plan, revised on 6/20/24, indicated the resident had potential to be physically aggressive to others, shoved others, and attempted to hit others. Interventions included intervene before agitation escalates, guide away from source of distress, engage in conversation, and if aggressive, walk away and approach later. The resident was to be encouraged to seek out a staff member when agitated. On 8/16/24, an intervention was added to this care plan to offer to take resident to the courtyard if agitated. A Behavior Management Monthly Review, dated 8/6/24, indicated Resident C had 18 incidents of verbal behaviors, 16 incidents of physical behaviors and 18 incidents of yelling in a common area. The behaviors currently being monitored were verbal yelling and physical behaviors in common areas. The report indicated the interventions were successful. A social services progress note, dated 8/12/24 at 10:54 a.m., indicated the resident had seen the mental health provider on 8/9/24. During the session, the resident had expressed to the clinician his frustration with loud peers. He wished he could live on his own. The clinician worked with the resident on positives of living in the facility and helped him identify ways to take breaks. A nurse's note, dated 8/15/24, indicated Resident C was in his room when he attacked another resident. Resident C indicated he had been trying to sleep. Resident C boasted about stomping on the other resident's head. The police removed Resident C from the facility and took him to the emergency department. The clinical record for Resident D was reviewed on 8/20/24 at 10:08 a.m. Diagnoses included mild neurocognitive disorder without behavioral disturbances, anxiety disorder, psychotic disorder, and insomnia. A current care plan, initiated on 9/5/23, indicated the resident had periods of restlessness. Interventions included to involve the resident in diversional activities as possible and to redirect the resident away from doors. A current care plan, revised on 1/10/24, indicated the resident was a wanderer related to impaired safety awareness, wandering up and down the halls. Interventions included to distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, a book, and to ensure safety with wandering. The care plans lacked a interventions regarding supervision to manage Resident D wandering and entering other resident rooms. A current care plan, revised 4/4/24, indicated the resident had potential to be physically aggressive and agitated and at times, felt he was protecting others. Interventions included to increase activities and one on one's (continuous supervision) when resident showed increased wandering behaviors and monitor and document signs and symptoms of the resident posing danger to self and others. A current care plan, revised 5/3/24, indicated the resident had impaired verbal communication as evidenced by absent speech, weak voice, problems finding correct words and decreased auditory comprehension. Interventions included to ask mostly yes or no questions, give him 5-10 seconds to respond, speak slowly and simply with a reassuring, calm tone, and use non-verbal gestures (i.e.: thumbs up, thumbs down, smile, etc.) An annual MDS assessment, dated 7/30/24, indicated the resident had a severe cognitive deficit and major mental illness. The resident had unclear speech and difficulty communicating some words or finishing thoughts. He usually understood others, but missed some part or intent of conversations. He had episodes of wandering on one to three days of the assessment period. He required substantial assistance for eating and was dependent on staff for hygiene, toileting, showering, and dressing. He was independent with ambulation. A progress note, dated 8/16/2024 at 3:15 a.m., indicated Resident D returned to the facility from the emergency room with six sutures to the left side of his forehead, with multiple scratches on his face, neck and chest. During an interview on 8/19/2024 at 2:49 p.m., CNA 1 indicated, on the evening of 8/15/24, staff heard someone yelling for help. CNA 1 found Resident D on the floor of Resident C's room. Resident C was standing over Resident D. Resident C appeared aggressive and Resident D was laying on the floor in a pool of blood. Resident C told CNA 1 he had beaten Resident D because he had woken him up. CNA 1 asked if he had kicked Resident D, and Resident C stated he had stomped him six to seven times. CNA 1 stayed with Resident C while other staff members removed Resident D from the room. During an interview on 8/19/2024 at 3:30 p.m., QMA 2 indicated she had heard a faint yell. CNA 1 had found Resident D on the ground, bloody, and Resident C was standing over him. QMA 2 and CNA 1 stood between the residents. QMA 2 indicated she went with Resident D and held pressure to his head until the ambulance arrived. She asked Resident C what he had done, and he indicated he had stomped on Resident D's head. During an interview on 8/19/24 at 3:46 p.m., the DON indicated the staff had heard someone yell out for help, and she observed Resident D in Resident C's room, laying on the floor. Resident D had blood on his head and on the floor. CNA 1 was trying to keep Resident C from Resident D. The DON indicated she left the room and called for more help. CNA 1 stayed with Resident C. The staff removed Resident D from the room while the DON called the police and the ambulance. During an interview on 8/20/2024 at 1:26 p.m., RN 3 indicated Resident C had a prior incident two months ago when he had shoved Resident D. RN 3 indicated she verbalized her concerns related to Resident C staying in the facility due to his behaviors. The staff asked Resident C if he wanted to go to go to a homeless shelter and he responded no. On 8/22/24 at 9:29 a.m. CNA 4 indicated Resident C remained in his room much of the time, but when he was out, he had a flashy temper. Noise seemed to irritate him. The staff would try to redirect him to his room, which was mostly effective. She was not aware of any other interventions for his behaviors. The resident kept his blinds closed and just wanted to be left alone. On 8/22/24 at 9:41 a.m., Activity Aide 5 indicated Resident C kept to himself a lot. He would become verbally aggressive if someone got close to him. The Activity Aide calmed him down by talking with him and providing reassurance. She would talk with him when someone got close to him and reassure him, they were not approaching him. Sometimes he could not be calmed or redirected. She knew of no other interventions to try other than talking to him and redirecting him. On 8/22/24 at 9:54 a.m., QMA 6 indicated Resident C remained in his room most of the time. Noise bothered him and he would go off. When a person got too close to him, he became agitated and would have behaviors. The QMA knew to move other resident's away from Resident C and redirect him to his room. She tried to assure when Resident C was seated with other residents to eat in the dining room that they were not loud. She was unaware of other interventions to manage the resident's behaviors. On 8/22/24 at 10:08 a.m., the Activities Director indicated a couple of months ago, she was assisting Resident D, who lacked balance, as he walked by Resident C's table in the main dining room. Resident C stood from his chair and punched Resident D in the chest. On another occasion, Resident C was outside, and another resident bumped Resident C's leg with his wheelchair, and Resident C stood up and began to yell and curse the other resident. The staff were able to calm him down. During an interview on 8/22/24 at 9:32 a.m., CNA 4 indicated Resident D wandered up and down the hallways most of the day, every day. Resident D couldn't sit for any length of time. He went into other's rooms frequently and was easily redirected. She was unaware of other interventions for his wandering, but to redirect him to the hallway. During an interview on 8/22/24 at 9:42 a.m., Activity Aide 5 indicated Resident D was very sweet and wandered up and down the hallways. He would go into other resident's rooms. She indicated she would redirect him out of other's rooms when she saw him enter them or found him in someone else's room. During an interview on 8/22/24 at 9:47 a.m., QMA 6 indicated Resident D mostly walked up and down in the hallway and would go into other resident's rooms. He was easily redirected, but could become agitated at times. He would calm, and cooperated upon re-approaching. During an interview on 8/22/24 at 10:04 a.m., the Human Resources Director indicated Resident D was very sweet and wandered up and down the hallways. She had seen him enter other resident's rooms. He entered her office at times and was easily re-directed. During an interview on 8/20/24 at 1:03 p.m., CNA 21 indicated when Resident D returned to the facility from the emergency department, he was reluctant to leave his room. Staff encouraged him to continue his normal activities and assured him he was safe. During an observation on 8/22/24 at 10:30 a.m., Resident D was observed walking up and down the length of the hallway. The resident would stop occasionally and hold on the rail and adjust his shoe, then continue to ambulate in the hall. During an observation on 8/22/24 at 1:07 p.m., Resident D was ambulating in the hallway with an unsteady gait. He entered another resident's room, who was not in the room during the observation. The resident stood in the corner of the room and looked around and entered the bathroom. No staff were observed in the area. A current facility policy, revised 5/2024, titled, Abuse Prevention, Identification, and Reporting Policy, provided by the Administrator on 8/2/24 at 9:24 a.m., indicated the following: All residents have the right to be free from abuse, neglect, misappropriation of resident property, exploitation, corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms It shall be the policy of the facility to follow the Indiana Department of Health Policies and Procedures for Long-term Care Abuse and Incident Reporting . This citation relates to complaint IN00441003. 3.1-27(a)(1)

Based on interview and record review, the facility failed to develop and implement an individualized behavior plan that maximized the resident's dignity for 1 of 5 residents reviewed (Resident B) when the SSD indicated to Resident B he would be able to be discharged to a group home if he had good behavior for 14 days. This practice resulted in his fixation on the date he was to be discharged to go to a group home and contributed to his increased frustration and behaviors of self harm, yelling at staff, throwing items, and banging his head, which lead to an inpatient stay at a psychiatric hospital. Findings include: Review of video footage with audio, on 8/29/23 at 11:00 a.m., indicated on 8/19/23 Resident B was being escorted in his wheelchair to his room from the nurses station area. CNA 12 pushed his wheelchair while CNA 23 walked backwards holding his legs from touching the ground. LPN 8 held a gown on the right side of him to shield the other staff member from him spitting on them. As they entered his room, a staff member called Resident B a nasty a--. Resident B's clinical record was reviewed on 8/29/23 at 10:38 a.m. Diagnoses included uncomplicated alcohol dependence, Wernicke's encephalopathy, delusional disorders, mild cognitive impairment of uncertain or unknown etiology, other seizures, drug induced subacute dyskinesia, major depressive disorder, recurrent severe without psychotic features, generalized anxiety disorder, psychotic disorder with hallucinations due to known physiological condition, impulse disorder, and diffuse traumatic brain injury with loss of consciousness of unspecified duration, subsequent encounter. His medications included levetiracetam (treat seizures) 250 mg (milligram) three times daily, divalproex sodium (treat seizures) 375 mg twice daily, quetiapine fumarate (treat psychotic features) 150 mg at bedtime, brexpiprazole (treat mood disorders) 3 mg daily, and folic acid-vitamin B6-vitamin B12 (treat Wernicke's encephalopathy) daily. Special instructions on his orders indicated, per his mother, Resident B could call her twice daily only from 12:30 p.m. - 1:00 p.m. (after lunch) and 5:30 p.m. - 6:00 p.m. (after dinner). If he yelled at others or was being inappropriate, the call could be held. An admission MDS (Minimum Data Set) assessment, dated 7/21/23, indicated he was cognitively intact. He required extensive assistance of one staff member for bed mobility, dressing, toilet use and personal hygiene. He required extensive assistance of two staff members for transferring. He required supervision with locomotion on and off the unit. He used a wheelchair. He had delusions (misconceptions or beliefs that are firmly held, contrary to reality) and other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred one to three days during the assessment period. His current care plans included the following: He had behaviors of yelling out in common areas (7/17/23). His interventions included to allow him time to voice frustrations (revised 8/12/23), approach calmly and in a soothing, non-judgmental manner (revised on 8/12/23), assess for pain and toileting needs (revised 8/12/23), give him your full attention to answer questions he had (revised 8/9/23), if he was in the common area/high activity area, please take him to his room to assist him (revised 8/12/23), offer him a snack or a drink (revised 8/12/23), praise him for all appropriate behaviors (8/22/23), take him to a quiet area (revised 8/12/23), and talk to him about the feelings and rights of others who are exposed to the negative behavior (8/21/23). He had the potential for psychosocial well-being problem related negative interaction with staff (7/25/23). His interventions included allow him time to answer questions and to verbalize feelings, perceptions, and fears (7/25/23), monitor/document his usual response to problems: internal and external (7/25/23), monitor/document his feelings relative to incident with peer (7/25/23), when conflict arose, remove him to a calm, safe environment and allow him to vent/share his feelings (7/25/23). He had the potential to be verbally aggressive by yelling and cursing at staff, calling staff derogatory names, etc. (revised 8/9/23). His interventions included analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document (revised 8/12/23), assess his understanding of the situation, allow time for him to express himself and feelings towards the situation (revised 8/12/23), provide positive feedback for good behavior, emphasize the positive aspects of compliance (revised 8/12/23), when he became agitated; intervene before agitation escalate, guide him away from the source of distress, engage calmly in conversation, if his response was aggressive, staff were to walk away calmly and approach later (revised 8/12/23). He had behaviors of throwing items i.e.: books, water pitcher, threatening to tip over medication carts, pour water on computers, throw feces on staff, throwing cups, etc.(revised 8/16/23). His interventions included ask him what you can do to help him (8/21/23), explain to him the behavior was inappropriate (8/12/23), offer to take him to quiet area to talk (revised 8/12/23), praise him for appropriate behavior (8/22/23), remove him from the area (revised 8/12/23), specific behavior management intervention: ask him if he would like to call his mother (revised 8/12/23), talk to him about the feelings and rights of others who are exposed to negative behavior (revised 8/12/23), and turn on soothing music (8/16/23). He had a behavior problem of self injurious behavior by banging on table, hitting the wall, threatening to break a window, etc. (revised 8/18/23). His interventions included answer his questions (8/18/23), approach/speak in a calm manner (revised 8/12/23), divert attention as necessary (revised 8/12/23), monitor behavior episodes and attempt to determine underlying cause, consider location, time of day, persons involved, and situations, document behavior and potential causes (revised 8/12/23), praise any indication of his progress/improvement in behavior (revised 8/12/23), remove from situation and take to alternate location as needed (8/12/23), and turn on soothing music for him in a quiet area (8/16/23). He had the potential to be physically aggressive i.e.: threats of harm to staff, scratching staff, etc. (revised 8/21/23). His interventions included to analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document (revised 8/12/23), assess and address for contributing sensory deficits (revised 8/12/23), assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. (revised 8/12/23), assist to set goals for more pleasant behavior and assist verbalization of source of agitation (8/21/23), when he became agitated, intervene before agitation escalates, guide him away from source of distress, engage calmly in conversation, if response is aggressive; staff were to walk away calmly and approach later (revised 8/12/23). His progress notes indicated the following: On 8/1/23 at 8:49 a.m., he continued to ask staff when was leaving to go to a group home. Staff replied he would need to change his behaviors to go to group home. He was agreeable. He then continued to ask the same questions. On 8/1/23 at 6:30 p.m., he came to the nurses station several times that shift and asked when he could go to the group home and asked the nurse to write it down. When he was reminded he had it on his notepad, he would get loud and cuss. He was reminded his behaviors had to improve prior to him discharging from the facility. He stated understanding and his behavior improved for only short amount of time before it started all over again. On 8/19/23 at 12:07 p.m., he was in the common area yelling at staff. He continued to make threats about harming himself and other residents. He called staff racial slurs and made bigoted statements. The nurse practitioner was aware of the situation, and no new orders were given. The facility was advised to give redirection to the date of potential discharge. On 8/19/23 at 2:31 p.m., he continuously yelled and shouted out racial slurs and derogatory names such b--ches, chubby, and fat a--. He was redirected to his room where he began to throw various items such as remotes, dresser pieces and his trash can. He took a water pitcher and threw it into the hallway, barely missing a staff member. He made threats to staff that he would take the dresser and beat you upside the head, [racial slur]. He continued to make threats of harm to staff. On 8/19/23 at 2:59 p.m., a staff member came into to help IT (Information Technology) to get the internet and the phone working. Resident B proceeded to threaten to throw urine and water pitchers on the staff member. The staff member was on the phone with IT and could not react to Resident B's questions. He was creating a hostile environment. On 8/19/23 at 6:03 p.m., he hocked up his spit, threatening to spit on an African- American staff member. He called staff names, when redirected by four staff members to his room, he began to spit on staff multiple times. He grabbed a CNA by her chest and began to scratch another CNA. He threw items and caused destruction in his room. He cursed loudly while continuing to spit. 911 was called by a staff member due to their injuries. The DON, psychiatric nurse practitioner, the administrator in training, and the manager on duty was aware. EMTs escorted him via ambulance. His mother was called and made aware of the situation. On 8/20/23 at 4:45 a.m., he returned from the local hospital via stretcher. He was awake and alert to person and place. He was transferred from stretcher to bed. A report from nurse at the ER indicated he was totally calm and cooperative while at the ER, other than he refused lab work when he first arrived. He agreed to lab work shortly after he refused. He had no other behaviors. No new orders were received. He denied any wants/needs at that time and his call light was in reach. On 8/21/23 at 12:53 p.m., he resorted to yelling for staff across the room, to get their attention for a continuously repeated reading of today's date and when he could depart. He continued to repeat requests for reading today's date. This would not change, but his behaviors were definitely belligerent. If staff did not stop in their tracks to repetitively answer today's date and his potential departure date. He would curse and threaten self harm or toss something at staff. He had no means or the mental capacity to harm himself. On 8/21/23 at 11:34 p.m., an SSD note indicated he could be easily redirected, but due to memory issues and behaviors he was redirected hundreds of times a day. His behaviors and questions on the date and when he was leaving were repetitively asked. It was difficult to get him on a task due to this complication of his disease process. At times, his memory was better than others. On 8/22/23 at 6:22 p.m., he sat at the nurses station consistently asked questions, Can I call my mom? and Its August 22nd, and I am leaving August 3? He carried around paper with this statement. Staff reminded him that only if behaviors decreased and if he followed his plan of care. He would state I am going to hurt myself tonight. Staff tried to console him and he started with the same repetitive questions. This behavior had been constant for the last an hour and a half and he rotated between the staff. He had been unable to be redirected. He was listened to and he was talked to about his current plan of care and goals, they were ineffective and would often worsen the behaviors. On 8/23/23 at 10:35 a.m., he sat in his wheelchair outside of the Human Resource office, where the morning meeting was going on. The Administrator opened the door, answered his repetitive question regarding the date and when he could leave. The door was shut to commence with the meeting. He started yelling and cussing saying he was going to kill himself. The office door was opened and he was bashing his head into the door and door knob repetitively. Staff intervened and separated him from the door. The NP was notified and gave an order to send to him to the ER for evaluation, treatment and to be sent for a psych stay. 911 was called. On 8/23/23 at 3:29 p.m., he returned to the facility with a diagnoses of a UTI, and he quickly began cursing and threatened to harm self. On 8/23/23 at 6:31 p.m., he had been demanding since returning from the hospital. He was reminded to be patient with staff who answered his questions and he was going to go to psychiatric hospital as soon as a bed was confirmed this evening or Thursday the 24th. He was very verbally repetitive. If staff didn't answer his repetitive questions, he would threaten to harm self. He went so far as to say he was going to break the mirror on the wall with his head. He tried to bang his head on the wall. He was reminded him to be kind and to stop threatening to harm self every time someone does not answer him immediately. He yelled across the room to get staff's attention. He was called some of the staff the N word, as well. On 8/24/23 at 7:55 p.m., he was on a leave of absence to an inpatient psychiatric hospital. Confidential interviews were conducted during the course of the survey. During a confidential interview, it was indicated Resident B was very confused. He knew he was confused, he wanted to know why he repeated himself and why he couldn't remember things. They tried to think of things to get his mind off his notebook. He constantly said he was going to kill himself or hurt himself and said he did not like living like that. He wanted to live in a group home. The SSD had told him he was going to a group home if he didn't have behaviors for two weeks. The SSD started writing the date in a notebook he carried. They told him if he had a behavior they would push the date back. The confidential interview didn't know why they gave him a date and then changed it if he had a behavior. They heard the SSD and the Environmental Supervisor tell him he had to stay longer because he had behaviors. The confidential interview felt this made him have more behaviors and frustrated him. They kept telling him he had to go two more weeks because he had a behavior. During an interview with the Interim Administrator, on 8/29/23 at 2:12 p.m., she indicated she started at the facility on 8/20/23. She became aware of the incident with staff and Resident B, on 8/25/23, while investigating a workman's comp issue. She was told Resident B had hurt two staff members during a behavior incident with Resident B on 8/19/23 at 5:20 p.m., and it lead her to view the video footage. After watching the video, she reported the incident to the State Agency and suspended the three staff members. They said Resident B had behaviors most of the day on 8/19/23. They tried to give him a date for discharge, they told him if he didn't have behaviors for 14 days he could go to the group home. There was a facility behavior care specialist that had a good relationship with him, and tried to redirect him. She was able to calm him after the incident. Another resident, Resident D, was protective of the staff. He watched Resident B's behaviors increase and he was going to potentially intervene by using metal from a cat food can to hurt Resident B. She thought the staff were trying to remove Resident B from the situation to keep him safe as well as others. He was to the point where he was unmanageable. Staff called the police, they came and took him to a local hospital, and the hospital sent him back to the facility. CNA 12 called Resident B a nasty a--. She tried to contact CNA 12 and she did not show up for work. The nurse practitioner had made some changes to his medication and attempted to do things in-house. During an interview with the Administrator, on 8/29/23 at 2:53 p.m., she indicated Resident B had a notebook that said he was going to a group home. She had initially thought he was really going to a group home. She spoke with the SSD about what group home he was going to, and she told her he wasn't going to a group home. He had to be good for 14 days before he could go. During an interview with the SSD, on 8/29/23 at 4:02 p.m., she indicated she was working on finding a group home for Resident B. She had reached out to three group homes. One was close to where his family lived. They said he could not have physical/aggressive behaviors for 14 to 30 days. He had not been accepted yet. She told him when he met his goals, she would fax the group homes the information they needed. Everyday they wrote the date and how many days he had left at the facility before he was going to a group home. He carried the notebook around with him all day. He threatened to throw urine at the staff, he made self injurious threats. A couple weekends ago, he was spitting, threatened to throw urine, called staff names and threw a dresser drawer into the hall. If there were a lot of people around, he wanted all the attention focused on him. If there were less people around, he was more controllable . An undated current facility policy, titled ABUSE PREVENTION AND PROHIBITION POLICY, provided by the Interim DON, on 8/30/23 at 11:00 a.m., indicated the following: .Policy .Residents residing in this facility will be treated with dignity and respect in accordance with their individual needs. They will not be subjected to verbal .and mental abuse .VERBAL ABUSE: Threatening a resident verbally, raising your voice to a resident in a scolding or abrupt manner, using offensive term/words .MENTAL ABUSE .saying anything to a resident which might cause him/her to worry or become alarmed .threats of punishment or deprivation This Federal tag relates to complaint IN00416170. 3.1-27(a)(1) 3.1-27(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from resident to resident physical abuse for 2 of 6 residents reviewed for abuse (Residents P and N). Resident P experienced being bitten by Resident N. He was sent to the hospital and required antibiotics to treat the resulting wound. B. Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from verbal abuse by a staff member for 1 of 6 residents reviewed for abuse (Resident J). Findings include: A. During an interview with Resident P, on 8/9/23 at 12:36 p.m., he indicated he was bitten on his wrist by Resident N about two weeks ago. It was the second time he had been bitten while at the facility, but not by the same person. Resident N was pi--ing him off and everyone around him was telling Resident N to shut up so he put his hand over his mouth and he bit him. He bled like a stuck pig. The area hurt after he was bitten but it didn't hurt now, unless he bumped it. He was sent to the hospital, where they wrapped his arm and put him on an antibiotic. Resident N was a dumb a--. During the interview, Resident P's left wrist had two irregular shaped, dime sized scabs on it and the top of his left hand was bruised. Resident P's clinical record was reviewed on 8/9/23 at 9:52 a.m. Diagnoses included other specified disorders of brain, slurred speech, personal history of traumatic brain injury, post-traumatic stress disorder, chronic, and major depressive disorder, recurrent severe without psychotic features. His medications included duloxetine (depression) 30 mg (milligram) daily, divalproex sodium (mood stabilizer) 500 mg three times daily, risperidone (antipsychotic) 0.75 mg twice daily, and medroxyprogesterone acetate (hypersexuality)10 mg daily. He was administered amoxicillin potassium clavulanate (antibiotic) 875-125 mg every 12 hours for his left arm for seven days (7/21/23 - 7/28/23). A quarterly MDS (Minimum Data Set), dated 6/18/23, indicated he was severely cognitively impaired. He did not exhibit behaviors. He required extensive assistance of one staff member for transfers. He required supervision when walking in his room or the corridor. He used a walker and a wheelchair. He had a care plan for the potential for psychosocial well-being problems related to the incident with his peer (7/21/23). His interventions included consult with: pastoral care, social services, psychiatric services, etc. (7/21/23), encourage participation to make his own decisions (7/21/23), monitor/document his usual response to problems: Internal - how individual made his own changes, External - expected others to control problems or leaves to fate, or luck (7/21/23), and when conflict arose, remove him to a calm safe environment and allow him to vent/share feelings (7/21/23). He had a revised care plan for a history of physical aggression towards staff such as hitting, pushing, and shaking fists and placing hand over others mouth, etc. (7/21/23). His interventions included analyze times of day, places, circumstances, triggers, and what de-escalated the behavior and document (12/9/22), assess and address for contributing sensory deficits (12/9/22), encourage seeking out of staff member when agitated (7/21/23), and when he became agitated: intervene before agitation escalated, guide him away from sources of distress, engage calmly in conversation, if his response was aggressive, staff were to walk calmly away, and approach him later (12/9/22). His nurses notes indicated the following: An incident note, dated 7/21/23 at 12:57 a.m., indicated Resident P was sitting with another resident who was yelling, and he put his hand over the other resident's mouth. The other resident grabbed his arm and bit him on the arm, wrist, and hand. The aide and the nurse separated the residents. His arm was cleaned and the nurse called for an ambulance. He returned from the hospital with a dressing on his arm and antibiotics were given. His vitals were taken. A Social Service note, dated 7/21/23 at 10:41 a.m., indicated the night prior, Resident P was sitting by the nurses station next to a peer. The peer started yelling out and Resident P placed his hand over the peer's mouth and the peer bit him. The staff were able to separate them immediately and get them each to a safe area. The staff cleaned the area and he was sent to the hospital to be treated. He returned with a dressing to his arm and he was given antibiotics. He was unable to recall the incident this morning and he denied any psychosocial distress. A Nurse Practitioner (NP) visit note, dated 7/21/23, indicated the NP was notified the night prior, Resident P was involved in a peer to peer physical altercation. He allegedly put hand over another resident's mouth and the peer bit him. An order was given to send him to the ER (Emergency Room) where his wound was addressed and he was started on antibiotic therapy. Today, he was at his baseline. No psychosocial distress was noted. His left arm was bandaged with bruising on his hand and his arm area. A skin/wound note, dated 7/22/23 at 4:49 p.m., indicated he had some large purple bruising on both hands and bite marks located on his left hand. There was swelling present and some drainage at the site. A nurses note, dated 7/22/23 at 4:51 p.m., indicated the resident had complaints of pain and discomfort at the site of the bite. A new dressing was applied due to drainage. A Social Service note, dated 7/24/23 at 2:20 p.m., indicated he denied any psychosocial distress related to incident with peer and he was unable to recall what happened. A social service note, dated 7/26/23 at 4:43 p.m., indicated he had no recall of the incident with the peer from last week and denied any psychosocial distress. Resident N was observed on 8/9/23 at 12:30 p.m. ambulating in the hallway near his room. He was talking loudly to himself with extra emphasis to each last word of a phrase he spoke loudly (don't do drugs, don't steal you will go to jail). He ambulated into his room and sat on his bed and continued to speak loudly to himself. Resident N's clinical record was reviewed on 8/9/23 at 10:15 a.m. Diagnoses included schizophrenia, profound intellectual disabilities, syngap1-related intellectual disability and generalized anxiety disorder. His medications included doxepin (anxiety) 50 mg three times daily, risperidone (schizophrenia) 1 mg in the afternoon and 4 mg twice daily, trazodone (insomnia) 150 mg daily, olanzapine (schizophrenia) 5 mg three times daily, perampanel (convulsions) 6 mg daily, benztropine mesylate (epilepsy) 1 mg twice daily, lacosamide (epilepsy) 200 mg twice daily and clobazam (convulsions) 10 mg twice daily. A significant change MDS, dated [DATE], indicated he was moderately cognitively impaired. He did not exhibit behaviors. He required supervision while walking in the corridor, and locomotion on and off the unit. He walked in his room independently. He had a revised behavior care plan for yelling out in the common area. He yelled he was given the wrong medication and yelled for Dr. Bombay, etc. (8/8/23). His interventions included allow him time to voice frustration (5/28/22), approach calmly and in a soothing, non-judgmental manner (5/28/22), assess for pain and toileting needs (5/28/22), if in a common area/high activity area, please take him to his room to assist him (5/28/22),offer him a shower (6/26/23), offer him a snack or drink (5/28/22), offer to call his father for him to talk to (6/13/22), and turn the TV to Dukes of Hazard, Smokey and the Bandit, Batman, etc. (6/26/23). He had a revised care plan for repetitive verbalizations i.e.: will yell over and over for Dr. Bombay, talk about dogs, etc. (5/28/22). His interventions included allow him to express feelings and concerns (5/28/22),establish a caring relationship with him (5/28/22), offer him a Dr. Pepper (6/13/22), offer him a shower (6/13/22), praise him for attempts to gain attention appropriately (5/28/22), relay accurate information to him (5/28/22), talk to him in a calm voice (6/13/22), and try to determine the reason for preoccupation with questions and verbalization (5/28/22). He had a revised care plan for the potential to be physically aggressive to others related to poor impulse control, grabbing at others, or/and attempting to/or hit/bite at others, tried to choke staff/placed arm around the staffs neck, he spat at the staff, he attempted to hit the staff, he poked his fingers in the staff faces', and bite others, etc. (7/21/23). His interventions included two staff members were to redirect him with aggression/increase agitation for safety (6/11/23), when he was agitated attempt to assist him to an area away from peers (6/11/23), and when he became agitated; intervene before the agitation escalated, guide him away from the source of distress, engage him calmly in conversation, if his response was aggressive, staff were to walk calmly away, and approach him later (12/6/21). He had a revised care plan for the potential to be physically aggressive to others related to poor impulse, grab at others, or/and attempt to/or hit/bite at others, try to choke staff/place arm around staffs neck, spit at staff, attempt to hit staff, poke his fingers in staff faces, bite others, etc. (7/21/23). His interventions included assess and address for contributing sensory deficits (12/6/21), assess and anticipate his needs: food, thirst. toileting needs, comfort level, body positioning, pain etc. (12/6/21), monitor/document/report PRN (as needed) any sign or symptoms of resident posing danger to self and others (12/6/21), observe for any attempts to bite others and redirect as/if needed (5/15/23), offer snack/Dr. Pepper (7/21/23), offer to call his father for him to talk to (7/21/23), offer to put on Smokey and the Bandit, Dukes of Hazard, or Batman (7/21/23), and offer to take him outside for a walk (7/18/23). A behavior note, dated 5/6/23 at 9:21 a.m., indicated he had been quietly walking around the common area dining room, hall, and lounge. A female resident was heard yelling out from in the front of the nurse's station. Resident N was found standing beside a female resident who was in her Broda (high back chair with wheels) chair with top of her right hand bruised and a bleeding from a skin tear. The QMA reported he just had her hand in his mouth. The residents were separated immediately. Resident N stated he wouldn't had to hurt her if she didn't hurt him. He was redirected to his room. A nurses note, dated 6/1/23 at 10:42 a.m., indicated he was readmitted from an inpatient stay at a neuropsychiatric hospital. He was started on 15-minute checks. An incident note, dated 6/7/23 at 10:33 p.m., indicated Resident N was being escorted to his room, as he had an increase in aggressive behaviors. Per the nurse report, Resident N bit her on her shoulder and placed his arm around her neck tightly. He then followed her as she came to the nurses station where he continued with his behaviors, throwing himself onto the floor and banging his body onto the floor. A call was placed to 911 dispatch to report incident. The police and EMT's arrived at the facility and Resident N continued shouting and threw himself on the floor. He was escorted by stretcher to a local hospital ER. A nurses note, dated 6/8/23 at 7:15 a.m., indicated he was transferred to a local psychiatric hospital. An admission summary note, dated 6/9/23 at 8:05 p.m., indicated he was readmitted to the facility from being treated for aggression, paranoid schizophrenia, and TBI (Traumatic Brain Injury). There were no new orders or changes received from his hospital discharge. The Psychiatric NP was in the facility and new orders were received to increase his risperidone 1 mg to three times daily from twice daily. He was calm and cooperative at the time, walking through-out facility with his visitor. He was alert to self and some situations. He was able to verbalize simple needs. His speech was loud and clear and his hearing was adequate. An incident note, dated 7/21/23 at 3:42 a.m., indicated Resident N was sitting by the nursing station along side another resident. Resident N was yelling and the other resident put his hand over his mouth. He grabbed the other residents arm and bit him. An aide and a nurse separated the residents and made sure they were in a safe area. The ambulance was called for both residents. Resident N did calm down and went with the ambulance people with no problems. A nurses note, dated 7/21/23 at 3:45 a.m., indicated Resident N arrived back from the hospital. He had no new orders from the hospital. He walked up and down the hallway talking to himself. He was asked if he wanted to lay down and rest. He declined and stated he wasn't tired. A social service note, dated 7/21/23 at 10:35 a.m., indicated Resident N was yelling by the nurses station. A peer was sitting next to him and placed his hand over his mouth. He grabbed the peers arm and bit him. During an interview with the Social Service Director, on 8/9/23 at 11:46 a.m., she indicated Resident P had verbal and physical behaviors. There were no other recent incidents besides putting his hand over Resident N's mouth. Resident N repetitively talked, he would put himself on the floor, bang on the wall, and he bit someone else months ago. She was not sure where the biting was coming from, but Resident P did put his hand over his mouth. She was not able to find anyone to take Resident N for a psychiatric stay. B. Review of a facility-reported incident, dated 7/25/23, indicated a staff member had expressed agitation towards a resident verbally. During an interview with Resident J, on 8/9/23 at 12:13 p.m., he indicated he did not have any concerns with the staff members in the facility and everyone was nice to him. He asked what the date was and that he would be going home on August 22. On 8/9/23 at 4:48 p.m., Resident J was observed sitting in his wheelchair in front of nurses station talking with staff. Resident J's clinical record was reviewed on 8/8/23 at 12:43 p.m. Diagnoses included alcohol dependence, Wernicke's encephalopathy, delusional disorders, mild cognitive impairment of uncertain or unknown etiology, drug induced subacute dyskinesia, major depressive disorder, recurrent severe without psychotic features, generalized anxiety disorder, and psychotic disorder with hallucinations due to known physiological condition. His medications included, divalproex sodium (mood stabilizer) 750 mg twice daily, valbenazine tosylate (tardive dyskinesia) 40 mg daily, lithium carbonate (mood disorders)150 mg twice daily, quetiapine fumarate (depression) 300 mg at bedtime and 50 mg daily. An admission MDS, dated [DATE], indicated he was cognitively intact. He had delusions. He had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds that occurred one to three days of the assessment period. He required supervision for locomotion on and off the unit. He had an impairment on one side of his lower extremity. He used a wheelchair. He had a care plan for the potential for psychosocial well-being problem related negative interaction with staff (7/25/23). His interventions included allow the him time to answer questions and to verbalize feelings, perceptions, and fears (7/25/23), monitor/document his usual response to problems: Internal - how individual makes own changes, External - expects others to control problems or leaves to fate, or luck (7/25/23), Monitor/document his feelings relative to incident with peer (7/25/23), when conflict arises, remove him to a calm safe environment and allow him to vent/share feelings (7/25/23). He had a behavior care plan for yelling in the common areas (7/17/23). His intervention included allow him time to voice frustrations (7/17/23), approach him calmly and in a soothing, non-judgmental manner (7/17/23), assess for pain and toileting needs (7/17/23), if he was in common area/high activity area, please take him to his room to assist him (7/17/23), and offer him a snack or a drink (7/17/23). During an interview with the Social Service Director, on 8/9/23 at 11:46 a.m., she indicated she followed up with Resident J afterwards, and they completed an investigation and reported the allegation. Dietary Aide 12 did not have a history of saying things to the residents like that. Resident J would ask repetitive questions, for example, what date was it, when was he going to the group home, and why did he have to stay at the facility. During a phone interview with Dietary Aide 12, on 8/9/23 at 2:27 p.m., he indicated his employment at the facility was terminated because Resident J wanted to call his mom and he was throwing a fit. While he was trying to get the phone for him, he tried to run over three or four nurses with his wheelchair near the nurse's desk. Resident J was about to hit him with his wheelchair, and was threatening to kill himself and the staff. The Dietary Aide was very touchy about the staff being hurt by the residents. He heard Resident J had assaulted police officers in the past. He had also attacked a nurse, bit her, and put her in a head lock. He told the resident not to be a f--king d--k. Resident J had alcoholic dementia, he wasn't going to remember anything that he said to him, and getting mad at him was pointless. He apologized to Resident J for cussing at him. He was just being over protective of the nurses. During an interview with the DON, on 8/9/23 at 12:42 p.m., she indicated she had heard Dietary Aide 12 called Resident J a d--k, but she did not hear it herself. Review of a current facility policy titled, ABUSE PREVENTION AND PROHIBITION POLICY, provided by the Interim Administrator, on 8/8/23 at 12:31 p.m., indicated the following: .Policy .Residents residing in this facility will be treated with dignity and respect in accordance with their individual needs. They will not be subjected to physical, verbal .abuse This Federal tag relates to complaint IN00413773. 3.1-27(a)(1) 3.1-27(b)

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse by Resident C and Resident E for 4 of 4 residents reviewed for abuse (Resident B and Resident D). This deficient practice resulted in fear and tearfulness for Resident B, and using the reasonable person concept, would cause fear and anxiety for Resident D. Findings include: 1. During an interview with Resident B, on 2/24/23 at 11:28 a.m., she indicated Resident C had grabbed her by her neck and choked her, she didn't know why she had done it. She had been crying, but she was somewhat okay now. Review of Resident B's nurse's notes indicated the following: On 2/10/23 at 5:30 p.m., the CNA called the nurse to Resident B's room. The CNA had just been coming back up the hall and saw Resident C in the room, hitting Resident B and choking her. She had stopped Resident C and separated the residents. The nurse spent several minutes calming Resident B and doing relaxed breathing exercises. Resident B said thank you. I love you, grandma, and she didn't want Resident C with her no more. Fifteen-minute checks were initiated. The Administrator, and the psychiatric NP (Nurse Practitioner) were notified. On 2/10/23 at 7:17 p.m., a social service note indicated Resident C was in her room when staff walked by and observed Resident C hugging Resident B aggressively. The staff had separated the residents immediately. Nursing completed a skin assessment, and she denied any distress related to the incident. She was moved to another room and her care plan was updated. During an interview with RN 26, on 2/24/23 at 1:30 p.m., she indicated she saw nothing. She charted just what the aide told her. There was no indication that Resident C had her hands on Resident B. Resident B said Resident C was choking her and had hit her in her breast. She did not have red marks; she had a tiny pale mark on her right clavicle area. Resident B was dramatic. This day, Resident B had asked why there was a camera and she indicated to her cameras don't lie. Resident C had escalated the day in question. She did believe Resident C had touched Resident B, and went to her bedside, but she had never seen Resident C be physically violent. She punched at the air and got loud, very loud. She did not see Resident C push Resident D down, as she was sitting behind the nurse's station at the time, and she couldn't see over the desk. She couldn't remember who, but someone else said later it wasn't a push. During an interview with CNA 13, on 2/24/23 at 2:16 p.m., she indicated she was assisting another resident when she heard CNA 7 hollering for a nurse. She went to Resident B's and C's room and saw that she was in bed with Resident C's hands around her neck, her face was red, and she was gasping for air. They were trying to separate them, but Resident C kept trying to get to her, and CNA 7 was in the middle of them. The nurse was not in the room yet, so she went to get her. Once they got them separated, she tried to talk to Resident C, and for her to think about what she was doing and had tried to redirect her. She had never seen Resident C put her hands on another resident. She would get worked up every once in a while and was known to yell at residents and slam doors. She liked her privacy and didn't like for people to go through her stuff. During an interview with CNA 17, on 2/24/23 at 2:31 p.m., he indicated he heard staff screaming for help and entered Resident B's room. Resident B and C were mostly separated when he entered the room. Resident B's face was red and her lips were blue. She was lying in bed, with her covers on, and Resident C was on the side of her bed, between her bed and the window. Resident C was actively swinging at Resident B, and was hitting her on the side of her head with the side of her hand. CNA 7 was behind Resident C, trying to pull her off Resident B. They had to physically remove Resident C from the room for Resident B's safety. He spent between 30 to 40 minutes walking with Resident C, trying to calm her down while nurses were checking on Resident B. She calmed down, but was still in a distressed state, and she was not excited to see the EMTs at the facility. She didn't normally assault anyone. She would scream almost to the point of passing out and could almost be manic. She had behaviors, but not violent with the residents. She gave a lot of warning signs before she would get violent. During an interview with Laundry Aide 8, on 2/24/23 at 4:12 p.m., she indicated Resident C was in the hallway rambling, and doing her schizophrenic thing at the nurse's station. Resident D was standing near the short wall, and she intentionally pushed Resident D with both hands on her chest, and she fell to the floor and onto her bottom, another resident was behind her and bent down to keep her from hitting her head on the half wall. Resident D was helped up off the floor and didn't act like she was hurt. Resident C kept acting out, rambling and swinging at RN 26 but didn't hit her. She refused to go on the ambulance. A couple CNAs got her to go outside and got her on the gurney. She seemed to have her screaming outbursts more often. She had never seen her touch another resident or staff until that day. Resident B was shook up by what Resident C had done to her. During an interview with CNA 7, on 2/27/23 at 10:02 a.m., she indicated she took a resident to her room, and when she walked back by Resident B and C's room, Resident C was yelling and screaming. The curtain was pulled but it looked like Resident C was pounding on something. Resident C was on Resident B's right side between her bed and the window, she was pounding on Resident B with the bottom of her fist in her chest area Resident B was screaming but couldn't hear her because of her voice is so low, then Resident C had both hands around Resident B's neck and was choking her. Resident B was turning blue. She started yelling and screaming for help. CNA 17 walked past the room and grabbed Resident C's other hand and redirected her out of the room. CNA 17 also yelled for help. RN 26 came down to the room and checked Resident B's neck. Once Resident C was removed from the room she immediately started pushing and yelling at staff in the halls. She pushed Resident D down hard with both hands to her chest area and Resident D hit the floor. She was yelling and cussing and telling everyone to get out of her way, they tried to calm her down. RN 26 immediately tried to step in front of Resident D while they were helping her up and Resident C started hitting RN 26. By then the EMTs were at the facility and they couldn't force her to go. Herself and another aide proceeded to grab Resident C from hitting other residents and she kicked QMA 24 in the leg. She had never seen Resident C be aggressive or have physical contact with another resident. She would just go off, by yelling and screaming. Resident B's clinical record was reviewed on 2/24/23 at 9:42 a.m. Diagnoses included major depressive disorder, recurrent, down syndrome, schizoaffective disorder, bipolar disorder, mild cognitive impairment of uncertain or unknown etiology, need for assistance with personal care, and muscle weakness (generalized). Her medications included hydrocodone-acetaminophen (narcotic pain reliever) 5-325 mg (milligram) twice daily, fluoxetine (treat depression) 20 mg daily, asenapine maleate (treat mental disorders) 10 mg twice daily, trazodone (treat sleep disorder) 200 mg daily, and olanzapine (treat mental disorders) 15 mg daily. An admission MDS (Minimum Data Set), dated 1/30/23, indicated she was moderately cognitively impaired. She required limited assistance for bed mobility and locomotion on and off the unit. She required extensive assistance for transfer, dressing, toilet use and personal hygiene. She required supervision for walking in her room and the corridor. She used a wheelchair. She had verbal behavioral symptoms directed towards others (e.g., threatening others, screaming at others, cursing at others) that occurred one to three days during the assessment period. She had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) that occurred one to three days during the assessment period, and she wandered one to three days during the assessment period. She had a current care plan for the potential for psychosocial well-being problem, related to an incident with a peer, initiated on 2/10/23. Her interventions were initiated on 2/10/23 and included the following: pastoral care, social services, psychiatric services, etc., encourage participation from resident who depends on others to make own decisions, increase communication between resident/family/caregivers about care and living environment: explain all procedures and treatments, medications, results of labs/tests, condition, all changes, rules, options, monitor/document resident's usual response to problems: internal - how she made her own changes, external - expects others to control problems or leaves to fate, or luck, provide opportunities for her and family to participate in care, when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. 2. Review of Resident D's nurse's notes indicated the following: On 2/2/23 at 8:15 a.m., Resident D was walking in the hallway, and Resident E came up behind her, and hit her in the neck and upper back area. There were no skin issues, distress or discomfort noted. On 2/10/23 at 5:45 p.m., in the front, left side of the nurse's station, a CNA asked the nurse if she had seen Resident C reach between the EMTs and push Resident D down to the ground. ROM (Range of Motion) was checked, and she was able to move all four extremities without difficulty. She had no signs or symptoms of pain or discomfort. She had no verbal response, per her baseline. She was free of reddened, discolored, or open areas. She was assisted onto her feet by two CNAs, with extensive assistance. She walked away into the dining room. On 2/24/23 at 1:30 p.m., Resident D was observed ambulating independently in the hall and common area. On 2/27/23 at 10:27 a.m., she was observed sitting on the couch in the common area with her head down. On 2/27/23 at 1:00 p.m., she was observed sitting on the couch in the common area. Resident D's clinical record was reviewed on 2/24/23 at 11:18 a.m. Diagnoses include unsteadiness on feet, other lack of coordination, restlessness and agitation, generalized anxiety disorder, muscle weakness (generalized), cognitive communication deficit, delusional disorders, unspecified dementia, severe, with psychotic disturbance, agitation, anxiety, and other behavioral disturbance. Medications included buspirone (treat anxiety) 10 mg four times daily, medroxyprogesterone acetate (treat hypersexual behaviors) 5 mg daily, escitalopram oxalate (treat depression) 20 mg daily and olanzapine 5 mg twice daily. A quarterly MDS, dated [DATE], indicated she was severely cognitively impaired. She required extensive assistance for bed mobility, transfers and toilet use. She required limited assistance for walking in her room and the corridor, and for locomotion on and off the unit. She required extensive assistance for dressing and personal hygiene. She did not use an assistive device. She had delusions. She had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) that occurred one to three days during the assessment period. She had other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds), she rejected evaluation of care and wandered four to six days of the assessment period. She had a current care plan for the potential for psychosocial well-being problem, related to a peer attempted to smack at her initiated on 2/2/23. Interventions were initiated on 2/2/23 to allow her time to answer questions and to verbalize feelings perceptions, and fears, monitor/document her usual response to problems: internal - how individual made her own changes, external - expects others to control problems or leaves to fate, or luck, when conflict arises, remove residents to a calm safe environment and allow to vent/share feelings. The ADON provided a copy of the 2/10/23 at 5:45 p.m., progress note for Resident D, with a handwritten statement by the ADON dated 2/11/23, indicating the following: Per follow up, it was determined that contact was never made. Nurse did not visually witness and CNA stated it appeared that way but never actually seen contact. So actual push was assumed During an interview with RN 41, on 2/27/23 at 11:27 a.m., she indicated staff were sitting at the nurse's station. Resident E had just come back from the hospital and was having behaviors. Resident D was wandering up and down the hall like she always did. Resident E thought Resident D had on a red sweatshirt that was hers. Resident E open-handed slapped Resident D in the neck and upper back. Resident D just kept walking. Resident E was taken back to her room and Resident D came up by the nurse's station. The incident was reported to Social Service because she was in the building at the time, and she was going to call the Administrator. Skin assessment and vitals were completed under risk management. 3. Resident C's clinical record was reviewed on 2/24/23 at 9:58 a.m. Diagnoses included schizoaffective disorder, bipolar type, unspecified intellectual disabilities, post-traumatic stress disorder, delusional disorder and anxiety disorder. Medications included quetiapine fumarate (treat bipolar disorder) 200 mg twice daily, haloperidol (antipsychotic) 5 mg three times daily and buspirone (treat anxiety) 15 mg four times daily. A quarterly MDS, dated [DATE], indicated she was moderately cognitively impaired. She required extensive assistance for bed mobility and toilet use. She required supervision for locomotion on and off the unit. She required limited assistance for dressing and personal hygiene. She did not use an assistive device. She had hallucinations and delusions. She had a behavior care plan, initiated on 8/23/22 and revised on 2/10/23, for yelling out in common areas, cursing, etc. Her interventions were initiated on 8/23/22 and included allow her time to voice frustrations, approach calmly and in a soothing, non-judgmental manner, assess for pain and toileting needs, if in common area/high activity area, please take me to my room to assist me, offer her a snack or drink and psychiatric consult as needed. She had a care plan, initiated on 2/10/23, for was/had potential to be physically aggressive. Her interventions, initiated on 2/10/23, were administer medications as ordered, monitor/document for side effects and effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and address for contributing sensory deficits, assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain etc., monitor/document/report PRN any signs or symptoms of resident posing danger to self and others, when the she became agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. Review of her nurses notes indicated the following: On 2/1/23 at 2:37 p.m., she got upset and threw blue water pitcher down the hall. On 2/1/23 at 4:21 p.m., she was in the common area, in the chair when she began to scream out loudly. Another resident was talking to himself when she rose up from the chair and started to yell at him These terrorists, same s---, different day. On 2/10/23 at 1:15 p.m., she had been rapidly pacing the halls and the common areas, while yelling and screaming in very loud aggressive tone on and off all morning. A call was placed to the psychiatric NP with a new order for no caffeinated coffee and to give afternoon Haldol (antipsychotic), early one time. On 2/10/23 at 5:30 p.m., the nurse was called to her room by the CNA that she needed a nurse right now. I need a nurse right now. The CNA said that she was just coming back up the hall and I saw Resident C on Resident B's side of the room and she was hitting her and choking her. She came in and stopped her right away. Resident C was in the hall screaming that the aliens were yelling and being overdosed on melatonin that was really medical marijuana. She was screaming loudly, her voice becoming hoarse and she was unable to be de-escalated. She paced rapidly. Resident C and B were separated, safety ensured, 15 minute checks were initiated immediately and the Administrator and psychiatric NP was notified a new order was received to send her to the emergency room for evaluation and treatment. A social service note, dated 2/10/23 at 5:31 p.m., indicated upon arrival to facility this morning resident was walking rapidly up and down the halls yelling, cursing, and screaming. Not talking to anyone, but just yelling and cursing. She was asked what was wrong and she stated she was being overdosed with melatonin, the aliens kept her up all night and kept yelling as she was walking. She was able to be calmed down. She continued to have episodes of yelling, cursing up and down the halls about every half hour or so this day. Multiple staff attempted to redirect her with multiple interventions and none were successful but for a few minutes at a time. Around 1:20 p.m. the psychiatric NP was notified about her behaviors and she gave an order for staff to administer her 2:00 p.m. Haldol early. She refused and threw the medication at first. After a few minutes, she took the medication as she was yelling and cursing about being drugged, kidnapped, etc. After the medication was administered she calmed for about 45 minutes, but then started to yell and curse again with talking to no one in particular. On 2/10/23 at 5:45 p.m., two EMTs were present with a stretcher to transfer her to the hospital. She refused to get on the stretcher, and stated she was not going. Then, the CNAs reported she had just reached between them and pushed another resident down on the ground. Staff attempted to calm her, and she pointed her finger aggressively at the nurse and screamed harshly that the nurse f-----g killed [NAME] and reached out and hit the nurse on her left forearm and right hand. Resident C was walked out to the ambulance. A social service note, dated 2/10/23 at 7:12 p.m., indicated Resident C was in her room with her roommate, when staff walked by and seen her aggressively hugging her roommate. Staff intervened immediately and they were separated. She was placed on one on ones while the psychiatric NP was called. The NP wanted her sent to the emergency room for evaluation. When EMT's arrived to take her, she refused to go and was yelling, screaming, and hitting staff. She did get on the stretcher and allowed to be taken to the emergency room. An IDT (Interdisciplinary Team) note, dated 2/12/23 at 9:36 a.m., indicated after interviewing staff and residents, during the altercation she had with the EMTs, it was determined she didn't push the other resident. The other resident in question was wondering the halls and happened to be by the altercation. 4. Resident E's clinical record was reviewed on 2/27/23 at 10:25 a.m. Diagnoses included Parkinson's disease, schizophrenia, major depressive disorder, recurrent, anxiety disorder, altered mental status, cognitive communication deficit, unspecified mood [affective] disorder, severe intellectual disabilities, personal history of traumatic brain injury, unspecified convulsions and anoxic brain damage. Her medications included lacosamide (treat seizures) 150 mg twice daily, risperidone 1 mg three times daily, buspirone 15 mg three times daily, lorazepam (treat anxiety) 1 mg three times daily, and divalproex sodium (anticonvulsant) 500 mg three times daily. A quarterly MDS, dated [DATE], indicated she was severely cognitively impaired. She required extensive assistance for bed mobility, transfers and toilet use. She required limited assistance for walking in her room and corridor, locomotion on and off the unit. She required extensive assistance for dressing, and personal hygiene. She had an impairment to one side of her upper extremities. She rejected evaluation or care and wandered one to three days during the assessment period. She had a care plan, initiated on 3/4/21 and revised on 2/2/23, for episodes of physical aggressive and behaviors of throwing items at staff ie: glasses and stuffed animals. She attempted to smack at others due to belief that others had her belongings. Her interventions were initiated on 3/4/21, to administer medications as ordered, monitor/document for side effects and effectiveness, analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document, assess and anticipate her needs: food, thirst. toileting needs, comfort level, body positioning, pain etc., communication: assist verbalization of source of agitation and give positive feedback, give the her as many choices as possible about care and activities, monitor/document/report PRN (as needed) any signs or symptoms of resident posing danger to self and others, when she became agitated: intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; if response is aggressive, staff to walk calmly away, and approach later. A mental health clinician would work with her on positive and negative ways to display her anger initiated on 4/28/21. She had a current care plan problem of potential for a psychosocial well-being problem related to alleged incident with peer initiated on 12/6/21. Her interventions were monitor/document her usual response to problems: internal - how individual makes own changes, external - expects others to control problems or leaves to fate, or luck and when conflict arises, remove residents to a calm safe environment and allow her to vent/share feelings initiated on 12/6/21. Consult with: pastoral care, social services , psychiatric services revised on 12/11/21. Review of her nurses notes indicated the following: On 2/2/23 at 7:41 a.m., she continuously screamed out and yelled at other residents. She thought other resident's items were hers. She attempted to grab items from others. She got upset with redirection and threw her glasses into the dining room. On 2/2/23 at 8:04 a.m. she was walking down the hall when another resident was in the hallway. She believed her shirt was on the other resident. She began to shout and hit the other resident in the back and the neck. They were separated and she was redirected to her room. She continued to shout as she was redirected. A social service note, dated 2/2/23 at 12:42 p.m., indicated she was yelling and screaming, attempted to grab items from others, due to belief that the items were hers, and when staff attempted to redirect her, she became upset and threw her glasses. A little later she was walking down the hall and believed that a peer had on her shirt. She started yelling and smacked at the residents back. A late entry, IDT note dated 2/6/23 at 7:06 p.m., indicated an intervention of 15 minute checks was implemented. She was safe afterwards. An current, undated, facility policy, titled ABUSE PREVENTIONS AND PROHIBITION POLICY, provided by the Administrator on 2/24/23 at 9:41 a.m., indicated the following: PURPOSE: To ensure the resident's right to remain free from .physical abuse .POLICY .Residents residing in this facility will be treated with dignity and respect in accordance with their individual needs. They will not be subjected to physical .abuse Cross reference F609. This Federal tag relates to complaint IN00401525. 3.1-27(a)(1)

Based on observation, interview, and record review, the facility failed to prevent physical and emotional abuse for 1 of 3 residents reviewed for abuse prevention (Resident F). Using the reasonable person concept, it is likely this deficient practice would lead to chronic anxiety, or fear. Findings include: The clinical record for Resident F was reviewed on 11/14/2022 at 10:31 a.m. Diagnoses included, but were not limited to, Huntington's Disease, major depressive disorder and cognitive communication deficit. Review of a current quarterly Minimum Data Set (MDS) assessment, dated 9/15/2022, indicated the resident was severely cognitively impaired. Review of Resident F's current care plans indicated the following: Resident has behaviors not directed towards others of crawling on the floor and into hall. Date Initiated: 02/23/2021 Revision on: 02/23/2021. Goal: Resident will have no injury related to crawling on the floor and in the halls through next review. Date Initiated: 02/23/2021 Revision on: 09/05/2022. Interventions: Assess for pain and toileting needs. Date Initiated: 02/23/2021. Offer snack or drink. Date Initiated: 02/2021. Psych consult as needed. Date Initiated: 02/23/2021. Resident has episodes of disrobing as evidenced by: will take off all of her clothes and come out of room Date Initiated: 02/20/2021 Revision on: 02/20/2021. Goal: Resident will remain adequately clothed, maintain dignity, and will stop disrobing through next review. Date Initiated: 02/20/2021 Revision on: 09/05/2022. Interventions: Asses for pain, toileting need, etc. Date Initiated: 03/03/2021. Instruct resident to not disrobe and reorient to surroundings as needed. Date Initiated: 02/20/2021. Observe resident frequently for intact clothing. Assist with putting clothes back on as needed. Date Initiated: 02/20/2021. Offer food, snack. Date Initiated: 03/03/2021. Question resident to ascertain any possible needs (toileting, etc.) Date Initiated: 02/20/2021. Refer to activities for diversion, if appropriate. Date Initiated: 02/20/2021. A security video, dated 10/30/2022 from 9:04 a.m. to 9:37 a.m., was reviewed on 11/14/2022 at 12:17 p.m. with the acting Administrator. During the review the following was observed: At 9:04 a.m., the resident was observed on the floor, crawling into the hallway, naked. The Laundry Supervisor and the Housekeeping Supervisor were observed in the area. These employees did not approach the resident. At 9:31 a.m., CNA 1 approached the resident. Audio was not clear and no verbal exchange could be heard. The CNA did not cover the resident, nor appear to attempt to assist or direct her back into her room. At 9:36 a.m., CNA 1 was observed dragging the resident into her room. Due to the angle and quality of the video, it was not clear if the CNA dragged the resident by the arm or leg. At 9:37 a.m., CNA 1 observed leaving the resident's room. During the video review, from 9:04 a.m. to 9:37 a.m., the resident could be seen rolling around on the floor and attempting to sit up and fall back onto the floor (for a 33 minute period). During these 33 minutes, several staff members were observed walking past the resident with no attempts to cover the resident or take her back to her room. Several resident's (male and female) were observed walking past or attempting to maneuver around Resident F in wheelchairs. Staff members did not assist or provide interventions. The resident remained on the hallway floor, naked, for thirty-three minutes. At 10:02 a.m., the resident was observed on the floor crawling into the hallway. The resident was again naked. The Laundry Supervisor and the Housekeeping Supervisor were observed walking past the resident. Male and female residents were observed walking or maneuvering wheelchairs around Resident F. At 10:04 a.m., CNA 2 was observed walking around the resident without intervention. At 10:15 a.m., CNA 2 was observed attempting to cover the resident with a gown. CNA 1 and CNA 2 were observed picking the resident up off the floor and taking her into her room. Resident F remained on the floor, naked and without intervention for an additional thirteen minutes. During an interview, at the time of the video viewing, the acting Administrator and the ADON each indicated the staff had not met the resident's needs. The acting Administrator indicated the resident should never have been left on the floor naked in a common area. Staff should have attempted to take the resident back to her room and dressed her or put a gown or covering on her while she was in the hallway. The resident should not have been dragged on the floor. The acting Administrator indicated CNA 1's employment had been terminated. During an interview, on 11/14/2022 at 1:47 p.m., Laundry Aide 7 indicated he had worked on October 30, 2022. The Laundry Aide indicated he saw Resident F on the floor naked. The resident is known for this behavior and does it daily. During an interview, on 11/14/2022 at 1:47 p.m., QMA (Qualified Medication Assistant) 6 indicated on October 30, 2022, she had seen Resident F naked on the floor in hallway several times. The QMA indicated she did not provide covering or any intervention for the resident. We had a lot of behaviors that day. It is not an excuse, to indicate the resident should not been left uncovered. During an interview, on 11/14/2022 at 2:26 p.m., CNA 5 indicated Resident F was known for disrobing in common areas and crawling on the floor. The CNA indicated staff were to attempt to get her back to her room and put clothes on her or cover her while she was in the common area. The CNA indicated it would not have been appropriate to leave the resident naked on the floor. During an interview, on 11/15/2022 at 10:18 a.m., the Assistant Director of Nursing indicated staff did not act appropriately. Resident F should have been redirected to her room and clothed. If the staff could not redirect the resident back to her room, they should have placed a gown on her or covered her while in the hallway. The ADON indicated the resident should not have been dragged across the floor to her room by staff. Review of a current undated policy titled Abuse Prohibition indicated the following: .Procedure . 2. Should an occurrence of abusive behavior be reported or witness, the Administrator shall be notified immediately . 4. The staff who witness or was made aware of the abusive incident will take immediate steps to protect The involved resident from further abuse, including verbal/mental/physical/neglect/involuntary seclusion and/or exploitation. Such steps could include, but are not limited to: a. Physically removing the resident(s) from the abusive environment. b. Physically removing the perpetrator of the abuse from the environment This Federal tag relates to complaint IN00393778. 3.1-27(a)(1)