The facility reported a census of 51 residents. The sample included six residents who were reviewed for abuse. Based on observation, interview, and record review, the facility failed to ensure residents remained free from resident-to-resident abuse when, on 09/03/25 at approximately 05:00 AM, Resident (R)1 wandered into R2's room and struck R2, a cognitively and physically impaired resident, in the head. Findings included:- R1's Electronic Health Record (EHR) documented diagnoses that included unspecified dementia (a progressive mental disorder characterized by failing memory and confusion).R1's 07/28/25 admission Minimum Data Set (MDS) documented a Brief Interview for Mental Status (BIMS) score of eight, which indicated moderately impaired cognition. The assessment documented R1 had physical behavioral symptoms directed towards others, rejection of care, and wandering behaviors that occurred one-to-three days during the look-back period.The 07/28/25 Behavioral Symptoms Care Area Assessment (CAA) documented R1 had wandering behaviors with rejection of care. The CAA documented risk factors included invading others' space and disruptions during activities and in the common areas.R1's 08/19/25 Significant Change Minimum Data Set was incomplete.R1's Care Plan dated 07/29/25 documented R1 wandered aimlessly and directed staff to develop a rapport and trust with R1 through regular visitation. The plan directed staff to anticipate R1's needs by following his physical or non-verbal indicators of discomfort and distress and follow up as indicated. Review of R1's EHR Progress Notes revealed the following: On 09/03/25 at 07:52 AM, Licensed Nurse (LN) G documented on 09/03/25 at 05:00 AM, staff heard someone yelling and found R1 in R2's room. R2's wife reported R1 had hit her and was trying to hit R2. LN G documented R2 nodded his head to indicate yes and rubbed the left side of his forehead when asked if R1 had hit him. LN G documented R2 had a red area on the left side of his forehead. LN G documented Administrative Staff A ordered one-on-one observation of R1.On 09/05/25 at 11:45 AM, LN I documented R1 left the facility with facility staff and his wife to go to a behavioral health unit (BHU).On 09/29/25 at 05:15 PM, LN I documented R1 arrived at the facility via Emergency Medical Services (EMS) from the hospital.The facility's investigation documented on 09/03/25 at 05:00 AM, staff heard yelling from R2's room and entered to find R1 swinging (fists) at R2's wife. Staff were able to remove R1 from R2's room and returned R1 to his room. The nurse assessed R2 and found a red mark on his upper left forehead without swelling or bruising.LN G's undated and unnotarized Witness Statement documented on 09/03/25, someone was yelling down the hall, and R1 was found in R2's room. R2's wife was present and reported R1 had hit her and said she was unsure if R1 had struck R2. R2 nodded yes when asked if R1 had hit him and rubbed the left side of his forehead. LN G documented R2 appeared to have a red area on the left side of his forehead. LN G also documented R1 was violent with staff and struck staff. LN G notified Administrative Staff A and was instructed to notify EMS and Law Enforcement Officers (LEO). Administrative Staff A ordered one-on-one observation for R1.Certified Nurse Aide (CNA) M's undated and unnotarized Witness Statement documented on 09/03/25 at an unknown time, she and CNA O heard yelling and went to investigate. Upon entering R2's room, R1 was standing between the bed and the wall with his arm up like he was ready to swing at R2; R2's wife was shielding him from R1. Staff removed R1 from R2's room, and R1 became violent and punched CNA M and kicked CNA O.CNA O's undated and unnotarized Witness Statement documented on 09/03/25 at an unknown time, she and CNA M heard yelling and went to investigate. R1 was observed with his arm up as if to hit R2, and R2's wife was attempting to block R1. Staff removed R1 from R2's room, and R1 became violent and punched CNA M and kicked CNA O.Administrative Staff B's undated and unnotarized Witness Statement documented on 09/03/25 at approximately 05:15 PM, she helped complete a care plan in R2's room and did not notice any marks on R2.Administrative Staff A's undated and unnotarized Witness Statement documented on 09/03/25 at an unknown time; no injuries were observed on R2's face or arms.Social Services X's undated and unnotarized Witness Statement documented on 09/03/25 at an unknown time; no injuries were observed on R2.Administrative Staff A's undated and unnotarized Witness Statement documented on 09/05/25 at 12:45 PM, LN I reported to Administrative Staff A that R2 had a black eye. Administrative Staff A documented that she and Activity Z went to R2's room and did not observe any bruising, swelling, or redness in R2's eyes or face.Administrative Nurse D's undated and unnotarized Witness Statement documented on 09/03/25 and 09/05/25 at unknown times, she looked at R2's face and did not see any bruising.Activity Z's unnotarized Witness Statement, dated 09/05/25 at 12:30 PM, documented she went with Administrative Staff A to R2's room to provide informational materials to R2's wife, and R2 did not have swelling, redness, or bruising to his face.Consultant GG's undated and unnotarized Witness Statement documented on 09/08/25 at approximately 10:30 AM, she was visiting with R2's wife regarding consultant/contract services after R2's discharge home, when R2's wife started to report unhappiness about how an abuse situation was handled. Consultant GG stopped R2's wife and reported the concern to Administrative Staff A. Administrative Staff A came into the room to speak with R2 and his wife. R2's wife stated she wanted to press charges against another resident.Administrative Staff A's unnotarized and undated Witness Statement documented on 09/08/25 at an unknown time, R2's wife reported to Consultant GG that she wanted to report to LEO and requested charges be filed against R1. Administrative Staff A went into the room and met with R2's wife, who requested to speak to LEO. Administrative Staff A called the police, and a LEO met with R2's wife.Review of the facility's investigation revealed documentation of one-on-one observation of R1 from 09/03/25 through 09/04/25.During an observation on 10/01/25 at 12:25 PM, R2 sat in his wheelchair in his room with his wife present.During an observation on 10/01/25 at 01:00 PM, R1 rested on his bed in his room with family present.During an interview on 10/01/25 at 12:25 PM, R2's wife reported R1 entered R2's room four times that she knew of before the incident on 09/03/25. R2's wife stated she was able to redirect R1 out of R2's room without incident, but on the morning of 09/03/25, she was awakened by R1 entering the room; R1 interlaced his fingers, raised his hands above his head, and tried to strike R2. R2's wife said she placed her arms and body between R2 and R1 and started yelling for help, and R1 struck her prior to staff responding and removing R1. R2's wife stated that at the time of the incident, she was unsure if R1 had struck R2 but confirmed facial bruising later developed.During an interview on 10/01/25 at 12:40 PM, CNA N reported on the morning of 09/03/25, the night shift informed her of an altercation between R1 and R2. Upon entering R2's room, she observed a bruise to R2's face near his eye. CNA N said if staff observed or suspected resident-to-resident abuse, staff should separate the residents and alert the nurse with the two-way radio, ensure the residents were safe, follow instructions from the nurse, and immediately fill out a report and/or witness statement.During an interview on 10/01/25 at 12:55 PM, Certified Medication Aide (CMA) R said if resident-to-resident abuse was observed or suspected, staff were instructed to separate the residents and redirect them as appropriate to ensure a safe environment. Staff would then alert other staff to notify the nurse, then follow instructions the nurse provided, and provide a written report and/or witness statement for the nurse. CMA R reported she was aware of the incident between R1 and R2 but was not directly involved in the event.During an interview on 10/01/25 at 01:15 PM, CNA P reported when she came to work on the morning of 09/03/25, R2 had bruising on his face near his eye. CNA P said Administrative Staff A spoke with staff to convince them nothing happened to R2.During an interview on 10/01/25 at 02:15 PM, LN H said if staff observe or suspect resident-to-resident abuse, they should separate the residents to ensure safety and alert other staff to let the nurse know or notify the nurse directly. When the nurse arrived in the area, the nurse would perform assessments and provide aid if needed, and document any injuries in the report and in the EHR progress notes. LN H said the nurse would collect written statements by any staff directly involved, notify administration and law enforcement, and fill out an incident report, including the witness statements from staff. LN H said she was aware of the incident between R1 and R2 but was not directly involved in the incident.During an interview on 10/01/25 at 02:40 PM, Administrative Staff A said that if resident-to-resident abuse was observed or suspected, the expectation was for staff to separate, ensure the safety of the residents, provide aid as necessary, and notify the nurse. The nurse was expected to call the building administration, the resident's physician, LEO, EMS, and the residents' representatives. If there was any suspicion that any resident struck another resident, the nurse should also collect written witness statements from the staff. If the incident was willful abuse, then a report would be filed with the State Agency (SA). Administrative Staff A stated on the morning of 09/03/25, she received a call from the nurse who reported R1 entered R2's room and struck R2 and hit R2's wife. Administrative Staff A confirmed LEO and EMS were notified. Administrative Staff A reported R1 was placed on one-on-one observation by Administrative Staff A until 08:00 AM, when R1's wife arrived and assumed one-on-one observation until she left at 06:00 PM. Staff then provided one-on-one observation if R1's wife was not present until R1 was transferred to a BHU. Administrative Staff A stated she had not reported the incident to the SA as required.The facility's Abuse, Neglect and Exploitation Policy and Procedure policy, dated 05/2023, documented that the facility prohibited abuse from any perpetrator that included but was not limited to staff, volunteer, contracted staff, vendor, family member, visitor, or any other resident.This deficient practice was cited at a scope and severity of G (actual harm, isolated) to reflect fear and anxiety because of the noncompliance using the reasonable person concept due to R2's impaired cognition.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility had a census of 42 residents. The sample included 12 residents, with two reviewed for pressure ulcers/pressure injury (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, record review and interview, the facility failed to implement interventions to prevent the development of a facility-acquired, right heel pressure ulcer for Resident (R)22 and R39 who were at risk for pressure injuries. Findings included: - R22's Electronic Medical Record (EMR) documented she admitted to the facility on [DATE] from the community. R22's EMR documented she had diagnoses of unsteadiness, osteoporosis (abnormal loss of bone density and deterioration of bone tissue with an increased fracture risk), and reduced mobility. R22's admission Minimum Data Set (MDS), dated [DATE], documented R22 had a Brief Interview of Mental Status (BIMS) score of 15, which indicated intact cognition. R22 required extensive assistance of one staff for transfers, walking in the room, toilet use, and bed mobility. The MDS recorded the resident had pressure reducing devices to her bed and chair but had no pressure ulcers and was not at risk for pressure injuries. The 09/23/22 Pressure Ulcer Care Area Assessment triggered and addressed in the care plan. The 09/10/22 Braden Scale (an assessment used to measure risk for pressure ulcer development) documented R22's score was 18, which indicated R22 was at risk for developing a pressure ulcer. R22's Quarterly MDS dated 04/19/23, documented R22 had a BIMS score of 12, which indicated moderate cognitive impairment. The MDS documented the resident did not walk and required total staff assistance with locomotion. R22 required extensive staff assistance with most activities of daily living (ADL) including bed mobility. The MDS documented the resident had lower extremity impairment on one side. The MDS recorded the resident had one unhealed stage three (full thickness skin loss) pressure injury, was at risk for pressure injuries, and had pressure reducing devices on her bed and wheelchair but was not on a turning and/or repositioning program. R22's ADL Care Plan, revised on 04/14/23, documented R22 required one staff assistance with ADLs except eating. R22's Skin Integrity Care Plan dated 09/28/22 and revised on 12/08/22 directed R22 was at risk for alteration in skin integrity as evidenced by a pressure area to the right heel. The care plan instructed the charge nurse to perform weekly skin assessments and notify the nurse if R22 had any new skin issues (initiated on 09/28/22). The care plan instructed staff to place heel protectors on R22 at all times and place a pressure reducing mattress to her bed at all times (created on 03/10/23 with initiation backdated to 10/05/23). The care plan lacked evidence of pressure injury preventative measures developed and/or implemented prior to development of the pressure injury. A Nurses Note, dated 10/06/22 at 10:15 AM documented staff noted an intact blister to R22's right heel which measured 4.7 centimeters (cm) by 6.7 cm. Staff notified the physician and staff placed heel lift boots on R22's bilateral feet. The note recorded staff would use skin prep (liquid skin protectant) twice a day to the area. The 12/05/22 at 09:30 AM, Wound Specialist Note documented R22 had an unstageable (full-thickness pressure injuries in which the base is obscured by slough [moist, loose, stringy dead tissue] and/or eschar [dry dead tissue]) pressure ulcer on her right heel. The wound was there for over a month. R22 received clindamycin (antibiotic medication) for infection. The note documented the right heel ulcer was debrided (medical removal of dead, damaged, or infected tissue to improve the healing potential for the remaining healthy tissue), and the ulcer increased in size in all dimensions by one millimeter (mm). The bone was exposed, and a wound culture was obtained. The note documented a vacuum assisted closure device (Wound-Vac-device which decreases pressure on the wound to help the wound heal more quickly) was ordered. The 01/19/23 at 09:15 AM Wound Specialist Note documented R22's right heel ulceration to the posterior (back) aspect of the right heel measured 4 cm by 3.4 cm and was granular in nature, had odor, and a Wound-Vac was placed on the ulcer. The 05/15/23 at 02:45 PM Wound Specialist Note documented R22's ulcer to the posterior (back) aspect of the right heel measured 3.8 cm by 2.2 cm and had one area of eschar on the top of the wound, and the physician instructed staff to use Santyl (a medication used to remove dead skin tissue and aid in wound healing) on the area with eschar. On 06/22/23 at 10:35 AM, R22 sat in a recliner with the footrest up and heel protectors on. LN H asked the resident if he could change the dressing to her right heel. R22 consented. LN H applied gloves, sat the items on a bedside table after removing other items, then removed the residents heel protector boot on her right foot. LN H removed a four-by-four gauze pad and revealed a small amount of serosanguineous (semi-thick reddish drainage) drainage on the dressing. The wound was approximately 4 cm in diameter with approximately 4 cm long with 0.25 cm wide eschar at the top of the wound. The wound area presented with visible eschar, at the top. On 06/26/23 at 04:07 PM, LN I stated when R22 was first admitted to the facility she walked short distances in her room to the bathroom, but not in the hallway. LN I verified the only interventions in place prior to the resident acquiring a pressure ulcer to her right heel was the charge nurse was to do weekly skin checks and notify the nurse of any new skin issues. On 06/27/23 at 09:50 AM, Administrative Nurse D verified appropriate preventative measure were not in place prior to R22 acquiring the pressure ulcer to her right heel, in the facility. Administrative Nurse D stated she was not employed at the facility at the time of R22's admission, but if she had been, she would have initiated appropriate preventative measures for R22 due to the resident's risk for developing pressure ulcers. The facility's Pressure Injury Prevention and Management Policy, revised 01/01/23, documented the facility should establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment, intervening to stabilize, reduce or remove underlying risk factors, monitoring the impact of the interventions and modifying the interventions as appropriate. The facility failed to develop interventions that addressed R22's risk for pressure ulcer development which resulted in a facility-acquired, unstageable pressure ulcer to the resident's right heel. - R39's Physician Order Sheet included diagnoses of arterial sclerotic heart disease (ASHD-a condition where the arteries become narrowed and hardened due to buildup of fat in the artery wall.), edema (swelling resulting from an excessive accumulation of fluid in the body tissues), atrial fibrillization (rapid, irregular heartbeat), and hypertension (elevated blood pressure). R39's admission Minimum Data Set (MDS) assessment, dated 04/17/23, recorded the resident had a Brief Interview for Mental Status (BIMS) score of four, which indicated severely impaired cognition. The assessment revealed the resident required extensive assistance of two staff for bed mobility, transfers, walking in room, dressing, toilet use, personal hygiene, and had functional impairment of upper extremity on one side. The MDS further documented the resident had a surgical wound. The 04/19/23 Pressure Ulcer Care Area Assessment (CAA) documented the resident had no pressure ulcers. The Urinary Incontinence CAA, documented R39 required two staff assistance with toileting, and the resident was incontinent and wore incontinent products. R39's Braden [Scale (an assessment tool used to assess and document a resident's risk for developing pressure ulcers) dated 04/12/23, documented a score of 16.0 which indicated the resident was at risk for pressure ulcer development. The Skin Integrity Care Plan, dated 04/19/23 directed the charge nurse to perform weekly skin assessments and notify the charge nurse of any skin alterations. The Activities of Daily Living [ADL] Care Plan, dated 04/19/23 directed two staff to assist the resident with toileting and the required incontinent products. The plan directed R39 required assistance of two staff with bed mobility, dressing and toileting. The Progress Notes, dated 06/08/23 at 10:38 AM, recorded the nurse left a message for the physician concerning R39 buttocks. The note recorded R39's scratch/wound was healed although there were petechia (pinpoint spots on the skin) noted on R39's buttocks and the skin were deep purple in color, in the area of the scratch/wound. The Weekly Pressure Ulcer Healing Assessment, dated 06/14/23, documented R39 had a facility-acquired right buttocks pressure ulcer identified on 06/14/23. The right buttocks pressure area measured 0.5 centimeters (cm) by 0.5 cm with no depth, a scant amount of exudate (secretion) with serosanguineous (exudate mixed with blood) drainage and was inaccurately documented as a stage one (skin intact, but red and non-blanchable). The assessment documented an order to change the dressing, pat dry, apply calcium alginate (highly absorbent material), and cover with Mepilex AG (a nonstick soft spongy grey foam pad that has silver within it and the foam dressing shields the wound and the silver helps to kill the bacteria). The Weekly Pressure Ulcer Healing Assessment, dated 06/22/23, documented R39 had a right buttocks pressure ulcer identified on 06/14/23. The right buttocks pressure area measured 3.4 cm by 7.0, with no depth, a moderate amount of serosanguineous drainage and noted the wound size had increased. The nurses cleansed with wound cleanser, patted dry, applied Mepilex AG, and changed the dressing on Monday, Wednesday, and Friday. On 06/21/23 at 12:00 PM, R39 laid on his back in bed and visited with his guests. On 06/22/23 at 09:00 AM, R39 laid in bed on his back. Administrative Nurse E, Certified Nurse Aide (CNA) M, and CNA N positioned R39 on his left side. Administrative Nurse E removed the old dressing and cleansed the open area on R39's right buttocks with wound cleanser. The wound appeared as a two-inch reddened round area with approximately three-quarters of an inch open. Administrative Nurse E applied a Mepilex dressing and covered with an Opsite (a breathable, flexible, waterproof dressing) dressing. Administrative Nurse E stated the wound treatment was recently changed after the resident's representative took a picture of the area and showed it to the physician's office, and the physician changed the treatment to a different dressing. On 06/22/23 at 09:10 AM, Administrative Nurse E verified R39 developed a facility-acquired pressure ulcer on his right buttocks. Administrative Nurse E verified in mid-May, the resident developed a scratch on his bottom that went away and then developed the pressure area mid-June. Administrative Nurse E stated the physician thought the area could be a Kennedy Ulcer (a term used to describe the development and rapid progression of a pressure-based tissue injury in residents identified as being imminently terminal) however she checked with the physician, and he did not diagnose the ulcer as a Kennedy ulcer but instead diagnosed a facility-acquired pressure ulcer. On 06/26/23 at 02:00 PM interview with Administrative Nurse D verified R39 had a scratch that was noted on his bottom mid-May and that went away in a few days. On 06/14/23 the resident developed a pressure area to his bottom and verified the pressure ulcer was facility acquired. Administrative Nurse D stated after the development of the ulcer the physician ordered an air mattress on the bed, and before the air mattress, the staff changed R39's position hourly. Administrative Nurse D verified the nurse who documented the stage one ulcer on the Weekly Wound Assessments should have documented at least a stage two ulcer (an open wound which extends into the layers beneath the skin) due to the skin area was open. Administrative Nurse D verified the interventions, including an air mattress or skin treatments, were not documented in the care plan and should be. The Pressure Injury Prevention and Management, policy dated 01/01/23, documented the facility was committed to the prevention of avoidable pressure injury, prevent infection and the development of additional pressure ulcers. The facility would establish and utilize a systemic approach for pressure injury prevention and management, including prompt assessment and treatment, interventions to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate. A Licensed Nurse would conduct a pressure injury risk assessment, using the Braden scale, on all residents upon admission/re-admission, weekly for four weeks, then quarterly or whenever the resident's condition changes significantly. The Braden scale would be used in conjunction with other risk factors not captured by the risk assessment tool. After completion of the assessments/evaluations the interdisciplinary team would develop a relevant care plan that included measurable goals for prevention and management of pressure injuries with appropriate interventions. Interventions on a resident's care plan would be modified as needed. The facility failed to implement preventative measures to prevent a facility-acquired stage two pressure ulcers for R39, who was at risk for pressure ulcer development. The facility failed to identify and respond to deep purple discoloration which evolved into an open pressure injury. The facility further failed to accurately assess R39's facility acquired pressure injury to obtain appropriate treatment orders. These deficient practices placed R39 at risk for further injury and/or delayed wound healing.