**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to protect each residents' right to be free from abuse for 3 (#8, #9, and #13) of 13 (#1, #2, #3, #4, #5, #6, #7, #8, #10, #11, #12 and #13) residents reviewed for abuse. The facility failed to protect: 1. Resident #8 from mental abuse by S11CNA; 2. Resident #9 from physical abuse by Resident #10; and 3. Resident #13 from physical abuse by Resident #11. This deficient practice resulted in an actual psychosocial harm on 05/10/2024 around 6:00 p.m., when S11CNA made degrading comments about Resident #8's bowel condition loudly at the Nurses' Station with Resident #8 seated nearby. Resident #8 experienced crying, sadness, and felt degraded after S11CNA's comments about him. Findings: Review of the facility's policy titled, Abuse and Neglect Policy, with a revision date of March 2023, revealed the following, in part: Purpose: It is the policy of this facility and the state agency, to prohibit the abuse, neglect, exploitation, or extortion of patients/residents (henceforth referred to as resident). This facility is committed to preserving the right of each person receiving services to be free from abuse. All forms of abuse of residents by other residents or employees of this facility are prohibited. Definitions: Physical abuse - physical contact such as hitting, slapping, pinching, kicking, choking, scratching. Verbal/Emotional/Psychological abuse - may be abusive because of either the manner of communication or the content of the communication; use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation; includes the use of oral, written, or gestured communication or sounds to residents, within hearing distance, regardless of age, ability to comprehend, or disability. Examples include but are not limited to: harassing a resident, mocking, insulting, ridiculing, yelling . Mental abuse/Violation of Privacy - may occur through either verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation or degradation. 1. Resident #8 Review of Resident #8's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Major Depressive Disorder, Generalized Anxiety Disorder, Acquired Absence of Right Leg Above Knee, and Acquired Absence of Left Leg Above Knee. Review of Resident #8's Quarterly MDS with an ARD of 06/05/2024 revealed he had a BIMS of 15, which indicated he was cognitively intact. Review of Resident #8's current Care Plan revealed the following, in part: Problem: ADLs - I need help with dressing, bathing, and personal hygiene due to my Bilateral Above Knee Amputations and Chronic Diarrhea . Problem: Alteration in bowel elimination related to I am incontinent. Review of Resident #8's Nurse's Note dated 05/15/2024 at 12:15 a.m. revealed the following, in part: Tonight I assisted Resident #8 in writing a statement regarding the way he was treated by a staff member on night shift on 05/10/2024. Resident #8 reported to me that the staff member embarrassed him by stating comments about his stomach/bowel issues in front of other residents, causing Resident #8 to get upset and cry. Resident #8 stated he was reluctant to report staff member for fear of possibly being further mistreated. Statement given to shift manager and the CNA assignment changed so the staff member is not assigned to the resident tonight. Signed: S10LPN Review of Resident #8's Incident Report revealed the following, in part: Date incident occurred: 05/10/2024 Date incident discovered: 05/15/2024 at 12:30 a.m. Type of incident: alleged abuse - emotional/verbal abuse Description of incident: Statement from Resident #8: On 05/10/2024, I was sitting in my wheelchair when the night shift arrived. S11CNA stated to me that she hoped I did not s*** my chair up the way that I s*** my bed up. S11CNA claimed she did not have time for that tonight. S11CNA said out in the hallway outside the day room and Nurses' Station in front of multiple other residents which was very embarrassing to me. I then rolled outside where the smoking area was and actually cried thinking this is how I have to live and I don't want to inconvenience anyone, but at the same time I have never been rude to S11CNA before. My feelings were hurt and I was embarrassed. When I rolled back into the building, I then told my nurse that I was ready to go to bed. I can put myself back to bed on my own. My nurse, S10LPN, then stuck her head out the smoking area door and stated to S11CNA that I would like to go to bed and would she please go and ensure that my bed was ready and that I was not soiled. At this time, S11CNA yelled at S10LPN, he can put himself to bed, she didn't have time to be bothered with my a**, and that I shouldn't be up in my chair anyway. S10LPN then came back into the building, and S12CNA came with her and ensured I was in bed and dry. Signed: Resident #8. Signature of person completing this form: S8RNM 05/15/2024 Supervisor review: do you suspect abuse or neglect? yes. On 06/04/2024 at 10:08 a.m., an interview was conducted with Resident #8. He stated, on 05/10/2024, he was by the medication cart outside the Nurses' Station at shift change, around 6:00 p.m. when S11CNA came out of the Nurses' Station and said something like, I hope you don't mess up the chair because you're hard enough to clean already. He stated S9LPN and S10LPN were at the medication cart giving report and heard the comments S11CNA made. He stated the comment made him feel bad, he went by the big window in the front of the facility, and cried and wondered what he did to end up here in this position. He stated after some time, he came back inside and asked for assistance getting back in bed. He stated S10LPN and S11CNA had words, S11CNA refused to assist him back to bed, and S10LPN and S12CNA assisted him back to bed. He stated he had chronic diarrhea for a long time and struggled with Depression because he never saw himself being in a place like this. He stated after the incident, he was sad for a few days. On 06/04/2024 at 10:35 a.m., an interview was conducted with S13CNA. She confirmed she was assigned to Resident #8 today. She stated she was aware of the incident that occurred on 05/10/2024 with Resident #8 and S11CNA. She stated following the incident, Resident #8 was sad about the situation and did not get out of the bed for a couple days. On 06/04/2024 at 1:34 p.m., a telephone interview was conducted with S8RNM. She stated an incident occurred between Resident #8 and S11CNA on 05/10/2024, and she was made aware of the incident on the night shift of 05/14/2024. She stated Resident #8 was very [NAME] and quiet. She stated Resident #8 was tearful when he explained to her that S11CNA said I hope you don't s*** your chair like you s*** your bed. She stated Resident #8 reported the incident occurred in front of other residents, S10LPN and S9LPN. She confirmed the above described incident was verbal and emotional abuse and when S11CNA was removed from Resident #8's unit, he began coming out of his room and engaging with other residents and staff. On 06/05/2024 at 9:32 a.m., a telephone interview was conducted with S9LPN. She stated Resident #8 was always very pleasant, friendly, and never had any behaviors. She stated, on 05/10/2024 at shift change, in a very loud in frustrated tone, S11CNA complained that Resident #8 was still up and every time he gets back in bed, he gets s*** everywhere and she did not want to clean it up. She stated Resident #8 was up in his wheelchair at the time the statement was made but was unsure of his exact location. She stated Resident #8 would have been able to hear the statements made by S11CNA if he was seated outside the Nurses' Station. She explained if Resident #8 overheard S11CNA, he would be very upset because he was generally very bothered and emotional related to his chronic diarrhea. She confirmed the statements made by S11CNA were very disrespectful. On 06/05/2024 at 2:04 p.m., a telephone interview was conducted with S11CNA. She confirmed Resident #8 had frequent diarrhea. She stated she never had a conversation with anyone about Resident #8's bowel movements. She stated she did not recall ever making a comment about Resident #8's bowel movements or him having a bowel movement in his chair or his bed. She stated if she had, that would have been abuse. Telephone interviews were unsuccessful with S10LPN on 06/04/2024 at 12:17 p.m., 06/04/2024 at 2:45 p.m., 06/05/2024 at 8:15 a.m., 06/0 5/2024 at 10:41 a.m., 06/05/2024 at 1:07 p.m., and 06/05/2024 at 2:51 p.m. Review of the State Agency Investigator's Report for Resident #8 revealed the following, in part: Incident date: 05/10/2024 Discovered: 05/15/2024 Alleged Victim: Resident #8 Statement by S10LPN: On 05/10/2024, I was working the night shift, Resident #8 was in his wheelchair outside of the Nurses' Station, as well as S11CNA. I could not really make out what was being said, but voices were raised and then all residents along with S11CNA went out to the smoking area. When I walked out back to this area, Resident #8 was in his wheelchair and had rolled down the sidewalk away from everyone else. Resident #8 appeared to be upset and possibly had been crying. After ten minutes, Resident #8 came back inside the building and stated he was ready to get in his bed. I went to get S11CNA, and informed her Resident #8 was ready to get into his bed. S11CNA began to yell at me outside in front of other residents. She said I don't have time to fool with him right now, he shouldn't even be up right now. I then came back into the building and was assisted by S12CNA to get Resident #8 in bed. I then asked the resident while in his room what was wrong and if something had happened. Resident #8 told me he didn't understand why staff were mean because he was never mean to anyone. He also told me how he can't help he has bad diarrhea, does not want to be like this, and surely doesn't do it on purpose. I encouraged the resident to report staff when they are mean and explained to him that is abuse. Resident stated that he was afraid to make anything worse but that he would think about it and let me know if he decided to report anything. When I came back to work, my RN Manager came to me and told me to go and help Resident #8 do a statement since he can't write. Statement done and signed by resident. Even though I did not hear exactly what S11CNA said to the resident, the attitude she had toward myself and the resident was not therapeutic and not conducive to patient care. Whatever S11CNA did say to the resident upset him enough that his demeanor changed to very sad and he obviously had been crying as it appeared he had tears in his eyes. On 06/05/2024 at 12:45 p.m., an interview was conducted with S6APS. He confirmed he investigated an allegation S11CNA emotionally abused Resident #8. He confirmed he interviewed S10LPN during his investigation. He stated S10LPN reported she did not hear S11CNA say anything directly to Resident #8 but when she went outside there were a lot of other residents outside and they were laughing and Resident #8 appeared to be crying. He stated S10LPN reported S11CNA was yelling at her as well. He stated S10LPN explained based on how Resident #8 reacted and S11CNA acted, she believed Resident #8 was abused by S11CNA. On 06/05/2024 at 4:00 p.m., an interview was conducted with S2DON. She stated Resident #8 had never made false reports against staff and was a very pleasant resident. She stated if S11CNA said what Resident #8 accused her of, that was abuse. On 06/05/2024 at 12:30 p.m., an interview was conducted with S5AA. He confirmed a state agency investigator investigated the allegation S11CNA abused Resident #8. He stated he reviewed the state agency investigator's report and investigation. He confirmed he substantiated the allegation because there was enough evidence to show S11CNA mentally abused Resident #8. 2. Resident #10 Review of Resident #10's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Cerebral Infarction and Unspecified Psychosis. Review of Resident #10's quarterly MDS with an ARD 04/18/2024 revealed a BIMS of 3, which indicated resident had severe cognitive impairment. Review of Resident #10's Nurse's Notes dated 05/18/2024 at 11:34 a.m. by S14RN revealed Resident #9 was bumping into Resident #10's Gerichair several times, Resident #9 grabbed Resident #10 and scratched Resident #10's nose. On 06/04/2024 at 1:22 p.m., an interview was conducted with S16LPN. S16LPN stated Resident #10 does not like noise and will curse at others when agitated. S16LPN stated if you are close enough to Resident #10 he will grab at you. Resident #9 Review of Resident #9's Clinical Record revealed she was admitted to the facility on [DATE] and had diagnoses, which included Moderately Intellectual Disabilities, Epilepsy, Schizophrenia and Extrapyramidal Movement Disorder. Review of Resident #9's quarterly MDS with an ARD of 05/09/2024 revealed a BIMS of 3, which indicated severe cognitive impairment. Review of Resident #10's Nurse's Notes dated 05/18/2024 at 9:38 a.m. by S17LPN revealed Resident #9 bumped into Resident#10's Geri chair several times, Resident #10 then grabbed Resident #9's face and scratched the right side of Resident #9's nose. Upon exam slight bleeding to right side, cleansed TAO applied. On 06/04/2024 at 1:58 p.m., an observation of the surveillance video was made with S18APD. On 05/18/2024 at approximately 9:38 a.m. both Resident #9 and Resident #10 were in the day room. Resident #9 backed up his wheelchair next to Resident #10's Geri chair, Resident #9 then leaned over Resident #10 and raised her right arm, Resident #10 immediately swatted his left arm and grabbed at Resident #9's face. Security immediately stepped in and separated both residents. On 06/04/2024 at 1:59 p.m., an interview was conducted with S18APD. S18APD confirmed Resident #10 grabbed Resident #9's face and it was considered physical abuse. 06/05/2024 at 10:00 a.m., an interview was conducted with S3CRO. S3CRO stated he was responsible for completing incident reports. S3CRO and S18APD reviewed surveillance of the incident that occurred between Resident #9 and Resident #10. S3CRO confirmed physical abuse occurred. 3. Resident #11 Review of Resident #11's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses which included Unspecified Intracranial Injury with Loss of Consciousness, Dementia, Major Depressive Disorder, Other Frontotemporal Neurocognitive Disorder, and Amnestic Disorder due to Known Physiological Condition. Review of Resident #11's Quarterly MDS with an ARD of 02/29/2024 revealed a BIMS of 1, which indicated severe cognitive impairment. Resident #13 Review of Resident #13's Clinical Record revealed he was admitted to the facility on [DATE] and had diagnoses, which included Personal History of Other Mental and Behavioral Disorders. Review of Resident #13's annual MDS with an ARD of 02/29/2024 revealed a BIMS of 15, which indicated he was cognitively intact. Review of Resident #13's Nurse's Note dated 05/19/2024 at 5:17 p.m. by S4RN revealed I heard yelling in the hallway by the dining room door. I saw Resident #13 on the floor next to his rollator walker. Resident #13 reported he could not get out of Resident #11's way, and Resident #11 pushed him to the floor. On 06/04/2024 at 10:54 a.m., an interview was conducted with Resident #13. He stated a few weeks ago Resident #11 pushed him to the floor while he was waiting to go into the dining area. He denied any pain or injuries as a result of this incident. On 06/04/2024 at 11:51 a.m., an interview was conducted with S4RN. She stated she recalled the incident that took place between Resident #11 and Resident #13. She stated she was in the hallway when she heard a lot of noise and commotion. She stated upon assessment of the noise, she observed Resident #13 sitting on the floor with his rollator walker next to him. She stated Resident #13 was cognitively intact, and when she asked him what happened, he stated, I couldn't get out of Resident #11's way fast enough so he pushed me out the way. On 06/05/2024 at 1:34 p.m., an interview was conducted with S3CRO. S3CRO confirmed he reviewed the video footage from 05/19/2024 involving Resident #11 and #13. He stated Resident #11 grabbed Resident #13 and pushed him to the floor with force. He confirmed he considered the altercation physical abuse. On 06/05/2024 at 2:01 p.m., an observation of the facility's surveillance footage was conducted with S2DON. On 05/19/2023 at 5:19 p.m., Resident #13 was observed standing in the hallway near the exit of the dining room door when Resident #11 forcefully shoved Resident #13 to the floor with both hands. Immediately following the observation, and interview was conducted with S2DON. S2DON stated Resident #11 grabbed Resident #13 and pushed him to the floor with force. She confirmed she considered the altercation physical abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record reviews, the facility failed to protect the resident's right to be free from physical abuse by another resident for 3 (#RF7, #F47, and #F125) of 11 (#F6, #F11, #F13, #F75, #F47, #F120, #F125, #F132, #F338, #RF7, and #RF8) residents reviewed for abuse. The facility failed to ensure: 1. Resident #RF7 was free from physical abuse by Resident #F132; 2. Resident #F47 and Resident #F125 were free from physical abuse by each other. This deficient practice resulted in an actual harm for Resident #RF7 on 01/05/2024 at 12:41 p.m. when he was punched in the face by Resident #F132 and sustained multiple facial fractures. Resident #RF7 took a canned beverage from Resident #F132's meal tray and Resident #F132 approached Resident #RF7 and punched him in the face. As a result, Resident #RF7's diagnostic scans revealed fractures to the Left Inferior Medial Orbital Floor, Superior Medial Maxillary Sinus Wall, Inferior Medial Orbital Wall, Left Inferior Lateral Maxillary Sinus Wall, and Anterior Inferior Maxillary Sinus Wall and blood and fluid in the Left Maxillary Sinus. This deficient practice resulted in an actual harm for Resident #F47 and Resident #F125 on 01/23/2024 at 11:25 a.m. when Resident #F125 removed the wheelchair arm rest and struck Resident #F47 on the right hand. Resident #F47 then approached and hit Resident #F125 on the right side of the head with his wheelchair arm rest. As a result, Resident #F47's diagnostic scans revealed a fracture to the Right Index Proximal Phalanx Fracture of the Second Finger. Resident #F125 was sent to emergency room where he received a CT of his Maxillofacial Structures and brain due to contusion and swelling of head. Findings: Review of the facility's policy titled, Abuse and Neglect Policy revealed the following, in part: A. Purpose: It is the policy of this facility to prohibit the abuse of residents. This facility is committed to preserving the right of each person receiving services to be free from abuse. All forms of abuse of residents by other residents are prohibited. b. Abuse - the willful infliction of injury, unreasonable confinement, intimidation or punishment, with resulting physical harm . i. Physical Abuse - physical contact such as hitting . 1. Resident #F132 Review of Resident #F132's Clinical Record revealed he was admitted to the facility on [DATE]. Review of Resident #F132's Quarterly MDS with an ARD of 10/20/2023 revealed a BIMS of 15, which indicated he was cognitively intact. Review of Resident #F132's current Care Plan revealed the following, in part: Problem: 01/05/2024 - Hit another resident for taking his food. Review of Resident #F132's Nurse's Note dated 01/05/2024 at 12:55 p.m. revealed the following, in part: SF5LPN was summoned to hallway by staff. SF5LPN visualized Resident #F132 standing in front of Resident #RF7. Resident #F132 stated, don't touch anything on my f****** walker again, and punched Resident #RF7 in his left eye. Once Resident #F132 was calmed, he stated, he stole my cold drink off my walker when I walked in the dining room. Signed: SF5LPN Review of the Resident #F132's Incident Report dated 01/05/2024 at 12:38 p.m. revealed the following, in part: Where incident occurred: Hall Type of incident: resident to resident activity Description of incident: while conducting watch in the kitchen SF9CGT heard an argument outside in the hall. At this time, SF9CGT saw SF10C and SF8CGT in front of Resident #F132 who was cursing at Resident #RF7 saying you stole my f****** drink. Witnessed: SF8CGT, SF10C, and SF11C. Completed by: SF9CGT Review of Resident #F132's Post Incident Huddle Report dated 01/05/2024 revealed the following, in part: Interventions needed or provided after the incident: order for increased observation due to hitting Resident #RF7 in the left eye. Any previous incidents: No Resident #RF7 Review of Resident #RF7's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Unspecified Impulse Disorder. Review of Resident #RF7's MDS with an ARD of 11/24/2023 revealed a BIMS of 15, which indicated he was cognitively intact. Review of Resident #RF7's Incident Report dated 01/05/2024 at 12:45 p.m. revealed the following, in part: Where incident occurred: Hall Type of incident: resident to resident activity Description of Incident: See Nurses' Note Assessment: Small scratch noted under right eye. Nurse completing report: SF4RN Review of Resident #RF7's Nurse's Note dated 01/05/2024 at 1:08 p.m. revealed the following, in part: Unwitnessed resident to resident altercation: nurse writer was in dining hall serving lunch, during this time altercation was heard outside of the door, upon walking to the area, the nurse writer witnessed Resident #RF7 and Resident #F132 in a verbal confrontation but were separated by security staff. Upon nurse writer interviewing residents, Resident #F132 was yelling stating that Resident #RF7 had taken his soda from meal tray, and Resident #RF7 was yelling Resident #F132 had hit him in the face. Assessment was completed. Small scratch noted under left eye. Signed: SF4RN Review of the facility's video footage of the hallway leading to the dining room from Resident #F132 and Resident #RF7's units was conducted on 01/11/2024 at 9:17 a.m. with SF6APM who confirmed the below observation: Video footage dated 01/05/2024 beginning at 12:40 p.m.: Resident #RF7 took a canned drink off of a tray resting on a rollator walker outside of the dining room. Resident #RF7 proceeded to propel himself up the hallway toward the day room with the canned drink. Resident #F132 then exited the dining room and spoke with a resident seated in the hallway. Resident #F132 immediately ambulated with his rollator walker and approached Resident #RF7. At 12:41 p.m., Resident #F132 stood in front of Resident #RF7 and hit Resident #RF7 in his face with his right fist then left fist. Resident #RF7 then crossed both of his arms in front of his face and SF10C intervened. An observation was made of Resident #RF7 on 01/10/2024 at 1:58 p.m. He had bruising surrounding his left eye. He had purplish-red bruising under his left eye and yellowish bruising laterally. He had a purple discoloration on the left side of his mouth. He had a large section of purple discoloration on his neck. His left eye and cheek were visibly swollen compared to the right side of his face. An interview was conducted with Resident #RF7 on 01/10/2024 at 2:00 p.m. He stated, on 01/05/2024, he was trying to pass Resident #F132 in the hallway when the other resident punched him on his left eye. An interview was conducted with Resident #F132 on 01/10/2024 at 2:39 p.m. He stated, on 01/05/2024 at lunch time, he retrieved his meal tray and placed it on the seat of his rollator to go back to his room to eat. He stated he left the rollator in the hallway while he went back into the dining room to get ketchup, and when he came back out, Resident #RF7 had taken his cold drink off of his tray. He stated he then went to Resident #RF7 and punched him in the face. An interview was conducted with SF4RN on 01/10/2024 at 2:30 p.m. She stated, on 01/05/2024, there was an incident involving Resident #RF7 and Resident #F132. She stated she heard a commotion in the hallway leading to the dining room, and then, saw security separating the two residents. She stated security reported to her Resident #F132 punched Resident #RF7 in the face. She stated immediately following the incident, Resident #RF7 had bruising under his left eye. She stated Resident #RF7 did not normally have any discoloration to his face or neck. She confirmed Resident #F132 physically abused Resident #RF7. An interview was conducted with SF5LPN on 01/11/2024 at 10:12 a.m. She stated, on 01/05/2024, she was assigned to Resident #F132. She stated she reported to the hallway outside of the dining room around lunch because a staff member was yelling for help. She stated when she arrived, Resident #F132 was standing in front of Resident #RF7. She stated Resident #F132 then punched Resident #RF7 in the face with a closed fist. She confirmed Resident #F132 punching Resident #RF7 in the face was physical abuse. She stated immediately following the incident, Resident #F132 was placed on increased observation and was educated to notify staff if another resident takes something from him. An interview was conducted with SF11C on 01/11/2024 at 10:21 a.m. She stated, on 01/05/2024 around lunch, she heard Resident #F132 and Resident #RF7 yelling in the hallway leading to the dining room. She stated Resident #F132 then punched Resident #RF7 in the eye with a closed fist. She stated SF10C, SF9CGT, and SF8CGT separated the residents. She confirmed Resident #F132 punching Resident #RF7 in the face was physical abuse. She stated she had never seen Resident #F132 become physically aggressive prior to this incident. A telephone interview was conducted with SF10C on 01/11/2024 at 11:21 a.m. He stated he recalled the incident involving Resident #F132 and Resident #RF7 on 01/05/2024. He stated when he first walked up, Resident #F132 hit Resident #RF7 in the face with a closed fist. He stated Resident #RF7 was screaming for help. He stated he separated the two residents. He stated immediately following the incident, Resident #RF7 had a bruise and swelling around his left eye. He confirmed Resident #F132 physically abused Resident #RF7. He stated he had never seen Resident #F132 become physically aggressive prior to this incident. An interview was conducted with SF8CGT on 01/11/2024 at 11:28 a.m. He stated, around 12:45 p.m. on 01/05/2024, he was in the dining area, and Resident #F132 and Resident #RF7 were in the hallway leading to the dining area. He stated he heard commotion going on in the hallway, and he responded. He stated by the time he got there, Resident #F132 was standing over Resident #RF7, and Resident #F132 hit Resident #RF7 in the face with a closed fist. He confirmed Resident #F132 physically abused Resident #RF7. He stated he had never seen Resident #F132 become physically aggressive prior to this incident. He stated immediately following the incident, Resident #F132 was placed on increased observation. An interview was conducted with SF9CGT on 01/11/2024 at 11:52 a.m. She stated, on 01/05/2024 at lunch, she was in the dining area. She stated Resident #F132 and Resident #RF7 were in the hallway leading to the dining room. She stated she heard hollering and approached the situation. She stated when she responded the residents were being separated, and Resident #F132 was yelling and saying Resident #RF7 stole his cold drink. She stated Resident #RF7 was wheelchair bound, and Resident #F132 walked around and was more mobile than Resident #RF7. She stated Resident #F132 punching Resident #RF7 in the face was physical abuse. She stated she had never seen Resident #F132 become physically aggressive prior to this incident. An interview was conducted with SF7LPN on 01/10/2024 at 2:13 p.m. She stated she was currently assigned to Resident #RF7. She confirmed Resident #RF7 had bruising surrounding his left eye from an incident between him and Resident #F132. She confirmed one resident punching another resident was physical abuse. She stated SF2NP ordered facial x-rays for Resident #RF7 on 01/08/2024 related to his facial bruising. She stated after SF2NP received Resident #RF7's x-ray report, he ordered a facial CT. An interview was conducted with SF3CRN on 01/11/2024 at 2:07 p.m. He stated he was responsible for abuse investigations. He stated after the incident occurred with Resident #F132 and Resident #RF7 on 01/05/2024, he reviewed the facility's camera footage. He stated Resident #F132's rollator was out in the hallway leading to the dining room with a meal tray and cold drink. He stated Resident #RF7 was also in the hallway and took Resident #F132's cold drink off of the tray. He stated when Resident #F132 returned to his rollator, another resident in the hallway notified Resident #F132 that Resident #RF7 took his cold drink. He stated then, Resident #F132 confronted Resident #RF7 and punched him in the face. He confirmed Resident #F132 physically abused Resident #RF7, and Resident #RF7 received facial fractures from the incident. He stated immediately following the incident, Resident #F132 was placed on increased observation. Review of Resident #RF7's X-ray Report dated 01/08/2024 at 11:58 a.m. revealed the following, in part: Exam: XR facial bones 3 views Indications: Altercation Impression: Limited examination with evidence of air-fluid level in the left maxillary sinus and possible fractured tooth, likely in the left mandible (the orbital floor appears intact although the limited views do not totally exclude possibility of orbital floor blowout fracture as a source of the left maxillary fluid). Review of Resident #RF7's Hospital Records from a local hospital dated 01/10/2024 revealed the following, in part: ED triage description of symptoms: Was hit in the face by other patient. Physical Exam: Head traumatic with ecchymosis of the left face. CT facial dated 01/10/2024 at 7:13 p.m.: Clinical indication: contusion, swelling Impression: There is a left inferior medial orbital floor and superior medial maxillary sinus wall with mild comminuted fragments and the mild comminuted fragments may be exaggerated by motion artifact. Majority of the inferior orbital wall is intact with only fracture at the inferior medial aspect .There is also fractures of the left inferior lateral maxillary sinus wall and anterior inferior maxillary sinus wall with mild depression and partially comminuted with partial opacification of the left maxillary sinus with blood and fluid. A telephone interview was conducted with SF2NP on 01/11/2024 at 8:56 a.m. He confirmed Resident #F132 punched Resident #RF7 in the face on 01/05/2024. He stated he ordered x-rays to Resident #RF7's face to be completed on 01/08/2024 related to his facial bruising from the incident. He stated the x-rays were unclear so he ordered a computed tomography scan, which was completed at a local hospital on [DATE]. SF2NP confirmed Resident #RF7 received facial fractures when Resident #F132 punched him in the face. An interview was conducted with SF1AA on 01/11/2024 at 2:44 p.m. He confirmed Resident #F132 punched Resident #RF7 in the face on 01/05/2024, which was physical abuse. He stated immediately following the incident, Resident #F132 was placed on increased observation. 2. Resident # F47 Review of Resident # F47's Clinical Record revealed he was admitted to the facility on [DATE] with diagnoses which included Quadriplegia. Review of Resident # F47's Quarterly MDS with ARD of 12/19/2023 revealed a BIMS of 15, which indicated intact cognition. Review of Resident #F47's Nurse's Notes dated 01/23/2024 at 12:20 p.m. revealed the following, in part: Resident #F47 came to the nurse's station and reported to SF20CNA that Resident #F125 hit him with his wheelchair armrest. SF20CNA reported the incident to SF19LPN. SF19LPN saw Resident #F47's index finger was dislocated, swollen, and painful and she began to ask Resident #F47 what happened. Resident #F47 stated, he was in the bathroom and Resident #F125 was trying to come in and he told him he could not come in and to get out. Resident #F125 took off his armrest and hit him. Resident #F47 stated he took off his armrest and hit Resident #F125 since he hit him. Resident #F47 was instructed to stay at nurse's station while SF19LPN went to assess Resident#F125. Signed SF19LPN Review of Resident #F47's Incident report dated 01/23/2024 at 11:25 a.m. revealed the following, in part: Where incident occurred: Resident's room Type of incident: Resident to resident activity Description of incident: See Nurse's note Witnessed: None Completed by: SF21RNS Review of Resident #F47's Post Incident Huddle Report dated 01/23/2024 revealed, in part: Interventions needed or provided after the incident: Resident sent to local hospital for evaluation of finger. Environmental factors or equipment involved: armrest of wheelchair. Any previous incidents: No Review of Resident #F47's hospital records X-ray Report dated 01/23/2024 revealed the following, in part: Exam: Right Index Finger- 3 views Indications: Pain Impression: Acute essentially non-displaced fracture of the proximal metadiaphyseal junction of the proximal phalanx. There is prominent dorsal angulation. No other fractures. No destructive lesions. Exam: XR Finger RT min 2V Indications: Post Reduction Impression: Proximal phalanx fracture of the second finger has been reduced. Overlying cast material obscures osseous detail. Review of Resident #F47's current physician's orders revealed, in part: Start date: 01/23/2024 Hydrocodone/APAP 5-325mg until Hydrocodone/APAP 7.5-325mg is available Review of Resident #F47's Medication Administration Record for January 2024 revealed Hydrocodone-Acetaminophen 5-325mg was administered once on 01/23/2024 and twice on 01/24/2024. Resident #F47 received Hydrocodone-Acetaminophen 7.5-325mg once on 01/25/2024. An observation was made of Resident #F47 on 01/24/2024 at 12:57 p.m. Resident #F47's right hand from fingertips to wrist was noted to be wrapped with gauze and an ace wrap. Resident #F47's right index and middle fingers were noted to be splinted. An interview was conducted with Resident #F47 on 01/24/2024 at 12:57 p.m. He stated on 01/23/2024 when he came out of his bathroom Resident #F125 hit him with a wheelchair arm rest on his right hand. Resident #F47 stated his pain was currently a 7 out of 10. He stated the splint was uncomfortable. Resident #47 stated his hand hurts when he touches things. He stated his right hand was his dominant hand and since the altercation staff had to do more for him. He stated staff had to bath, dress, and help him get in the wheelchair and did not have to prior to the incident on 01/23/2024. An interview was conducted with Resident #F47 on 01/25/2024 at 12:30 p.m. He stated his right hand still ached. Review of Resident #F125's Clinical Record revealed he was admitted to the facility on [DATE], with diagnoses which included, in part: Unspecified Sequelae of Cerebral Infarction, and Personality Disorder. Review of Resident #F125's Quarterly MDS with ARD of 11/17/2023 revealed a BIMS of 99, which indicated the BIMS could not be completed. Review of Resident #F125's Care Plan revealed, in part: Problem: onset 01/23/2024-I have had an actual Injury/Behavior Review of Resident #F125's Nurses Notes dated 01/23/2024 at 12:19 p.m. revealed the following, in part: Resident #F125 was sitting in WC on side of his bed, right eye was swollen, bleeding, and bruised. When Resident #F125 was asked what happened he stated someone hit me. Signed SF19LPN Review of Resident #F125's Incident report dated 01/23/2024 at 11:25 a.m. revealed the following, in part: Where incident occurred: Resident's room Type of incident: Resident to resident activity Description of incident: See Nurse's note Witnessed: None Completed by: SF21RNS Review of Resident #F125's Post Incident Huddle Report dated 01/23/2024 revealed, in part: Interventions needed or provided after the incident: Resident was sent to ER via ambulance for evaluation of eye trauma s/p altercation. Environmental factors or equipment involved: armrest of wheelchair Any previous incidents: No Review of Resident #F125's Hospital Records dated 01/23/2024 revealed the resident received a CT of his Maxillofacial Structures as indicated due to contusion and swelling. Further review revealed he received a CT of the Brain without contrast as indicated due to head injury. No abnormalities were noted. An observation was made of Resident #F125 on 01/24/2024 at 1:16 p.m. Resident #F125's right eye was noted to have dry scabbing and discoloration to the corner and under the eye. An interview was conducted with Resident #F125 on 01/24/2024 at 1:16 p.m. Resident #F125 stated he did not recall an altercation with another resident. Resident #F125 could not answer probing questions. An interview was conducted with SF21RNS on 01/24/2024 at 1:30 p.m. She stated she completed the incident investigation and post huddle incident form for the altercation between Residents #F47 and #F125. She confirmed the altercation between Resident #F47 and #F125 was a form of physical abuse. A telephone interview was conducted with SF19LPN on 01/25/2024 at 11:17 a.m. She confirmed SF20CNA notified her of the altercation between Resident #F47 and Resident #F125. She confirmed Resident #F47's index finger was dislocated, swollen, and painful. She confirmed Resident #F125's right eye was swollen, bleeding, and bruised. She confirmed she dressed Resident #F125's right eye with a gauze dressing. An interview was conducted with SF18DON on 01/25/2024 at 4:23 p.m. She confirmed the altercation between Resident #F47 and #F125 was resident to resident physical abuse. An interview was conducted with SF17ADM on 01/25/2024 at 4:35 p.m. He stated he was informed of the altercation between Resident #F47 and #F125 on 01/23/2024 by SF21RN. He confirmed the details of altercation stating Resident #F125 attempted to enter the bathroom in his designated room, his roommate Resident #F47 was occupying the bathroom. Resident #F125 began yelling at Resident #F47 to hurry up. Resident #F125 then entered the bathroom, removed his detachable armrest from his wheelchair and stuck Resident #F47 on the hand. Resident #F47 also removed his arm rest and struck Resident #F125 in the face. She confirmed the incident between Resident #F47 and #F125 was physical abuse.