**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake: MI00125053. Based on observation, interview and record review, the facility failed to prevent employee to resident abuse for one sampled Resident (R3) of 2 reviewed for abuse, resulting in the likelihood for further abuse towards R3, additional residents including those who may yell or scream, and those who were cognitively impaired (from a reasonable person's concept) that were provided care by the employee. Findings include: A review of the facility's reported incident summary noted, On 12/04/2021 at approximately 3:20pm, [CNA C] reported to [Nursing Home Administrator NHA] that she witnessed [Nurse D] say F*ck This, F*ck you, I can't F*cking do this anymore, Hitler had the right idea to resident [R3] . On 5/24/22 at 1:00 PM, R3 was observed in their room laying in bed that was positioned low to the floor, with a mattress on the floor next to the bed. R3 was unable to recall the incident when questioned. No other concerns were reported at that time from R3. A review of R3's medical record revealed, R3 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses of Dementia with Behavioral Disturbance, Psychotic disorder, Epilepsy. A review of R3's quarterly Minimum Data Set (MDS) assessment noted, R3 with an impaired cognition and that R3 required extensive assistance with activities of daily living. A review of progress notes for R3 noted, 12/5/2021 14:55 (2:55 PM) Nurses' Notes Text: Notified MD (Medical Director) and R/P (responsible party) (son) via phone (left message) of an incident that occurred yesterday afternoon between an employee and resident . [Nurse E]. On 5/25/22 at 2:46 PM, Nurse E was interviewed and asked about the incident that was mentioned in the progress note dated 12/5/21. Nurse E explained, that she didn't remember and that she thinks it was something that happened with a staff person. On 5/25/22 at 2:56 PM, the NHA was asked about the incident that happened with R3 and a staff member in December 2021. The NHA provided the incident report and investigation. A review of the incident report noted, a verbal incident that occurred with R3 and Nurse D that was witnessed by CNA C. On 5/25/22 at 3:25 PM, CNA C was asked about the incident and stated, [R3] went to the hospital and came back on another unit, [R3] is one of my favorites so I went to go check on [R3]. I walked on the unit (F wing) hallway and I heard him [Nurse D] say 'F*ck this, F*ck you, I can't f*cking do this anymore, Hitler had the right idea.' I attempted to take [R3] out of the hallway to my unit which was the Dementia unit. We were going there and [R3] did not want to go on the unit, so we went into the day room and got [R3] a soda. I went back to my unit and told my nurse (Nurse H) and texted the [NHA], this was on a Saturday. He said he would handle it. CNA C was asked if Nurse D worked the rest of the shift Saturday and stated, Yes. Sunday he came back but was sent home around noon or lunch. My unit Nurse (Nurse H) said if they didn't handle it she was quitting. She quit that day. On 5/26/22 at 9:00 AM, the NHA was asked about the incident and stated, So when I was notified some pieces were missing, I was told he (Nurse D) was having some inappropriate language, it wasn't communicated that it was at a resident. CNA C Did not tell me that he was talking to [R3]. I was told [Nurse D] is cussing in the building, CNA C did not mention that it was at a resident or around a resident. Sunday I came in and the Nurse (Nurse H) told me more, that it was towards [R3] I called the Unit Manager to cover and Human Resources and Payroll to do some interviews with me. The NHA was asked the reason Nurse D was not sent home after the incident. The NHA explained, it was not reported that it was towards a resident. After getting the full story and interviews Nurse D was suspended pending the investigation. The NHA continued and stated, [R3] was interviewed and said he was cussing at [R3]. Nurse D did say that [R3] kept coming to the cart and antagonized him. Nurse D asked the other Nurse (Nurse E) to take care of [R3] on Saturday and Sunday and had no other contact with [R3]. The NHA was asked if this Nurse had a history of verbal abuse and stated, Not towards residents or around residents. He has used inappropriate language with staff. On 5/26/22 at 9:13 AM, Nurse E was asked if they took over the care of R3 and stated, Yes Saturday he (Nurse D) asked me to take over for him with [R3] and on Sunday. A review of the facility's investigation and staff interviews revealed, Statement of Staff Member. Staff member interviewed: [CNA C] Interview 12/5/21 . 1. Was there an incident that happened between [Nurse D] and [R3]? I went down to unit 3 to setup visitation between residents, this around 3pm. As I was walking up I heard [Nurse D] say F*ck this, F*ck you, I can't f*cking do this anymore, Hitler had the right idea. 2. What happened next? [CNA G] was attending to [R3], and then I notified you. 3. Who was [Nurse D] talking to ? I believe it was to [R3]. 4. Was there any other witnesses? [CNA F] and [CNA G] were in the general area. 5. Where was this general area? At the end of F wing on desk 3, right after the shower room. Signature: 12/5/21. Statement of Staff Member. Staff member interviewed: CNA G called. Interview: 12/5/21. Location of interview: Phone interview. 1. Did you witness an incident with [R3] and [Nurse D] yesterday? Yeah. 2. What did the incident entail? I was talking to [Nurse D] at his cart around 3:15pm [R3] came up asking about a shower. I don't recall the full conversation, but I know [CNA C] came up to [Nurse D] and said that was inappropriate. I don't know about what. So I just removed [R3] from the situation of whatever [CNA C] and [Nurse D] were arguing about. 3. Did you hear [Nurse D] say anything about Hitler? I personally didn't hear anything. Signature: CNA Date: 12/9/21. Statement of Resident [R3] interviewed: Interview: 12/5/21. 1. Was there an incident between you and [Nurse D] yesterday? He was cussing and had a nasty attitude. 2. What did he say? F*ck you. 3. Why did he say that? He didn't give me my medication. I asked him why he didn't give me my medication and he didn't say nothing. 4. So what made him swear? I don't know. We were just talking and he said that. 5. Did he say anything about Hitler? I didn't hear that. No why? He believes in Hitler? 6. Did he touch you physically? Yeah he touched my chair and pushed it down. 7. Were you injured? No I wasn't injured. 8. Did this effect you emotionally? No not at all. 9. Do you feel safe in the facility? I feel safe yeah. Signed 12/6/21. Statement of Staff Member. Staff member interviewed [Nurse D] Interview: 12/5/21 1. Did you say the words F*ck this, F*ck you, I can't f*cking do this anymore, Hitler had the right idea? No that is not accurate. 2. You say that I (sic) not accurate, what along the lines of this did you say? I don't recall what was said, I know the word F*ck came out of my mouth, but not that many times. I do not recall saying anything about Hitler. I do recall saying I can't take this anymore. 3. Do you recall where this took place? Right at the med cart on F wing. 4. Was there people around? Yes there were several people, I know [CNA G] was there. She was trying to tell me something, I don't recall who else was there. 5. Was what you were saying directed at [R3]? No it was directed at the concept of the situation, I cannot take more of trying to do my job while someone yells and screams. 6. What time did this place? Around 3pm, just a little after, approximately. Signature: Nurse Date: 12/5/21. Performance improvement Form [CNA D] Date: 12/5/2021. Reason for Counseling/Corrective Action: Witness provided statements involving (Nurse D) and a resident. used foul language and racial inappropriate comments. Alleged violation of code of conduct 6.14 violation the company's polices , including . harassments discriminations, violence prevention, etc 6.11 violation the rights of resident . including abuse, etc. Has this concern been previously discussed with the employee Yes. Counseling sessions/corrective action. Admin and HR collected witness statements. Suspend pending investigation Nurse D Personal Action Request (PAR): Separation Last day of work 12/05/2021. Separation Date: 12/7/21. Reason for separation: Terminated. Code of Conduct violation. Inappropriate language. signed 12/7/21 administrator. A review of the facility's policy titled Abuse, Neglect and Exploitation dated 01/01/2021 noted, Policy: It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Definitions: . Verbal Abuse means the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of there age, ability to comprehend, or disability . VI. Protection of Resident The facility will make efforts to ensure all resident are protected from physical and psychological harm during and after the investigation. Examples include but are not limited to: A. Responding immediately to protect the alleged victim and integrity of the investigation . VII. Reporting/Response. A. 3. Reporting to the state nurse aide registry or licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for services .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to administer nonpsychiatric and/or psychotropic behavior medications and manage behaviors appropriately per physician orders, for one Resident (Resident #23) of four residents reviewed for behaviors, resulting in mental anguish, uncontrolled anger and impulsiveness. Findings include: On 05/24/2022 at 11:19 AM, Resident #23 was observed in the room next to their room, helping set up a meal tray for another resident. Resident #23 was dressed and groomed and talking in a very quiet tone. The Resident was calm and smiling. During this time, an interview was attempted but the Resident did not answer questions appropriately. On 05/25/2022 at 07:45 AM, Resident #23 was up in the lobby wearing the same outfit as the previous day. The Resident was yelling and screaming, I'm starving to death! The staff around were attempting to console the Resident without success. The Resident then exited the lobby, and could be heard screaming down the hallway. Staff followed the Resident. On 05/25/2022 at 08:00 AM, Resident #23 was continuing to pace up and down multiple hallways screaming and accusing other random residents of hitting them. The Resident then began to follow this Surveyor down the hallway screaming, Who is she? What is she doing here? Staff were following behind the Resident attempting to distract the Resident. The Resident continued to pace back and forth up and down hallways threatening staff and refusing all assistance from staff. There were two staff members following the Resident. Resident #23 was yelling, I want to go to the kitchen! , I hate it here! and Leave me alone! I'm tired of this! The Resident would stop at random doorways of resident rooms and offices and yell and scream. On 05/25/2022 at 08:22 AM, Resident #23 continued to yell and scream in the hallways. The Resident quickly approached this Surveyor screaming, Who are you? When answered, the Resident yelled, I don't care! Now there were three staff members following the Resident. The Resident quickly left the room, went down a hall yelling. A voice was heard yelling that Resident #23 had hit them. At that time, Resident #23 yelled, I hate this place! On 05/25/2022 at 08:42 AM, a scuffle could be heard from the adjacent hallway with Resident #23 and staff yelling that the Resident was trying to hit them and they were petitioning the Resident out to the hospital. The Resident yelled, I am not going to [local hospital]! Resident #23 continued the same behaviors until 08:54 AM (05/25/2022), when three police officers had to handcuff the Resident onto a stretcher to exit the building. A record review of the Physician Orders for Resident #23 revealed the following: Clozapine 50 mg (milligrams) Q (every) 12 hrs (hours) Dx (diagnosis) Paranoia Schizophrenia, Anxiety D/o (disorder), ordered 05/06/2022. Labs: CBC (complete blood count) with Diff weekly one time a day every Thu (Thursday) for Clozaril monitoring related to SCHIZOAFFECTIVE DISORDER, UNSPECIFIED. A record review of the May 2022 Medication Administration Record (MAR) for Resident #23 revealed the following: Resident #23 did not receive their prescribed dose of Clozapine on 05/03/2022-05/05/2022 and 05/12/2022-05/23/2022. A CBC was documented as being drawn on 05/21/2022 only. A record review of the Minimum Data Set (MDS) assessment dated [DATE] revealed that Resident #23 was most recently admitted to the facility on [DATE] with the diagnoses of Schizoaffective Disorder, Psychosis, Paranoid Schizophrenia and Major Depressive Disorder. The following behaviors were coded on the MDS: trouble falling asleep, delusions, physical behaviors, verbal behaviors, rejection of care, and wandering. Resident #23 had a Brief Interview for Mental Status (BIMS) score of 15, indicating and intact cognition. A record review of the Progress Notes for Resident #23 revealed the following: 2/15/2022 11:30 (AM) .Resident walking up and down the hallways. Refusing to put grip socks or shoes on. Resident stating .is 'pregnant & will need an abortion'. Going across hall to another resident's room & shutting off .TV. Attacked another nurse & stated she is 'evil'; Spoke to NP (Nurse Practitioner) & making arrangements to send resident out. 2/20/2022 16:00 (04:00 PM) .Pacing back and forth yelling at this writer and throwing things if in reach all afternoon . 2/20/2022 17:46 (05:46 PM) .discharged at this time to .neuro behavior center .Combative upon transport arrival. Yelling, screaming, kicking ,hitting. Physical assist onto the stretcher at that time transport staff had to put soft restraints on her wrists and ankles . 3/24/2022 08:01 (AM) Yelling down the hallway 'My inside organs are falling out' .resident is lying in .bed nude from the waste down refusing to put on pull ups. Going to .doorway wrapping the privacy curtain around .continues yelling out 'I have colitis of the bowels.' 3/27/2022 14:23 (02:23 PM) .Resident, this afternoon did swing at the CNA (Certified Nurse Assistant) again and is yelling in the hall. Resident is returning to .behaviors .had prior to being sent to Indiana. Every shift this writer works the behaviors in report and the behaviors .displays are no different then before .send out. 3/28/2022 16:34 (04:34 PM) .Call made and message left with residents guardian to discuss alternate placement. Awaiting return call. Will continue to follow PRN (as needed). 3/28/2022 18:48 (06:48 PM) .Resident became aggressive and threatening towards other residents whose room are across the hall .When I attempted to redirect [Resident #23] .became aggressive and combative towards me. As I was stepping away .began to punch me in the shoulder several times until I was able to get some distance away from (Resident #23). DON (Director of Nursing) and Administrator were notified, resident was petitioned out to [local hospital]. EMS (Emergency Medical Services) arrived and was able to convince .to go the hospital. Resident left building via EMS. 4/5/2022 06:01 (AM) .Resident needs supervision r/t (related to) .behaviors. Is a danger to .self and others. Temper and ability to change moods quickly. Nothing has really changed with this resident . steady on (their) feet .Verbally abusive to others and since .return this week has not been physically abusive to anyone yet. Did refuse . medication this morning. 4/6/2022 18:55 (06:55 PM) .returned to facility from [local hospital] Psychiatric unit on 4/4/22. Patient refuses physical exam patient states 'I went to [local hospital] and they dyed my hair red, and now its on fire so I can't talk to you'. Patient clearly through observation did not have .hair colored. Nursing reports patient refuses oral medications today 4/6/22 .CBC with diff weekly for Clozaril monitoring .Reorient Redirect to environment as needed. Continue with supportive measures Encourage compliance with medications and care. Follow closely with psych . 4/10/2022 13:51 (01:51 PM) .Behaviors are more than daily. Residents new behavior is to throw . tray with all the food on it out in the hall then scream that its not the way (Resident #23) likes it. 4/11/2022 16:00 (04:00 PM) .Yelling and chasing the house keeper this afternoon. unknown reason. Yelling across the hallway at another resident. Continues to complain about all foods. Poor food and fluid intake. 4/14/2022 02:00 (AM) Resident upset with wall panel in hallway by dinning room [ROOM NUMBER] that alerts staff that a call light is on and residents need assistance. Resident is screaming that it needs to be turned off now it is driving resident crazy resident up and down the hallway yelling. Resident asked to please not yell and was educated on what it was and why it is there and that it can not be turned off. Resident received a one time IM (intramuscular injection) ativan per Doctor after multiple attempts to redirect patient. 4/16/2022 16:00 (PM) .Will constantly ask for food and then when it is given .will just storm away stating something was wrong with it. Yet then yell down the hallway 'I am starving'. Many substitutes offered and rejected so .can have something to yell about. Or make staff run back and forth to the kitchen for all of their efforts are in vein. 4/22/2022 16:00 (04:00 PM) .Pacing back and forth down the hallway. Looking upset and agitated. When asked what was wrong .yelled 'I don't know the DEVIL took over.' 4/24/2022 13:02 (01:02 PM) Resident running up and down D hall. Writer has told (them) to stop several times and .continues to .reply .'I can't stop its controlling me'. 4/24/2022 13:05 (01:05 PM) .Follow up of behaviors that occur daily. Today its running up and down the hall 'it' is making (them) do it and .can't stop. Resident has been redirected several times today and the behavior continues. 4/28/2022 08:05 (AM) behaviors getting increasingly worse this a.m. Constant complaints and yelling about ALL food. Running up and down the hallway yelling and becoming anxious. Screaming 'I have anorexia' New order for Ativan (an antianxiety medication) . 4/30/2022 11:05 (AM) Resident continues to get upset with staff and others easily. Resident does not like bed, so took it upon .self to go to another hall and bring a different bed back with (them). Unable to redirect ., so allowed (Resident #23) to switch .beds at this time. Resident is content at this time after beds switched. Will continue to monitor. 4/30/2022 11:59 (AM) See MAR, which has been reviewed, for a list of the current nonpsychiatric medications-Clozapine 50 mg Q12 hours .Complaint: Refusing medications at times; Eccentric behavior .seen today for follow-up psychiatric evaluation at the request of the primary team and social work, to evaluate acute psychiatric symptoms and assess the effectiveness of the current psychotropic drug regimen in relation to these acute symptoms. At the previous psychiatric evaluation, no psychotropic medication changes were made. The patient has developed a significant new problem which requires immediate attention. The Patient is being seen in close follow up to ensure .is remaining compliant with .medications. Today .presents in a very good mood and speaks with me in a normal fashion. Not demonstrating any uncontrolled psychosis or delusions or hallucinations at this point in time .is also reported by staff to be more calm and interactive with no issues .Plan: Clozapine-Monitor mood, behavior, delusions, paranoia, hallucinations. Document concerns. Notify service of any changes . 5/1/2022 08:05 (AM) .Resident mood has changed often and drastically throughout the shift. Has had pressured speech most of the day when speaking to others. At one moment .is yelling and stating .hates others and multiple things about the facility, the next moment .comes out of (their) room, (Resident #23) is telling others that .loves them. Resident is also refusing to brush .teeth today, stating it will 'kill me'. Resident is often seen quickly walking up and down the hallways. 5/14/2022 16:00 (04:00 PM) .Running up and down the hallway at lunch time yelling about food .will request things to eat and then .will refuse. Yelling, 'I got nothing to eat' 'I am going to starve'. Screaming 'I am going crazy.' Yelling that .mother and father are in 'Hell' and 'That is where I am going'. 5/16/2022 16:00 (04:00 PM) .resident began to get restless this afternoon. pacing up and down the hallway mumbling/talking to .self. 5/22/2022 15:06 (03:06 PM) .Behavior occurred - interventions ineffective. Resident has behavior issues daily. No intervention has proven to be effective. Currently .has been out of .medication that was prescribed for such issues. 5/22/2022 17:44 (05:44 PM) Nurses' Notes .Resident continues with unresolved behaviors that maybe .medication was starting to help but .no longer has this medication and is regressing back to so many behaviors a day its becoming impossible to keep them straight, Every meal,that the resident tells kitchen what .wants,resident throws on the floors or [NAME] that (they are) not eating that slop. Today every meal .went in all the residents rooms on D hall telling them that this place is starving (them) and .has nothing to eat .ordered tuna fish then smashed it in .hands and took it in the rooms like that to show what they give (them) to eat. At supper .ran up and down d hall yelling .was being starved ,then down A hall and writer found .in the dining room by the kitchen yelling .was starving and nobody gives (them) any food. 5/25/2022 10:10 (AM) .Resident was pacing up and down the hallways this morning yelling out. Resident stating 'I want a [NAME] Crocker cook book'. This writer approached resident with a notepad and pens to write recipes. Resident began yelling at this writer 'I hate you [staff name]'. Resident pacing back and forth screaming up and down the hallways at staff. Unable to re-direct. Resident approached this writer in the office, ripping the phone out of this writers hand. Resident sweeped the desk of this writer throwing all objects off of the desk. Social Service Director completed petition for mental health. This writer contacted (company name) EMS (Emergency Medical Services) to set up transport to [local hospital] for mental health treatment. Resident was resistive to going with (contracted company name) EMS. Three officers assisted with transport. This writer contacted residents Guardian .CMH (community mental health) also notified of transfer. 5/25/2022 15:59 (03:59 PM) .Resident stated to staff member, 'I hit you lst time but i will kill you this time' . A review of the care plan for Resident #23 revealed the following: Focus-Altered thought process r/t paranoia, delusions, hallucinations. (Resident #23) may see .deceased father whom .believes is the anti-Christ .has a history of accusing staff of trying to kill (them) .makes accusations against staff due to delusions and memories from her past; res (resident) may feel there's cement dust coming in through .window and declines to close .window. res perceives the carpeting as dirty despite carpets being cleaned and will lay towels about the floor to walk on; res may yell at others in the hallway- typically delusional, confused content. res fixated on refusing new shoes, threw out black tennis shoes that use to fit .declines larger sizes, refuses slippers and slipper socks to wear. res caring partner has purchased multiple socks, slippers, gripper socks - res refuses to wear. res will go barefoot in facility despite multiple attempts to provide and education. Date Initiated: 11/02/2020. Revision on: 01/26/2022. Goal-(Resident #23) resident and others will not experience negative outcomes related to altered thought processes. Intervention-Provide medications as ordered .Date Initiated: 11/02/2020 . On 05/26/2022 at 07:43 AM, an interview was completed with the DON and Nursing Home Administrator (NHA). They were asked about the medication not available for Resident #23. The DON explained that the facility has recently switched providers (psychiatry) and pharmacy and that they were not able to get the medications without a weekly CBC draw. The DON stated, They (the pharmacy) used to send us a seven day supply but they don't do that anymore. The DON explained that they did not draw the correct CBC initially. The DON also stated, (Resident #23) refuses labs to be drawn sometimes and they (the pharmacy) won't send it (the medication). The DON was asked about utilizing different medications that did not require blood draws and stated, (Resident #23) has been on everything. A review of the facility policy titled Behavior Management Program dated 10/18/2020 revealed the following: .Residents on an antipsychotic residents exhibiting behaviors negatively affecting self or other residents will be reviewed by the Behavior Management team .the team will examine the root cause of behaviors/mood .The team will identify target behaviors .b. Social Service team will monitor behaviors .