**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** This citation pertains to Intake Number(s): MI00138552. Based on observation, interview, and record review, the facility failed to ensure physical abuse did not occur for two (R804 and R805) of five residents reviewed for abuse, resulting in R804 choking R805, and other residents reported feeling scared, unsafe, and/or had nightmares after the abuse occurred (R807, R808, R809). Findings include: Review of a Facility Reported Incident (FRI) was submitted to the State Agency on 7/15/23 revealed the facility reported a physical abuse incident that occurred between R804 and R805. An unannounced, onsite investigation was conducted from 8/1/23 through 8/2/23. Review of R804's clinical record revealed R804 was admitted into the facility on 3/9/22, was discharged to the hospital on 7/15/23, and readmitted on [DATE] with diagnoses that included: schizoaffective disorder bipolar type, post traumatic stress disorder (PTSD), and dementia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R804 had intact cognition and verbal behaviors. Review of a care plan initiated on 3/10/22 revealed, (R804) at risk for changes in mood/behav (behavior) r/t (related to) dx (diagnoses) depress (depression)/[NAME] d/o (delusional disorder), schizoaffective d/o bipolar type .He can be paranoid/short tempered/easily angered, not tolerant of alternative lifestyles . Review of R804's progress notes revealed the following documentation: 7/12/23 at 7:46 PM, Nursing Progress Note written by Nurse 'K' - Late Entry: .around 730pm, writer sitting at nursing station, could hear resident yelling in room with closed door, after knocking, resident refused entrance but after being unable to hear what writer was saying resident allowed writer in room, multiple items on floor, question what happened, resident yelled I hate this place, I hate my stuff, I hate being here, confirmed that he through <sic> items on floor, pushing walker, punching table, cont (continued) to yell, writer stated, you need to stop, resident through <sic> self into chair, sliding chair back and almost falling out, writer about to calm resident with 5 sensed calming tech, resident started talking about topics that anger resident, politic, religion, gay people, his lawyer, his brother, able to redirect, to find out that his phone was not working properly, writer assisted with phone, needs to be changed. assisted resident with calling brother in meeting room called the fishbowl, he left message, resident calmer with no yelling however clear unlined agitation. 7/13/23 at 12:05 PM Nursing Progress Note written by Nurse 'K' - .around 1030am, resident in hallway coming back from dayroom, resident talking to self with agitation, I'm never going to that room again (dayroom), I hate this place, I hate my life, I hate everything, writer overheard resident, question if resident needed anything, resident yelled, (Nurse 'K') there is no point to this or anything, picking up handles of walker and slamming walker down, resident walked quickly away, able to stop resident with calm words, resident sat with nurse doing breathing exercises, effective, discussed what resident needed, resident mad about other resident being 'babied', discussed how everyone is here for a reason and the staff are using their skilled <sic> to help everyone based on their dx (diagnosis), resident pleased with answer and able to move pass challenging moment, resident wanted to call brother, assisted, effective. 7/14/23 at 9:48 PM Physician's Progress Notes - Patient has an episode of severe agitation and staff is worried for his safety .Response: 1- anxiety and depression worsening- discussed with NP (Nurse Practitioner) and DON (Director of Nursing). Will add Abilify (an antipsychotic medication) 5mg (milligrams) for two weeks and if not enough change increase to 10 (mg). DC (discontinue) seroquel (an antipsychotic medication) as it has not helped . 7/15/23 at 2:36 PM Nursing Progress Note - resident lost control of himself and choked another resident in the dining room Responsible party notified , Physician notified, Administrator notified , DON notified . Immediate intervention implemented: resident transferred to (hospital) for psych (psychiatric) eval (evaluation) . Further review of R804's progress notes revealed the following: On 10/25/22, a Social Services Progress Note documented, .We received his notes today. He told him that he was 'mood swings' and a bad temper, but claimed he was not aggressive . On 12/15/22, an Activity Progress Note documented, Resident has become frequently anxious about other residents' involvement in activities .expressed frustration not being able to sit by certain residents, have other residents' attention, and expresses anxiousness about other residents possibly bumping into others . On 12/15/22, a Nursing Progress Note documented, resident had difficulty in dayroom on 12/14/22, Resident stated, I don't want some of the other resident around, they don't need to be in there, they are nothing but stupid .Resident stated that the other people give him anxiety . On 3/6/23, a Nursing Progress Note documented, .social with staff and other resident, in dayroom, resident complaining about other resident volume and dementia behaviors happening on other side of room . On 3/9/23, a Nursing Progress Note documented, during morning meds resident stated that he was feeling so angry and discussed <sic> with this world, resident was watching TV, resident stated he was watching the news ad <sic> they were talking about people choosing to change to become the opposite sex, resident shaking fist, face turning red . On 3/30/23, a Physician's Progress Notes documented, Pts (patient's) anxiety does not seem to be improving - nursing reports he gets very riled up by a few other residents . On 4/5/23, a Physician's Progress Notes documented, Per nursing pt has been having more increased anxiety .they report small incidents will set him off and he gets worked up easily. On 4/13/23, a Nursing Progress Note documented, at shift change, resident self propelled in w/c (wheelchair) from room to day room multiple time with hurried fashion, stopping to say something to nursing staff .upon last lap, resident stopped for shortly, then continued to room, slammed door and yelled loud being heard at nursing station . On 4/17/23, a Nursing Progress Note documented, during am (AM) med pass, resident shaking head, shaking fist, yelling about how other residents were taking the seat that his friend .normally sits in during activities .BP (blood pressure) elevated, face red . On 4/22/23, a Nursing Progress Note documented, Resident has been anxious and crying intermittently for 2 days. He stated, 'I have very angry thoughts. On 5/1/23, a Nursing Progress Note documented, resident has been having difficulty tolerating certain residents in the dining room during activities and at other times too. resident will get very anxious and upset and taking himself out of the situation . On 5/3/23, a Physician's Progress Notes documented, Pts (patients) anxiety does not seem better controlled even with adjustment and <sic> med (medication) .he discussed with me some things that were making him anxious .he does have anxiety about 2 residents in the facility and he does not like their behaviors . On 6/1/23, a Physician's Progress Notes documented, Pt continues to have anxiety that waxes and wanes. It is more situational and he is more agitated when around certain residents . On 7/3/23, a Nursing Progress note documented, Resident tries to get residents/staff to engage in conversation about religion and politics. When someone refuses or states I don't want to talk about the subject he gets upset . On 7/4/23, a Nursing Progress Note documented, resident having increased behavior, easy to anger, such as when his BP is higher than expected, no extra straw for drink, when someone doesn't say hello back to him. Resident pounds fist on table to chair, slamming his door, quickly ambulating in hallways multiple laps. When talking to resident in general conversation resident turns conversation political or religion. these topics cause him to become agitated . On 7/7/23, a Nursing Progress Note documented, around 730am, resident at desk asking for ice cup, writer on phone call, indicated to resident to wait a minute, resident hit walker with closed fist, stormed off yelling that no one ever does what I need, slamming door . On 8/2/23 at 9:50 AM, an interview as conducted with R805. When queried about what happened in the dining room on 7/15/23, R805 reported he was in the dining room listening to music and R804 came into the room and started yelling at him to turn it off. R805 reported he was trying to turn the music off and R804 lunged toward me and started strangling me. R805 reported it was really scary and he was note sure if I would feel safe if he returned. R805 reported he was told R804's medication was wrong but stated, That's no reason to attack someone!. Review of R805's clinical record revealed R805 was admitted into the facility on 2/2/23 and readmitted on [DATE] with diagnoses that included: Parkinson's Disease, PTSD, and schizoaffective disorder. Review of R805's MDS assessment dated [DATE] revealed R805 had intact cognition and verbal behaviors that significantly intruded on the privacy or activities of others and significantly disrupted the care or living environment. Further review of R805's clinical record revealed progress notes on 5/26/23, 5/27/23, and 5/29/23 that indicated R805 had verbal altercations with other residents in the dining room during activities. Review of R805's care plans revealed there was no care plan regarding the documented verbal aggression displayed toward other residents. Review of an investigation conducted by the facility and submitted to the State Agency regarding the incident of R804 choking R805, revealed the following: Incident Summary: The Administrator was notified today at 12:09 pm that (R804) approached (R805) in the Dining room, who was playing music from his phone to a speaker, and voiced to (R805) to turn that music off, 'No one wants to hear it'. (R804) then allegedly attempted to choke (R805) .Minor scratch was noted on (R804) and Redness in skin tone was noted on (R805's) Face and neck . .Investigation Summary/Actions Taken: .Resident #1 (R804) .(R804) was most often extremely pleasant toward staff and residents. (R804) frequently struggled with his anxiety and therefore had many medication adjustments (It should be noted that there were multiple documentations in R804's progress notes about their anger and negative feelings toward some of the other residents who were in the dining room dating back to 10/2022) .Resident #2 (R805) .(R805) loves to listen to music and interact with other residents in the facility . .Summary of Incident: The administrator was informed by the Registered Nurse (RN) on duty (Nurse 'J') that, at or about 12:00pm on 7-15-23, (R804) (alleged perpetrator), was in the resident dining room. Other resident in the dining room were: (R805 - alleged victim), (R809) BIMS (Brief Interview of Mental Status - an evaluation to determine cognition) of 15 (A score of 13 to 15 indicates intact cognition), (R808), BIMS of 14, also (two residents who were either non-verbal or had severely impaired cognition). (Nurse 'D') (RN) was passing medication outside the dining room. (R805) (victim) was listening to music on his phone. (Nurse 'D') stated that she saw (R804) quickly move towards (R805) and grabbed him by the throat. (Nurse 'D') quickly intervened, telling (R804) to stop and removed his hands from (R805's) throat. (R805 also grabbed (R804's) hands and tried to assist in removing them from his throat. (R804) was escorted from the dining room. At this time (R804) repeatedly informed (Nurse 'D') that he was sorry and did not know what came over him. It was also noted that (R804) reported that he was worried that other residents would no longer like him and not want him around them. He feared he was going to jail and reported that he couldn't be trusted and that he needed to go somewhere else .(R805) reported he was afraid and did not want (R804) around him anymore .Police were called at 12:23pm and arrived at 12:45pm .(R804) was observed, on 1:1 (one to one), until 3:00 PM when he was sent for psychiatric evaluation at (local hospital) . Interviews: (R804) .Its all my fault. Just put me in jail. I need to go somewhere else . (R805) .I was playing the radio in the dining room. (R804) asked me to turn off my (expletive) music and next thing I knew, he was choking me .Do you feel safe in the facility? .Yes if (R804) isn't here anymore . (R809) .(R804) came into the dining room and verbalized, turn off your (expletive) music. (R805) was trying to turn his music off and (R804) lunged at him and started choking him . (R808) .(R804) started yelling and caught (R805) by the throat. I don't want him to do that to me .Do you feel safe in the facility? .Not with him, (R804) . .In Conclusion: The facility has determined that (R804) made physical contact with (R805) by placing his hands on (R805's) throat and trying to choke him. (R804) was undergoing a medication change, which likely was a contributing factor to the unexplained behavior (It should be noted that R804 had several medication changes throughout their admission due to anxiety, anger, and agitation, as well as documented incidents of issues with other residents in the dining room). The Investigation substantiated the incident occurred as described by all parties however, it does not substantiate willful physical abuse. (R804) was extremely remorseful immediately after the incident and he voiced that he did not know what came over him. (R804) further voiced that he needed to sent somewhere else because he could not trust himself. The investigator finds that (R804) was not acting deliberately when he acted out and therefore finds the allegation of physical abuse to be unsubstantiated. The administrator met with (R805) who voiced that he felt safe in the facility but that he would not feel safe if (R804) was returned to the facility. (R804) was sent to (local hospital) for evaluation and treatment. After consultation with the Interdisciplinary team, the Residents physician as well as the medical director, it was determined that (R804) will not be readmitted to the facility at this time, and until the facility can be assured his plan of care has been altered to ensure the safety of other residents with whom he encounters. The risk to the safety and security of our resident population, along with signed statements attesting to the fear and anxiety that would be caused by (R804's) return has made his, (R804's) readmission unadvisable at this time . Further review of the facility's investigation revealed the following: A signed statement by R809 that documented they feel safe in the facility, although she is worried about him (R804) coming back. A second signed statement by R805 dated 7/15/23 that documented, Yes I feel safe here but that does not meant I want you to bring (R804) back because I don't. He will just go off and do the same thing. I won't feel safe if he is here. A signed statement by a resident who resided in the facility, R807, that documented the following in response to being asked if they felt safe at the facility: With exception of (R804). He should never come back. He flies off the handle. On 8/2/23 at 8:10 AM, R804 was observed in their room laying on the bed with the door closed. CNA 'B' was seated in a chair in the resident's room. R804 got out of bed and into the wheelchair. R804 reported CNA 'B' would know more than he would about why she had to sit in the room with him. Throughout the day, R804 was observed walking around the facility with CNA 'B'. On 8/2/23 8:20 AM, R809, who witnessed the altercation between R804 and R805, was observed lying in bed. Their hands appeared contracted. R809 reported they are dependent on staff for activities of daily living (ADLs). When queried about any witnessed altercations between residents in the facility, R804 reported they witnessed R805 playing music on their phone, R804 came in the dining room and told R805 to turn the music off because it was bothering everyone. R809 explained that nobody else in the dining room was bothered by R805's music and R804 was not in the room when he turned it on. R808 further explained that R805 was trying to turn the music off and R805 came back into the dining room, yelled, and then lunged at R805 and started choking him. R809 stated, It was terrifying. I felt helpless because I could not help (R805). R809 reported R805 appeared to be in shock and was trying to take R804's hands off of his neck. R809 stated, I don't feel safe around him (R804) anymore. He was always up and down. I didn't feel unsafe before and now I do. R809 reported she was told R804 was readmitted into the facility and that she was very unhappy about it. R809 stated, I don't feel safe. (R804) is a ticking time bomb. Review of R809's clinical record revealed R809 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included: multiple sclerosis and quadriplegia. Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed R809 had intact cognition and was totally dependent on staff for ADLs, bed mobility, and transfers. BIMS = 15, total dependence on staff for ADLs, bed mobility and transfers. Review of R809's progress notes revealed a Social Services Progress Note dated 7/20/23 that read, (R809) was witness to an incident between 2 residents on 7/15/23 in which one of the residents but <sic> his hands on the others throat .When I spoke with her today, I asked how she would feel if the resident who had put his hands on the other resident returned to us, She stated, 'It won't be good because he likes to instigate stuff, nobody will be happy'. I asked if she would feel safe here if he returned, She stated, 'No, he's a ticking time bomb, no one knows what to say to him because he can blow up any time, you never know with him. On 8/2/23 at 8:30 AM, R807, who was interviewed as part of the facility's investigation and expressed feeling unsafe around R804, was interviewed. R807 stated, I heard they brought (R804) back last night. I'm really upset about it. We made it clear that we felt unsafe around him and they said he wouldn't be coming back. Review of R807's clinical record revealed R807 was admitted into the facility on 9/28/22 and readmitted on [DATE] with diagnoses that included: osteoarthritis and type 2 diabetes. Review of a MDS assessment dated [DATE] revealed R807 had intact cognition and no behaviors. On 8/2/23 at 8:36 AM, R808, who witnessed the altercation between R804 and R805, was observed seated in a wheelchair in her room. When asked about what she witnessed in the dining room on 7/15/23, R808 reported R804 was yelling at R805 and then grabbed his throat and started choking him. R808 stated, It was so scary. Review of R808's clinical record revealed R808 was admitted into the facility on 2/17/21 with diagnoses that included: Alzheimer's disease. Review of a MDS assessment dated [DATE] revealed R808 had intact cognition. Review of a Social Service Progress Note dated 7/20/23, revealed, (R808) was witness to an incident on 7/15/23 between 2 residents in the dining room where one resident had placed his hands around the others neck .I met with her again today and asked her how she would feel if the resident that had grabbed the other returned to us. She stated 'I don't want him coming after me, he don't like me either. He never liked (R805), I don't know why, (R805) never did nothing to him'. I then asked her if she would feel safe here if he did return, she stated 'I don't know, I would feel on edge like he would grab my throat, I laugh too much, he doesn't like my laughing. On 8/2/23 at 9:03 AM, a phone call was made to Nurse 'D'. Nurse 'D' was interviewed via telephone. When queried about what happened on 7/15/23 between R804 and R805, Nurse 'D' reported R804 tried to strangle R805. Nurse 'D' explained they were walking into the dining room and R804 had a walker and was to the left of them and R805 was on the right, R804 became enraged and went for (R805's) neck and latched on. Nurse 'D' had to assist with getting R804's hands off of R805's neck. Nurse 'D' reported R809 was traumatized and Nurse 'D' no longer feels safe working with R804. On 8/2/23 at 10:05 AM, an interview was conducted with Nurse 'M. When queried about what occurred on 7/15/23 between R804 and R805, Nurse 'M' reported on that day, they were assigned to R805 and R805 reported that R804 tried to choke him because he was upset about R805's music. R805 reported they were trying to assess R805 and he was pretty shook up. When queried about R804 and any known behaviors, Nurse 'M' reported R804 was very anxious and would get upset over nothing. Nurse 'M' reported R804 usually calmed down after you talked to him. Nurse 'M' further reported that R805 and R807 antagonized R804 and said mean stuff to him (R804). On 8/2/23 at 11:55 AM, an interview was conducted with Nurse 'K' who documented about R804 being agitated and angry when leaving the day room on 7/12/23 and 7/13/23. When queried about why R804 was so upset about the day room, Nurse 'K' stated, He was just agitated. Nurse 'K' reported they sat with R804 and worked with R804 through his feelings and discussed ways to deescalate. When queried about any problems R805 had with other residents in the facility, Nurse 'K' reported R804 did not like some of the residents, but never saw him interact with them. On 8/2/23 at 11:30 AM, an interview was conducted with Unit Manager, Nurse 'J'. Nurse 'J' was queried about the other residents involved in the progress notes she documented on 5/29/23 in R804's clinical record that read, This resident approached another resident to attempt to stop negative disrespectful behavior toward others. He was then called names and talked to disrespectfully by resident. He then was told to shut up and mind his own business and some other curse words .activities coordinator was in charge at the time of this event and deescalated the situation to ceasing it. and the note on 5/1/23 that read, resident has been having difficulty tolerating certain resident in the dining room during activities and at other times too. Resident will get very anxious and upset and take himself out of the situation . Nurse 'J' reported on 5/29/23 she documented for Activities Aide 'G' but was not present during the incident. Nurse 'J' could not recall the incidents that triggered the progress notes on 5/29/23 and 5/1/23. When queried about any known issues with R805 and other residents, Nurse 'J' reported R804, R807, and R805 have issues. R807 feeds into it all and takes sides and R804 has a long history of mental issues and has not made friends with anyone .He is bugged by everything and gets upset about a lot of stuff. When queried about how other residents feel about R804, Nurse 'J' reported R809 is very scared and R808 had a nightmare the next night because she was afraid (R804) would choke her too. Nurse 'J' reported R805 and R807 were afraid initially but now they said they are not. On 8/2/23 at 12:02 PM, Activities Aide 'G' was interviewed by telephone. Activities Aide 'G' reported there were a couple of incidents that involved verbal altercations between R804 and other residents. Activities Aide 'G' reported most were fairly unprompted and due to miscommunication. Activities Aide 'G' explained on 5/29/23 she had Nurse 'J' write a note for her because she doesn't have access to charting and she thought R804 was under the impression another resident was being disrespectful which led to verbal altercations including yelling and swearing and saying shut up. Thinks it was between R804 and R805. On 8/2/23 at 1:27 PM, an interview was conducted with the Administrator, who was the facility's Abuse Coordinator. When queried about whether he was aware of any ongoing tension or problems between R804 and other residents, specifically R804 and R805 as documented in their clinical records, the Administrator reported he was not. He was aware that R804 was going through some medication changes due to anxiety, but not aware of any abuse situations. The Administrator reported he was aware that R804 would do things such as slam his walker down. When queried about what was in place to prevent resident to resident incidents between R804 and other residents prior to the day when R804 tried to choke R805, the Administrator reported R804 was followed by behavioral health and they were trying different medications and monitoring him. Review of a facility policy titled, Abuse, Neglect and Exploitation, revised 6/2023, revealed, in part, the following: 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 .The facility will identify, correct, and intervene in situations in which abuse .is more likely to occur .The facility will identify by ongoing assessment, care planning for appropriate interventions and monitoring of residents with needs and behaviors which might lead to conflict .