**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect two resident's (Resident #18 and Resident #7) right to be free from physical abuse. On 6/15/25 LPN A followed Resident #18 into an unoccupied resident room rolled him/her out of the bed onto the floor multiple times and LPN A walked the resident backwards which resulted in the resident falling and sustaining a fracture of the right tibial plateau (a break in the top portion of the shinbone near the knee joint, that often occurs due to high-energy impacts such as falls). The resident was sent to the local hospital and transferred to another hospital for surgical evaluation. In addition, staff failed to protect Resident #7's right to be free from abuse when Resident #27 hit him/her on the back of the head. The facility census was 56. The Administrator was notified on 7/11/2025 at 2:30P.M. of an Immediate Jeopardy (IJ) which began on 6/15/2025. The IJ was removed on 7/14/2025 as confirmed by surveyor onsite verification. Review of the facility's undated Abuse and Neglect policy showed:- Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes deprivation by an individual including a caretaker, of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental, or physical condition cause harm, pain or mental anguish. - Corporal punishment, which is physical punishment, is used as a means to correct or control behavior. - Convivence is defined as the result of any action that has the effect of altering a residents behavior. that is not in the residents best interest. - Manual method means to hold or limit a residents voluntarily movement by using body contact as a method of physical restraint. - Mistreatment means inappropriate treatment of a resident. - Each resident has the right to be free from abuse, neglect and corporal punishment of any type by anyone. -The resident has the right to be free from abuse including freedom from involuntarily seclusion and physical or chemical restraint not required to treat the residents medical symptoms. Review of the facility's undated Resident Rights policy showed:-Residents have the right to be free from all abuse;-Residents shall not be subjected to physical, sexual, or emotional injury or harm.-Residents have a right to care which maintains or enhances the quality of life.Review of the facility's Person-Centered Interventions Behavior Management Program, dated 2022, includes:- When addressing a resident in crisis approach the person with a calm demeanor, avoid getting into a power struggle, utilize empathy and try to understand the residents point of view, respect the residents personal space and stand a little further back than arms reach (if you are too close to the person in crisis, then he/she may believe that you are being aggressive and that could further intensify the escalation of the event, Keep your hands to your side so the resident can see you have nothing you will use against them.- Person Centered Interventions includes guidance for a 2 to 3 person and did not include a physical de-escalation technique that could be used by only one staff member.1. Review of Resident #18's Annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 05/21/25, showed:-No cognitive impairment;-The resident had delusions;-The resident received antipsychotics (a class of medications primarily used to treat mental health disorders) daily;-Diagnoses included, schizophrenia, bipolar disorder, anxiety, and depression.Review of the resident's care plan, dated 05/29/25, showed:-The resident is at risk for falls;-The resident has behaviors;-Staff are directed to maintain a safe environment.Review of the nurse progress notes showed:-06/15/2025 at 04:00 A.M., the resident came to nurses station became verbally aggressive to LPN A. The resident said he/she will sleep where he/she chooses and went to room that was not the resident's room. LPN A went to the other room where the resident was in bed with the covers pulled over his/her head and pulled the covers down to verify it was the resident. The resident sat up in the bed and started grabbing, punching and scratching LPN A. LPN A utilized PCI technique, securing the resident's arms and lowering the resident to the floor onto his/her knees as the resident was kicking and screaming;-06/15/25 at 04:15 A.M., the Assistant Director of Nursing (ADON) went to the resident's room and the resident said his/her right knee hurt. The resident's knee was swollen; -06/15/25 at 05:31 A.M., the resident was sent to the hospital;-06/15/2025 at 08:17 A.M., the resident's guardian called and said resident was being sent to another hospital due to a fractured tibial plateau;-06/18/2025 at 05:47 P.M., the resident was re-admitted to the facility with diagnosis of right tibial plateau fracture.Review of the facility's Event Investigation dated, 06/15/25, showed:-At approximately 04:00 A.M., the resident became physically aggressive toward LPN A;-The resident initiated the altercation by pulling LPN A's hair and punching and scratching LPN A's head and arms;- LPN A implemented PCI technique and brought the resident safely to his/her knees to manage the aggression;- During this time the resident continued to resist by kicking his/her legs; -Certified Medication Technician (CMT) C and Certified Nurses Aide (CNA) A assisted the resident to bed. Observations and interviews with Resident #18 on 07/01/25 at 09:35 A.M. and 7/2/25 at 10:00A.M., showed: -The resident sat in a wheelchair with a brace in place to his/her right leg;-The resident said LPN A had got into it with him/her and broke his/her leg;-The resident said he/she was not usually in a wheelchair, but he/she had to be until the fracture is healed;-The resident said his/her right knee hurts, but pain medications help; -The night before the altercation with staff he/she had slept in a spare room, because his/her roommate snored;-He/she thought it was okay to sleep in another room;-On 06/15/25 at around 04:00 A.M., he/she walked to the empty room and LPN A followed him/her into the empty room;-LPN A told the resident he/she needed to get back into his/her bed;-LPN A went around the bed and started pulling up the sheets that the resident was laying on top of;-LPN A pulled the sheets up and rolled the resident out of bed and he/she got back into the bed and LPN A did it again multiple times; -The last time LPN A rolled him/her off the bed he/she got up and sat up on the bed and LPN A got in his/her face so he/she started punching and scratching LPN A;- He/she said, I should not have done that, but LPN A got in my face and All I wanted to do was sleep;-LPN A went to get CMT C and CNA A, because he/she was not able to stand up and could not put any weight on his/her right foot; - CMT C and CNA A helped him/her back to his/her room and into bed because his/her knees hurt; -He/She went to the hospital for a few days;-The hospital told resident he/she had a broken knee cap;- LPN A apologized and said he/she did not know she hurt him/her; - He/she is afraid of LPN A and a LPN A was still working at the facility. During an interview on 07/02/25 at 01:34 P.M., LPN A said:-On 06/14/25 the resident said he/she wanted to be moved to 400 hall and off the 200 halls, because the resident's roommate snored; -The resident went to an empty room and laid down;-The administrator told LPN A to get the resident to sleep in his/her own bed;-The administrator told LPN A not to let the resident sleep in another bed again;-On 06/15/25 at around 04:00 A.M., the resident came to the nurses station holding a pillow and said he/she could not sleep and he/she started down the hall to an empty room;-The resident went into an empty room and LPN A followed the resident;-The resident got in bed and covered up his/her head;-LPN A took the cover off the resident's head and told the resident he/she had to go back to the other room, because the administrator said he/she needed to sleep in his/her own room;-The resident stood up and started hitting LPN A;-The resident stepped toward LPN A and LPN A grabbed both of the residents' wrists and put them behind his/her back;-LPN A was facing the resident and walked the resident backwards toward the closed bathroom door;-When the resident and LPN A got to the closed bathroom door the resident went down to the floor and hit his/her knees and then the resident said ouch and that his/her knee hurt;-LPN A said he/she did not remember exactly how the resident got down to his/her knees;-The resident did not specify which knee was hurt at this time;-He/She did not pull the covers up and roll the resident out of the bed on to the floor at any time;-CNA A came down to the resident's room, because he/she said he/she heard some noise and the resident was setting on the floor at this time with his/her legs out in front of him/her.-CMT C came to the room and CNA A and CMT C assisted the resident back to bed;-The resident was complaining of knee pain;-The ADON had arrived at the facility and came to assess the resident;-He/She did not intentionally hurt the resident;-He/She did not want the resident to hurt himself/herself or others;-He/She should have left the room to get help and not try to de-escalate the resident alone;-The resident had a right to be safe at the facility. During an interview on 07/02/25 at 02:30 P.M., the Administrator said:-LPN A called the night that the incident happened and said the staff had dealt with the behavior;-He/She told LPN A to try to keep the resident in his/her own bed because that was the resident's bed;-LPN A said the resident had been up at the nurse's desk throughout the night;-The resident went into an empty room and LPN A followed/her;-The resident got in the room before LPN A did and had been covered up from head to toe;-LPN A took the covers down from the resident's head and the resident jumped up and went toward LPN A;-The resident started hitting/smacking LPN A;-LPN A said she used PCI training, but LPN A did not give any details;-LPN A said he/she got the resident to calm down by using PCI training;-LPN A said the resident fell down while the PCI technique was being administered and the resident complained of knee pain; -He/She did not feel this was abuse;-LPN A tried to keep the resident from harming himself/herself or others;-It was an unfortunate accident with no intent of abuse;-The resident had the right to be safe and free from accidents.During an interview on 07/02/25 at 03:47 P.M., CNA A said:-On 06/15/25 at around 04:00 A.M., LPN A did not call for help while he/she was in the resident's room;-He/She went to the resident's room, because he/she heard a sound like a trash can fell over;-When he/she got the resident's room the resident was sitting on the floor in front of the bed;-He/She has not seen LPN A be rude or rough with the residents;-The resident can be combative at times.During an interview on 07/02/25 at 04:12 P.M., CMT C said:-On 06/15/25 at around 04:00 A.M., LPN A did not call for help while he/she was in the resident's room;-CNA C told him/her to come to the resident's room;-The resident was sitting on the floor next to the bed;-The resident said LPN A hurt him/her;-He/she did not report the incident to anyone;-He/She had not seen LPN A be rude or rough with the residents;-The resident can be combative at times;-After CMT C entered the resident's room the resident told him/her LPN A hurt him/her;-The resident did not say how LPN A hurt him/her.During an interview on 07/02/25 at 04:43 P.M., the resident's physician said:-He was aware of the situation leading up to the fall;-The resident was combative with cares;-The resident was sent to the hospital for knee pain and found to have a right tibial plateau fracture.During an interview on 07/02/25 at 04:55 P.M., the resident's guardian said:-She was aware of the of situation;-The resident was combative with cares;-The facility did not report the resident was in pain;-She expects the resident to be safe and pain free.During an interview on 6/27/25 at 11:30 and 7/10/25 at 2:18P.M. the Ombudsman said:-The resident told her a staff member broke his/her knee;-The resident said he/she went to the hospital;-The resident did not say he/she was in pain at the time of the incident.2. Review Resident #7's Quarterly MDS, dated [DATE], showed:-Moderate cognitive impairment;-Diagnoses included: stroke, dementia and seizure disorder.Review of the resident's care plan, updated 06/22/25, showed staff educated the resident on not moving other residents' wheelchairs and to ask for staff assistance.Review of Resident #27's Annual MDS, dated [DATE], showed:-Severe cognitive impairment;-Verbal behaviors directed toward others;-Independent with the use of a wheelchair for mobility;-Diagnosis included, multiple sclerosis, thyroid disorder and high cholesterol.Review of the resident's care plan, dated 06/27/25, showed:-Used a wheelchair for mobility;-Impaired decision making.Review of the facility's investigation, dated 06/22/25, showed:-Resident #7 asked Resident #27 to move so he/she could get around him/her;-Both residents sat in wheelchairs;-Resident #7 moved Resident #27's wheelchair and went around him/her in the hall;-Resident #27 hit resident #7 with an open hand in the back of the head.Review of Licensed Practical Nurse (LPN) B written statement, dated 06/22/25, showed:-He/She sat at the nurses desk;-He/She observed Resident #7 go around Resident #27 in the hall;-Resident #27 reached out and slapped resident #7 with an open hand on the back of the head;-Resident #27 told Resident #7 to not come around him/her on this hall.Review of Resident #27 nurse's notes, dated 6/22/25 at 06:30 P.M., showed:-LPN B witnessed Resident #27 reach out and slap Resident #7 in the back of the head;- Resident #27 told Resident #7 do not come around him/her on this hall;-Resident #27 said Resident #7 was a [NAME].During an interview on 07/02/25 at 08:21 A.M., LPN B said:-He/she was at the nurse's desk on 06/22/25;-Resident #7 moved Resident #27's wheelchair and went around Resident #27:-Resident #27 reached out and slapped Resident #7 in the back of the head after he/she got around him/her;-Resident #27 told Resident #7 to not come around him/her on this hall;-Resident #27 said Resident #7 was a [NAME];-Resident #7 did not complain of pain;-Resident #7 did not say he/she was afraid of Resident #27.During an interview on 07/03/25 at 08:55 A.M., the Administrator said: -Resident #27 hit Resident #7 on the back of the head;-Resident #27 hit Resident #7, because Resident #7 moved his/her wheelchair;-Resident #27 told Resident #7 to stay off his/her hall;-Abuse is willful and intended;-Hitting is considered a form of abuse;-Resident #7 did not complain of pain;-Resident #7 did not say he/she was afraid of Resident #27;-He/She expected Resident #7 to be free from abuse;-He/She expected all residents to be free form abuse.During an interview on 07/03/25 at 08:58 A.M., the DON said:-Resident #27 hit Resident #7 on the back of the head;-Resident #27 hit Resident #7, because Resident #7 moved his/her wheelchair;-Resident #27 told Resident #7 to stay off his/her hall;-Abuse is willful and intended;-Hitting is considered a form of abuse;-He/She expected Resident #7 to be free from abuse;-He/She expected all residents to be free form abuse.MO256314At the time of the abbreviated survey, the violation was determined to be at the immediate and serious jeopardy level J. Based on observation, interview and record review completed during the onsite visits, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements.At the time of exit, the severity of the deficiency was lowered to the G level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action be taken to address Class I violation(s).