Based on interview and record review, the facility failed to ensure professional standards of practice where met, when staff failed to transcribe one resident's new treatment order onto the electronic treatment administration record (eTAR), resulting in the new treatment order not being administered from 7/24/24 to 8/2/24 as ordered by the physician for one resident (Resident #8) resulting in the wound showing signs and symptoms of infection. The sample was 18. The census was 96 with 83 residents in certified beds. Review of the facility's Following Physician Orders Policy, dated June 29, 2021, showed: -Purpose: It is the policy of the community to ensure that all Licensed Professional Nurses (Registered Nurse (RN)/Licensed Practical Nurse (LPN)/ Licensed Vocational Nurse (LVN)) and other healthcare professionals, follow physician orders in accordance with state, federal regulations, and their respective practice acts; -Procedure: -All physician orders will be followed as prescribed and if not followed, the reason shall be recorded on the resident's medical record; -All physician or other health care professional's verbal, telephone or written orders will be immediately entered in the electronic health record (EHR) by the nurse obtaining the order. Review of the facility's Wound Care Protocol Policy, dated reviewed 7/23, showed: -How to assess/document: Initially assess the ulcer(s) for location, measurement, exudate (fluid that leaks out of blood vessels into nearby tissue), and tissue type; -Treatment should be determined based on the assessment; -Documentation of the initial and weekly assessment finding should be noted in the wound management section of the EHR. Review of Resident #8's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by the facility staff, dated 9/5/24, showed: -Cognitively intact; -No behaviors or refusal of care; -Diagnoses included: anemia (decrease in number of red blood cells), high blood pressure, diabetes, and muscular dystrophy (a genetic disease that cause progressive weakness and loss of muscle mass). Review of the care plan in use at the time of survey, showed: -Problem: currently has an alteration in skin integrity and required wound monitoring; -Goal: wound will not increase in size or exhibit signs of infection through next review; -Approach: Staff monitor the condition of skin during activities of daily living (ADL, self care) care. Nursing to complete weekly skin audits and document as required. All abnormal/new findings are reported to physician for treatment; -Wound treatment(s) to be completed per eTAR/physician order. Review of the resident's weekly skin audits, provided by the facility for June, July, and August 2024, showed: -On 6/1/24, open area noted on right ankle; -On 7/13/24, wounds to scrotum/ right ankle and right shin; -No other skin assessments were provided. Review of the progress notes dated 7/10/24 through 7/14/24, showed: -On 7/10/24 at 2:11 P.M., new wound noted to resident's scrotum (a pouch of skin containing the testicles) area, buttocks noted to be red. Wound on scrotum measures 0.6 centimeters (cm) X 1.0 cm. Peri area (area between legs and buttocks) was painful to touch due to wound being sore and buttocks being red and inflamed. Orders for Santyl (sterile enzymatic debriding ointment) and zinc (skin barrier) have been entered. Physician has been notified; -On 7/14/24 at 3:41 P.M., seen by the wound management team related to multiple wounds. Will continue to monitor wounds weekly for progress; -The note did not show the wound on the scrotum; -Staff did not document the treatment had changed or the resident refused the treatment; -Staff did not document why the treatment was not completed. Review of the wound management team notes, dated 7/18/24, showed: -Location: scrotum/posterior (back); -Type: Pressure ulcer/injury (any lesion caused by unrelieved pressure that results in damage to the underlying tissue): unstageable (depth obscured); -Wound bed description: no description was documented; -Measurements: no measurements were documented; -Exudate: moderate; -Peri-wound: erythema (redness of the skin), macerated (a softening and breaking down of the skin resulting from prolonged exposure to moisture) and scarring; -Color: sero-sanguineous (containing blood and serum); -Wound status: initial evaluation; -Treatment: cleanse with Normal Saline (NS) then apply Santyl and apply dry dressing, change daily and as needed. Review of the eTAR, dated 7/1/24 through 7/25/24, showed: -An order for Santyl apply to wound on scrotum, start date was 7/14/24 and discontinue date was 8/2/24; -Documentation showed: treatment was not completed on 7/15, 7/16, 7/17, 7/22, 7/23 and on 7/25; -There was no order for gentamicin and there was no order for weekly skin audits. Review of the progress notes, dated 7/24/24 through 7/30/24, showed: -On 7/24/24 at 12:47 P.M., resident was seen by the wound management team on 7/17/24 related to multiple wounds. New treatment order for gentamicin (antibiotic) and Santyl to the scrotum; -On 7/26/24 at 1:04 P.M., resident was seen by wound management team on 7/25/24 related to multiple wounds. Will continue the current treatments in place for all wounds. Will continue to monitor wounds weekly for progress; -There was no documentation showing the treatment was changed, or the resident refused the treatment and no documentation showing why the treatment was not completed. Review of the wound management team's notes, dated 7/25/24, showed: -Location: scrotum/posterior; -Type: Pressure ulcer/injury: unstageable (depth obscured); -Wound bed description: 25% granulation tissue (new connective tissue that forms in a wound during the healing process) and 75% necrotic tissue (dead or dying tissue); -Measurements: 3.1 cm length, X 6.3 cm width X 0.2 cm depth; -Peri-wound: erythema, macerated and scarring; -Exudate: moderate; -Color: sero-sanguineous; -Wound status: unchanged/stable; -Treatment: cleanse with NS then apply Santyl and apply dry dressing, change daily; -Wounds: scrotum/posterior-new on 7/18/24, stable, continue santyl and gentamicin. Review of the eTAR, dated 7/26/24 through 7/31/24, showed: -An order for Santyl apply to wound on scrotum, start date was 7/14/24 and discontinue date was 8/2/24; -There was no order for gentamicin. Review of the progress notes, dated 8/1/24 through 8/4/24, showed: -On 8/4/24 at 1:42 P.M., provider summary received for routine visit on 8/2/24. No new recommendations at this time, staff to continue to monitor and treat wound on left toe and continue monitoring and treatment of pressure ulcer to left medical side of left knee with tubi grip (elastic tubular support bandage) for added protection. No other concerns at this time; -The note did not show wound on scrotum. Review of the wound management team's notes, dated 8/1/24, showed, -Location scrotum/posterior; -Wound Bed Description: 0 % Granulation Tissue and 100 % Necrotic Tissue; -Measurements: 4.8 cm x 3.7 cm x unable to determine (UTD) depth; -Peri-wound: Erythema, Macerated and Scarring; -Exudate: Moderate; -Color: Sero-sanguineous; -Treatment: Cleanse with NS then apply Santyl and apply dry dressing; change daily and as needed; -Wound Status Improved - continue current treatment plan; -Wound: scrotum/posterior-new on 7/18/24, stable, continue santyl and gentamicin. Review of the eTAR dated 8/1/24 through 8/3/24, showed: -An order for: Santyl apply daily to wound on scrotum, start date was 7/14/2024 and discontinued on 8/02/2024; -An order for: Santyl, cleanse posterior scrotum with NS, mix Santyl and gentamicin, apply nickel thick and cover with a foam dressing, start date was 8/3/24; -An order for: gentamicin ointment 0.1 %; mix with Santyl and apply nickel thick to right ankle, right shin, and posterior scrotum, change daily, start date 8/3/24. Review of the progress notes, dated 8/4/24 through 8/15/24, showed: -On 8/15/24 at 5:10 P.M., resident was seen by wound doctor and was recommended to send to hospital for treatment. Contacted emergency medical service (EMS) for transport to the hospital. Review of the wound management team notes, dated 8/15/24, showed: -Location scrotum/ posterior; -Type: Pressure Ulcer/Injury: Unstageable (Depth Obscured); -Wound Bed Description: 100 % Granulation Tissue and UTD/ % Necrotic Tissue; -Measurements: 6.0 cm x 2.8 cm x UTD depth; -Exudate: Moderate; -Peri-wound: erythema, macerated and scarring; -Color: Sero-sanguineous; - Wound Status Deteriorated - See plan of care (POC); -Additional Notes: send out to hospital due to deteriorated wound with odor. Altered mental status (AMS). -Treatment: Cleanse with NS then apply Santyl; gentamicin; cover with foam dressing daily and as needed; -Wound: scrotum/posterior (new on 7/18/24): deteriorated, send out due to signs of infection. Review of the eTAR, dated 8/3/24 through 8/16/24, showed: -An order for: Santyl, cleanse posterior scrotum with NS, mix Santyl and gentamicin, apply nickel thick and cover with a foam dressing, start date was 8/3/24; -Documentation showed: On 8/7/24, not administered: day shift; on 8/10/24, not administered, resident unavailable, up in wheelchair doesn't want treatment completed at this time; on 8/13/24, not administered: previous shift; -An order for: gentamicin ointment 0.1 %; mix with Santyl and apply nickel thick to right ankle, right shin, and posterior scrotum, change daily ,start date 8/3/24; -Documentation showed: On 8/10/24, not administered, resident unavailable, up in wheelchair doesn't want treatment completed at this time; on 8/13/24, not administered: previous shift; During an interview on 10/2/24 at 9:00 A.M., the Wound Nurse said the floor nurse was responsible for completing the weekly skin audits and providing the treatments. She provided wound care for resident who required a wound vacuum (wound treatment that uses suction to help wounds heal). When the wound management team visited the facility, she rounded with the Nurse Practitioner (NP), then she would document some type of note in the EHR regarding the wounds. During an interview on 10/4/24 at 12:00 P.M., the Nurse Manager said skin audits were completed weekly on the resident's shower day, by the floor nurse. If the resident had a wound, it should be documented on the skin assessment and documented with treatment in place. If the wound was new, staff should assess the wound and document it, notify the physician and note any orders that were obtained or whatever the physician said to do and notify the resident/resident representative. If the nurse documented a new order in the progress notes she would expect for the order to also be noted on the physician order sheet and the eTAR. The Nurse Manager checked the eTAR for July 2024 and said she did not see an order for the gentamicin. She would expect for an order to be placed on the physician order sheet and on the eTAR. During an interview on 10/4/24 at 12:08 P.M., the NP said when she visited the facility, she assessed the wounds that were being treated unless the staff notified her the resident had a new wound or area of concern. If a resident needed new orders, the NP either wrote them down on a piece of paper or gave the nurse a verbal order. The nurse at the facility was responsible for entering the orders into the EHR. The NP said she likely gave an order for gentamicin and santyl because she preferred to use an antimicrobial agent (kills microorganisms or inhibits their growth) sometimes with the santyl. During an interview on 10/4/24 at 1:53 P.M., the Administrator said she would expect for staff to follow physician orders and for skin audits to be completed weekly.

Based on interview and record review, the facility failed to ensure one resident was free from verbal abuse and intimidation (Resident #1). On 8/19/23 between 3:30 P.M. and 4:30 P.M., during medication pass, Certified Medication Technician (CMT B) was observed by Certified Nurse Aide (CNA) C and Nurse A standing chest to chest with the resident, yelling/cursing at the resident, and/or throwing a towel at the resident. CMT B initially refused to leave the resident's room when Nurse A instructed him/her to do so and continued to yell and curse at the resident who was visibly upset. Furthermore, the facility failed to follow their policy, state and federal regulations when staff failed to ensure CMT B was removed from the building when he/she was seen by staff sitting in the resident smoking area and walking through the building unsupervised. The census was 103. Review of the facility's Freedom from Abuse, Neglect and Exploitation Policy, most recently revised in 9/2022, showed: -Resident Safety Position Statement: It is the policy to maintain a living environment that is professional and residents are free from threat or occurrence of harassment, abuse (verbal, physical, or mental); -Providing a safe environment for the resident is one of the most basic and essential duties of the facility. Employees and volunteers have a unique position of trust with vulnerable residents. Having access to private information, being in a physically intrusive position and having elevated status and special relationships with residents makes ethical and professional behavior essential; -Residents must not be subjected to abuse by anyone; -Abuse is defined as the willful infliction of intimidation or punishment with resulting physical harm, pain or mental anguish. Instances of abuse, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, physical abuse, and mental abuse; -Verbal Abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents, regardless of their ability to comprehend or disability. Examples of verbal abuse include, but are not limited to, threats of harm, or saying things to frighten a resident; -Procedure for investigation; -The supervisor will do everything possible to protect the resident's welfare and safety from harm during the investigations; -An employee suspected of a violation of these safety policies, may be suspended pending investigation; -Administrator or designee on duty will assess the resident (including the size, location, etc. of any injury), and assure proper documentation of the date, time, and location of the reported or suspected incident. Review of Resident #1's Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 9/16/23, showed: -Moderately impaired cognition; -Rejection of care: Behavior not exhibited; -Diagnoses included Post Traumatic Stress Disorder (PTSD, a psychiatric disorder that may occur in people who have experienced or witnessed a traumatic event, series of events or set of circumstances), anxiety disorder, and depression. Review of the resident's care plan, in use during the investigation, showed; -Problem: Cognitive Loss/Dementia, required monitoring for cognition due to impaired short term memory, decreased safety awareness/impaired decision making, disorganized thinking, and need for reorientation -Approach: Allow ample time to communicate needs. Always approach in a calm, non-threatening manner breaking tasks into small steps; -Problem: Psychotropic Drug (chemical substance that changes the function of the nervous system and results in alterations of perception, mood, cognition, and behavior) Use, at risk for adverse medication reactions related to taking psychotropic medication to assist in managing diagnosis of anxiety, PTSD and major depressive disorder; -Approach: Monitor resident's mood and response to medication; -No staff interventions to address the resident's PTSD, history of trauma, identification of potential triggers of re-traumatization and need for trauma informed care. Review of the facility's self-report, dated 8/19/23 at 6:00 P.M., showed: -CMT B entered the resident's room at approximately 3:50 P.M., on 8/19/23; -The resident became upset when the CMT educated the resident he/she was supposed to observe the resident taking his/her medications and wasn't supposed to leave medications unattended; -The resident threw the health shake in CMT B's face. While CMT B was attempting to clean up the mess, the resident attempted to strike at CMT B. CMT B caught the resident's hand to prevent being struck, exited the room and reported to the charge nurse; -The Administrator and Director of Nursing (DON) interviewed the resident, who reported it was simply a disagreement because he/she wanted to finish what he was doing and didn't feel he/she needed to be watched while taking medications; -When asked if he/she felt CMT B was threatening or abusive to him/her, he/she reported no. When asked if he/she felt safe, he/she reported yes. The resident did offer that he/she just does not like CMT B; -The Administrator called and notified the resident's family member of the situation. The resident's family member reported the resident was very combative with CMT B another time when he/she came to give him/her his/her medications. The resident's family member explained he/she attempted to redirect the resident's behavior and encouraged him/her to be kind to staff; -When asked, the family member felt maybe CMT B reminded the resident of someone he/she didn't like in the past. The facility suggested finding an alternative person to provide medications to the resident and the family member agreed; -CMT B was suspended pending investigation and the facility was in the process of interviewing three residents and employees on CMT B's assignment today. Review of the resident's medical record, showed: -Psychiatry note, dated 9/8/23 at 4:56 P.M.; -Past psychiatric history, excerpt from 7/17/2018, He/She is very impatient and cannot wait for anything. He/She goes from 0-100 in seconds. Has had problems since he/she came back from Vietnam. Family member reports he/she was not like this when he/she first met him/her before Vietnam. When he/she is angry, he/she yells, throws thing (threw a coffee cup today because there was another cup in the holder when they got to the car). Married for 49 years and he/she used to be more aggressive physically. He/She had hit a family member a couple times then, he/she would take a hammer and beat wood to get the anger out. He/she would sometimes punch the walls to avoid hitting others; -Military: Vietnam army combat-has suffered PTSD symptoms. Review of the Social Services notes, dated 8/19/23 through 8/24/23, showed; -No documentation regarding the incident between the resident and CMT B; -No documentation regarding a nurse's assessment following the incident between the resident and CMT B; -No documentation any support services were offered to the resident to assist in managing past trauma/abuse or coping skills. Review of the facility's investigation, dated 8/19/23, showed: -A typed, one page document, which included three staff interviews, each interview consisted of one sentence, in quotation marks, unsigned; -CNA C's statement showed, Quiet. No issues. Stayed to self and was busy working; -A typed resident interview, dated 8/19/23, and signed by the DON, which read, DON and Administrator interviewed the resident regarding incident with CMT B. Administrator conducted interview with this Registered Nurse (RN) (the DON) present. Administrator asked the resident if he/she felt safe, he/she reported yes. Administrator asked if he/she was threatened, hit, cussed at or felt abused in anyway, resident reported no, that it was a disagreement and I just don't like that guy, we had a scuffle. He/she didn't like being treated like a child and CT B wouldn't leave his/her pills. The Administrator asked what the resident meant by a scuffle, the resident reported he/she meant an argument. Administrator educated the resident if he/she felt anything was abusive, he would ensure the employee would not re-enter the building, and the facility would assist with pressing charges, and the employee would never have access to him/her again. The resident reported again, he/she was not abused. The administrator asked him/her if he/she was comfortable with CMT B providing care to him/her and he/she responded he/she would prefer he/she did not. Administrator assured the resident he would no longer receive care from CMT B. Administrator asked the resident if he/she would sign a statement saying he/she was not abused and he/she did not feel threatened and the resident agreed. No further concerns were noted; -A typed statement, signed by the resident, which read, Resident #1, was interviewed by the Administrator and DON on 8/19/23 at 4:30 P.M. CMT B and he/she had a simple misunderstanding this evening. He/She didn't feel there was abuse or neglect of any kind. He/She feels safe in at the facility; -Witness, signed by the DON, dated 8/19/23; -No interview with Nurse A, the nurse assigned to the resident's hall, who reported the incident to the DON, Review of CMT B's written statement, dated and signed, 8/19/23, showed upon taking the resident his/her medication, the resident said, What do you want? He/she let the resident know he/she had his/her dinner time medications. At that point, the resident took them from his/her hand and said, Get the fuck out! CMT B let the resident know he/she had to witness him/her take the medication. At that point the resident threw his/her health shake all over CMT B and the floor. The resident stood up and started walking towards him/her. CMT B told the resident he/she would leave and asked him/her to have a seat so he/she would not fall. The resident then decided to throw all of his/her medications at CMT B and started trying to stand face to face with him/her while his/her back was to the wall. At that point, Nurse A stepped in and asked him/her to leave. At which point, he/she called the Administrator to notify him/her and stepped out to the smoke area. He/She came in to continue passing medications to be told he/she was suspended. Review of the facility's Summary of Investigation, showed: -CMT B entered the resident's room at approximately 3:50 P.M., on 8/19/23. CMT B provided the resident with a health shake and medications. The resident became upset when CMT B educated him/her that he/she was supposed to observe the resident take his/her medications and wasn't supposed to leave medications unattended. The resident threw his/her health shake in CMT B's face. While CMT B attempted to clean up the subsequent mess, the resident attempted to strike at CMT B. CMT B caught the resident's hand to prevent being struck, left the room, and reported to the charge nurse; -The Administrator and DON interviewed the resident who reported that it was simply a disagreement because he wanted to finish what he/she was doing and didn't feel he/she needed to be watched while taking medications. When asked if he/she felt that CMT B was threatening or abusive to him/her, he/she reported no, when asked if he/she felt safe, he/she reported yes. The resident did offer he/she didn't like CMT B. The Administrator called and notified the resident's family member of the situation. The resident's family member reported the resident was very combative with CMT B another time when he/she came to give him/her his/her medications. The family member felt maybe CMT B reminded the resident of someone he/she didn't like in the past. The facility suggested finding an alternative person to provide the resident's medications and the family member agreed; -CMT B was suspended pending investigation and the facility interviewed three residents and employees on CMT B's assignment on 8/19/23. All resident and staff interviews indicated CMT B was professional when providing care. No concerns noted. Physician and family were notified with no concerns noted; -Disposition: The facility was unable to substantiate abuse or neglect involving this incident. They have ensured CMT B would not directly care for the resident moving forward as an intervention, to prevent further conflict; -Typed signature of the Administrator, dated 8/23/23. Review of the resident's electronic nurse's progress notes, dated 8/25/23, (Recorded as Late Entry on 8/26/23 1:50 A.M.), showed during dinner this resident had an episode in which he/she was very agitated. Aide explained prior situation occurred and the sighting of specific individual. When asked what was wrong this resident stated He/She was promised to never see this son of bitch again. This nurse allowed this resident to vent and share thoughts and emotions. After venting this resident stated he/she was ok and would let the nurse know if he/she needed further assistance or had any other issues. Later this nurse was approached by another nurse who stated this resident stated he/she was going to kill this individual and brandished a knife at the dinner table. Other nurse notified DON. Psychiatric evaluation recommend. Family member contacted. Dr contacted. Awaiting EMS arrival. Review of the resident's hospital records, dated 8/25/23 through 8/26/23, showed: -Resident presented to the Emergency Department (ED) with a chief complaint of aggressive behavior; -Psychological Evaluation: Patient states about a month ago, he/she was involved in a physical altercation with a caregiver after the caregiver attempted to give the patient pills. Patient states he/she was assured he/she would not see the caregiver again, however, last night, while eating, he/she saw the caregiver again. Patient states in the middle of the night, he/she was awoken by police, who asked the patient if he/she had intentions on hurting someone as they received a call from his/her room. Patient denies medical complaints apart from a posterior headache; -Medical Decision Making/Summary: Patient who presented for evaluation due to aggressive behaviors at the facility, has a history of dementia, but was able to provide a history. Review of the resident's Social Services Progress Note, dated 8/28/23 at 3:39 P.M., (Recorded as Late Entry on 8/30/23 3:57 P.M.), showed Social Worker followed up with resident in regards to a previous incident that took place. Resident states he/she was doing fine, no concerns voiced. Psychosocial well-being intact. Mood was pleasant at this time. Resident was smiling and making jokes. There were no social service concerns. Social Worker will continue to monitor and provide assistance as needed. Review of the resident's care plan, showed no documentation or interventions regarding the incident involving the resident and CMT B or the resident's psychiatric hospitalization. During an interview on 10/2/23 at 12:50 P.M., on 10/3/23 at 11:09 A.M., and on 10/5/23 at 2:40 P.M., the Administrator said there had been an incident which involved CMT B and the resident. The resident was in his/her room eating, and wanted to finish before he/she took his/her medications. The resident wanted the medications left with him/her and CMT B refused to leave the medications. The resident became upset and started yelling. CMT B tried to explain he/she was not being mean, it was his/her job to ensure medications were taken and not left with the resident. The resident became irate when CMT B wouldn't immediately leave the room. The resident threw his/her health shake at CMT B's face. The resident stood up and tried to hit CMT B. CMT B was told to leave the room by the resident, but he stayed in the room and attempted to clean up the spilled health shake. The Administrator said he was out of town and the DON came to the facility. The interviews were conducted on her phone while on he was on speaker. The DON and the Administrator had conversations and listened to the responses with the staff. CNA C was the real witness, and he/she didn't witness anything but an argument. CNA C heard cursing when he/she got to the door. CMT B was coming out of the door, and CNA C went to the charge nurse, but didn't witness anything. The resident said it was not abuse, he/she just got mad. His/Her family member said the resident had it out for CMT B. He/She had tried to give the resident medications in the past and the resident called CMT B a fairy. The family member said he/she had gotten on to the resident about the name calling and he/she thought this was over. CMT B was suspended, the facility did inservices on resident rights and abuse, and it was explained, if asked to leave, leave and get a witness. The resident had a skin assessment following the incident and there were no injuries. The resident and CMT B gave essentially the same stories. The one difference in the story was the blocking of the hand. The resident said CMT B grabbed his/her arm, and he/she lost his/her balance and he/she sat back down on the bed. The resident said CMT B never cussed at him/her, only tried to redirect him/her. The resident said he/she felt he/she was being treated like a child. The resident said he/she did not feel abused by CMT B and did not feel unsafe during the incident and following the incident. The resident said he/she couldn't stand CMT B and would get upset if he/she saw him/her. CMT B was removed from the hall assignment and did not pass the resident medications again. The resident had PTSD and became upset easily. Something triggered him/her when CMT B was giving him/her medications, and the resident threw his/her medications on the floor. Later, the resident saw CMT B in the dining room. CMT B was not near the resident and did not speak to the resident. But, the resident became triggered and lashed out, threatening CMT B harm and was sent out for a psychiatric evaluation. During an interview on 10/3/23 at 1:32 P.M. and on 10/4/23 at 11:40 A.M., the resident said he/she was watching television, and CMT B made a mess of everything. When CMT B was asked to leave, instead of leaving, he/she wanted to exaggerate the situation. The resident wanted CMT B to leave and he/she knew if he/she stayed in the resident's room, the resident would lose it. He/She did not try to hit CMT B, he/she just wanted him/her to go. Most people would shut up and back off, but CMT B did not. He/She told CMT B he/she didn't have to take it. The resident felt CMT B's behavior was abusive; he/she was pushing a button that was not there to push. The resident had rights, even though some people did not understand that. CMT B finally left, but afterward, the resident was still angry, like he/she didn't get to finish it. The facility did nothing, someone promised him/her he/she wouldn't see CMT B again. He/she said he/she saw CMT B in the dining room and he got mad again. During an interview on 10/6/23 at 3:14 P.M., the resident's family member said he/she was called the night of the incident, and he/she said that was the very first incident involving CMT B. He/She did not recall a conversation where the family member said he/she witnessed a previous interaction between the resident and CMT B. The resident was a Vietnam Veteran, and had some pretty tough things happen to him/her during the war. The war left a big impact on him/her. He/she had some violence in his/her childhood too. Staff had to understand the resident was not in his/her own environment and was used to living at home. The resident was extremely independent and wanted to do everything himself/herself. Generally, he/she was easy to get along with. He/she said he/she didn't realize how upset the resident was following the incident. He/she said sometimes the resident's memory was not good, but every time he/she told the story of what happened between him/her and CMT B, it was the same story, so it stuck in his/her head. It was the resident's understanding, CMT B had been terminated and he/she would not see CMT B again. He/she was unaware of the statement or content of the statement the resident signed following the incident. No one at the facility has ever asked him/her if there are triggering behaviors and what do if the resident becomes upset. During an interview on 10/4/23 at 12:44 P.M., CMT B said he/she went to give the resident his/her evening medications. When he/she entered the room, the resident was asleep. He/She called the resident's name and the resident didn't answer. He/she said, I've got your medicine. He/she said the resident's name again and the resident screamed at him/her and snatched the health shake out of his/her hand, then snatched the medications out of his/her hand. The resident told CMT B to, Get the fuck out of the room. The resident stood up and threw the health shake at CMT B's face. CMT B said it seemed like being supervised was the trigger. The resident had war experience with some type of PTSD. CMT B said both his/her and the and resident's voices were elevated, and he/she had his/her back to the wall. Nurse A walked into the resident's room and told CMT B he/she needed to get out there. Nurse A wanted to know what was going on, but CMT B said he/she wanted to talk to the Administrator. CMT B said he/she didn't know what brought this on. The resident's behaviors were probably from sundowning (a set of symptoms or dementia-related behaviors that may include difficulty sleeping, anxiety, agitation, hallucinations, pacing and disorientation, sometimes known as 'sundowning' but is not necessarily linked to the sun setting or limited to the end of the day). CMT B said he/she may have looked like someone in the resident's past which may have been a trigger. Since that incident, the resident had gone off when he/she saw CMT B. CMT B walked through the dining room and heard from other staff the resident wanted to stab him/her. There was some type of fixation because of the altercation. The resident was still triggered when he/she saw CMT B, just the sight of him/her was enough of a trigger. CMT B said someone said they thought they saw him/her with a butter knife. The resident was sent out for a mental evaluation, but CMT B wasn't worried about it. CMT B said he/she didn't know the resident's diagnoses, but it was getting worse and the older he/she got, he/she became more aggressive. During an interview on 10/6/23 at 11:30 A.M., CNA C said he/she heard a commotion, and the resident's door kept partially opening. Previously, he/she had seen the resident and he/she was sitting in his/her room, eating peacefully. Something was going on that wasn't right, like something was happening on the other side of the door. CNA C was the first staff to arrive on the scene and heard cussing and the door was bumping. He/She walked into the resident's room and there was chocolate shake everywhere, all over the floor. The resident was sitting on the bed, and he/she asked CMT B to come out of the room. CMT B, said no, and the resident wasn't going to keep talking to him/her like that. CMT B refused to leave the room. When he/she walked into the resident's room, he/she couldn't believe what he/she was seeing, and he/she ran to get Nurse A. CNA C didn't want to yell and shout and alarm the other residents, but it looked like an employee and a resident were about to go to blows. He/She did not try to put him/herself in the middle of the two, they were standing in the middle of the floor. CMT B was not up against the wall. He/She told Nurse A it was getting serious, he/she needed to see this. When they returned to the resident's room, the resident and CMT B were standing chest to chest cussing each other out. Nurse A asked CMT B to leave the room. CMT B started yelling This is how (he/she) is, This is how (he/she) does, This mother fucker was cussing him/her out and disrespecting him/her. When he/she handed a towel to CMT B to clean up the shake, CMT B threw the towel at the resident's foot and said, Fuck that, I don't care if (he/she) falls and busts (his/her) ass. CMT B got into a verbal altercation with Nurse A, who told CMT B he/she was messing up. He/She couldn't talk to the resident like that. Nurse A asked CMT B to leave the room several times. The resident was yelling for CMT B to get out of his/her room, but CMT B refused to leave the room. Afterwards, CNA C went back to the resident and said he/she was sorry that happened, but he/she needed to clean the floor. The resident said CMT B was a punk ass kid and was not going to shove pills in his/her face and watch him/her take those pills. The resident said he/she asked CMT B to come back or give him/her the medications. CMT B snatched his/her drink out of the resident's hand, and grabbed his/her wrist. When CNA C entered the room, the resident looked like he/she was pushed back on the bed and was trying to catch his/her balance on the bed. The resident was calm earlier, and even after that happened. It was all about your approach with him/her. He/She normally just sat and watched television. The resident had a table where he/she sat with buddies and they all got along. The incident happened around 4:00 P.M., and it didn't take long for the DON to get there. When the DON arrived, they were asked to write statements. The DON didn't understand why CMT B was still in the building. Nurse A had asked CMT B to leave the building, but he/she did not comply. CNA C thought CMT B left when the DON left, but he/she was still there, around 5:00 or 6:00 P.M. CMT B sat outside in the resident smoking area and smoked his/her vape pen. The resident smoking area was in a small courtyard, off of the resident's hall. CMT B had to come back into the building to leave. There was no one was watching CMT B to make sure he/she stayed in the courtyard. CMT B was unsupervised and went over to another hallway to talk to his/her family member to tell them what was going on. He/She had no training in PTSD, but he/she was a people person and knew how to talk to people. He/She knew how to deescalate a situation. The resident was told he/she had to sign paperwork and signed it. He/She said when CMT B grabbed his/her wrist, he/she knew they would evict him if he/she punched CMT B in his/her face. He/She was told to write a statement about exactly what he/she saw. Nurse A wrote a statement too. He/She placed the statement under the DON's door, but took a screen shot of it because Nurse A told him/her to make sure to take a picture of it. He/She said CMT B came back to work. The situation was being put under the rug instead of nipping it in the bud from the beginning. He/She thought something physical was going on before he/she entered the room. The resident kept talking about CMT B grabbing him/her by the wrist, and the resident looked like he/she was in the process of falling back on the bed when CNA C first entered the room. Whenever the resident saw CMT B, he/she got upset all over again. You can't be that upset with just words, he/she believed something happened to the resident. The resident was angry in a traumatizing way. After the incident, he/she heard the resident crying and the resident told him/her about the paperwork. The resident said this was a bunch of bull, they just made the resident sign it and did not give him/her a chance to read it. He/She signed it because he/she couldn't afford to get evicted. During an interview on 10/5/23 at 1:31 P.M., Nurse A said at approximately 4:30 or 5:00 P.M., CNA C said he/she witnessed an altercation between the resident and CMT B. There was a confrontation between the them. He/She walked into the room and the resident was screaming that CMT B had just pushed him/her down. CMT B put his/her hands on the resident and the resident was very upset. When he/she walked in the resident's room it looked like CMT B was getting ready to beat the resident's ass. Nurse A told CMT B to leave, but he/she stood there, face to face, chest to chest, with the resident. He/She told CMT B to leave again, but he/she refused to leave. Nurse A asked the resident what happened and he/she told him/her what happened. The resident said he/she didn't want the medicine then because he/she had food in his/her mouth, but CMT B said he/she needed to take the medication. CMT B had a towel in his/her hand and threw it in the resident's face. The resident told CMT B to get the fuck out of his/her room. CNA C tried to get CMT B out of the room. The resident was furious and screamed Get the fuck out of the room. He/She couldn't sleep after what he/she witnessed. He/She had never seen anyone get so mad at a resident. CMT B looked like he/she was going to fight. He/She grabbed CMT B and told him/her to get out of the room. CMT B said he/she was not going anywhere. CMT B said he/she was going to call the Administrator. Nurse A asked why CMT B was going to do that because Nurse A just saw CMT B physically and verbally abuse the resident, he/she needed to leave. CMT B called the Administrator. CMT B told the resident Fuck you and I hope you fall and bust your ass. The resident was hysterical. Nurse A called the DON, and said she needed to get up there right then, CMT B was into it with a resident. Afterwards the DON talked to him/her and CNA C, who were the only two witnesses. The DON said she knew Nurse A didn't see what happened and said to just write that on a paper. Nurse A reported the incident to the DON, wrote a statement and gave it to the Administer. Nurse A did not make a progress note because the DON said she would take care of everything. The DON said she would put in a skin assessment. The DON and Assistant DON were siblings and related to CMT B. Anyone else would have been fired. The DON did not make CMT B leave the premises; he/she stayed where the residents sat. The DON knew CMT B was still on the premises. He/She sat in the the smoking area, and other residents were present. CNA C reported to him/her that CMT B was still outside. The resident had behavior issues. You didn't debate or argue with the resident. They manipulated the situation, the resident believed what he/she signed was paperwork that said he/she would not have to work with CMT B again. The resident signed a paper he/she thought said this person abused him/her and he/she would never work around him/her again. A week later, he/she saw CMT B and got upset, like if you saw someone who abused you. He/she cried because he/she thought he/she wouldn't have to ever see him/her again. When he/she saw CMT B it triggered him/her and they sent him/her to the hospital. During an interview on 10/10/23 at 1:05 P.M., the DON said she received a call from Nurse A, who said there was a situation at the facility and he/she needed her. She told Nurse A she was in route, about five minutes away. Upon her arrival, CMT B was standing by the cart at the nurse's station, and she had him/her go to the conference room. She said she interviewed Nurse A and CMT B, told them to write statements and slide the statements under her door. She said the statements she documented in her investigation were all in regard to CMT B. She asked them if there were any issues prior to the incident. During an interview on 10/10/23 at 10:36 A.M., the Social Worker said she was familiar with the resident. The resident was alert and oriented x 2 (person and place) with some confusion. If the resident wasn't allowed to use his/her independence, it could trigger behaviors. He/She did not mean any harm. If not offered choices, that would be a trigger. When providing care, activities, anything and not given time to think about it could be a trigger. If he/she said not right now,it was just best to leave the situation and come back. She could come back in ten minutes and the resident was a whole different person. She was told a CMT tried to give the resident his/her medications, and he/she wanted them left with him/her. The CMT told[TRUNCATED]