**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to provide protective oversight for two residents (Resident #1 and #3) with psychiatric diagnoses and a history of self harm who resided on the secured behavioral unit. On 02/25/25, Resident #3, who had and had a history of ingesting batteries, swallowed two AA batteries, which resulted in transfer to the emergency room (ER) and a procedure to remove the battery. On 02/26/25 at 12:44 P.M., Resident #1 became agitated and made threats of self harm by swallowing items. Resident #1 was placed on 15 minute checks, continued to make self harm threats, and ingested two AA batteries at 3:49 P.M., which resulted in an ER transfer. The facility did not provide documentation or evidence the 15 minutes checks were completed for Resident #1. The facility also failed to keep the environment free of accident hazards by not securing all of the rooms on the secured behavioral unit, when Resident #2 opened an unlocked clean utility room with four safety razors, a large bundle of plastic grocery bags, and two 12 cup coffee carafes full of hot coffee. Resident #2 had a history of ingesting harmful items. The facility census was 74. The administration was notified on 02/27/25 at 6:51 P.M., of an Immediate Jeopardy (IJ) which began on 02/25/25. The IJ was removed on 02/27/25, as confirmed by surveyor onsite verification. The facility did not provide a policy regarding accidents/incidents. 1. Review of Resident #3's face sheet showed: - admission date of 08/24/24; -Diagnoses of schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar disorder), insomnia, anxiety, bipolar disorder (a mental health condition characterized by extreme mood swings, including periods of intense happiness or irritability (mania) and periods of deep sadness or hopelessness (depression)), suicidal ideations, suicide attempt, personality disorder (a mental health condition that involves long-lasting, disruptive patterns of thinking, behavior, mood and relating to others), borderline personality (a mental illness that severely impacts a person's ability to regulate their emotions), and post traumatic stress disorder (PTSD - a mental health condition triggered by a terrifying event). Review of the resident's Preadmission Screening and Resident Review (PASRR - a federal requirement to help ensure individuals are not inappropriately placed in nursing homes), dated 12/02/24, showed; - Diagnoses of schizoaffective disorder, major depressive disorder, personality disorder, bipolar disorder, PTSD, mood disorder (a mental health problem that primarily affects a person's emotional state), attention deficit hyperactivity disorder (a neurodevelopmental disorder characterized by persistent patterns of inattention, hyperactivity, and/or impulsivity that interfere with daily functioning), reactive attachment disorder (a rare and severe mental health condition that affects children's ability to form healthy attachments with caregivers), and oppositional defiant disorder (a behavioral disorder characterized by persistent patterns of angry/irritable mood, argumentative/defiant behavior, and vindictiveness); - Resident unable to care for self due to recent hospitalization due to swallowing batteries, flat affect, and urge to harm self; - In September, the resident swallowed two batteries and stated to psychiatry the continued desire to harm self. On 10/05 (2024?), he/she swallowed batteries again; - Resident had a mental health disability as defined by PASRR; - Resident was withdrawn, depressed, paranoid, labile (emotional, involves sudden and extreme mood swings) mood, positive suicide attempt by overdose, history of self harm, received Department of Mental Health (DMH) services intermittently since childhood; - Resident had behavioral difficulties or mental illness symptoms requiring 24 hour monitoring; - Provision of structured environment, low stimulation, assess and plan for level of supervision required to prevent harm to self or others; - Crisis intervention to include suicidal precautions. Plan to identify clear steps to be taken to support individual during crisis, specify who to contact for assistance, how staff will work together, as well as identify physician, and law enforcement; - Support services of referral to DMH; - Community based psychiatric treatment required include: medication education and psychiatric follow up; - Resident's needs at this time could be met in a nursing facility; - Resident required following supports and services: behavioral support plan, structured environment, crisis intervention services, medication therapy, activity of daily living (ADL) program, and personal support network. Review of the resident's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument required to be completed by the facility staff, dated 02/11/25, showed: - Cognition intact; - Clear speech and able to understand - Independent with eating; - Independent for all ADLs and mobility. Review of the resident's revised Care Plan, dated 02/18/25, showed: - Resident had a court appointed guardian; - Resident had impaired psychosocial skills as evidenced by behaviors; - Resident had impaired decision making/poor judgment and resided on a secured behavior unit; - Resident had experienced trauma with a diagnosis of PTSD; - Resident was at risk to harm self or others. Resident was at risk of elopement. There was a history of self harm and suicide attempt by overdose. Resident had frequent suicidal thoughts and self injury behaviors, multiple suicide attempts, severe self mutilating behaviors, overdose, and history of swallowing glass and batteries; divert resident's behavior by using coping skills, don't confront resident, allow resident to explore feelings, report any suicidal thoughts or self harming to the nurse immediately. - On 08/26/24, the resident swallowed a AA battery from the TV remote and was sent to the ER. The resident transferred to another hospital due to trying to jump out of the ambulance several times during the transport. Resident placed on 1:1 until 09/01/24 upon return; - On 09/20/24, the resident told a CNA he/she had swallowed a battery. A battery was missing from the TV remote. The resident was sent to the ER and transferred to another hospital for a procedure to remove the battery. The resident returned from the hospital and found his/her belonging removed from the room. The resident became aggressive, threw the side table, water pitcher, and attempted to punch the wall. Two Certified Nurse Aides (CNAs) put the resident into a primary restraint technique (PRT - a method designed for one person to safely and effectively restrain a person without causing pain or injury) hold and the physician gave orders for two injections. Resident to be placed on 15 minute checks upon return; - On 02/25/25, the resident reported to staff he/she asked another resident for batteries that he/she then swallowed. They were AA batteries. The resident was placed on 1:1 and sent to the ER where a procedure occurred and the batteries were removed. Resident placed on 1:1 upon return; - The resident received psychotropic (drugs that affect the brain and nervous system, influencing mood, behavior, and mental processes. They are used to treat a wide range of mental health conditions) medications. Monitor for side effects and report to physician if observed: Poor coordination, dry mouth, increased heart rate, urinary retention, agitation, hallucinations, orthostatic hypotension, drowsiness, blurred vision. Review of the resident's Nurse's Notes showed: - On 02/25/25 at 1:59 P.M., the resident reported to staff that he/she asked another resident for some batteries and swallowed two AA batteries. Complained of feeling upset, agitated, and had an urge to swallow the batteries. The resident was placed 1:1, called the physician, and sent to the ER; - On 02/25/25 at 5:54 P.M., the ER called and reported they found two batteries the resident swallowed in x-ray and was being sent to another hospital for further treatment; - On 02/26/25 at 8:36 A.M., the hospital called and reported the procedure was completed and both batteries removed. The resident would be discharged back to the facility. 2. Review of Resident #1's PASSR, dated 10/27/21, showed: - Resident met the federal definition of serious mental illness but didn't require specialized services; - Resident met the federal definition of intellectual disability but didn't require specialized services; - Resident met the skilled nursing facility admission requirements; - Diagnoses of schizoaffective (a condition characterized by abnormal thought processes and deregulated emotions), bipolar disorder (a mental disorder that causes unusual shifts in mood), depression, adult victim of sexual abuse, intellectual disability, Asperger's (a developmental disorder that falls under the broader category of autism spectrum disorder ), and elopement risk; - Resident had auditory hallucinations (where you hear, see, smell, taste or feel things that appear to be real but only exist in your mind) and nightmares of abuse, poor insight, referral notes of paranoia (an unfounded and/or exaggerated mistrust of others), disorganization, nonsensical speech; - Current psychiatric support services at time of evaluation included outpatient psychiatric follow up and a secured behavioral unit; - One overdose suicide attempt; - Resident was childlike; - Support and/or services needed include: community based psychiatric treatment, behavioral support/supervision, day programing/treatment/partial hospital program, financial assistance, medical follow up, individual counseling, medication education, referral to department of mental health, residential services, skills training, and social work services; - Due to nature of trauma and recent elopement from a residential care facility, the nursing facility was the least restrictive setting. Would need long term trauma based therapy; - If admitted to a nursing facility, needed assessment and implementation of behavioral support plan to include monitoring of behavioral symptoms and provision of behavioral supports; - It was recommended the resident received behavior unit services for structure and stability; - Crisis intervention should include safety plan to address elopement behaviors, stress reactions related to trauma, and plan with clear steps to support resident during a crisis situation; - Recommended services to include: behavioral support plan, structured environment, crisis intervention services, discharge planning, medication therapy, ADL program, and personal support network. Review of the resident's face sheet showed: - admission date of 06/05/24; - Diagnoses of bipolar disorder, major depressive disorder (long-term loss of pleasure or interest in life), and anxiety (persistent worry and fear about everyday situations). Review of the resident's quarterly MDS, dated [DATE], showed: - Cognition intact; - Verbal behavior directed toward others; - Other behavior not directed toward others; - Wandering; - Clear speech and able to understand; - Independent with eating with a mechanically altered diet; - Independent for all ADLs and mobility. Review of the resident's Care Plan, last reviewed on 12/03/24, showed: - Required an anti-anxiety medication; - Required an anti-depressant medication; - Resident experienced trauma; - Resident had behavior symptoms and resided on a secured behavioral unit due to behaviors. Resident was at risk of harm to self or others and elopement. Resident had an overdose suicide attempt, scared of male peers, and was childlike; - On 09/14/24, the resident reported to staff another resident triggered him/her talking about suicide. The resident brought a glass covering from a light in the bedroom to staff and said he/she was considering using it to slit his/her wrists. Staff encouraged resident to focus on progress and not be influenced by others. Resident placed on 15 minute checks; - On 11/17/24, the resident became upset because another peer had extra soda. The resident cursed at staff and slammed his/her door. The resident pointed out an abrasion to the left wrist when checked on. Said he/she did it last night, but didn't look fresh and no blood present. Staff asked resident about reason of being upset and spoke with resident. Staff encouraged coping skills to be used. Items removed from room that could be a safety hazard and placed on 15 minute checks. Resident is using a marker to draw on arm instead of something to scratch it; - On 12/22/24, the resident tore off the right index finger fingernail related to being upset over another person. Resident educated by staff on not harming self and possible infection from injury; - On 12/27/24, the resident had an increase in behaviors and had become verbally and physically aggressive toward staff, peers, and not easily re-directed. Notified physician who ordered a medication change; - On 01/23/25, the resident had a nightmare and became upset. Staff spoke to resident about nightmare not being real and resident being safe. Resident calmed down; - On 01/29/25, the resident reported using a coloring pencil to self harm to the left wrist resulting in a 1 centimeter (cm) superficial cut. Staff spoke with resident, encouraged to focus on self and use coping skills. Coloring pencils removed from resident; - Divert resident's behavior by using coping skills, don't confront resident, allow resident to explore feelings, report any suicidal thoughts or self harming to the nurse immediately. - Resident required psychotropic medications related to diagnoses of bipolar disorder, restlessness, and agitation; - Resident had a legal guardian. Review of the resident's Nurse's Notes showed: - On 02/26/25 at 9:56 A.M., the resident worked with therapy before a smoke break and missed it. When the resident returned to the unit, the resident demanded staff to take him/her to smoke. Before staff could respond, the resident slammed his/her door and was verbally aggressive. The nurse redirected the resident with 1:1 conversation and took the resident to smoke; - On 02/26/25 at 12:44 P.M., the resident had increased behavioral outbursts made self harm threats of swallowing pens and pencils. When asked why, the resident said, I don't know, I just do. The pens and pencils were removed from the resident's possession. The resident was placed on 15 minute checks and in the dining room eating lunch. The resident appeared calm with a normal affect; - On 02/26/25 at 3:49 P.M., the resident came to staff, smiled, and said, I swallowed a battery. The nurse asked why since he/she didn't have a history of swallowing batteries, and the resident said, I don't know, I just did. The resident said it was AA batteries from his/her radio. The nurse looked in the radio and found no batteries in it or any his/her room. The Director of Nursing (DON) and the physician were notified with an order to send to the ER for treatment. The guardian was notified of the transfer; - On 02/26/25 at 5:09 P.M., the resident returned from the ER with instructions to allow the resident to pass the batteries. The resident was placed on 15 minute checks for monitoring. Batteries were removed from his/her room. Resident denied any active self harming thoughts at that time; - On 02/27/25 at 1:37 A.M., the resident complained of stomach pain earlier in the shift; - On 02/27/25 at 9:13 A.M., the resident said he/she wanted to kill him/herself and would do whatever it took to do it. The resident placed on 1:1 until not suicidal. Review of the resident's 15 minute checks showed: - No documentation from when the resident returned from the hospital on [DATE] at 5:09 P.M., through 02/27/25 at 6:00 A.M. During an interview on 02/27/25 at 11:00 A.M., Resident #1 said he/she was on 1:1 because he/she had been bad. He/She swallowed batteries from his/her radio. The hospital said he/she had to pass them. During an interview on 02/27/25 at 11:10 A.M., Certified Nursing Assistant (CNA) A said he/she was Resident #1's primary 1:1 for the day shift on 02/26/25. Resident #1 threatened to self harm multiple days resulting on 1:1. The resident swallowed two AA batteries on 02/26/25. The resident went to the ER. During an interview on 02/27/25 at 4:56 P.M., CNA E said he/she worked last night and did 15 minute checks when Resident #1 returned. Resident #1 swallowed batteries, went to the hospital, and returned. CNA E came in on 02/27/25 at 6:00 P.M., and said Resident #1 was never on 1:1. CNA E said the 15 minute checks were not documented, but should have been. During an interview on 02/27/25 at 11:20 A.M., CNA B said Resident #1 was on 1:1 for self harm by swallowing batteries. Resident #1 went to the hospital and was currently figuring out emotions and why he/she did the action. During an interview on 02/27/25 at 11:25 A.M., CNA C/Unit Coordinator said Resident #1 was placed on 1:1 on the morning of 02/26/25, due to getting into an argument with another resident who told him/her to kill himself/herself and to swallow more batteries. Resident #1 became suicidal and was placed on 1:1. When swallowed the batteries on 02/26/25, the staff sent the resident to the ER. He/She saw no care instructions for the resident. The nurse told him/her to watch Resident #1's fecal material for the passing of the batteries. He/She couldn't find the documentation of the 15 minute checks when Resident #1 returned from the hospital. During an interview on 02/27/25 at 6:00 P.M., CNA F said Resident #1 was monitored last night after returning from the hospital. He/She wasn't aware of any 15 minute checks on Resident #1, but did 10 to 15 checks just because of coming back from the hospital from self harm. Resident #1 had to pass the batteries. No documentation of the checks were done last night, because no one said to do them. He/She had no training provided at this facility. During an interview on 02/27/25 at 2:30 P.M., CNA C/Unit Coordinator said the charge nurse made the decision on if a resident was placed on 15 minute checks or 1:1. The resident stayed on that monitoring for usually 72 hours and it should be documented in the nurse's notes. He/She wasn't aware of any policy and procedure regarding resident checks, but the whole unit was on 30 minute checks unless it was increased individually. If a resident had verbal threats of self harm or harm to others, they were placed on 15 minute checks. If that escalated to physical harm, then it was moved to 1:1 until they returned to their baseline. During an interview on 02/27/25 at 2:45 P.M., the Assistant Director of Nursing (ADON) said the charge nurse decided if a resident was on a 15 minute check or 1:1. There wasn't a policy or procedure for the nurse to follow. If the nurse was not sure, they were able to call the DON or ADON for directions. The point was to keep the resident safe with the least restrictive environment. During an interview on 02/27/25 at 3:45 P.M., CNA B said if a resident expressed a desire to harm themselves, then he/she let the nurse know and kept the resident in sight. During an interview on 02/27/25 at 3:55 P.M., CNA C/Unit Manager said if a resident expressed a desire to self harm, he/she redirected and started coping skills. If the resident couldn't be redirected, the nurse was notified. Most of the residents liked to write their feelings down. During an interview on 02/27/25 at 4:38 P.M., Licensed Practical Nurse (LPN) D said he/she was told in report Resident #1 had swallowed two batteries. Resident #1 went to the hospital and they sent him/her back to pass the batteries. Resident #1 was on 15 minute checks and the staff checked the residents that often anyway on the secured behavioral unit. 3. Observation on 02/27/25 at 3:58 P.M., of the secured behavioral unit showed: - Resident #2 opened an unlocked clean utility room door with four safety razors in a tub above the sink, a large bundle of plastic grocery bags, and two 12 cup coffee carafes full of hot coffee; - Another door beside the clean utility room was open and a bucket of mop water sat in it; - Multiple tubes of toxic acrylic paint sat on the counter in the dining room. During an interview on 02/27/25 at 4:33 P.M., CNA G said the water in the mop bucket on the secured behavior unit had a triple-multisurface cleaner poured into it. During an interview on 02/27/25 at 6:00 P.M., CNA F said Resident #2 had a history of swallowing items and batteries 4. During an interview on 02/27/25 at 5:00 P.M., CNA C/Unit Coordinator said an administrator from another facility came and did some training on self-harm, behaviors, and de-escalation. Resident #2 had a history of swallowing items and batteries. Generally, Resident #3 would talk real slow and then start cursing and become loud. That's when he/she was going to self harm. No razors should be in the clean utility room. The clean utility room door should be locked and staff should ensure the door was locked after exiting. He/She had the keys to the clean utility closet but all staff knew to lock it. The utility room with the mop bucket was left unlocked and the water should be just regular water because the residents like to mop their rooms to feel productive. NOTE: At 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 visit, it was determined the facility had implemented corrective action to address and lower the 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 D 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). Complaint MO249053

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect residents on the secured behavioral unit from abuse through deprivation of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This deficiency affected three sampled residents (Resident #11, #61, and #68) on the secured behavioral unit, resulting in humiliation and embarrassment for those residents and back pain for Resident #68 from sleeping on a mattress on the floor and had the potential to affect all residents on the secured behavioral unit. The facility also failed to protect one resident's (Resident #11) right to be free from physical abuse when Certified Nurse Assistant (CNA) A physically forced Resident #11 to the ground and physically restrained Resident #11 while on the ground, making Resident #11 feel humiliated. The facility's census was 74. The administration was notified on 01/15/25 at 3:15 P.M. of an Immediate Jeopardy (IJ) which began on 01/14/25. The IJ was removed on 01/17/25, as confirmed by surveyor onsite verification. Review of the facility's policy, Abuse, Neglect, Exploitation, Mistreatment, and Misappropriation of Resident Property, undated, showed: - It is the policy of this facility that each resident will be free from abuse; - Abuse can include verbal, mental, sexual, or physical abuse, misappropriation of resident property and exploitation, corporal punishment, or involuntary seclusion; - The resident will also be free from physical or chemical restraints imposed for purposes of discipline or convenience and that are not required to treat the resident's medical symptoms; - Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility; - No abuse or harm of any type will be tolerated, and residents and staff will be monitored for protection; - The facility will strive to educate staff and other applicable individuals in techniques to protect all parties; - All employees of this facility are mandated reporters; - All employees who have been alleged to commit abuse will be suspended immediately pending investigation; - If the allegation is substantiated, there is a potential that the employee will be terminated, added to the Employee Disqualification List and not allowed to work in a nursing home, disciplined by their licensing agency and charged with a crime. Review of the document Resident Rights, signed by all staff upon hire and annually, undated, showed: - A resident has the right to participate in their care. Residents are entitled to take part in planning their care and in being informed of all aspects of their care. Residents may refuse any treatment they do not want; - A resident has the right to keep their possessions. Residents may retain personal possessions as space permits, unless to do so would infringe on the rights of others; - A resident has the right to be free from abuse. Residents shall not be subjected to physical, sexual, or emotional injury or harm. 1. Observation on 01/14/25 at 12:13 P.M. showed a printed paper posted on Resident #11's bathroom door which read: - Actions and Consequences, you all are aware of the rules, they are now set in place. So, if you have one of these actions there will be consequences and we will be following through with each one of them. - The document was then divided into two columns, one labeled Action the other Consequences. The Consequences column had two options for each action depending on a resident's smoking status; - Action: Arguing with another resident. Consequence: Sent to room to work on coping skills; - Action: Arguing with staff, not listening. Consequence: Resident loses one smoke break; - Action: Arguing with staff, not listening. Consequence: Resident loses one day of snack cart; - Action: Cursing out staff. Consequence: Resident loses two smoke breaks; - Action: Cursing out staff. Consequence: Resident loses a week of snack cart; - Action: Hitting a staff member or a resident. Consequence: Resident loses smoke break for 48 hours; - Action: Hitting a staff member or a resident. Consequence: Resident loses snack cart for two weeks; - Action: Stealing from another resident. Consequence: Resident loses two smoke breaks; - Action: Stealing from another resident. Consequence: Resident loses snack cart for a week; - Action: Attention seeking Self-Harming behavior. Consequence: Resident loses belongings and smoke break for the day and is to wear a gown with pants; - Action: Attention seeking Self-Harming behavior. Consequence: Resident loses belongings and snack cart for the week and is to wear a gown with pants; - Action: Refusing medication. Consequence: Resident loses everything until medication is taken; - Action: Taking off a resident tray or sharing food. Consequence: Resident loses smoke break for 24 hours; - Action: Taking off a resident tray or sharing food. Consequence: Resident loses snack cart for the week; - Action: Resident refusing shower for two days. Consequence: Resident loses smoke break until shower is taken; - Action: If a resident stands where staff is charting after staff has redirected. Consequence: Resident loses one smoke break, and snack cart for the day; - Action: Resident not listening to being sent to room, due to behavior on the hall and not shutting the door when asked. Consequence: Resident will lose all privileges for the rest of the day; - Action: Resident sharing anything without staff approval. Consequence: Resident loses one smoke break; - Action: Resident sharing anything without staff approval. Consequence: Resident loses one snack cart day; - Action: Resident going past the double doors with the phone after being reminded. Consequence: Resident loses one smoke break; - Action: Resident going past the double doors with the phone after being reminded. Consequence: Resident loses one snack cart day; - Action: Resident not following directions or listening to the staff when asked of something. Consequence: Resident loses one smoke break; - Action: Resident not following directions or listening to the staff when asked of something. Consequence: Resident loses one snack cart; - Action: Resident keeping things in their room, that are not allowed. Consequence: Resident loses one smoke break per item found in room; - Action: Resident keeping things in their room, that are not allowed. Consequence: Resident loses snack cart days per item found in room. Review of Resident #11's medical record showed: - admitted on [DATE]; - Diagnoses of bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs), schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly), and nicotine dependence (a chronic brain disorder that causes a person to compulsively need nicotine, a substance found in tobacco products and includes withdrawal symptoms like restlessness, agitation, increased hunger, insomnia, constipation, or diarrhea); - Per the Preadmision Screening and Resident Assessment (PASARR) Level II screening (a comprehensive assessment of current and historical treatment): Resident has history of depression, anxiety, paranoia, agitation, aggression, mood swings, non-compliance with medication and treatment, impulsive behaviors, poor decision making, racing thoughts, irritation, anger outbursts, poor sleep at times, poor appetite at times, at a previous facility was found walking on the road, non-compliance with rules, suicidal ideation - thought of hanging self, history of suicidal attempt, punching walls, and marijuana use. Review of the resident's quarterly Minimum Data Set (MDS, a federally mandated assessment instrument completed by the facility staff), dated 11/05/24, showed: - No cognitive impairment; - Exhibited hallucinations in the seven-day look back period; - Independent with activities of daily living (ADLs); - The resident routinely received antipsychotic medication in the seven-day look back period. Review of the resident's care plan, revised 11/11/24, showed: - Resident at increased risk for behavioral/mood problems due to history of behaviors. At risk to harm self or others. At risk to elope from facility; - History of physical violence. - Unit Coordinator got approval per guardian directive that if resident has a behavior, staff can take away any open hall activities and a smoke break and do room searches for safety reasons; - Unit Coordinator spoke with resident's guardian in regard to the unit policies and procedures and went over each one with the guardian. The guardian agreed with the unit policies and procedures, and states she gives verbal consent and to add these to resident's guardian directives; - Care plan did not address actions/consequences list. Review of the resident's Physician's Order Sheet (POS), dated 01/17/25, showed: - An order for nicotine gum, two mg, give one piece four times a day as needed for nicotine withdrawal, dated 03/27/23; - An order for nicotine lozenge; four mg, may have one lozenge buccal (in the cheek) every two hours as needed between 11:00 P.M. and 7:00 A.M. for nicotine withdrawal, dated 07/26/24; - An order for Latuda (antipsychotic medication), 120 mg, give one tablet with 20 mg tablet to equal 160 mg daily, for bipolar disorder, dated 05/24/23; - An order for Latuda, 40 mg, give one tablet with 120 mg tablet to equal 160 mg daily, for schizophrenia, dated 05/24/23; - An order for Trileptal (anticonvulsant medication), 150 mg, give one tablet by mouth twice daily, for schizophrenia, dated 11/03/23; - An order for carbamazepine (anticonsulvant used to treat bipolar disorder), 100 mg, give one chewable tablet by mouth twice daily, for mood disorder, dated 04/26/24; - An order for chlorpromazine (antipsychotic medication), 50 mg, give 50 mg by mouth daily, for schizophrenia, dated 12/27/24; - An order for Abilify Maintena suspension (antipsychotic medication), 400 mg, give 400 mg intramuscularly every 28 days, for mood disorder, dated 07/12/23; - An order for Geodon solution (antipsychotic medication), 20 mg/ml, give one ml intramuscularly every 12 hours as needed for behaviors, dated 01/11/25; - An order for trazodone (antidepressant medication), 50 mg, give one tablet at bedtime as needed, for insomnia, dated 08/09/24. Review of the resident's Medication Administration Record (MAR), dated 01/01/25 through 01/17/25, showed no administration of either nicotine gum or nicotine lozenges for nicotine withdrawal. Review of the resident's progress notes showed: - On 01/13/25 at 11:11 A.M., Resident this morning screaming and yelling at all staff and guardian on the phone. Resident was redirected several times and ignored redirection. Resident stating that staff and Director of Nursing (DON) is the reason why he/she cannot advance to another facility. Resident yelling and screaming at staff still nurse came down and tried to redirect. Redirection ignored once again. Resident currently calmed down at this time; - On 01/13/25 at 5:35 P.M., Resident had behavioral outburst this morning of yelling, cussing, and being verbally aggressive towards staff. Staff was able to redirect resident with 1:1 conversation, after conversation, resident calmed down and has had no behaviors since; - On 01/13/25 at 11:07 P.M., Resident had outbursts most of the day. The resident voiced that he/she was upset about losing his/her smoke break. Resident later became extremely loud and began cussing and yelling. Staff alerted this nurse upon arrival in room, resident was resistant to a Geodon (antipsychotic medication) injection, but eventually stated he/she would take one. Injection given in right deltoid (shoulder muscle) without difficulty; - On 01/14/25 at 2:32 P.M., Resident standing at the end of the hallway looking outside the window and screaming how he/she wants to die, wants to leave, hates his/her guardian. DON was speaking with this resident. Resident expressed wanting the PRN (as needed) Geodon to help him/her calm down. The DON spoke with this resident regarding possible placement at behavior hospital and resident expressed he/she wanted to do that. The DON stated she would look into it. Resident let this nurse give him/her PRN Geodon in right deltoid, tolerated well. Resident went back to his/her room to calm down. - On 01/14/25 at 5:37 P.M., Resident this evening around 4:00 P.M. started to have increase in behavioral outburst and show signs and symptoms of manic behavior and had started to punch the walls and attempted to attack staff. Resident also making homicidal ideations towards staff and others and becoming more violent and showing signs and symptoms of becoming a danger to himself/herself and others. Staff attempted to re-direct resident, but resident was not responding to redirection. Nurse notified psychiatric physician of increase in resident's behaviors and that he/she was not responding to re-direction and that PRN Geodon had been administered a few hours prior. New order given for resident to be sent to the emergency room for psychiatric evaluation and treatment as indicated; - On 01/15/25 at 4:17 P.M., Resident called facility. Unit Coordinator answered. Resident stated to Unit Coordinator that I need you to pack my shit. I am being discharged from the facility. Unit Coordinator stated that he/she knew nothing of that and that if resident was being discharged that it would most likely be back to the facility. Resident stated No, if I go back to the facility, it's not going to be pretty for you! I will tear that entire place up and destroy you and the facility! I cannot live there anymore and I will not. Do you hear me? Unit Coordinator tried to speak, but resident just continued to get louder and then hung up the phone. Unit Coordinator called guardian and guardian stated, Oh well, all I can say is good luck. Review of the facility's Incident Investigation, dated 01/12/25, showed: - At 9:30 P.M. on 01/11/25, Resident #11 and CNA A were arguing back and forth on the 500 hall. Resident #11 punched CNA A in the left side of the face and CNA A took Resident #11 to the ground and held the resident until the nurse was able to give a PRN (as needed) injection and the resident calmed down; - No injuries to the resident or complaints of pain at this time; - Resident #11 was escorted to his/her room and CNA A was taken off the hall and made to leave the facility. Review of the facility's In-service Training Record, dated 04/04/24, showed CNA A was present for Abuse and Neglect Training, which included the Abuse Policy and a handout titled Freedom from Abuse, Neglect, Misappropriation, and Exploitation. Review of Resident #11's progress note, recorded as a late entry by Licensed Practical Nurse (LPN) B on 01/12/2025 at 2:56 A.M. showed: - LPN B heard yelling from the 500 hall unit. Upon entering the unit, he/she observed this resident and CNA A arguing. LPN B was able to calm the situation down for a minute and was walking with the resident back to his/her room as he/she and CNA A were still yelling back and forth; - Resident #11 turned around and went back to CNA A, where he/she acted like he/she was going to urinate on CNA A's feet. Resident #11 then stood up and exchanged words with CNA A, then punched CNA A on left side of face; - Resident #11 was taken to the ground and this nurse obtained an order for Geodon (antipsychotic medication) injection that was given; - Resident #11 was held until he/she said he/she would not be aggressive towards staff anymore. LPN B walked the resident back to his/her room; - CNA A then showed LPN B that Resident #11 had busted CNA A's lip when Resident #11 hit CNA A and bit CNA A's left forearm and drew blood from bite mark; - LPN B had CNA A wash his/her arm with soap and water and then use alcohol pads to bite mark. The DON was notified and other appropriate persons. Will continue to monitor. Review of the resident's behavior notes from the behavior binder showed: - On 01/14/25, Resident was fine and laughing this morning with Unit Coordinator. Resident asked Unit Coordinator for his/her smoke break back. Unit Coordinator stated per guardian, resident lost smoke breaks for assaulting a staff member. Resident started screaming and cussing at Unit Coordinator. Resident called guardian screaming and yelling, demanding guardian to get him/her out of this facility or shit was about to be really bad for everyone here. Resident started screaming and cussing at guardian. Guardian hung up the phone. Resident yelling at Unit Coordinator demanding that Unit Coordinator give resident back his/her smoke breaks that per guardian, resident lost due to resident assaulting a staff member twice. Unit Coordinator stated that those are the consequences for his/her actions. Resident stated I would hit you in your fucking face if I wouldn't lose a smoke break because of it. Observation of the resident on 01/14/25 at 1:30 P.M. showed the resident, wearing his/her own clothes, appearing agitated, pacing on the hall, speaking about religion, tithing, and giving his/her money to television evangelists and how he/she hates his/her guardian, while other residents were outside smoking. During an interview on 01/14/25 at 12:13 P.M., Resident #11 said he/she had an altercation with Certified Nursing Assistant (CNA) A and he/she punched CNA A in the face. CNA A put him/her in a head lock and threw him/her to the ground and CNA A sat on him/her. He/She can still go out and get fresh air during smoke break times. They have an actions and consequences list on the bathroom door. Some residents ruin things for other residents. The resident's toilet was flooding, so he/she yelled that they needed a plunger and blankets. CNA A was complaining about it being clogged. Resident #11 and CNA A got into it because the toilet overflowed. This was a Friday morning and CNA A also worked Saturday. It was at 3:52 P.M. when he/she asked for another roll of toilet paper. CNA A said he/she just gave Resident #11 a roll yesterday. CNA A said he/she uses too much toilet paper. He/She uses about a roll a day. He/She bitched about it. CNA A talked about it on smoke break and told Resident #11 that CNA A's family of nine doesn't use that much. CNA A came into Resident #11's room and didn't knock. CNA A said, You're still mad about the toilet paper? He was telling CNA E about the incident and Resident #11 felt humiliated and now he/she can't smoke for three days. He/She got toe to toe with CNA A, and CNA A pointed at his/her room and told him/her to go to his/her room. He/She punched CNA A and CNA A got him/her in a head lock and threw him/her to the ground and CNA A sat on him/her. Resident #11 told LPN B to get an injection because he/she knew he/she needed it. CNA A was sitting on his/her butt and he/she was up on her elbows and CNA A was pushing his/her head back down. During an interview on 01/16/25 at 3:06 P.M., CNA J/Unit Coordinator said staff get training about how to take down a resident properly, but CNA A did not have that training and he/she will not be coming back. During an interview on 01/17/25 at 11:00 A.M., the Assistant Director of Nursing (ADON) said that when employees are hired, they get abuse/neglect training and it's documented in the payroll system. Agency staff do written training when they are hired. During a telephone interview on 01/21/25 at 3:48 P.M., CNA E said he/she was working the locked unit the night the incident occurred between Resident #11 and CNA A. Resident #11 came out in the hall from his/her room and had a verbal altercation with CNA A. CNA E believes Resident #11 was upset with CNA A about a previous toilet paper situation where CNA A did not want to give the resident toilet paper because CNA A believed the resident was using too much. CNA A and Resident #11 were a good distance apart on the hall yelling at each other; they weren't up in each other's face at this point. The resident was so loud that LPN B and another CNA outside the locked unit at the nurses station heard them and LPN B came back on the unit. LPN B had his/her hands on the resident's shoulders attempting to redirect the resident back to his/her room. The resident was still yelling at CNA A, who was still responding to the resident yelling. Resident #11 came back around and came at CNA A and punched him/her in the mouth. CNA A grabbed the resident around his/her shoulder and neck area and tackled the resident to the floor. The resident was lying flat on the floor on his/her stomach with his/her hands on the ground. CNA A wasn't really kneeling on the resident, but instead half-way straddling the resident's back. CNA A had his/her right hand on the resident's right shoulder holding him/her there. LPN B left the locked unit to obtain an injection for behaviors, came back and gave the resident the injection. LPN B asked if the resident was going to go back to his/her room if CNA A let the resident up, to which the resident replied he/she would. The resident returned to his/her room, they pulled CNA A off the hall and CNA E worked the rest of the night. CNA E picks up shifts at this facility quite often, but has only worked on the locked unit a couple of times. He/She believed the facility offers training for these types of situations, but the facility has not offered a class to him/her since he/she has worked there. During a telephone interview on 01/22/25 at 2:25 P.M., LPN B said he/she heard the resident yelling, so he/she walked back to the unit. When he/she first arrived on the unit, CNA A and Resident #11 were arguing, which is not uncommon for the resident. He/She was able to redirect Resident #11 and were going back to the resident's room to sit and chat about what was going on, and LPN B got the resident about halfway down the hall and Resident #11 and CNA A were still arguing. Resident #11 ran up to CNA A and pulled his/her pants down and said that because CNA A didn't want to give Resident #11 any more toilet paper that he/she was going to piss on CNA A's shoes. Resident #11 didn't do that, but instead slugged Resident #11. CNA A got Resident #11 in a hold around his/her neck and took the resident down. On the way down, Resident #11 bit CNA A's arm. After that, LPN B was able to give Resident #11 an injection. The facility provides training on how to take a resident down. LPN B does not have the training, but quite a few of the agency CNAs have the training. LPN B works at the facility about two to three days a week. LPN B was aware of the Actions/Consequences program and that staff would take belongings or smoke breaks away. LPN B could see how some residents could possibly view the program as a punishment. LPN B did not feel that behaviors were escalated except for Resident #11, who really did not like consequences at all. Resident #11 had a lot of behaviors. During a telephone interview on 01/22/25 at 4:53 P.M., CNA A said Resident #11 was becoming aggravated and aggressive over an incident with some toilet paper. CNA A asked Resident #11 why he/she needed more toilet paper because CNA A had previously given Resident #11 some. CNA A had found out that Resident #11 had also gotten two other rolls from someone else and either Resident #11 or Resident #11's roommate had clogged the toilet with a roll the morning before. Resident #11 came out of his/her room when everyone else was asleep and was hollering and CNA A was trying to coerce Resident #11 back to his/her room to calm down so the resident could talk about it when he/she was calmer. Anything CNA A would do or say to calm the resident down didn't help. LPN B had Resident #11 walking back to his/her room, and then the resident came running back at CNA A and threatened to pee on CNA A's foot. Resident #11 got up in CNA A's face and punched him/her in the face and bloodied CNA A's lip. The resident's arms were down by his/her waist after this happened. CNA A then got behind Resident #11 and had his/her hands at the resident's elbows and gently tried to take the resident by his/her arms in order to sit the resident down as gently as possible to keep him/her from hurting himself/herself or anyone else. On the way down, Resident #11 bit CNA A on the forearm. After the resident bit CNA A, CNA A sat the resident down on his/her bottom and rolled the resident over onto his/her stomach. LPN B came back to give Resident #11 a shot and LPN B asked the resident if he/she was going to come after anyone and the resident said no, so CNA A let Resident #11 go and Resident #11 walked back to his/her room. CNA A was sent home after that. CNA A had not had any type of training either from the facility, a previous employer, or the staffing agency through which he/she is employed. CNA A believed the house staff receives training, but they never mentioned anything to him/her about receiving training. CNA A was working about four days a week at the facility, but feels he/she wasn't able to pick up as many shifts recently until the incident happened. CNA A said the facility had in services, but they occurred when he/she wasn't there. During an interview on 01/21/25 at 4:43 P.M the DON said CNA A started picking up shifts at the facility in July of 2023. The only training/inservice CNA A participated in was the one on abuse and neglect on 04/04/24, which was provided during survey. The facility typically does not include agency staff in trainings unless it is for Person-Centered Interventions (PCI - a training for two-person team and three person defensive hold). Agency staff have certain trainings they have to complete through the staffing agency to keep their accounts active, but she does not have access to those things other than to know if CNA A passed or failed them. 2. Review of Resident #61's medical record showed: - admission date of 06/05/24; - Diagnoses of schizophrenia, restlessness and agitation, and oppositional defiant disorder (a condition characterized by a persistent pattern of defiant, angry, and irritable behavior towards authority figures, such as parents, teachers, or caregivers); - Per the PASARR Level II screening: Resident with history of overdose on opiates to end life, held gun to his/her head, poor insight/judgment, looseness of association, flight of Ideas, thought broadcasting, poor sleep, grandiose delusions, decreased appetite, depressed mood, elevated anxiety level, irritability, decreased energy, feelings of helplessness/hopelessness/guilt, self-isolation, excessive worry, panic attacks, heart racing, and sweating. Review of the resident's quarterly MDS, dated [DATE], showed: - No cognitive impairment; - Physical (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually) and verbal (e.g., threatening others, screaming at others, cursing at others) behavioral symptoms directed toward others, other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) and wandering all occurred one to three days in the seven-day look back period; - Independent with ADLs; - The resident received antipsychotic, antianxiety, and antidepressant medication in the seven-day look back period. Review of the resident's care plan, revised 11/29/24, showed: - The resident resides on the secured behavioral unit due to history of behaviors. At risk to harm self or others. At risk for elopement; - Care plan does not address actions/consequences list. - History of acting like a police officer/threatening to arrest staff/and making/pointing finger guns at staff; reported that he/she was a volunteer fireman and police explorer; - Whatever the resident listens to/watches on YouTube, that is what he/she becomes next (during recent power failure, the resident put on a jacket, acted as if he/she was a security guard, checked all perimeters, and reported to staff that all was secured; - History of overdose of opiates to end life; held gun to his/her head; - Poor insight/judgment; looseness of association; flight of ideas; thought broadcasting; poor sleep; grandiose delusions; decreased appetite; depressed mood; elevated anxiety level; irritability; decreased energy; feelings of helplessness/hopelessness/guilt; self-isolation; excessive worry; panic attacks; heart racing; sweating; crying spells; presents with grandiose bravado demeanor; behaving in an intimidating manner; delusions; likes to stand close to people and be in their space; sleeping excessively; and suicidal ideation; - History of threatening to elope if staff at previous facility did not send him/her to the hospital. Also hit and kicked staff at previous facility; - Resident's preferred coping skills are exercise, listening to music, talking to someone close to him/her, smiling at five people, and playing with modeling clay. Review of the resident's POS, dated 01/17/25, showed: - An order for trazodone, 100 mg, give one tablet by mouth at bedtime, for insomnia, dated 06/05/24; - An order for risperidone (antipsychotic medication), one mg, give one tablet by mouth twice a day, for schizophrenia, dated 11/20/24; - An order for divalproex extended release (anticonvulsant medication used as a mood stabilizer), 500 mg, give 1000 mg by mouth once daily, for schizophrenia, dated 11/26/24; - An order for zoloft (antidepressant medication), 100 mg, give 200 mg by mouth once daily, for major depressive disorder, dated 11/26/24; - An order for Invega Sustenna (antipsychotic medication), 234 mg/1.5 ml, give 234 mg intramuscularly every 21 days, for schizophrenia, dated 12/18/24; - An order for Geodon solution, 20 mg/ml, give 20 mg intramuscularly one time, for restlessness and agitation, dated 01/13/25; - An order for Ativan solution (antianxiety medication), two mg/ml, give two mg intramuscularly one time, for restlessness and agitation, dated 01/15/25; - An order for Geodon solution, 20 mg/ml, give 20 mg intramuscularly one time, for restlessness and agitation, dated 01/15/25. Review of the resident's progress notes showed: - On 01/12/25 at 5:30 P.M., resident threatening to hit staff and hovering over staff on hall. Staff told resident to stop hovering over them. Resident did not like that and got mad, yelling at staff. Resident went into office and grabbed scissors. Resident tried to cut right thumb. There is a small mark on resident's finger. Unit Coordinator instructed to remove resident's belongings from room to prevent resident from harming himself/herself in any other way. When staff tried to pack resident's belongings up, resident got mad and tried attacking staff. Staff initiated defense team with staff support and handled appropriately. No injuries present. Staff put resident's belongings in office and locked office. - On 01/13/25 at 3:52 P.M., Resident started having a behavioral outburst, was cussing at staff, being verbally aggressive to staff, and making threatening statements to staff. Staff attempted to verbally redirect resident. Resident was not easily redirectable at this time. Nurse notified psychiatric physician of resident's current behavior. New order given for Geodon injection. With CNAs present, nurse administered injection to left deltoid with no complications; - On 01/15/25 at 11:15 A.M., Resident was having a behavioral outburst, and showing signs and symptoms of attention seeking behaviors. Nurse went to speak with resident with other staff present. When asked why he/she was upset, resident stated I want all my shit back. Staff reminded resident that he/she was making suicidal ideation (SI) statements and for his/her safety, that not all items could be returned at this time.[

Based on observation, interview and record review, the facility failed to ensure one resident (Resident #1) was free from neglect when the staff failed to assess and provide prompt medical treatment when the resident complained of pain after a fall that resulted in fractures to the resident's tibia and fibula (the two long bones in the lower leg) and to the left humeral (upper arm bone) bones. The facility census was 68. The Administration was notified on 05/11/2023 at 3:00 P.M. of a Past Non-compliance Immediate Jeopardy (IJ) which occurred on 04/28/2023. Staff informed the facility administration of the incident on 04/30/2023 at which time the facility started an investigation. The investigation resulted in the termination of Licensed Practical Nurse (LPN) A. The facility also inserviced on abuse, neglect, reporting timely and the chain of command. The IJ was corrected on 05/10/23. Review of the facility's Overview of the Regulation, Abuse and Neglect policy, dated 2017, showed: - Residents are to be free of any and all types of abuse, neglect, misappropriation and exploitation; - The facility must have policies, procedures and education for new and existing staff about freedom from abuse; - Facility staff must know how and when to report suspected abuse; - Neglect is the failure of the facility, it's employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress; - If any staff witnesses or are informed of abuse, they must first protect the resident, intervene and stop the abuse. Review of Resident #1's medical record showed: - Date of admission of 07/20/22; - Diagnoses of paranoid schizophrenia (a long term mental disorder that affects a person's ability to think, feel, or behave clearly, sometimes including delusions or hallucinations), insomnia (difficulty sleeping), depression (a serious medical illness that negatively affects how you feel, the way you think and how you act), anxiety disorder (persistent worry and fear about everyday situations), nightmare disorder (a pattern of repeated frightening and vivid dreams that affects your quality of life), post traumatic stress disorder (PTSD) (a person has difficulty recovering after experiencing or witnessing a terrifying event), borderline personality disorder (a mental illness that severely impacts a person's ability to regulate their emotions). Review of the resident's care plan, updated 04/25/23, showed: -The resident resided on a secured behavioral unit; -The resident at risk of harming self and others and for elopement; -An intervention to assess whether his/her behavior endangers the resident and/or others and to intervene if necessary. Review of the resident's nurses notes for 04/28/23 through 05/01/23 showed: - On 04/28/23 at 06:45 P.M., Licensed Practical Nurse (LPN) A documented the resident lay on the floor after staff took the resident down because the resident was punching the walls. LPN A contacted the psychiatrist and received an order for a psychiatric injection. After receiving the injection, the resident refused to get up off the floor due to the pain in his/her left knee and left shoulder. LPN A told the resident that the refusal to get up was a behavior and he/she would not be gotten up out of the floor. Against LPN A's judgement, two staff assisted resident out of the floor and into a chair; - No entry on 04/29/23 related to a post fall assessment or complaints of pain; - On 04/30/23 at 11:03 A.M., the resident remained in bed all day and staff reported he/she was total care all day related to complaints of pain to his/her left upper and lower extremities. Upon assessment, moderate bruising was present to the left upper extremity and his/her range of motion (ROM) has declined. He/she reported a pain level of a 10 out of 10. The resident had some edema present to the left knee and the ROM to the knee was also decreased. The resident reported the inability to stand or to ambulate. The resident presentation indicated discomfort. X-rays were ordered; - No documentation of the date or time the resident was sent out to the emergency room; - On 05/01/23 at 12:35 AM, the resident arrived back at facility per ambulance. The report given from the emergency room showed the resident had a left humerus fracture, a left tibial plateau fracture, and a left fibula fracture. The resident was non-weight bearing. Review of the resident's left tibia/fibula x-ray report, dated 4/30/23, showed: - Acute comminuted fractures (a bone that is broken in at least two places) through the lateral tibia plateau (the flat top portion of the tibia bone that runs from the knee to the ankle); - Acute comminuted fractures involving the proximal (closer to the center of the body) metaphysis (the trumpet-shaped end of a long bone) and the head of the fibula. Review of the resident's left shoulder x-ray report, dated 4/30/23, showed: - An acute fracture through the humeral head (the large rounded head of the humerus) and neck regions. Review of the facility's investigation, dated 05/01/23 and started on 04/30/23, showed: - Resident #1 had self-harming and other harming behaviors resulting in Certified Medication Technician (CMT) B performing an approved behavioral crisis physical intervention (a physical hold used during a behavioral crisis) on 04/28/23; - CMT B and the resident lost their balance which resulted in both falling to the floor; - The resident reported pain in his/her left leg immediately; - The resident told LPN A the fall broke his/her leg; - CMT B told LPN A that he/she heard a snap and a crack when the resident fell; - The resident refused to stand after the fall; - Certified Nursing Assistant (CNA) D said the resident told LPN A he/she could not stand. LPN A said, I'm not picking your ass up out of the floor and if you refuse to get up, I'll get you a damn pillow. You can sleep on the floor; - LPN E's witness statement showed the resident complained of left knee pain and could not bear weight. LPN E said a thorough assessment of the left leg was completed with pitting edema (swelling) noted at the knee. Palpation of the knee showed no pain. Staff assisted the resident into a chair. LPN E assessed the resident on the morning of 04/29/23, and did not feel there were any significant findings and did not document. The resident was given Tylenol for pain. The facility felt at no time did the staff willingly neglect the resident. Observation of Resident #1 on 05/11/23 at 9:30 A.M., showed staff pushed the resident in a wheelchair on the locked unit. The resident sat in a high back wheelchair with an extended foot/leg rest that kept the left leg straight. The left leg had an immobilizer on it that extended above and below the knee down to the ankle. The left ankle, foot and lower leg had noted swelling. The resident did not move his/her left arm. The resident had yellow to light purple bruising down his/her left upper arm, shoulder, and onto the chest. During an interview on 05/11/23 at 9:30 A.M., the Director of Nursing (DON) said Resident #1 had behaviors and hit the wall (4/28/23). The resident drew back in an attempt to hit CMT B and staff reacted with a primary restraint technique (PRT) (an approved behavioral crisis physical intervention). CMT B lost his/her balance and both fell sideways. There were no signs of a fracture and LPN A felt the resident was not truthful about his/her pain. Within two days, the resident had bruising and staff obtained an order for an x-ray. The resident's left leg and left shoulder were broken. The resident had osteopenia (a decrease in bone mineral density which can cause bones to fracture more easily) and took multiple calcium depleting psychiatric medications. Staff performed the PRT correctly. LPN A refused to be interviewed. Resident #1 had an orthopedic appointment on 05/12/23. During an interview on 05/11/23 at 9:45 A.M., Resident #1 said due to his/her behaviors, CMT B had to perform a PRT on 04/28/23. CMT B had control of the resident's right side, but not the left, and they ended up falling after the resident tried to swing CMT B around. The resident couldn't get up due the left leg pain and immediately told CMT B and LPN A his/her left leg was broken. LPN A laughed and said the resident was fine. LPN A told the resident to get up and if he/she didn't, then he/she would be written up and could sleep on the floor. LPN A never assessed him/her for injuries. On Sunday, 04/30/23, was the first time a nurse even looked at him/her. His/her only concern was that LPN A ignored his/her pain and laughed at him/her. During an interview on 05/11/23 at 11:30 A.M., CMT B said he/she tried to talk Resident #1 down verbally, but that didn't work so CMT B performed the PRT (4/28/23). CMT B's left foot was behind the resident's left foot and when the resident swung his/her body, CMT B's foot prevented the resident's foot from pivoting and both fell down. He/she thought the resident's left leg looked abnormal and he/she immediately complained of pain. CMT B heard a crack and pop and told LPN A. There was swelling to the left leg and the knee was kind of turned inside with the foot out about 20 degrees. CMT B told LPN A something wasn't right four to five times in the first 30 minutes after it happened. The resident was not able to bend the leg or get up. CMT B never saw LPN A assess the resident. The resident refused to get out of bed, bear weight, and was fully mobile prior to the incident. During an interview on 05/11/23 at 12:25 P.M., CNA C said Resident #1 heard voices that were telling him/her to hurt him/herself and others. CNA C went to find LPN A. CMT B heard CNA C and went back to the unit to assist. CMT B asked the resident to stop hitting the wall. CMT B performed the PRT, had control of Resident #1's right side but didn't have control of the left side, and they fell. The resident could only bear weight to the right leg. On 04/29/23 between 2:30 A.M. and 3:00 A.M., the resident asked to be carried to the bathroom. LPN A offered a urinal and the resident refused it. The resident complained of a lot of pain. CNA C never saw LPN A assess Resident #1 but did see him/her in the hall when CNA C left to assist another resident. During an interview on 05/11/23 at 2:05 P.M., CMT B said LPN A administered a psychiatric injection to the resident while he/she lay on the floor. He/she released the resident when they both fell and the resident said, Let me go. The resident voiced his/her pain very plainly to everyone, including LPN A. During an interview on 05/11/23 at 2:52 P.M., CNA D said he/she didn't see the fall. Afterwards, Resident #1 was propped up against CNA D's legs. LPN A yelled at the resident to get off the floor. CNA D told LPN A he/she couldn't get the resident up because the resident was hurt. LPN A said, I'm not going to pick your ass up out of the floor, I'll get a pillow and you can sleep here. CNA D and CNA F lifted the resident into a wheelchair and then onto the bed. He/she went to do the paperwork for the incident but LPN A said not to do it because he/she would take care of it and document it as a behavior. LPN A never assessed the resident for injuries even though he/she was saying his/her left leg was broken and refused to get up. During an interview on 05/11/23 at 2:15 P.M., the DON said it was expected that an assessment be performed by a nurse after any altercation, PRT or a fall. An assessment should have been completed on Resident #1, especially with the complaint of pain. She received a text that a PRT had been performed on the resident and LPN A called the doctor to obtain an order for a psychiatric injection. She was not notified about Resident #1 falling or complaining of pain. She did not become aware of the injury until 04/30/23. None of the staff saw LPN A assess the resident after the incident. Resident #1 denied LPN A assessed him/her after the injury. LPN A was agency staff but had been working shifts since at least June 2022. She did not have any documentation about the PRT in the agency book that was given to the agency staff as she did not want them to perform it if they were not trained. The staff were expected to contact her if a PRT was performed. Had LPN A notified her of the incident, an x-ray would have been ordered or the resident would have been sent to the emergency room. During an interview on 05/11/23 at 3:30 P.M., the Administrator said it was expected the DON let him know of abnormal events like falling with a PRT and an injury. Had the DON known about the injury, they would have ensured care had been provided. Anytime staff placed their hands on a resident, a resident falls, or a resident complains of pain, an assessment should be completed by a nurse. MO00217777 & 217879