**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide appropriate treatment and behavioral health services for one sampled resident (Resident #204) who had a known history of self-harm. The resident admitted to the facility on [DATE], with a history of self-harm and recommendation of intensive monitoring. The facility staff failed to consistently implement recommendations made in the resident's Pre-admission Screening and Resident Review (PASRR) assessment and the plan of care related to behavioral health services to ensure highest practicable well-being. The facility failed to ensure the interdisciplinary team reviewed, updated, and implemented individualized approaches to care after incidents of self-harm including: hitting a wall until his/her hand was swollen and greenish on 3/21/25; using broken glass from an overhead light to cut his/her left inner arm on 3/22/25; punching the wall with his/her right fist causing it to be swollen and bruised on 3/23/25; using a razor blade to cut the top of his/her left hand requiring sutures on 3/27/25; banging his/her head on a dresser resulting in a bruise over the left eye on 3/31/25; breaking into the smoking room and being found with his/her head in the ceiling and then slamming his/her body into a door three times, requiring the use of Zyprexa (an antipsychotic) 10 milligrams (mg) intramuscular injection (IM) a medication for self-harming behaviors as an intervention on 4/1/25; and threatening to cut him/herself and banging his/her head on the dresser resulting in two black eyes on 4/5/25. The facility failed to ensure staff had knowledge of resident care needs, including history of self-harm, interventions or resident triggers for behaviors. Facility policy showed residents who have self-harming behavior should have a staff person assigned to them within eyesight. The facility had no documentation or plan for intensive monitoring or oversight. As a result of the facility failure to provide treatment and services the resident was sent the emergency room on multiple occasions for x-rays and treatment. The census was 115. The Administrator was notified on 4/10/25 at 5:20 P.M. of the Immediate Jeopardy (IJ) which began on 4/8/25. The IJ was removed on 4/10/25, as confirmed by surveyor onsite verification. Review of the facility's Intensive Monitoring Policy, revised 4/30/24, showed: -The purpose of the policy was to ensure a system was in place for residents who required increased monitoring for crisis, behavioral, and/or psychiatric issues. -Residents who required more intensive monitoring due to crisis, behavioral/psychiatric symptoms were to be monitored by the facility staff. -Intensive monitoring was defined as periodic (hourly, every two hours, or every shift) check completed on a resident by a facility staff member. -One-to-one monitoring was completed by a designated employee assigned by a Facility Supervisor for residents who required intensive monitoring of a dedicated staff member within eyesight of the resident. -Residents who were showing poor impulse control including crisis, behavior and/or psychiatric issues may be placed on intensive monitoring or one-to-one/two-to-one monitoring at the discretion of the administrative staff or Facility Supervisor. -Based on the assessment of the resident, either intensive monitoring or one-to-one/two-to-one monitoring was to be implemented. -Resident on any type of intensive monitoring was to have an assigned employee within eyesight of the resident until the resident stabilized or returned to prior level of function. -Education on the reasoning of the intensive monitoring, including resident triggers and interventions. -The employee was to therapeutically interact with the resident while monitoring the resident. -The facility's Interdisciplinary Team was to address the resident's behavioral concerns and ensure interventions were in place to address the resident's needs including psychiatry follow-up, counseling, and any medical needs. -Once the resident stabilized and/or returned to prior level of function, the facility's Interdisciplinary Team was to meet and discuss whether to continue or discontinue the intensive monitoring. -The facility staff was to document all completed intensive monitoring. Review of Resident #204's Preadmission Screening and Resident Review (PASRR, a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care), dated 12/19/24, showed: -He/she had the following diagnoses: --Schizophrenia (a severe psychiatric disorder with symptoms of emotional instability, detachment from reality, and withdrawal into the self). --Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). --Schizoaffective Disorder (a mental condition that causes loss of contact with reality and mood problems). --Bi-Polar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). --Borderline Personality Disorder (BPD - a mental illness marked by an ongoing pattern of varying moods, self-image, and behavior). --Mood Disorder (a variety of conditions characterized by a disturbance in mood as the main feature). --Major Depressive Disorder (a state of intense sadness or despair that has advanced to the point of being disruptive to an individual's social functioning and/or activities of daily living). --Obsessive Compulsive Disorder (OCD, an anxiety disorder characterized by intrusive thoughts that produce uneasiness, apprehension, fear, or worry; by repetitive behaviors aimed at reducing the associated anxiety; or by a combination of such obsessions and compulsions). --Autism or Autism Spectrum Disorder (a neurological and developmental disorder that affects how people interact with others, communicate, learn, and behave). -He/she had behavioral difficulties and/or mental illness symptoms requiring 24-hour monitoring/management. -He/she had a history of hitting the wall in his/her last facility, breaking his/her hand, as well as taking a razor to his/her arm and making a deep laceration. -The resident had a history of numerous placement situations and hospitalizations usually for self-harm or threatening harm to others. -He/she also had multiple suicide attempts including overdosing and cutting himself/herself. -The resident's family voiced concerns the resident would kill himself/herself while cutting. -He/she had a long history of medication non-compliance along with his/her self-harming behaviors, erratic behaviors with multiple psychiatric hospitalizations. -The resident had shown that his/her cutting were not suicidal, but instead to relieve emotional pain, irritability, and agitation. -He/she had cut as recently as December 2024. -Along with his/her history of self-harm and non-compliance, he/she also showed a history of hallucinations, delusions, seclusiveness, destroying property, wandering, OCD, uncooperation with medications, eating, activities, hygiene, along with recently selectively muting himself/herself. -He/she had been on an inpatient psychiatric unit since 12/4/24 on 15-minute suicide watch. -He/she had had behaviors of running down a hallway and slamming himself/herself into walls and doors at the previous placement as well as jumping into the Mississippi River in order to self-harm. -He/she had one-to-one supervision as well when inpatient. -The resident had expressed a coping mechanism of utilizing a seclusion room with the door open and lights tuned low when he/she was overstimulated. -He/she had participated in being in the seclusion room several times during his/her previous psychiatric stay. -The resident showed poor insight and poor decision-making skills, difficulty with expressing his/her emotions, as well as difficulty with interpersonal relationships. -The final determination stated the resident required close supervision and monitoring to maintain his/her safety due to his/her long history of self-harm and suicidal ideations. -He/she required monitoring of behavioral symptoms, trauma informed services, and positive behavioral support services. -He/she remained at a high risk for self-injury requiring 24-hour monitoring and staff intervention to prevent self-harm, monitor eating, mutism, limited overstimulation, providing a quiet, supervised space away from others to de-escalate in times of increased anxiety/agitation. -The resident was to have a structured environment with low stimulation, minimum visual/auditory distractions, a level of supervision required to prevent harm to himself/herself or others, personal space with a daily schedule of tasks and activities. -A crisis plan was to be developed that indicated clear steps that were to be taken to support the resident during a behavioral crisis including knowing who to contact for assistance, how to work together with the resident during the crisis, and how to determine when the crisis was over. -The crisis plan was to identify the physician, emergency medical services, and/or law enforcement who were to be appropriately contacted. Review of the resident's facility Clinical admission form, dated 2/20/25 at 11:49 P.M., showed: -He/she was admitted to the facility with no family present. -He/she was ambulatory, showed no medical issues, and his/her vital signs were stable. -He/she showed no signs of issues with his/her mood, was pleasant with no noted negative behaviors. -The resident showed issues with his/her skin with previous lacerations/scars to his/her left forearm, right abdomen, and right thigh. -The care planning portion of the form showed no safety concerns, no concerns with harm to himself/herself or others, no behavior management issues, no disturbed sensory perception concerns, no concerns with social interactions, no concerns for risk of injury, no concern with coping, and did not identify any supervision needs. Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment tool completed by staff and used for care planning), dated 3/16/25, showed he/she: -Was cognitively intact. -Had nearly daily issues with feeling down, hopeless or depressed, having little pleasure in doing things, sleeping too much or too little, having little energy, and feeling bad about himself/herself. -Showed no negative behaviors during the 90-day look-back period. Review of the resident's undated Nursing Care Plan on 4/8/25, showed: -The resident had a problem with his/her psychosocial well-being including ineffective coping, low self-esteem, taking everything personally, an altered perception of reality and at-risk for self-harm. - The care plan did not include any interventions related to supervision needs or known triggers/stimuli that could lead to challenging behaviors. -On 3/21/25 he/she became angry, hitting the wall and throwing objects causing his/her right hand to swell and bruise. Review of the resident's Nurse's Notes, dated 3/22/25 at 4:38 A.M., showed: -On 3/22/25 the resident had been placed on one-to-one staff observation after he/she cut his/her arm in anger. -Administrator A had spoken to the resident who stated when Licensed Practical Nurse (LPN) A asked two Certified Nursing Assistants (CNAs) to watch him/her, they argued about who would provide the one-to-one staff observations as it was a shitty job which he/she said he/she took very personally as if no one wanted him/her. -It was explained to the resident he/she needed one dedicated person to provide observation. -The resident expressed understanding and felt better after discussing the issue. -The resident stated the cutting was only to make him/her feel better and he/she did not have another outlet. -Administrator A gave the resident his/her contact information telling the resident he/she could call if he/she needed to vent his/her feelings. -The resident stated he/she does not show his/her emotions until they explode. -He/she stated when he/she got manic, he/she got very anxious, his/her thoughts raced and became obsessive over certain thoughts, causing him/her to self-harm. -The resident had five new dissolvable stitches in his/her arm yet denied pain. -The resident remained on intensive monitoring and had been since returning from the hospital. -He/she had cut himself/herself in the past, not trying to kill himself/herself, but instead, cutting made him/her temporarily happy. -He/she provided coping mechanisms such as speaking with his/her family member, coloring and playing his/her Nintendo Switch, which had been damaged by his/her roommate on 3/13/25 and had not yet been replaced by the facility, which he/she had expressed frustration over numerous times. -He/she stated he/she would like his/her service dog to visit him/her, but his/her family with the dog, lived far away. -He/she stated his/her latest self-harming episode was partly, because his/her family member was in the hospital and he/she was worried about that. -He/she stated the family member was his/her best friend and they used to do everything together. -He/she had ordered food that unbeknownst to him/her, had wheat in it, which he/she was allergic to. -He/she then had been made to feel like the allergic reaction was done on purpose and was his/her fault by the Dietary Manager. -He/she broke his/her overbed light and used the casing of the light cover to cut his/her forearm. -He/she felt like a failure and felt overwhelmed as he/she was having issues with his/her roommate and felt punished as the staff was making him/her move rooms, not his/her roommate. -He/she was upset the staff had to remove the food in his/her room which contained wheat or gluten even though he/she knew he/she was allergic and had a bad reaction to those foods. Review of the resident's Nurse's Notes, dated 3/22/25 at 12:38 P.M., showed: -The resident was found sitting on the bathroom floor bleeding from his/her left forearm. -Pressure was applied to the laceration with a towel to stop the bleeding and 911 called. -The resident stated he/she cut himself/herself with the light cover in his/her room. -The resident stated he/she cut himself/herself, because he/she was angry because the staff blamed him/her for an allergic reaction he/she had the night before when he/she ordered food delivery containing wheat and/or gluten, which caused the resident to have to go to the hospital and get medication and fluids for the reaction. Review of the resident's Self-Inflicted Injury Report, dated 3/22/25, showed: -The staff called a code after having found the resident on the bathroom floor bleeding from his/her left forearm. -Pressure was applied to the cut and 911 was called. -The resident stated he/she cut himself/herself with the light cover in his/her room. -He/she was angry because he/she felt the staff blamed his/her for having an allergic reaction to some food he/she had ordered and because his/her close family member was in the hospital. -He/she was taken to the hospital for evaluation and treatment. -The incident was not witnessed. -The injury was to his/her left forearm. -He/she was completely alert and oriented. -There were no predisposing factors prior to the incident. Review of the resident's Nurse's Note, dated 3/22/25 at 3:51 P.M., showed Administrator A documented: -The resident returned from the hospital and was placed on one-to-one staff observation. -He/she was placed on an antibiotic to prevent infection and orders to keep the stitches clean and dry. During an interview on 4/9/25 at 11:45 A.M., CNA T said: -He/she was working the day shift on 3/22/25, but not providing direct care for the resident. -He/she was not aware the resident had a history of self-harming behaviors. -It would be nice to know what the resident's history was so he/she could have paid closer attention to the resident. -He/she was not aware of what the resident's triggers or interventions were, but he/she could probably find them in the care plan. -He/she had not seen the resident much during the day as each time he/she walked by the resident's room, the resident was in his/her room in bed, refusing to do any activities. -He/she happened to go into the resident's room and found the resident on the floor of the bathroom, bleeding from his/her left forearm. -He/she noticed the resident had a lot of old cutting scars on his/her left forearm on the top of his/her arm and underneath his/her arm at the time he/she found the resident. -The resident had both linear scars and X shaped scars on his/her arms. -He/she called for help and the nurse attended to the resident and sent him/her to the hospital. -The resident had broken the light above his/her bed and used the glass shards to curt himself/herself. -The resident had not been on one-to-one staff observation prior to his/her cutting. -He/she did not recall having any de-escalating technique or mental health education at the facility, but he/she had a behavioral health background, having worked in mental health facilities in the past, so he/she felt prepared to work with mentally ill residents. Review of the resident's undated care plan on 4/8/25, showed facility staff did not update the resident's care plan with the incident on 3/22/25 or add any new interventions to prevent self-harm. The care plan did not include any interventions related to supervision needs or known triggers/stimuli that could lead to challenging behaviors. Review of the resident's One-on-One Documentation Form, dated 3/23/25, showed the resident assigned one-to-one staff observation from 9:15 A.M. through 9:00 P.M. Review of the resident's Nurse's Notes, dated 3/23/25 at 9:10 P.M., showed: -The resident became angry and began hitting the wall and throwing objects. -A Code [NAME] (an overhead page indicating a resident had escalated their behavior to a point of needing extra staff assistance to keep the resident safe from harm) was called and upon assessment the resident was standing up in his/her room. -LPN F asked him/her to stop and what was wrong. -The resident stated he/she was angry at his/her guardian, because of his/her dog. -The resident's right hand was swollen and turned a greenish color. -911 was called, the physician and guardian were notified, and the resident was sent to the hospital for assessment and treatment. Review of the resident's Self-Inflicted Injury Report, dated 3/23/25, showed: -The resident became angry and began hitting the wall and throwing objects. -A Code [NAME] was called and staff came to assist. -The staff asked him/her to stop and what was wrong. -The resident stated he/she was angry with his/her guardian related to his/her dog. -Upon assessment, his/her right hand was swollen and greenish in color. -911 was called and the resident went to the hospital for evaluation and treatment. -His/her guardian was notified and stated the resident was angry as he/she did not know where his/her dogs were. -He/she was completely oriented. -There were no predisposing factors. Review of the resident's care plan showed no new interventions put in place after the 3/23/25 incident. The care plan did not include any interventions related to supervision needs or known triggers/stimuli that could lead to challenging behaviors. During an interview on 4/10/25 at 11:40 A.M., LPN F said: -He/she was working 3/23/25. -The resident had not shown any signs of escalation, but had been on his/her phone during the evening. -It appeared that one of the phone conversations the resident had caused him/her to quickly escalate. -The resident was not on one-to-one staff observation as it was only being done during the daytime hours. -No behavioral interventions were put in place after this incident. Review of the resident's Nurse's Notes, dated 3/24/25 at 11:26 A.M., showed: -He/she returned from the hospital with no new orders. -The resident remained on one-to-one staff observation for protective oversight. Review of the resident's Nurse's Notes, dated 3/24/25 at 6:58 P.M., showed: -He/she remained on behavior monitoring with no signs of negative behaviors. -He/she had been in his/her room most of the day, so he/she was discontinued from one-to-one staff observation. Review of the resident's Nurse's Notes, dated 3/27/25 at 1:30 A.M., showed: -It was discovered the resident had a 4.5 centimeter (cm) deep laceration to the back of his/her left hand. -The resident initially stated he/she had fallen and cut his/her hand, however, later disclosed he/she cut himself/herself with a razor blade. -His/her hand was dressed with gauze and 911 was called to transport the resident to the hospital for treatment. -The resident's guardian, Administrator A, and Nurse Practitioner (NP) were all notified. Review of the Registered Nurse Investigation (RNI), dated 3/27/25 at 8:31 A.M., showed: -The resident cut himself/herself with a razor blade he/she had hidden in a box of tissues. -He/she cut the top of his/her left hand. -The incident was not witnessed. -Pressure was applied to the cut and the resident was sent to the ER. -All appropriate individuals were notified. -Counseling, a new Nintendo Switch, rubber band therapy, therapy dogs were all discussed as coping skills. -The resident was placed back on one-to-one staff observation while awake and environmental room checks of the room were completed. Review of the resident's undated care plan on 4/8/25, showed facility staff did not update the care plan after the 3/27/25 incident and did not add any new interventions to prevent the resident from self-harm. The care plan did not include any interventions related to supervision needs or known triggers/stimuli that could lead to challenging behaviors. Review of the resident's Nurse's Notes, dated 3/31/25 at 3:25 P.M., showed: -The resident stated he/she fell in his/her room. -LPN A asked how he/she fell. -The resident stated he/she did not know. -LPN A observed a bruise over the resident's left eyebrow area. -The resident's room was checked for any items with which he/she could have harmed himself/herself and none were found. -It was later determined after resident interview that the resident admitted to banging his/her head on his/her dresser instead of falling. -All appropriate persons were notified. During an interview on 4/10/25 at 12:22 P.M., LPN A said: -He/she did not believe the resident was assigned one-to-one staff observation during the incident on 3/31/25. -The resident had not shown any self-harming behavior just prior to the incident. -The resident later told LPN A the resident banged his/her head either on his/her dresser or the sink, causing the bruising and the cut above his/her left eye. -The resident was sent to the hospital for evaluation and treatment. Review of the resident's care plan showed staff did not update the care plan after the 3/31/25 incident or with new intervention to prevent self-harm. Review of the resident's Nurse's Notes, dated 3/31/25 at 8:48 P.M., showed: -A peer of Resident #204 was having a behavior throwing chairs in the dining room. -The peer's behavior caused Resident #204 to trigger and he/she charged at his/her peer. -Multiple staff attempted to keep the residents apart and no blows were exchanged. -The resident got ahold of his/her peer's clothing, but he/she quickly released the clothing. -The resident calmed down after his/her peer was removed from the area. -No further issues occurred, and only superficial scratches were discovered on the resident's chest. Review of the resident's undated care plan on 4/8/25, showed facility staff did not update the care plan after the 3/31/25 incidents, including any new interventions or needs related to the resident's self-harming behaviors or safety concerns. During an interview on 4/10/25 at 10:40 A.M., LPN F said: -The resident had been fine at the beginning of the shift on 3/31/25. -He/she believed the resident's peer becoming escalated caused the resident to escalate as the resident later said the loudness and chaos of the unit made him/her upset. -He/she was not present for the incident until it was over, however, he/she would have expected the staff to remove the resident from the chaos before it caused the resident to escalate. -He/she was not aware loudness and chaos caused the resident to escalate in the past. -He/she did not believe the resident was on one-to-one staff observation at the time of the incident. Review of the resident's Nurse's Notes, dated 4/1/25 at 9:00 P.M., showed: -The resident became agitated and broke into the smoke room. -He/she was found climbing the window bars into the ceiling. Review of the resident's Nurse's Notes, dated 4/1/25 at 9:33 P.M., showed: -The resident was discovered sitting on top of the heater in the smoke room. -Staff were present and at a safe distance. -The resident agreed to go to Administrator A's office. -The resident was noted to run down the hall and into the unit door three times. -No apparent injury noted and an as needed (PRN) medication was given per the resident's request. -The resident calmed down after having been allowed to vent and verbalize his/her feelings. -All appropriate individuals were notified, and the resident was monitored for safety, increased anxiety and agitation. During an interview on 4/9/25 at 11:15 A.M., CNA I said: -He/she worked 4/1/25. -He/she was just ending his/her shift when he/she heard chaos coming from the smoke room. -When he/she got there, Resident #204 was standing up on the heater, holding onto the bars on the windows with his/her head up through the ceiling tile. -The resident had been fine all day and he/she had no signs of escalating. -As far as he/she was aware, the resident did not say why he/she did this or say anything about being upset to anyone. -Administrator A took the resident to his/her office to calm down. -He/she was not aware of what the resident's triggers or interventions were. -He/she was aware of the care plan, but had not looked at it. During an interview on 4/10/25 at 12:22 P.M., LPN A said: -He/she was just finishing up his/her day when he/she heard someone say to come to the smoke room. -On 4/1/25 the resident had broken into the smoke room and was standing on top of the heater, hanging on to the window bars, attempting to put his/her head into the ceiling. -Administrator A arrived and de-escalated the situation, taking the resident to his/her office. -The resident had shown no signs of escalation during the shift and was not on one-to-one staff observation as far as he/she could recall. -The resident did not say what upset him/her or why he/she did it. Further review of the resident's care plan on 4/8/25, showed staff did not update the care plan after the incident on 4/1/25 and no new interventions were put in place for the resident's self-harming behavior. The care plan did not include any interventions related to supervision needs or known triggers/stimuli (loudness or chaos) that could lead to challenging behaviors. The care plan did not include parameters for when pharmalogical interventions could be used. The care plan did not show an order for an intramuscular injection of Zyprexa at 10 mg ordered for an intervention PRN (as needed) medication for self-harming behaviors. Review of the resident's Nurse's Notes, dated 4/4/25 at 11:28 A.M., showed: -The resident was noted at 10:30 A.M., to be pacing back and forth while on the phone. -When he/she got off the phone, he/she began punching the walls, causing a large hole in the wall. -The resident was removed from the unit and escorted to Administrator A's office where he/she quickly de-escalated. -The resident called and spoke to one of his/her guardians who suggested the resident use his/her ear buds to drown out the chaos around him/her. -The resident's right hand was noted to be red and bruised from punching the walls in his/her room. -The NP was notified and ordered x-rays of the resident's hand. -The x-ray showed no fracture. -All appropriate individuals were notified. Further review of the resident's care plan showed staff did not update the care plan after the incident on 4/1/25 or 4/4/25. The care plan did not include any interventions related to supervision needs or known triggers/stimuli that could lead to challenging behaviors. No new interventions were put in place for the resident's self-harming behavior, including the use of ear buds as a coping mechanism. Review of the resident's One-on-One Documentation Form, dated 4/5/25, showed the resident was on one-to-one staff observation, (provided by CNA I) from 7:00 P.M. to 9:45 P.M., when he/she was sent to the hospital for thoughts of self-harm. Review of the resident's Nurse's Notes dated 4/5/25 at 9:30 P.M., showed: -The resident came to CNA H and stated he/she was about to explode and harm himself/herself by cutting. -He/she was shaking significantly and did not appear to have been in control of his/her emotions. -He/she was interviewed by the Director of Nursing (DON) and was sent out to the hospital for further evaluation. Review of the resident's medical record showed it did not contain information the resident received trauma informed services or positive behavioral support services as indicated in the resident's PASRR. The resident's medical record showed no counseling services provided to the resident, daily living skills training, development of a personal support network, drug therapy/monitoring, medically related social services, physician services, a structured environment, and structured socialization as directed by the care plan to prevent self resident's self-harming behavior. Review of the resident's One-on-One Documentation Form, dated 4/9/25, showed the resident was on one-to-one staff observation provided by CNA T from 4:30 P.M., to 5:45 A.M. During an interview on 4/9/25 at 3:45 P.M., Hospital Registered Nurse (RN) A said: -He/she had taken care of the resident on the first day he/she was in the ER on [DATE] and he/she was out of control the whole time he/she was there. -They had to keep someone with him/her at all times or they were afraid he/she would harm himself/herself. -Hospital RN A was off the day before and back on 4/9/25. -When he/she came back to work on 4/9/25 the resident was completely different. -The resident was calm and cooperative with no voiced intent to harm. -He/she believed the psychiatrist who saw the resident may have changed up some of the resident's medications, but he/she was not sure about that. -The resident told him/her that when he/she had these urges to self-harm, he/she had to do it or someone would have to physically stop him/her as the urges were too great for him/her to stop on his/her own. During an interview on 4/10/25 at 12:28 P.M., CNA H said: -He/she was not aware of what triggered the resident at any point in time when he/she self-harmed, or what interventions were in place other than one-to-one staff observation. -The resident had been on one-to-one staff observation during the day off and on throughout his/her stay at the facility. -A little while after the one-to-one caregiver left 4/5/25, the resident came and said he/she was getting upset and was about to explode and harm himself/herself. -CNA H immediately notified the charge nurse who called the NP and had the resident sent to the hospital. -He/she stayed with the resident until the resident left for the hospital. During an interview on 4/9/24 at 3:32 P.M., the resident said: -They had taken him/her off one-to-one staff observation prior to this last hospitalization on 4/5/25. -He/she had been in the ER for three or four days this time. -Sometimes when he/she was supposed t

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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to keep one sampled resident (Resident #9) free from abuse. On 12/8/24 Certified Nursing Assistant (CNA) K kicked at Resident #9. Resident #89 grabbed Resident #9 by the neck out of 23 sampled residents. The facility census was 111 residents. Review of the facility's Abuse and Neglect policy dated 1/5/23 showed: -Physical abuse included purposely beating, striking, or injuring a resident. It included but was not limited to hitting and kicking. -Verbal abuse included using profanity or speaking in a demeaning, non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. Examples included yelling at a resident. -Employees are trained through orientation and ongoing training on issues related to abuse prohibition practices such as dealing with aggressive residents, and recognizing signs of burnout, frustrations, or stress that may lead to abuse. -On a regular basis, supervisors will monitor the ability of staff to meet the needs of residents and staffs understanding of individual resident care needs. Situations such as inappropriate language, insensitive handling, and impersonal care will be corrected as they occur. Review of the facility's Resident Rights policy dated 7/5/23 showed residents have the right to be free from mental and physical abuse. 1. Review of Resident #9's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Impulse disorder (a psychiatric condition that makes it difficult to control actions or reactions). -Borderline intellectual functioning (below average cognitive functioning). -Schizophrenia (a chronic mental illness that interferes with a person's ability to think clearly, to distinguish reality from fantasy, to manage emotions, make decisions, and relate to others). -Bipolar (mood disorders characterized usually by alternating episodes of depression and mania). -Anxiety Disorder (a psychiatric disorder causing feelings of persistent anxiety). -Post-Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering after experiencing or witnessing a shocking, scary, or dangerous event). Review of the resident's quarterly Minimum Data Set (MDS - a federally mandated assessment instrument completed by facility staff for care planning) dated 11/26/24 showed the resident was cognitively intact with no behaviors. Review of Resident #89's Face Sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Schizoaffective disorder (a mental condition that causes loss of contact with reality and mood problems). -Intellectual disabilities. -Schizophrenia. -Bipolar. -Asperger's syndrome (a developmental disorder that makes it difficult to interact with others and understand social cues). Review of Resident #89's quarterly MDS dated [DATE] showed he/she: -Was cognitively intact. -Had verbal behaviors 1-3 days during the look back period. -Had no physical behaviors. Observation of the facility video of the incident on 12/8/24 showed: -The video was undated and not time stamped. -A resident was standing at the nurse's station with his/her back to the camera using the telephone. The charge nurse was in the nurse's station behind the clear partition and CNA K and CNA L were standing at the nurse's station next to the resident on the telephone with their backs to the camera leaning on the medication cart. -CNA L and CNA K appeared to be talking to the nurse behind the partition while the one resident was on the telephone and other residents were walking up and down the hall. -Resident #9 walked up behind CNA K, CNA K turned to face the resident. The resident began pointing to a box (later identified as the cigarette box for the unit) and down the hall. CNA L then turned around to face the resident. -Resident #9 and CNA K's facial expressions and body language demonstrated both were talking in heated, elevated, agitated tones. CNA K was forcefully pointing his/her finger towards the resident. CNA L also began talking in a heated. elevated tone. The nurse remained behind the clear partition in the nurse's station. -Resident #89 is seen walking into frame behind Resident #9, then walks off. -Resident #9 is still talking in an agitated state when the nurse comes out from behind the nurse's station and gets between Resident #9 and CNA K. CNA L walks out of the camera frame. -The resident that was on phone then walked out of camera frame and Resident #89 walks up behind Resident #9. -Resident #9 and CNA K are still talking to each other in elevated agitated tones with the charge nurse standing between them. -Resident #9 rips off his/her jacket and lunges towards CNA K attempting to throw punches at CNA K. -Resident #89 comes up behind Resident #9 and attempts to put his/her forearm around the resident's neck as if to place in a choke hold. -Unidentified staff come into frame to pull Resident #89 off of Resident #9. The nurse was still between Resident #9 and CNA K. -CNA K begins lunging at Resident #9 with the charge nurse between the two, holding onto CNA K. -The charge nurse is then seen physically restraining CNA K to keep him/her from Resident #9 as two unidentified staff are each holding an arm on Resident #9. -CNA K is then seen kicking at Resident #9. Review of the resident's Progress Behavior note dated 12/8/24 showed the resident told the Administrator the staff on his/her unit jumped on him/her. An investigation immediately ensued. Review of the facility investigation dated 12/12/24 showed: -An undated screenshot of a text message at 9:11 P.M. from the charge nurse, Licensed Practical Nurse (LPN) C, indicating the resident took a cigarette from him/her then went to the CNA to get a cigarette. The charge nurse told the resident he/she already had a cigarette from him/her. The CNA and the resident went to the smoke area. When they came back to the nurse's station with other aides, they were talking back and forth and the resident and staff were loud. The resident became aggressive and tried to attack. Two CNAs held the resident's hands while he/she moved the other CNA from the situation. An as needed medication (PRN) was administered to the resident and the resident calmed down. -Resident #9 and Resident #89 were not interviewed. -CNA L and CMT E were not interviewed. Review of LPN C's written statement dated 12/11/24 showed: -On 12/8/24 a CNA L and the resident came to the nurse's station and asked for a cigarette. -The resident was told he/she had already received a cigarette. -On return from the smoke room the resident was agitated, talking loudly, and one of the CNA K was also loudly talking. -The resident tried to attack the CNA K. -Two CNA L and CNA J held the resident while he/she held the other CNA K and moved the CNA K. **NOTE**LPN C was attempted contact for interview on 12/23/24, 12/24/24 and 12/26/24. LPN C did not return the call. Certified letter mailed for contact. During an interview on 12/17/24 at 2:18 P.M., Resident #9 said: -Staff told him/her they were going to take his/her cigarettes away during a recent incident a week or so ago. -He/She pushed the staff with his/her belly. -The staff and two residents were hitting him/her. During an interview on 12/19/24 at 10:59 A.M., Resident #89 said: -Resident #9 was talking and suddenly got mad and attacked a staff member. -The staff member and Resident #9 were both hitting each other. -He/She hit Resident #9 to get the resident off of CNA K. Review of CNA K's written statement dated 12/10/24 showed: -Resident #9 said he/she was allowed to have his/her cigarettes if he/she asked for them. -When Resident #9 had the cigarettes taken away, he/she began making threats towards the staff and fighting the staff. During an interview on 12/20/24 at 3:58 P.M., CNA K said: -Resident #9 was upset about cigarettes. He/She had asked a nurse about getting them when he/she should not have. -He/She told the resident he/she could not have them. -He/She and the resident began arguing verbally about it. -He/She denied the resident attempted to hit him/her and he/she did not attempt to hit the resident. Review of CNA J's written statement dated 12/8/24 showed: -CNA L said to the resident You have to calm down or else we're gonna have to call a Code Green! (Code [NAME] is a signal to other staff to assist with a behavioral episode). -He/She called the Code [NAME] three times on the walkie talkie. By the third call, he/she witnessed the resident start punching CNA K. -He/she then jumped up and as he/she was running to separate everyone, Resident #89 grabbed Resident #9 by the neck as he/she was swinging at CNA K. -He/she separated everyone the best he/she could, telling the other residents to go to their rooms as he/she was attempting to get Resident #9 in a two-man hold. -At this time they were still yelling for a Code [NAME] for extra help. A few minutes passed when he/she yelled for the Certified Medication Technician (CMT) to run for help since no one can hear us! Finally some help came. - Resident #9 made it seem as if he/she was a trigger, so he/she removed him/herself. During an interview on 12/20/24 at 3:27 P.M., CNA J said: -He/She did not normally work back on the secured care unit. -He/She had been in another room with two other residents when another CNA (CNA L) told him/her the nurse was giving Resident #9 cigarettes. -He/She and CNA L went to talk to CNA K in the closed smoke room about the cigarettes. CNA K showed him/her the cigarette box was almost empty. -Resident #9 was outside the smoke door but was able to get into the smoke room and was getting upset. -They were able to calm the resident down and all of them left the smoke room. -Toward the end of the shift, he/she heard staff call for a Code Green he/she went to see what/who it was regarding. -He/She saw CNA K and CNA L were trying to calm Resident #9 down, but then Resident #9 started to hit CNA K. -Resident #89 came up from behind Resident #9 and him/her in a choke hold and he/she had to pull Resident #89 off of Resident #9. He/She did not see CNA K hit or kick Resident #9, but things were happening so fast and he/she was focused on calming Resident #9 down. -Resident #9 was put in a two person hold and Resident #89 was educated to not intervene in the future because it could trigger him/her or other residents. During an interview on 12/23/24 at 12:05 P.M., the Administrator said: -He/She did not feel as though what was on the video was abuse. -The staff were not interacting with the resident appropriately. It appeared both sides were agitated and not talking calmly. -There was no audio to the video, so he/she could not tell what was actually being said. -He/She could not tell if CNA K was kicking at the resident but was giving him/her the benefit of the doubt that perhaps he/she could have been kicking to get the smoke box out of the way. --NOTE: The smoke box was not in view of the camera and was not in between the resident and CNA K at the time CNA K kicked at the resident. -The investigation provided was the complete investigation. During an interview on 12/23/24 at 4:02 P.M., the Director of Nursing (DON) said: -Abuse investigations were completed by him/her and the Administrator. -He/She had seen the video of the altercation between Resident #9 and Resident #89 and CNA K. -The investigation provided was the complete investigation. -Investigations should include interviews with all witnesses, including any staff and residents identified or involved in the incident. During an interview on 12/23/24 at 12:05 P.M., the Administrator said: -The investigation provided was the complete investigation. -No witness statements or interviews were included in the investigation. During an interview on 12/23/24 at 4:02 P.M., the DON said: -Resident to resident altercations should be thoroughly investigated. -A complete investigation would include witness statements from staff and other residents. -Statements from the residents involved in the incident should be included in an investigation. During an interview on 12/17/24 at 2:18 P.M. Resident #9 said: -Staff told him/her they were going to take his/her cigarettes away during a recent incident a week or so ago. -He/She pushed the staff with his/her belly. The staff and two residents were hitting him/her. During an interview on 12/20/24 at 3:27 P.M., CNA J said: -He/she heard Code Green. Staff were trying to calm Resident #9 down when Resident #9 started hitting CNA K. -Resident #89 came up behind Resident #9 and put him/her in a choke hold. -He/she and CNA L were able to remove Resident #89 and educated him/her about intervening in other resident behaviors. -He/She and CNA L put Resident #9 in a two person hold by holding his/her hand and arm. -He/she said the incident happened so fast he/she could not remember who was doing what, he/she was focused on holding onto Resident #9 arm and trying to calm Resident #9 down. During an interview on 12/20/24 at 3:46 P.M., CMT E said: -He/She normally works on the locked unit. -He/She was in the cafeteria area when he/she heard a commotion. -He/She saw Resident #9 and CNA K at the nurse's station. It looked like they were both hitting each other, but he/she was on sure who hit who, it looked like both were swinging from where he/she was at. -He/She called a Code [NAME] and was told to go find staff to assist. During an interview on 12/23/24 at 11:52 A.M., CNA L said: -He/She was doing rounds checking on residents getting ready for the next medication pass time. -He/She came out of a resident room and saw Resident #9 standing at the medication cart with the nurse. -The nurse handed the resident a couple of cigarettes. -He/She asked what was going on since the staff were not supposed to do that (hand out cigarettes when it was not smoke break time). -The nurse said he/she was giving out cigarettes. He/She told the nurse he/she was not supposed to do that. The nurse said he/she had been doing that all day. -He/She took the cigarettes from the resident and walked with him/her to the smoke room. -He/She spoke to CNA K and CNA J about the resident getting extra cigarettes from the nurse. -As they were discussing it, Resident #9 came into the smoke room and started screaming at the staff. -They walked to the front of the unit by the nurse's station. Resident #9 continued to scream at the staff and an altercation broke out. -He/She went to call a Code Green, and that was when the altercation happened. It happened so fast, he/she did not see anyone other than Resident #89 hit Resident #9. During an interview on 12/23/24 at 12:05 P.M., the Administrator said: -He/She did not feel as though what was on the video was abuse. -The staff were not interacting with the resident appropriately. It appeared both side were agitated and not talking calmly. -There was no audio to the video, so he/she could not tell what was actually being said. -He/She could not tell if CNA K was kicking at the resident but was giving him/her the benefit of the doubt that perhaps he/she could have been kicking to get the smoke box out of the way. -Hitting or kicking a resident would be considered abuse. --NOTE: The smoke box was not in view of the camera and was not in between the resident and CNA K at the time CNA K kicked at the resident. During an interview on 12/23/24 at 4:02 P.M., the DON said: -Abuse investigations were completed by him/her and the Administrator. -He/She had seen the video of the altercation between Resident #9, Resident #89 and CNA K. -Staff should not have been yelling or pointing at the residents. -CNA K was being held back by the nursing staff. -CNA K did kick at Resident #9. It was not clear if contact was made. -This incident should have been considered potential abuse by CNA K. MO00246305

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 8. Review of the facility's Tuberculosis Testing policy, dated 6/29/23, showed: -The purpose of the policy was to ensure each resident of the facility was tested for TB. -Upon admission and readmission each resident received a two-step purified protein derivative (PPD) tuberculin skin test (TST-a test to detect TB completed by injecting a small amount of TB protein under the top layer of skin on your inner forearm). -All TB tests and chest x-rays records were kept on file in resident medical records. Review of Resident #1's face sheet, undated, showed the resident was admitted to the facility on [DATE]. Review of the resident's annual MDS dated [DATE], showed: -The resident was cognitively intact. -The resident was diagnosed with: --Diabetes (disease that occurs when the body's blood sugar, is too high). --Anemia (a condition of not having enough healthy red blood cells to carry oxygen to the body's tissues). --High blood pressure. Review of the resident's Electronic Health Record (EHR) Immunization page, showed the resident received: -Step one of the TST on 9/4/24 and was read on 9/7/24 with a negative result. -A second step TST was not documented. 9. Review of resident #23's face sheet, undated, showed the resident was admitted to the facility on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed: -The resident was cognitively intact. -The resident was diagnosed with: --High blood pressure. --Hyperlipidemia (an abnormally high concentration of fats in the blood). --Seizure disorder (a sudden burst of electrical activity in the brain). Review of the resident's EHR Immunization page, showed the resident received: -Step one of the TST on 3/11/22. --A read date was not documented. --A second step TST was not documented. -Step one of the TST was administered on 4/5/23. --A read date was not documented. --A second step TST was not documented. -Step one of the TST was administered on 10/27/24 and was read on 10/30/24 with a negative result. --A second step TST was not documented. 10. Review of Resident #72's face sheet, undated, showed the resident was admitted to the facility on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed: -The resident was cognitively intact. -The resident was diagnosed with: --High blood pressure. --Diabetes. --Hyperlipidemia. Review of the resident's EHR Immunization page, showed the resident received: -Step one of the TST on 9/4/24 and was read on 9/7/24 with a negative result. -A second step TST was not documented. 11. Review of Resident #98's face sheet, undated, showed the resident was admitted to the facility on [DATE]. Review of the resident's annual MDS, dated [DATE], showed: -The resident was cognitively intact. -The resident was diagnosed with: --Chronic Obstructive Pulmonary Disease (COPD-a constriction of the airways causing difficulty or discomfort in breathing). --Tachycardia (an increased heart rate for any reason). --Diabetes. Review of the resident's EHR Immunization page, showed the resident received: -Step one of the TST on 3/15/24 and was read on 3/18/24 with a negative result. --A second step TST was not documented. -Step one of the TST was administered on 9/4/24 and read on 9/7/24 with a negative result. --A second step was not documented. 12. Review of resident #108's face sheet, undated, showed: -The resident was admitted to the facility on [DATE]. -The resident was diagnosed with: --Asthma (a chronic disease in which the bronchial airways in the lungs become narrowed and swollen, making it difficult to breathe). --Hyperlipidemia. Review of the resident's quarterly MDS, dated [DATE], showed the resident was cognitively intact. Review of the resident's EHR Immunization page, showed the resident received: -Step one of the TST on 10/27/24 and was read on 10/30/24 with a negative result. --A second step TST was not documented. -Step one of the TST on 9/4/24 and read on 9/7/24 with a negative result. --A second step was not documented. 13. During an interview on 12/19/24 at 10:25 A.M., the MDS Coordinator said: -Residents only received one step of the TST. -He/She was unsure why, that was what the Administrator told him/her. -Resident's had an annual one step TST, per company policy. -After that the residents received a signs and symptoms questionnaire. During an interview on 12/20/24 at 9:53 A.M. the Administrator said: -If a resident had not been hospitalized then they were able to get a one-step TST yearly. -If the resident had been in the facility for one consecutive year and they had not been exposed to TB then they would receive a signs and symptoms questionnaire. During an interview on 12/20/24 the Regional Director of Operations (RDO) said: -When a resident was admitted to the facility from anywhere then they received a two step TST. -Resident's who were discharged and returned to the facility should have an initial TST upon their initial admission. -If there was not an initial two-step TST on record then they did not have one and a TST should be performed. -Nurses were responsible for administering the first step TST upon admission but not later than 72 hours after admission. -The first step was read 48 to 72 hours after the first step was administered. -The second step was administered 14-21 days after the first was read. -Nurses were responsible for administering and reading the TST's for residents. -The DON or the Assistant Director of Nursing (ADON) followed up to ensure they were being administered. -TB tests and results were documented in the EHR and showed on the MAR as a task that needed completed. -He/She expected all staff to follow the facility's policy regarding administering and documenting resident TB tests. 4. Review of the facility's policy, General Medication Administration Process, dated 6/26/24 showed: -Staff was to wash hands prior to administering medication per facility protocol and product. -Staff was to perform hand hygiene and before preparing medication and before and after direct contact with the resident. Observation on 12/19/22 at 8:33 A.M. of medication pass on the Men's locked unit with Certified Medication Technician (CMT) D showed: -CMT D did not perform hand hygiene before starting the medication pass. -He/She did not have hand sanitizer on the medication cart. -He/She went into room [ROOM NUMBER] and administered medication to the resident. -He/She did not perform hand hygiene after administering the medication to the resident. Observation on 12/19/22 at 11:22 A.M. of medication pass on the Men's locked unit with CMT D showed: -He/She did not perform hand hygiene before starting the medication pass. -He/She did not have hand sanitizer on the medication cart. -He/She administered medications to the residents in room [ROOM NUMBER] and 210. -He/She did not perform hand hygiene after administering the medication to the residents. -He/She locked the medication cart to wake a resident up to take their medication. -He/She did not perform hand hygiene after nudging the resident. -He/She did not perform hand hygiene after unlocking the medication cart. -He/She administered medication with a glass of water he/she had poured to the resident in room [ROOM NUMBER]. -He/She took the glass after the resident drank from it and threw it away. -He/She did not perform hand hygiene after taking the glass back from the resident. -He/She administered medication to the resident in room [ROOM NUMBER] which included an inhaler (a handheld device that delivers medication into the lungs). -He/She put the lid back on the inhaler then put the inhaler in a drawer in the medication cart. -He/She did not perform hand hygiene. -He/She administered medication to the resident from room [ROOM NUMBER] along with a glass of water. -He/She did not perform hand hygiene. -He/She administered medication to the resident from room [ROOM NUMBER] along with a glass of water. -He/She pulled his/her phone out of his/her pocket and looked at it then put the phone back into his/her pocket. -He/She did not perform hand hygiene. -He/She had not worn gloves. During an interview on 12/19/22 at 12:12 P.M. CMT D said: -He/She did not have any hand sanitizer on his/her person. -He/She should have performed hand hygiene before, after medication pass, and after administering medication to each resident. -The facility had provided education on hand hygiene during medication pass a couple of months ago. During an interview on 12/20/24 at 10:00 A.M. the DON and Registered Nurse (RN) A said: -Staff should have washed their hands before, during, and after medication pass. -They should have had hand sanitizer on the medication cart. -The staff had education about hand hygiene many times. During an interview on 12/23/24 at 4:10 P.M. the DON said: -He/She expected the nursing staff to cleanse their hands before they start medication pass, after administering medications to a resident, and after they were done with medication pass. -If they pulled something out of their pocket they also should have done hand hygiene. -He/She was ultimately responsible to ensure staff was performing hand hygiene according to protocol. 5. Review of Resident #19's face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Non pressure chronic ulcer of the back. -Open wound right upper arm. -He/She had a guardian. Review of the resident's care plan dated 8/11/24 showed: -He/She had actual impairment to skin integrity to right axilla area (armpit). -He/She was to avoid scratching. Review of the resident's annual MDS dated [DATE] showed: -He/She was cognitively intact. -Had unhealed pressure ulcers. -Had an infection of the foot. -Was getting dressings to the foot. Review of the resident's Physician's Order Sheet (POS) dated December 2024 showed the following order: -Cleanse open areas to lower right leg with wound cleanser, pat dry, apply silver alginate (medication used for treatment of infected chronic wounds) and cover with bordered gauze dressing (an absorptive dressing that consists of three layers), every day shift for wounds. Observation on 12/20/24 at 2:55 P.M. of wound care showed: -The resident had 5 wounds on his/her lower right leg. -LPN A used a gauze soaked in normal saline to cleanse the resident's leg. -LPN A swiped down the right side of the resident's leg using one gauze to wipe the three wounds. -LPN A swiped down the left side of the resident's leg using one gauze to wipe the two wounds. -LPN A cleansed his/her hands and changed gloves. -LPN A reached into his/her pocket to pull out a pen. -LPN A pulled the resident's curtain tighter closed with the same gloves on. -He/She applied medication to the residents wounds without changing gloves first. During an interview on 12/20/24 at 2:55 P.M. LPN A said: -He/she should have changed gloves after wiping each wound. -He/She forgot to change gloves and cleanse hands after putting his/her hand in his/her pocket and pulling the curtain shut. During an interview on 12/20/24 at 10:00 A.M. the DON and RN A said: -Staff should wash their hands every time they changed gloves. -Staff should use different gauze for each wound that was cleaned. -If staff touched anything they needed to change gloves and wash their hands. During an interview on 12/23/24 at 4:10 P.M. the DON said: -If the nurse was doing wound care and reached into his/her pocket or pulled the curtain shut they should have changed gloves and cleansed their hands. -When cleansing a wound staff should use new gauze for each wound. -The staff had a lot of education on hand washing. -He/She was ultimately responsible for ensuring staff was doing wound care appropriately. 6. Observation on 12/16/24 at 1:00 P.M. did not show anyone on the Men's locked unit was on EBP. -There were no signs on any of the resident's doors. -There was no isolation cart near any of the resident's rooms. Observation on 12/17/24 at 9:00 A.M. did not show anyone on the Men's locked unit was on EBP. -There were no signs on any of the resident's doors. -There was no isolation cart near any of the resident's rooms. Observation on 12/17/24 at 3:15 P.M. did not show anyone on the Men's locked unit was on EBP. -There were no signs on any of the resident's doors. -There was no isolation cart near any of the resident's rooms. During an interview on 12/19/24 at 8:33 A.M. CMT D said: -He/She had education about EBP provided by the former DON maybe a month ago. -If a resident was on EBP it would have been documented on the Medication Administration Record (MAR). -There would have been a sign on the resident's door stating he/she was on EBP. -There would have been an isolation cart outside the resident's room. -He/She had not seen a sign or isolation cart outside anyone's room this week. -No one at this time on the Men's locked unit was on EBP. -Resident #19 had a wound on his/her leg that nursing had been treating. -The charge nurse was responsible for alerting the staff if someone was on EBP. -If a resident was on EBP staff should have worn gloves, face mask, gown and booties. -There was no physician's order for Resident #19 to have been on EBP. -He/She was not aware that any of the residents were currently on EBP. During an interview on 12/20/24 at 10:00 A.M. the DON and RN A said: -Before this week they had not been using EBP. -Anyone who had an open wound should have been on EBP. -There should have been a sign on the resident's door indicating he/she was to have been on EBP. -There should have been an isolation cart with PPE in it at the resident's door. -The physician should have written an order for EBP. -Staff had education about EBP. -The DON was responsible for ensuring the residents who had open wounds or any kind of tubing were on EBP. During an interview on 12/23/24 at 4:10 P.M. the DON said: -Resident #19 had an open wound and should have been on EBP. -Any resident that had an open wound or any kind of tubing coming out of their body should have been on EBP. -There should have been a sign on the resident's door indicating he/she was on EBP and what kind of PPE staff was expected to wear while caring for that resident. -There should have been an isolation cart outside the resident's room with PPE for the staff to wear while caring for the resident. -There should have been a physician's order stating the resident was on EBP. -It should have been documented in the care plan the resident was on EBP. -It should have been passed on it the shift report the resident was on EBP. -He/She was ultimately responsible to ensure residents were on EBP and that staff was aware of it. -Staff had education from him/her and previously from the form DON about EBP. 7. Observation on 12/17/24 at 9:47 A.M. and on 12/19/24 at 8:33 A.M. of the medication room on 200 locked unit (men's) unit showed: -The only sink in the medication room was dirty with rust. -There were no paper towels in the medication room. -There was no hand soap in the dispenser. -The floor was dirty and sticky. During an interview on 12/19/24 at 8:33 A.M. CMT A said: -He/She did not know who was responsible for cleaning the medication room. -He/She did not clean it. -The medication room should have been cleaned daily. -The floor should have been cleaned daily. -There should have been soap and paper towels in the medication room for staff to wash their hands. -He/She had never seen anyone clean the medication room. -Housekeeping should have cleaned it. Observation on 12/19/24 at 11:00 A.M. showed: -The only sink in the medication room was dirty with rust. -There were no paper towels in the medication room. -There was no hand soap in the dispenser. -The floor was dirty and sticky. During an interview on 12/19/24 at 11:00 A.M. LPN A said: -When they were done with the medication carts they pushed them into the locked nurse's station. -He/She did not know who was responsible for cleaning the medication room, maybe housekeeping. -The medication room should have been cleaned daily. -The floor should have been cleaned daily. -There should have been soap and paper towels in the medication room for staff to cleanse their hands. -He/She had never seen anyone clean the medication room. -Housekeeping should have cleaned it. -The nurse would have to unlock the door as housekeeping didn't have a key to the medication room. During an interview 12/23/24 at 9:50 A.M. Floor Technician A said: -He/She had worked at the facility for several years and had not cleaned the medication rooms. -Cleaning the medication rooms was up to the Nursing staff. During an interview on 12/23/24 at 4:10 P.M. the DON said: -The sink and floor in the medication room should have been cleaned. -There should have paper towels and soap in the medication room for hand hygiene. -Housekeeping should have cleaned and ensured there were supplies in the medication room daily. Based on observation, interview, and record review, the facility failed to ensure staff were using appropriate infection control practices during wound care for three sampled residents, (Resident #19, #1 and #14), failed to ensure Enhanced Barrier Precautions (EBP-strategy to decrease transmission of infections and/or cross-contamination during high-contact care activities for residents in nursing homes that include wearing gowns, gloves and at times a face mask) were used for one sampled resident with open wounds (Resident #19), failed to have appropriate EBP signage on the doors and Personal Protective Equipment (PPE) available near the rooms for three sampled residents (Resident #19, #1 and #14), failed to ensure the medication room on the Men's Locked Unit was kept clean and hand hygiene products were available for staff, and failed to ensure staff preformed hand hygiene during medication pass, out of 23 sampled residents, and failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases when the facility failed to provide Tuberculosis (TB-a communicable disease that affects especially the lungs, that is characterized by fever, cough, difficulty in breathing, abnormal lung tissue and function) testing for five sampled resident (Resident #1, #23, #72, #98 and #108) out of five sampled residents. The facility census was 111 residents. Review of the facility Standard Precautions-Infection Control policy dated 5/14/2024 showed: -Standard Precautions refer to the infection prevention practices that apply to all residents, regardless of suspected or confirmed diagnosis or presumed infection status. --This includes hand hygiene, selection and use of Personal Protective Equipment (PPE-e.g., gloves, gowns, face masks, respirators, eye protection). Respiratory hygiene and cough etiquette, safe injection practices, environmental cleaning and disinfection, and reprocessing of reusable resident medical equipment. -Hand Hygiene is a general term for cleaning hands by handwashing with soap and water or the use of an antiseptic hand rub, also known alcohol-based hand rub (ABHR). --During the delivery of resident care services, avoid unnecessary touching of surfaces in close proximity to the resident to prevent both contamination of clean hands from environmental surfaces and transmission of pathogens from contaminated hands to surfaces. -Personal Protective Equipment refers to protective items or garments worn to protect the body or clothing from hazards that can cause injury and to protect residents from cross-transmission. Review of the facility Hand Hygiene policy dated 6/26/2024 showed: -All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, resident, and visitors. -Alcohol-based hand rub with 60-95% alcohol is the preferred method of cleaning hands in most clinical situations. -Wash hands with soap and water whenever they are visibly dirty, before eating, and after using the restroom. -The use of gloves does not replace hand hygiene. -If the task requires gloves, perform hand hygiene prior to donning (putting on) gloves, and immediately after removing gloves. -Use ABHR includes but not limited to: --Between resident contacts. --After handling contaminated objects. --Before applying and after removing PPE, including gloves. --Before and after handling clean or soiled dressings, linens, etc. --Before performing resident care procedures. --After handling items potentially contaminated with blood, body fluids, secretions, or excretions. --When, during resident care, moving from a contaminated body site to a clean body site. Review of the facility Clean Wound Dressing Change policy dated 5/18/2024 showed: -Provide wound care in a manner to decrease potential for infection and/or cross-contamination. -Each wound will be treated individually. -When multiple wounds are being dressed, the dressings will be changed in order of least contaminated to most contaminated (i.e. change extremity wounds before wounds contaminated with stool). -Set up clean field on the overbed table with needed supplies for wound cleansing and dressing application: --If the table is soiled, wipe clean. --Place a disposable cloth or linen saver on the overbed table. -Place only supplies to be used per wound on the clean field at one time (include wound cleanser, gauze for cleansing, disposable measuring guide and pen/pencil, skin protectant products as indicated, dressings, tape). --Use no-touch techniques to remove ointments and creams from their containers (i.e. use tongue blade or applicator). Liquid solutions should be poured directly onto gauze sponges. -Establish area for soiled products to be placed. Wash hands and put on clean gloves. Place a barrier cloth or pad next to the resident, under the wound to protect the bed linen and other body sites. -Loosen the tape and remove the existing dressing. -Remove gloves, pulling inside out over the dressing. Discard into appropriate receptacle. -Wash hands and put on clean gloves. -Cleanse the wound as ordered, taking care to not contaminate other skin surfaces or other surfaces of the wound (i.e. clean outward from the center of the wound). Pat dry with gauze. -Measure wound using disposable measuring guide. - Wash hands and put on clean gloves. -Apply topical ointments or creams and dress the wound as ordered. Protect surrounding skin as indicated with skin protectant. -Secure dressing. [NAME] with initials and date. -Discard disposable items and gloves into appropriate trash receptacle and wash hands. Review of the facility Enhanced Barrier Precautions dated 5/18/2024 showed: -EBP (gown and gloves) must be used for wounds and/or indwelling medical devices even if the resident is not known to be infected or colonized with a Multidrug-resistant Organism (MDRO). -Any wound care requiring a dressing including chronic wounds, but not limited to pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous stasis ulcers. -Make gowns and gloves available immediately near or outside of the resident's room. -Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). -Position a trash can inside the resident room and near the exit for discarding PPE after removal, prior to exit of the room or before providing care for another resident in the same room. -EBP are intended to be placed for the resident's entire stay in the facility or until resolution of the wound or discontinuation of the indwelling device that placed them at higher risk. 1. Review of Resident #1's admission Record showed he/she initially admitted on [DATE] and readmitted [DATE] with the following diagnoses: -Paraplegia (loss of movement of both legs and generally the lower trunk). -Pressure ulcer (PU-localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction) left buttock, stage III (full-thickness skin loss extending into the tissue beneath the skin, forming a small crater). -PU Right heel stage III. -PU Left heel stage IV (Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling). -Unspecified open wound right foot, subsequent encounter (any encounter after the active phase of treatment). -PU Right buttock stage IV. -Type II Diabetes Mellitus (DM-condition that affects the way the body processes blood sugar (glucose). -Acute Lymphoblastic Leukemia (a type of cancer of the blood and bone marrow that affects white blood cells) not having achieved remission. -Neuromuscular dysfunction of bladder (a disorder of urinary bladder control due to damage to the spinal cord or to the nerves supplying the bladder). Review of the resident's care plan dated 11/25/24 showed: -Limited physical mobility related to diagnosis of Paraplegia. -Area of trauma to the right buttock with potential to get worse due to non-compliance. -Pressure ulcer to left and right buttocks, and accidental puncture & laceration of skin, subcutaneously (the layer of tissue that underlies the skin) during other procedure. -Suprapubic indwelling catheter (a hollow flexible tube that is used to drain urine from the bladder and inserted through the abdominal wall into the bladder) with drainage bag (bag that collects urine) related to a Neurogenic bladder. Observation on 12/16/24, 12/17/24 and 12/18/24 throughout each day showed no EBP signage on the resident's door nor a cart for EBP supplies outside his/her room. During an interview on 12/18/24 at 1:53 P.M., Licensed Practical Nurse (LPN) B said there should be a sign on the resident's door for EBP due to the indwelling catheters and open wounds. Observation on 12/18/24 at 1:56 P.M., of the resident's wound care and dressing changes showed LPN B: -Used EBP of gown and gloves. -Opened wound supply cart in resident's room and removed items and placed on the bedside dresser without cleaning it or placing a clean barrier surface down. -Did not change gloves or wash/sanitize hands. -Cut old dressing off the resident's left foot and touched other objects in room without changing gloves or washing/sanitizing hands. -Another staff brought his/her name badge in and he/she put it in pocket under gown without changing gloves or washing/sanitizing hands. -Placed chux pad (a disposable, absorbent pad used to protect surfaces from incontinence) under the resident's feet and removed old dressing on right foot. -Did not change gloves or wash/sanitize hands. -Cleaned wounds on both resident's feet with wound cleanser and gauze. -Turned resident to right side to clean the left lateral foot better, with same gloves. -Change gloves sanitized hands and re-gloved. -Cut Xeroform (medicated Vaseline gauze) dressing to fit wound area and covered with an abdominal pad (ABD an extra thick primary or secondary dressing used for wounds) dressing on left foot. -Did not change gloves or wash/sanitize hands. -Looked through the wound supply cart for another ABD pad. -Did not change gloves or wash/sanitize hands. -Placed another ABD over top of foot for protection and wrapped with Kerlix wrap (a name brand of gauze wrap). -Changed gloves but did not wash/sanitize hands. -Removed dressing on right lateral foot near heel, two small areas and cleaned with wound cleanser and gauze. -Rubbed lower left leg, dry skin, and bottom of foot with A&D ointment (a Vaseline ointment with vitamins A and D added). -Removed gloves and put on new gloves without washing or sanitizing hands and went through cart again to find items. -Did not change gloves or wash/sanitize hands. -Placed Xeroform dressing on each area. -Searched through cart again for more Xeroform without changing gloves or washing/sanitizing hands. -Searched back through supply cart for an ABD pad without changing gloves or washing/sanitizing hands. -Placed ABD dressings over top and side of left foot. -Turned on call light with same gloves on to have another staff get more ABD pads and Kerlix wrap. -Did not change gloves or wash/sanitize hands before touching bed frame and gathering trash while waiting. -Wrapped self-adhesive ace wrap over the left foot dressing to keep in place still did not change gloves or wash/sanitize hands. -Opened Kerlix package and wrapped right foot, did not change gloves or wash/sanitize hands. -Applied A&D ointment on lower right leg. -Rolled resident to left side with the same gloves on. -Removed old buttocks dressings. -Did not change gloves or wash/sanitize hands. -Cleaned buttock area wounds with wound cleanser and gauze. -Did not change gloves or wash/sanitize hands -Went through cart drawer again to get a Q-Tip to measure depth of opened areas. -Did not change gloves or wash/sanitize hands. -Packed both holes with Dakin's solution (a type of hypochlorite solution that is made from bleach, water, and baking soda it kills most forms of bacteria and viruses and prevents germ growth in wounds) soaked Kerlix and under buttocks fold area. -Placed Xeroform over the small buttocks areas and covered with an ABD pad. -Gathered up supplies and assisted resident to turn to right side with same gloves on. -Removed old dressing and cleansed left buttocks areas with wound cleanser. -Did not change gloves or wash/sanitize hands. -Placed Xeroform over areas. -Turned on call light to get a clean brief for resident. -Did not change gloves or wash/sanitize hands. -Placed ABD pad over buttocks. -Placed clean brief under resident. -Did not change gloves or wash/sanitize hands. -Cleaned peri area with wet wipes. -Did not change gloves or wash/sanitize hands. -Readjusted resident's catheter tubing's (resident had a Foley catheter [a tube with retaining balloon passed through the urethra into the bladder to drain urine] and a Suprapubic catheter) and cleaned both catheter tubing's. -Did not change gloves or wash/sanitize hands. -Fastened the resident's brief pulled up the resident's pants. -Removed gloves, took scissors to the medication room and cleaned scissors with bleach wipes and washed hands. During an interview on 12/19/24 at 10:49 A.M., the wound company Nurse Practitioner said the resident: -Had a history of leukemia and Osteomyelitis (bone infection usually caused by bacteria). -Had gone through multiple rounds of IV antibiotics that had not helped in the wound healing process. -Refused to be admitted to a hospice (end of life) program. -Refused Nephrostomy (a passage way maintained by a thin tube placed through the back into the kidney to temporarily drain urine that is blocked) tubes to help with healing. -Wounds were healing and doing much better then when he/she first started seeing this resident. During an interview on 12/20/24 at 9:57 A.M., Certified Nursing Assistant (CNA) M said when doing catheter care: -Washed his/her hands and gown and glove up. -Clean the catheter tubing with a wet wipe starting at the top insertion area and wipe down several inches. -When finished remove gloves and wash hands. -Change gloves and wash/sanitize hands when going from a dirty area to a clean area. -The nurse us

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #9) out of seven sampled residents, was free from abuse when on 8/6/24 Licensed Practical Nurse (LPN) G was verbally and physically abusive. LPN G called the resident names, pulled the resident's hair and kicked the resident while the resident was laying on a mattress on the floor which resulted in a contusion to the resident's right hip and pain to his/her left knee. The resident was heard yelling and crying during the altercation and needed an injection to calm his/her agitation after the incident. Multiple staff witnessed the altercation and did not intervene. The facility census was 109 residents. The Administrator was notified on 8/29/24 at 11:29 A.M. of an Immediate Jeopardy (IJ) which began on 8/6/24. The IJ was removed on 8/30/24, as confirmed by surveyor onsite verification. Review of the facility's Abuse and Neglect Policy, reviewed and revised on 6/12/24, showed: -Abuse was defined as a willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain, or mental anguish. -Physical abuse included handling a resident with any more force than was reasonable for a resident's proper control, treatment, or management. -Mistreatment was inappropriate treatment or exploitation of a resident. 1. Review of Resident #9's undated Face Sheet, showed the resident admitted to the facility on [DATE] with the following diagnoses: -Major depressive disorder (a mental health condition that caused a persistently low or depressed mood and a loss of interest in activities that once brought joy). -Anxiety disorder (a condition in which a person had excessive worry and feelings of fear, dread, and uneasiness). -Post-traumatic stress disorder (PTSD-a mental health disorder that can develop after a person is exposed to a traumatic event). -Bipolar disorder (a mental health condition characterized by extreme mood swings that include emotional highs and lows). -Schizophrenia (a chronic and severe mental health disorder that affects how a person thinks, feels and behaves). -Intermittent explosive disorder (a mental health condition characterized by sudden, intense outbursts of anger or aggression). -Moderate intellectual ability. Review of the resident's admission Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 5/20/24, showed he/she was cognitively intact. Review of the resident's care plan, dated 6/28/24, showed: -He/she had a history of being abused as a child and PTSD with no known triggers. -The environment should be free from actual or perceived judgement and physical or perceived danger. -He/She was at risk for displaying signs and symptoms of bipolar disorder, displaying high and low emotions. Interventions included: helping him/her to stay on task; calm redirection; decreasing stimulation; using a firm and calm approach; avoiding getting in a power struggle; keeping his/her routine consistent. -He/She was at risk for displaying signs and symptoms of schizophrenia. Interventions included avoiding arguing or getting defensive with him/her; being respectful, non-judgmental and honest with him/her; respecting his/her personal space. -He/She had a history of behavioral challenges requiring protective oversight, such as being physically aggressive toward staff and peers, frequent elopements, obsessing about things, impulsive thoughts and actions, disordered thoughts. Interventions included: CALM (a communication strategy often used to de-escalate tense or potentially volatile situations) technique if needed; plans to change inappropriate behavior; 1:1 observation; pharmaceutical interventions as needed. -He/She had a long history of mental illness. He/She had a low tolerance for restrictions, becoming physically assaultive and physical and verbal aggressions. Interventions included: psychiatric management and counseling if needed; behavior modification programs as needed; interdisciplinary team and guardian involvement. -He/She had a long history of PTSD and functional impairment from symptoms, including aggressiveness and self-destructive behavior. Interventions included: encouraging the resident to express emotions in a safe environment, assessing the resident for suicidal or homicidal ideation's and ensuring the safety of the resident and others; administering medications as appropriate; assessing for anxiety. Review of the resident's Medication Administration Record (MAR), dated 8/6/24, showed: -At 2:15 A.M., he/she was given an injection of Olanzapine (a medication used to treat conditions such as schizophrenia and bipolar disorder) as ordered 10 milligrams intramuscularly as needed (PRN) for three times a day for increased agitation. Review of the resident's progress note, dated 8/6/24 at 3:45 A.M., showed: -LPN F notified by staff the resident was having a behavior. Upon arrival, he/she noted the resident throwing papers and picking up trash cans to throw at staff. -LPN F notified Certified Medication Technician (CMT) C (who was the house supervisor) for assistance with getting a PRN (as needed) medication and syringe. -While preparing the PRN medication, the resident was approached by LPN G and was told to go to his/her room. -The resident entered his/her room and LPN G followed him/her into the room. -LPN F heard the resident say stop kicking me, and stop pulling my hair. -LPN F entered the resident's room with other staff and observed the resident sitting on the bed with LPN G standing over him/her. -LPN F asked what was going on and neither LPN G or the resident answered. -LPN F asked the resident for permission to administer the PRN injection and the resident was cooperative. The PRN medication was not effective. -The resident then threw a trash can at staff into the hallway and started kicking the wall, kicking the staff, and using racial slurs. -Staff entered the room to initiate a Code [NAME] (a facility wide alert that there is a situation involving a resident who was exhibiting violent or potentially dangerous behavior), and a CALM hold and LPN G stated, No, don't call it. I got this. I got him/her by myself. -LPN F then observed LPN G kick the resident. -LPN F intervened, separated the resident, made sure he/she was safe and asked LPN G to leave the unit. -LPN G did not leave the unit immediately. -LPN F then notified the administrator and Director of Nursing (DON) and was instructed to call the Police Department (PD). -The resident's range of motion and vital signs were at baseline and the resident denied pain or discomfort. -PD was notified twice before arriving at the facility. Review of the resident's hospital visit summary, dated 8/6/24, showed he/she was seen related to contusion (bruise) of his/her right hip and left knee pain related to a physical assault. Review of the resident's progress note, dated 8/6/24 at 10:05 A.M., showed: -Resident returned from the hospital and escorted by staff 1:1 to the social worker's office. -He/she had a pleasant attitude and stated he/she was feeling better. -When asked how he/she was feeling about the incident, he/she stated he/she was not affected unless the nurse (LPN G) returned. -He/She did not want that nurse on his/her unit. Administrator was notified. Review of the facility investigation, dated 8/6/24, showed: -The incident was alleged abuse. -There was one resident witness, Resident #32, the resident's roommate. -The incident involved Resident #9 and one other staff member. -The resident was unable to identify the staff person, just that it was a staff person with black hair. -Initially he/she stated the staff person slapped him/her and he/she fell to the bed; he/she then stated he/she was pushed and dragged by his/her arms out of the bed onto his/her knees. -Staff reported to the DON the resident had been kicked and hair pulled by LPN G. -Two employees reported they witnessed the resident being abused by kicking and hair pulling. -The DON instructed the staff to call Kansas City Police Department (KCPD). -An assessment of the resident was completed by the DON when he/she arrived at the facility. -A skin assessment was done by staff and no discoloration or injury was noted to face or knees. -The resident was sent to the hospital for evaluation due to increased behaviors, destruction of property, and increased physical aggression toward staff and peers. -LPN G was detained by KCPD and taken to jail. -LPN G was suspended pending investigation. -The resident stated he/she was kicked, hair pulled, and dragged over the floor by LPN G, but his/her story was convoluted. He/She remained on 1:1 observation. Review of the resident's Psychosocial Post-Incident Impact Questionnaire, dated 8/6/24, showed: -The resident said he/she was not trying to hurt him/herself or anyone; the nurse was trying to hurt him/her. -He/She was only biting him/herself so staff would not come near him/her and he/she only hit the nurse's hand. -Walking down the hallway, pacing back and forth, and walking around the dining area helps him/her to calm and it worked if the staff would leave him/her alone. -He/She did not feel like he/she could have done anything differently, because the nurse wouldn't listen to him/her or let him/her out of his/her room and made him/her cry really hard. -He/She felt safe and was ok as long as she (the nurse) was gone. -He/She wanted to press charges against the staff member who assaulted him/her. Review of the resident's skin evaluation, dated 8/6/24 at 10:49 A.M., showed: -The resident had a new skin issue located on his/her right lateral thigh, which was bruising. Review of the resident's undated written statement showed: -This bitch pulled him/her to the ground off his/her bed and put his/her foot on his/her back, even though he/she told him/her to get his/her foot off of him/her. -Then he/she (the staff person) said he/she would bitch-slap him/her and he/she would fuck me up. Review of Agency Certified Nursing Assistant (CNA) J's written witness statement, dated 8/6/24, showed: -He/She saw LPN G kicking, hitting, and being verbally abusive toward Resident #9. LPN G also pulled the resident's hair. -The resident started crying and was yelling to the staff to stop beating on him/her. -When Agency LPN F heard what was going on, he/she immediately told LPN G to leave the unit. -LPN G refused to leave the unit and made the statement, I love fucking with him/her. During an interview on 8/7/24 at 10:00 A.M., Agency CNA J said: -He/She had never worked with LPN G before. -When the incident took place, LPN G was not suppose to be working on that unit. -The resident was calling LPN G names. -The resident was having a behavior and getting agitated. He/She has the mentality of a five-year old. -The staff put on gloves in case they had to do a safety hold to give the resident a injection. -LPN G came over from another unit, but did not offer to help the staff with the resident, just started calling the resident names. -The resident was only combative with LPN G and tried to kick him/her. The resident was on a mattress on the floor. -LPN G was standing over the resident kicking him/her. He/She would walk up on the resident, kick him/her and back up, and kept doing it. -The staff were going to put the resident in a safety hold and LPN G said, No, I got it, get out! -As soon as the staff walked out, he/she heard the resident shouting at LPN G to stop hitting me and stop pulling my hair and start crying. He/She did not see LPN G pulling the resident's hair. All of the staff heard this. -Agency LPN F told the staff what to say about this incident so he/she would not get in trouble, but he/she was the resident's nurse and should have stood up to LPN G. He/She sat there and listened to LPN G abuse the resident and did nothing. -LPN G was going to do what he/she was going to do with the resident, even if the staff had stepped between them. -The corporate staffing agency did not offer any deescalation or CALM training. A lot of staff do not know how to work with mental health patients. -The staff could not touch LPN G to stop him/her or it would have been assault. All they could do was be the eyes and ears of the situation. Review of LPN G's written employee statement, dated 8/8/24, showed: -The resident was standing in the hallway talking and he/she told the resident to come on and go to his/her room. The resident then went to his/her room. -He/She told the resident he/she was going to sit with him/her for a little while to give everyone else a break because they had been dealing with him/her for a while. -The resident told him/her to get the fuck out and he/she said no, that he/she was going to be with him/her for a while. -The resident said, I'm getting out of here and you can't stop me and acted like he/she was going to go past him/her, but didn't and went to the wall where the head of the bed was. -The resident started slapping and kicking the wall. -He/She asked the resident to stop and the resident said no. -He/She asked him/her again to stop because everyone was going to sleep. -The resident said, Fuck you, bitch, no! -He/She said this was the last time he/she was going to ask and he/she was going to count to three and assist the resident to stop his/her actions. -The resident continued to kick the wall, which made a hole in the wall. -He/She went to the resident and put his/her hands on the resident's shoulders and pulled him/her from the wall. -The resident pulled away and flopped down on his/her mattress and said, Don't you push me again! -He/She said he/she didn't push him/her, that the resident broke from him/her. -The resident said, Get the fuck away, bitch, I'll kill you! He/She leaned back on the mattress and raised his/her legs and started kicking the wall where he/she had already been kicking it. -He/She put his/her hand on the resident's head and said to stop it and go to bed. -The resident laid down on his/her bed and grabbed the top of his/her head and said, You bitch, you pulled my hair. -He/She told the resident he/she did not pull his/her hair and the resident then said he/she didn't care and began kicking the wall again. -He/She asked the aides to come in the room and move the mattress and while waiting for them, the resident called him/her racial epithets. -The aides came in the room and helped him/her move the mattress. -The resident then began to kick him/her several times, as well as kick the night stand and the wall -He/She told the resident to quit kicking him/her and the resident continued to attempt to kick him/her. -He/She used his/her foot to block the kicks. -The resident continued to call him/her a bitch and yelled, You are abusing me! -He/She said, How am I abusing you? I am blocking you from kicking me! -The other staff were outside the room. The resident was still kicking at him/her. -The other nurse came in the room with a PRN injection and an oral medication. -The resident was given the injection and the resident was swatting at the staff and initially refused. Staff checked the resident's mouth to make sure he/she swallowed. -The resident flopped back down on the mattress and the staff left the room. -The resident continued to kick at the wall and yelled for him/her to give her the blankets. -He/She got the blanket for the resident and the resident threw it right back at him/her. -Nobody came into the room after that. He/She gave the resident the blanket back and turned off the light, at the resident's request. -He/She did not see anyone come in the room when the resident was yelling that he/she was being abused. -The resident also called him/her a pussy, and he/she replied, If I am a pussy, then you are a pussy. -He/She was in no way trying to hurt the resident, just trying to prevent him/her from hurting him/herself and prevent him/her from damaging property. During an interview on 8/7/24 at 10:30 A.M., LPN G said: -That night, the resident had just gotten back from being sent out to the hospital for behaviors. -When the resident was brought back, he/she walked him/her back to the unit. A skin assessment was not done on the resident at that time. -Two hours later, the resident was having a behavior and the staff were at their wits end from dealing with him/her. -He/She thought he/she would try to help out and give the other staff some relief, since the resident can wear out the 1:1 observation staff; the resident had a 1:1 at the time. -He/She said, 'I'll give you guys a break. -He/She was dealing with the resident and the resident was calling him/her names and racial names. The resident said, Fuck you, you stupid (racial slur), I'm going to fucking kill you. -He/She told the resident to go to his/her mattress and the resident said no. -The resident went to the wall and started hitting it with his/her hand and kicking it. -He/She told the resident to stop it, that it was too early in the morning and people were trying to sleep. -The resident said no and kept calling him/her names and saying, fuck you and calling him/her the N word. -He/She grabbed the resident's upper arms to turn him/her away from the wall so he/she could stop kicking and punching the wall. -When he/she turned the resident, the resident flopped down on the mattress and said, Don't you ever push me again. -He/She told the resident he/she didn't push him/her. -The resident continued kicking, so the staff moved the mattress. -Before they moved the mattress, he/she put his/her hand on the top of the resident's head and told him/her to stop again. -The resident then said, Don't you ever fucking pull my hair! That is when he/she had the staff help him/her move the mattress. -They didn't call a Code [NAME] because anyone who would have responded were already there. -The staff were in and out and moved the mattress to the center of the room, so the resident could not kick the walls anymore, so the resident started kicking at him/her. -The resident's kicking made contact with him/her and also with the nightstand. He/She used his/her feet to block the resident's kicks from him/her and the nightstand. He/She never made any contact with the resident's hip or thigh. -The resident kept saying, You're abusing me, and he/she said, How can I be abusing you when you are kicking me? -He/She moved the nightstand. -Nobody intervened to help him/her or stop the kicking. -Agency LPN F gave the resident a injection and an oral medication and the resident stood against the wall. -The resident stopped trying to kick him/her and asked for a cover, because he/she was going to go to bed, and asked for the light to be turned off. -He/She turned the light off and stayed for a few more minutes and then left. -He/She 100% thought the staff misconstrued what they saw. -At the end of the shift, the police came. He/She talked to the police officers and was then arrested for assault. -The police said they were going by what the others had said. Review of CNA F's written witness statement, dated 8/6/24, showed: -At about 2:15 A.M., the resident was having a behavior. -LPN G from 3 North came over to see what the problem was. -While he/she was charting, he/she then heard the resident say, Stop kicking me! -He/She got up to see what was going on. -Agency LPN F came up to handle the situation and give the resident medication. -He/She saw LPN G kick the resident once. During an interview on 8/9/24 at 11:40 A.M., CNA F said: -He/She was not the only one in the resident room. He/She was in the doorway. -He/She saw LPN G kick the resident after the resident kicked him/her. -It was possible LPN G was blocking the resident from kicking him/her with his/her foot. -He/She did not see LPN G pull the resident's hair. -He/She did hear LPN G call the resident a pussy. -Nobody stopped LPN G, but he/she felt he/she should have stepped between them. -The staff had CALM training. They were supposed to step between them. He/She knew that now. -LPN G should not have kicked back at the resident; that was abuse. -He/She assumed the charge nurse should have handled the situation and he/she also felt LPN G should have known how to handle the situation. -They were all nurses and should know what to do. Review of Agency CNA G's written witness statement, dated 8/6/24, showed: -On 8/5/24 at around 10:30 P.M., he/she was told to do 1:1 observation with the resident, which he/she had previously done in the past. -The resident was calm and they talked about correcting behaviors and forgiveness, and happy memories he/she had. -Around 12:30 A.M., he/she noticed a change in the resident's behavior, he/she starting pacing and getting agitated, and he/she notified the other CNA. -Around 1:00 A.M., he/she let the other CNA take over so he/she could help on 3 North. He/She told the nurse he/she was there to help and take a break from the resident, so he/she could be with a familiar face for a while. -He/She came back to 3 South at 2:00 A.M. and the resident was still pacing. -Around 3:00 A.M., LPN G came up and told Agency LPN F he/she had this. They discussed calling a Code [NAME] and LPN G said the resident did this all the time, he/she had this. -LPN G made the resident go in his/her room and he/she started hearing the resident screaming, You are pulling my hair! Stop kicking me! -He/She saw LPN G kick the resident. -He/She asked if this was protocol and LPN G said, He/She always does this. -They then had a kicking match. -The nurse came in and said he/she had the resident's medication. -He/She did not know whether to help hold the resident or not, because he/she was shocked. -After the resident got his/her injection, LPN G was cool and he/she left and asked what to do. -He/She was told when the resident woke up, ask him/her if he/she was ok. -The staff stated this situation was not ok and he/she needed to report what he/she had seen and heard. -He/She did not confront LPN G because he/she was scared. -He/She told the resident, when he/she awakened at 4:30 A.M. if he/she was not ok to let him/her know. -The resident said the nurse hurt him/her and he/she asked a staff person to call 911. During an interview on 8/9/24 at 11:30 A.M., Agency CNA G said: -He/She was not a regular employee at the facility and had only worked there 3 or 4 times previously. -He/She had done 1:1 observation of the resident when he/she worked. -He/She did not know the other staff's names. -He/She was in the room when the incident happened for some of the time. Other staff were in and out of the room. -The resident had been pacing around and was agitated and said the staff were going to beat him/her if he/she did not go to sleep. -He/She heard a lot of banging in the room. The resident was kicking the wall and the dresser and kicked LPN G in the knee. -The resident took off his/her shoes and threw one at the wall and one at LPN G, who threw the shoe back. -The resident was calling LPN G the N word. -LPN G called the resident a pussy. -He/She did not see LPN G pull the resident's hair. He/She saw the resident kick LPN G and LPN G kick the resident back. -Agency LPN F told LPN G he/she had it from there and LPN G refused to leave. -The resident had not been combative before or when he/she came back from the hospital. -Nobody stepped in between LPN G and the resident. Everyone was afraid. He/She was afraid he/she would get beat up. -When LPN G threw the shoe, he/she covered his/her eyes, but told him/her he/she was going to call the police. -When the incident happened, he/she was by the door of the room, about two feet away. -When he/she saw LPN G and the resident's physical aggression, he/she put his/her hand over his/her mouth and slid down the wall and asked, Is this protocol? One of the other staff said no, this wasn't supposed to be happening. LPN F also said no. -Agency LPN F coached everyone that they should write down what they witnessed and heard; if they felt like something was wrong, it was wrong. -Agency LPN F said he/she was not going to put his/her license on the line, because he/she told LPN G to stop and he/she didn't. -The police were called, and while they were waiting for the police to arrive, he/she told LPN G the police had been called, because the resident did not feel he/she had protected him/her. -LPN G said, Ain't nobody can protect him/her from me; not even his/her family wants him/her. -He/She felt the other staff knew protocol, so they should have stepped in, but did not because they were afraid of LPN G. Review of CNA I's written witness statement, dated 8/6/24, showed: -At about 2:15 A.M., the resident began to have a behavior. -They called the nurse to come to 3 South, and he/came, but did not have his/her medication key, so he/she called LPN G to come over with a medication. -While Agency LPN F was preparing the medication, LPN G told the resident to go to his/her room. -The resident did not want to go to his/her room, but he/she did. -Other staff came with Agency LPN F to go in the room. -He/She was standing outside the door. Agency LPN F wanted to call a Code Green, but LPN G said he/she had it. -He/She heard the resident say to stop kicking him/her and also to stop pulling his/her hair. -He/She went in to see what happened. LPN G was pushing the nightstand out of the room, so he/she took the nightstand, because the resident was kicking it. The resident was given his/her medication and the nurses left, and then the resident went to sleep. Review of CMT C's written witness statement, dated 8/6/24, showed: -He/She was called to bring medication to the unit. -The nurse on 3 South (Agency LPN F) needed needles for an injection. -The resident was having a behavior. -He/She asked the nurse on 3 North (LPN G) to unlock the cart and hand him/her a needle. -LPN G asked why he/she needed the needle and he/she replied that the resident was having a behavior. -LPN G stated he/she was going to go over there and be nosey, and left. -He/She was getting pain medications for other residents at the time. -He/She arrived on 3 South and the resident was in his/her room with LPN G. -He/She heard the resident saying to leave him/her alone and the nurse calling him/her a pussy and said, shut up, pussy bitch, kick me! -LPN G kept antagonizing the resident. -The resident kicked the LPN G by this time. -Other people started coming in the room. -Agency LPN F asked LPN G to leave the unit. -LPN G said, No, I got this. -He/She was in shock and tried to intervene, but LPN G grabbed the resident by his/her hair and kicked him/her several times. Every time the resident kicked him/her, LPN G kicked him/her back. -He/She was confused and had never experienced something like this before. During a interview on 8/12/24 at 10:00 A.M., CMT C said: -He/She got a call from Agency LPN F on 3 South that he/she needed a medication, but did not have any needles. -He/She asked LPN G if he/she had any needles on his/her cart. -LPN G asked who the injection was for, and he/she told him/her. -LPN G said he/she was about to go be nosy and started to head over to that unit. -By the time he/she got to the unit, LPN G was already in the room. -Agency LPN F was sitting down and he/she handed him/her the medication. -Only LPN G and the resident were in the resident's room. -Everyone else was standing around and looking around. -LPN G was not the nurse caring for the resident. -There was not a Code [NAME] called. He/She could not see what was going on, but heard the resident yelling at LPN G to leave him/her alone. -If the resident was having a behavior, he/she was known to tell staff to leave him/her alone. -LPN G called the resident a punk bitch, which was going to escalate the situation and make it worse. -When Agency LPN F was trying to give the resident his/her injection, the resident was saying to leave him/her alone. -The staff told the resident the medication was going to help him/her to try to calm down. -LPN G told the resident he/she was going to take the shot and the resident said he/she was going to call the administrator. LPN G told him/her nobody was going to save him/her. -Before he/she was given the injection, the resident had said to stop kicking him/her. The resident had also picked up the trash can and thrown it at staff, and was kicking his/her foot and saying he/she did not want the medication. -LPN G said, I dare you to kick me, and the resident kicked him/her and he/she kicked back, two to three times. These were actual kicks, not blocks. -He/She heard the resident said LPN G had pulled his/her hair, and he/she saw and it was definitely a pull. -He/She then let Agency LPN F know, because he/she had already left the room. -He/She did not know the procedure that he/she could touch a staff person to stop the situation. He/She did not want to start a fight in the room. During an interview on 8/7/24 at 11:35 A.M., the Social Worker said: -The resident had the mind of an 8-year-old and had trouble processing information. During an interview on 8/7/24 at 11:40 A.M., the resident said: -He/She kicked LPN G because he/she kicking him/her. -He/She told all the staff about it. He/She was unable state which staff he/she told. -He/She had scratches on his/her knee, because all of the staff pulled him/her on the ground. -He/She thought LPN G was very rude to him/her and nicer to other residents, which made him/her feel uncomfortable and sad. -LPN G pulled his/her hair and made him/her cry. -He/She didn't know why LPN G pulled his/her hair. -His/Her mattress was on the floor because he/she broke the footboard. -He/She called LPN G a bitch, bullshit and the N word and LPN cursed back at him/her. -LPN G called him/her names and said, Get your fat pussy up! -LPN G dragged him/her on the floor and pulled his/her arms. He/She did that all the time. -He/She tried to go tell someone and LPN G blocked him/her from going out the door. -There were some other staff members involved. He/She didn't know the names. -He/She said when he/she had a behavior, the staff were not supposed to stop it, they were supposed to call the social worker or the Administrator, but they never did. -He/She said he/she had two bruises from this incident and pointed at his/her hip. -He/She wanted to press charges on LPN G. He/She told the police he/she didn't know why LPN G would act that way. Observation of the resident on 8/7/24 at 11:40 A.M. showed the resident had a quarter-sized discolored green, yellow and purple area on his/her right hip that he/she said that it was from this incident with LPN G. The skin was not broken. Review of Resident #32's MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 8/9/24 at 12:20 P.M., Resident #32 said: -He/She was the resident's current roommate. -He/She kept his/her privacy curtain open. -He/She heard someone call Resident #9 a pussy. During an interview on 8/29/24 at 11:00 A.M., Agency LPN F said: -The r

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one sampled resident (Resident #23) was free from physical abuse from facility staff and other residents out of six sampled residents, when on 4/14/24 11:00 A.M. Housekeeper B used physical force to take the resident from his/her feet to the ground. While on his/her back, Resident #16 ran up the hall and kicked three times at Resident #23 with no staff intervention and then grabbed Resident #23's right arm. CNA D, Dietary Aide A, and Housekeeper B drug the resident across the hallway, flipped the resident over and had the resident's arms outstretched with Housekeeper B on the right arm, CNA A had the resident's left arm, Dietary Aide A had his/her knee on the resident's lower back buttocks area with the resident on his/her stomach. LPN A and CMT A watched the entire events and did not intervene. When the house manager showed up, CNA D, Dietary Aide A and Housekeeper B released the resident. Hall Monitor C used his/her foot to nudge the resident to get up. The resident stood up on his/her own, Hall Monitor C grabbed the resident by the collar of the resident's shirt and had another hand on the resident's arm, then walked the resident to his/her room. Hall Monitor C shoved the resident into his/her room by using his/her forearm pushing into the resident's neck. The employees remained on shift and at 12:20 P.M. Hall Monitor C walked toward Resident #23 and began punching the resident multiple times forcing the resident backwards. Hall Monitor C took the resident to the ground and continued to slap the resident. The resident's arms were flailing when Hall Monitor C grabbed the resident by the torso and arms and drug the resident into a resident room. LPN A, Dietary Aide A, Housekeeper B and CMT C were all present, having witnessed the entire event and did not intervene. No staff called the manager on duty to report the events. The resident reported fear of the facility staff. The events resulted in the bruising of resident left eye and chest soreness. The facility census was 109 residents. The Administrator was notified on 4/19/24 at 1:30 P.M. of an Immediate Jeopardy (IJ) which began on 4/14/24. The IJ was removed on 4/19/24, as confirmed by surveyor onsite verification. Review of the facility's policy titled Abuse and Neglect Policy dated 1/5/23 showed: -Physical abuse was purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or inhumane way. -Physical abuse included handling a resident with anymore force than reasonable for a resident's proper control, treatment, or management. -Physical abuse also included, but was not limited to, hitting, slapping, punching, biting, and kicking. -Physical abuse also included corporal punishment, which meant physical punishment used to correct or control behavior. -Mistreatment, neglect, or abuse of residents was strictly prohibited by the facility. -The facility was committed to protecting the residents from abuse by anyone including, but not limited to, facility staff, other residents. 1. Review of Resident #23's face sheet showed he/she admitted to the facility with the following diagnoses: -Schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). -Anxiety Disorder (any group of mental conditions characterized by excessive fear of or apprehension about real or perceived threats). -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Paranoid Schizophrenia (a pattern of behavior where a person feels distrustful and suspicious of other people and acts accordingly, delusions and hallucinations are the two symptoms that can involve paranoia). -Major Depressive Disorder (MDD- a mental health disorder characterized by persistently depressed mood or loss of interest in activities, causing significant impairment in daily life). -Post-Traumatic Stress Disorder (PTSD- a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Review of Resident #23's Quarterly Minimum Data Set (MDS- a federally mandated assessment instrument completed by facility staff for care planning), dated 2/8/24, showed he/she was cognitively intact. Review of Resident #23's care plan, dated 4/15/24, showed: -The resident had a history of PTSD which affected his/her behavioral symptoms and could flare-up without a known trigger with the following interventions: --Assess resident for suicidal or homicidal ideations to ensure safety of resident and others. --Encourage the resident to express his/her emotions in a secure setting. --Allow the resident the freedom to acknowledge his/her feelings and release any repressed emotions that may be exacerbating his/her distress. --Establish trust with the resident. --Provide a calming and reassuring environment. -The resident had a history of behavioral challenges that required protective oversight in a secure setting with the outcome that the resident would not receive any serious injuries due to his/her behaviors with the following interventions: --Use Crisis Assessment Linkage and Management (CALM) techniques as needed. --Use one-to-one (1:1- a term used by healthcare support workers whose role is to provide one to one nursing or observation care to an individual resident for a period of time) monitoring as needed. -On 4/14/24 the resident had been placed on a 1:1 for behavioral monitoring related to auditory hallucinations (sensory perceptions of hearing noises without external stimulus), in which he/she became physically aggressive with staff and peer and a Code [NAME] (a behavioral emergency and/or incident needing physical support and presence when an individual poses a threat to himself/herself or others) had been called. -On 4/15/24 the resident had been sent to the local hospital's emergency room for evaluation and treatment after being assaulted by peer/staff the day before. Review of Resident #16's face sheet showed he/she had admitted to the facility with the following diagnoses: -Schizoaffective Disorder (a chronic mental health condition characterized primarily by symptoms of schizophrenia, such as hallucinations or delusions, and symptoms of a mood disorder, such as mania and depression). -Restlessness and Agitation. -Paranoid Schizophrenia. -Intermittent Explosive Disorder (repeated, sudden bouts of impulsive, aggressive, violent behavior or angry verbal outbursts). -Attention-Deficit Hyperactivity Disorder (ADHD- a chronic condition including attention difficulty, hyperactivity, and impulsiveness). -Personal History of Traumatic Brain Injury (TBI- brain dysfunction caused by an outside source). Review of Resident #16's Quarterly MDS, dated [DATE], showed he/she was cognitively intact. Review of Resident #16's care plan, dated 4/15/24, showed: -The resident had a history of behavioral challenges that required protective oversight in a secure setting with the desired outcome that the resident would not harm self or others with the following interventions: --Provide physical and verbal cues to alleviate anxiety. --Give positive feedback. --Assist in verbalization of source of agitation. --When the resident became agitated the staff were to intervene before agitation escalated, guide the resident away from source of distress, engage calmly in conversation, if the response was aggressive then staff were to walk calmly away and approach the resident later. -The resident had a history of physical/verbal aggression towards others and self, attention seeking, and inappropriate behaviors with a history of Code Greens needing to be called. -The resident liked to insert himself/herself in situations when he/she did not need to be involved. -On 4/14/24 the resident was involved in physical aggression towards a peer after inserting himself/herself in matters not pertaining to him/her. Observation of the facility camera footage of the first incident, dated 4/15/24 at 11:24 A.M., showed: -The footage was a recording of the camera footage and not the actual recording. -No date or time could be seen in this video. -The recording was six minutes and 33 seconds long. -The footage took place in a hall on the unit close to the dining room. -At two minutes and 45 seconds: --LPN A was talking with Resident #23 in the hallway. --CMT A was standing at his/her medication cart. --Housekeeper B and CNA D were in the hallway. --Dietary Aide A was at the end of the hallway, sitting on a chair. --Resident #23 was attempting to leave the dining room and entered the hallway. --Resident #23 had attempted to push through CMT A and Housekeeper B to head into his/her room. -- Housekeeper B placed his/her left arm underneath Resident #23's left arm and placed his/her left forearm and hand on Resident #23's upper chest. --Resident #23 attempted to continue down the hall. --Housekeeper B then placed his/her right forearm and hand underneath Resident #23's right arm and onto Resident #23's upper chest. --Housekeeper B performed a one person take down of Resident #23, slamming Resident #23 on the ground. --LPN A, CMT A, and CNA D remained in the hallway and observed the take down. --Dietary Aide A remained at the end of the hall sitting in a chair. --Housekeeper B was attempting to keep Resident #23 on the floor. --Resident #23 was flailing and kicking his/her legs in attempt to get released from Housekeeper B's hold. --LPN A, CMT A, and CNA D continued to observe Resident #23 and Housekeeper B struggling without intervention. --LPN A and CMT A remained in the hallway observing the altercation. --Dietary Aide A remained at the end of the hall sitting in a chair. --Resident #16 started to run down the hallway towards the altercation. --Resident #16 started to kick Resident #23 while Resident #23 remained on the ground. No staff intervened. --Resident #23's left arm and leg become visible on the screen. --Housekeeper B remained to have his/her hands on Resident #23's body. --Resident #16 walked back towards the altercation. --Resident #23 remained on the floor and was kicking his/her legs toward Housekeeper B. --Resident #23 became blocked by residents again. --LPN A was calling out to Dietary Aide A and pointing down at the altercation. --Dietary Aide A got up from his/her chair and started to run down the hall. --Dietary Aide A continued to run down the hall towards the altercation. --Housekeeper B had a hold of some part of Resident #23's lower body and was beginning to drag Resident #23 towards the other side of the hallway. --CNA D had a hold of Resident #23's right arm, but did not look like he/she was pulling on Resident #23. --Resident #23 was positioned on his/her left side. --Housekeeper B remained to have a hold of Resident #23's lower body and dragged Resident #23 to the other side of the hall. --CNA D remained to have a hold of Resident #23's right arm. --Resident #16 had a hold of Resident #23's left arm. No staff intervened. --LPN A and CMT A remained in the hallway. --Dietary Aide A was still running down the hall. --Resident #16 let go of Resident #23's left arm. --Dietary Aide A reached the resident and bent down. --Housekeeper B continued to have a hold on Resident #23's lower body. --CNA D continued to have a hold on Resident #23's right arm. --Resident #23's body is mostly blocked and could not be seen on camera except for a part of his/her right arm and hand. --Resident #23's right arm was outstretched with his/her right-hand facing palm side down on the floor. --Housekeeper B and CNA D were still bent over Resident #23, but hand positions could not be seen. --Housekeeper B's right hand was holding Resident 23's right wrist. --CNA D was holding an unidentifiable part of Resident #23's body. --LPN A and CMT A remained in the hallway without touching Resident #23 and did not intervene --Resident #23's head and left arm became visible on camera. --CNA D was holding a part of Resident #23's left lower arm. --Dietary Aide A was crouched over Resident #23's body. --Resident #23 was lying on his/her stomach. --CNA D was holding Resident #23's left wrist and had his/her knee on top of Resident #23's elbow. --Dietary Aide A was crouching over the back part of Resident #23's body. --Housekeeper B was crouching over Resident #23's right side. --Resident #23 remained on his/her stomach. --Housekeeper B had a hold of Resident #23's right wrist/hand. --Dietary Aide A was still crouching over the back part of Resident #23's back side. --Resident #23 remained on his/her stomach with his/her right arm outstretched. --CNA D was crouched over Resident #23's left arm, but where he/she was holding Resident #23 was not visible on camera. --Dietary Aide A appeared to be holing a part of Resident #23's back side. --LPN A and CMT A were by the medication cart and appeared to be talking with each other. --Resident #23 remained on his/her stomach being held down by Housekeeper B, Dietary Aide A, and CNA D. --Housekeeper B had a hold of Resident #23's wrist/hand. --Dietary Aide A remained holding Resident #23's lower back/buttocks area. --CNA D had remained holding Resident #23's left lower arm. --LPN A and CMT A remained at the medication cart. --The Activities Director who was also the Manager on Duty at that time appeared at the top of the frame and started to walk down the hallway towards Resident #23 and the staff. --Resident #23 remained on the floor. --Housekeeper B, Dietary Aide A, and CNA D remained a hold of Resident #23 in the same positions as before. --CMT A was waving the Activities Director down the hall. --LPN A remained at the medication cart. --The Activities Director continued down the hall. --Resident #23 remained on the floor. --Housekeeper B, Dietary Aide A, and CNA D remained a hold of Resident #23 in the same positions as before. --LPN A bent down and appeared to be picking up something off the floor next to Resident #23. --The Activities Director continued to walk down the hall. --CMT A returned to the medication cart. --Resident #23 remained on the floor. --Housekeeper B, Dietary Aide A, and CNA D remained a hold of Resident #23 in the same positions as before. --LPN A and CMT A remained at the medication cart. --Hall Monitor C came into the frame at the top of the hall. --The Activities Director reached Resident #23 and the staff. --Resident #23 remained on the floor. --The Activities Director appeared to be discussing the incident with LPN A, CMT A, Housekeeper B, Dietary Aide A, and CNA D. --Housekeeper B, Dietary Aide A, and CNA D remained a hold of Resident #23 in the same positions as before. --Hall Monitor C continued down the hall. --Hall Monitor C reached Resident #23 and the staff. --CNA D released his/her hold of Resident #23's left arm and started to walk up the hall. --Housekeeper B released his/her hold of Resident #23's right wrist and started to walk up the hall. -- Dietary Aide A released Resident #23's lower back/buttocks area and started to walk up the hall. --Hall Monitor C nudged Resident #23's left side with his/her right foot. --Resident #23 got up from the floor. --Housekeeper B, Dietary Aide A, and CNA B continued up the hall. --The Activities Director and Hall Monitor C walk towards Resident #23. --Resident #23 started to walk towards his/her room. --The Activities Director went to the right side of Resident #23. --Hall Monitor C went to the left of Resident #23 and grabbed Resident #23's left wrist. --Resident #23 continued towards his/her room. --The Activities Director stayed to the right of Resident #23. --Hall Monitor C remained to the left of Resident #23, continued to have a hold of Resident #23's left wrist with his/her left hand, and grabbed the back of Resident #23's shirt with his/her right hand. --Resident #23 and Hall Monitor C continued towards Resident #23's room. --Hall Monitor C continued to hold Resident #23's left wrist and shirt. --The Activities Director walked behind Resident #23 and Hall Monitor C and was a few paces behind them. --Hall Monitor C shoved Resident #23 into his/her room. --The Activities Director continued to walk towards Resident #23's room. NOTE: Resident #23 stayed in his/her room for the remainder of the camera footage. --Hall Monitor C entered Resident #23's room. --The Activities Director continued towards Resident #23's room. --Resident #23's roommates exited the room and walked up the hall. --The Activities Director exited Resident #23's room. --LPN A and CMT A remained in the hallway. --The Activities Director waited outside of Resident #23's room facing away from the camera. --LPN A and CMT A remained in the hallway. --Hall Monitor C exited Resident #23's room. --The Activities Director started to walk up the hall. --Hall Monitor C remained outside of Resident #23's room and appeared to be talking to Resident #23. --LPN A and CMT A remained in the hall. --Hall Monitor C walked back towards Resident #23's door and stopped at the door frame and appeared to speak to Resident #23. --The Activities Director continued to walk up the hall. --LPN A and CMT A remained in the hall. --Hall Monitor C exited Resident #23's doorway and walked up the hall. --The Activities Director stopped at the medication cart, but only the lower half of his/her body was visible on camera. Observation of the facility camera footage of the second incident, dated 4/15/24, showed: -The footage was a recording of the camera footage and not the actual recording. -The recording was two minutes and 14 seconds long. -The footage took place on the unit hall near the elevator. -- Resident #23 entered the hall and into the frame of the footage with LPN A. -At 11:19:36 A.M. through 11:20:01 A.M.: --Resident #23 walked down the hall and LPN A walked down the hall in front of Resident #23 with about a three-door space between them. --LPN A exited the camera frame from the front of the hall. --Resident #23 continued to walk down the hall. --Hall Monitor C entered the frame at the bottom of the hall near the elevator. --Hall Monitor C made a punching/swinging motion towards Resident #23. --LPN A entered the frame at the bottom of the hall near the elevator. --Hall Monitor C and Resident #23 appeared to exchange some words with each other. --Hall Monitor C put his/her left and right arm up in a fighting stance, pulled his/her right arm back, and proceeded to punch Resident #23 in the jaw/neck area with his/her left fist. --Resident #23 brought his/her right arm up and put his/her right hand into a fist and attempted to block Hall Monitor C's punch, then made contact to Hall Monitor C's left shoulder with his/her right fist. --After Resident #23 made contact with Hall Monitor C's shoulder he/she punched Resident #23 again in the jaw. --Resident #23 continued to have his/her right arm up attempting to block the second punch. --LPN A remained by the elevator and appeared to observe the physical contact that was made between Hall Monitor C and Resident #23. No staff intervened. -At 11:20:13 A.M.: --Resident #23 swung at Hall Monitor C with his/her right arm and again made contact with Hall Monitor C's left upper arm/shoulder area. --Hall Monitor C punched Resident #23 again in the jaw causing Resident #23 to take a step back. --Resident #23 had hunched down in preparation to hit Hall Monitor C again, then raised his/her right arm, punched Hall Monitor C in his/her left shoulder and started to raise his/her right arm again in preparation to hit Hall Monitor C again. --Hall Monitor C appeared to make contact with Resident #23's chest/torso area once with his/her right hand and once with his/her left hand, then pushed Resident #23's head back with his/her right hand and made contact to Resident #23's upper body/neck area with his/her left hand. --LPN A began to walk towards the altercation. --Resident #23 attempted to hit Hall Monitor C again. --Hall Monitor C grabbed Resident #23's right and left wrists preventing Resident #23 from hitting him/her. --LPN A put his/her right hand up reaching out to Hall Monitor C's backside. --LPN A made contact with Hall Monitor C's back appearing to stabilize or push Hall Monitor C in the back towards Resident #23. --Hall Monitor C released his/her grip to Resident #23's wrists, kicked towards Resident #23, but contact could not be determined, while also bringing his/her left arm up and swinging towards Resident #23's face. --Resident #23 attempted to swing at Hall Monitor C with his/her left hand once he/she was released from the grip of Hall Monitor C and took a step back away from Hall Monitor C. --Resident #23 continued to step backwards away from Hall Monitor C. --Hall Monitor C lowered his/her hands, but walked toward Resident #23 when Resident #23 was stepping back. --LPN A continued to observe and walk towards the altercation, but was a few paces behind Resident #23 and Hall Monitor C. --Resident #23 continued to step away from Hall Monitor C. --Hall Monitor C raised his/her left arm and punched Resident #23 in the head. --LPN A continued to observe and walk towards the altercation, remaining a few paces behind Resident #23 and Hall Monitor C. --Resident #23 put his/her hands up attempting to cover his/her face and hunched over to avoid more hits by Hall Monitor C. --Hall Monitor C continued to walk toward Resident #23, it could not be determined if any contact with Resident #23 was made. --Housekeeper B and Resident #16 entered the frame at the bottom of the hall. --LPN A continued to observe and walk towards the altercation, remaining a few paces behind Resident #23 and Hall Monitor C. --Resident #23 remained hunched over and stepping back away from Hall Monitor C. --Hall Monitor C continued to walk towards Resident #23, raised his/her arms up reaching for the back of Resident #23's shirt. --LPN A, Housekeeper B, and Resident #16 continued to observe and walk towards the altercation. -Dietary Aide A entered the frame at the bottom of the hall. --CMT A appeared at the top of the frame and was exiting a resident's room. --Resident #23 was attempting to get away from Hall Monitor C and had his/her hands up attempting to protect himself/herself from more hits from Hall Monitor C. --Hall Monitor C continued to grab Resident #23's shirt preventing Resident #23 from leaving the altercation. --LPN A, Housekeeper B, Dietary Aide A, and Resident #16 continued to observe and walk towards the altercation. No staff intervened. --CMT A stood outside of the resident's room he/she had just exited and observed the altercation and did not intervene. --Hall Monitor C continued to hold Resident #23's back of shirt and started to push Resident #23 towards the floor. --Resident #23 had put his/her right arm and hand out to help brace for the impact as he/she was being pushed towards the floor. -- LPN A, Housekeeper B, Dietary Aide A, and Resident #16 continued to observe and walk towards the altercation. --CMT A remained in the hall and observed the altercation and did not intervene. --Resident #23 disappeared from the frame. --Hall Monitor C appeared to be hunched over Resident #23. --Resident #23 reappeared on camera and was on the floor and Hall Monitor C appeared to have some sort of hold on Resident #23. --Hall Monitor C was hunched over Resident #23 and was holding Resident #23's left arm. --LPN A, Housekeeper B, Dietary Aide A, and Resident #16 made a semi-circle around the altercation and remained to observe the altercation without intervention and did not intervene. --CMT A remained in the hall observing the altercation and had taken a couple steps forward towards the altercation and did not intervene. --Resident #23 remained on the floor, but had kicked his/her right leg up towards Hall Monitor C. --Hall Monitor C remained hunched over Resident #23 and had a hold on Resident #23. --When Resident #23 tried to kick Hall Monitor C, Hall Monitor C began to slap Resident #23 with his/her left hand. --LPN A, CMT A, Housekeeper B, Dietary Aide A, and Resident #16 continued to observe the altercation without intervention. --Resident #23 remained on the floor and had his/her legs up in the air bent at the knee. --Hall Monitor C remained over top Resident #23 with his/her legs straddled over Resident #23's left leg and continued to slap Resident #23. --LPN A, CMT A, Housekeeper B, and Dietary Aide A continued to observe the altercation without intervention. -Resident #23 remained on the floor with his/her legs up in the air bent at the knee. --Hall Monitor C remained over top of Resident #23 with his/her legs straddled over Resident #23's left leg and was holding onto Resident #23. --Resident #23 remained on the ground and had lifted his/her right arm up and appeared to be reaching for Hall Monitor C. -- LPN A, CMT A, Housekeeper B, and Dietary Aide A continued to observe the altercation without intervention. --Resident #23 remained on the ground in the same position as before. --Hall Monitor C continued to straddle Resident #23's left leg and had a hold of Resident #23's left arm. --Resident #23 remained on the ground and in the same position as before. --Hall Monitor C appeared to be reaching towards a resident's room while keeping the same hold on Resident #23. --CMT A, Housekeeper B, and Dietary Aide A continued to observe the altercation without intervention. --Hall Monitor C began to drag Resident #23 into a resident room while keeping Resident #23 in the same position as before and exited the camera frame. --LPN A, CMT A, Housekeeper B, and Dietary Aide A began to walk towards the resident room where Hall Monitor C was dragging Resident #23 into. --Dietary Aide A and Housekeeper B turned around and began to walk down the hall. --LPN A and CMT A continued to walk towards the resident room where Hall Monitor C and Resident #23 were located. --Hall Monitor C and Resident #23 remained off camera. --CMT A entered the resident's room where Hall Monitor C and Resident #23 were located. --LPN A continued to walk towards the same room. --Hall Monitor C and Resident #23 remained off camera. --CMT A exited the resident's room and stayed by the door frame. --LPN A walked to the door frame and stayed next to CMT A. --Hall Monitor C and Resident #23 remained off camera. --LPN A and CMT A began to walk away from the resident's room and walk down the hall. --Hall Monitor C and Resident #23 reappeared into the camera frame. --Hall Monitor C had a hold of Resident #23's shirt and was walking Resident #23 out of the resident's room. --LPN A remained at the end of the hall by the elevator. --CMT A began to walk into a different resident's room. --Hall Monitor C and Resident #23 continued to walk up the hall in the same hold as before. --LPN A walked onto the elevator, did not intervene, and exited the camera frame. --Hall Monitor C and Resident #23 continued to walk up the hall in the same hold as before. --CMT A exited the other resident's room and did not intervene. During an interview on 4/18/24 at 11:28 A.M., the Administrator said: -The date that could be seen on the video footage of the second incident was 24 hours behind indicating the incident occurred on 4/14/24. -The time that could be seen on the video footage of the second video was an hour behind indicating the incident occurred between 12:19 P.M. through 12:21 P.M. NOTE: This was verified while on-site. Review of Resident #23's Skin Evaluation, dated 4/15/24 at 9:31 A.M., showed: -The resident had bruising to his/her right eye, left temporal area, and right knee. -The resident had redness to his/her right and left fingers. -The resident had a scratch to his/her right lower leg. Review of Resident #23's hospital discharge paperwork, dated 4/15/24 at 5:34 P.M., showed: -The resident was seen for assault, contusion to the chest wall, abrasions at multiple sites, and contusion of face. -A Computed Tomography (CT) Scan (a diagnostic imaging procedure that uses a combination of X-rays and computer technology to produce images of the inside of the body) of the resident's face, head, neck, and chest were completed and had not shown any abnormalities. -An X-ray was completed of the resident's left ankle which had not shown any acute fracture or bony abnormality. Review of and Admin/Registered Nurse (RN) Investigation, completed on 4/15/24 at 10:16 A.M., showed: -The date of the incident was 4/14/24. -Resident #23, Resident #16, and Housekeeper B were involved in the incident. -Investigative Narrative: --The nurse stated Resident #23 had been in the hall asking to be removed from 1:1 monitoring. --Resident #23 had been placed on 1:1 monitoring for protective oversight. --Resident #23 had stated sometimes hearing voices and since they were not telling him/her to self-harm he/she didn't need to be on a 1:1, he/she only needed a PRN. --The nurse had educated Resident #23 on the reasoning of the 1:1 monitoring. --Resident #23 had continued to plead with the nurse. --Housekeeper B then inserted himself/herself into the conversation and told Resident #23 to shut up and move on. --Resident #23 then began to curse and use racial slurs towards Housekeeper B. --The nurse tried to take control of the situation and had asked a CNA to take Resident #23 to his/her room. --Resident #23 then started to walk to his/her room and had flared out his/her arms as he/she walked past Housekeeper B, subsequently hitting Housekeeper B in the face with an open hand. --Housekeeper B then grabbed Resident #23 from behind, interlocking his/her arms with Resident #23's arms and slammed Resident #23 to the ground. --Resident #23 and Housekeeper B were entangled on the floor and had exchanged hits. --Resident #23 had kicked Housekeeper B in his/her face and chest several times. --Resident #16 observed the altercation and joined the altercation by kicking and punching Resident #23. --A Code [NAME] had been called and staff had responded appropriately. --The nurse was then able to successfully separate the involved parties. -In conclusion the incident was a result of abuse. Review of an Employee Statement, dated 4/15/24 at 10:56 A.M., from Hall Monitor C showed: -He/She had not hit Resident #23. -Resident #23 had tried to swing on the Activities Director, so he/she and the Activities Director put Resident #23 in a two-man hold. Review of an Admin/RN Investigation, completed on 4/15/24 at 11:32 A.M., showed: -The date of the incident was 4/14/24. -Resident #23, Hall Monitor C, LPN A, and CMT A were involved in the incident. -Resident #23 stated the following: --He/She had spoken with the Administrator related to a cigarette break. --He/She had gone down the hall to inform Hall Monitor C about the approved smoke break. --He/She had been told by Hall Monitor C that he/she wasn't getting nothing. --After making that comment Hall Monitor C began inflicting harm to him/her. --He/She was hit with a closed fist in his/her upper torso area. --He/She was repeatedly punched in his/her arms and slapped across the face. --He/She was then grabbed by Hall Monitor C to the nearest room. --He/She was then escorted to his/her room by Hall Monitor C and was told to stay in his/her room. --The altercation was witnessed by LPN A, CMT A, Housekeeper B, and the kitchen [NAME]. -When reviewing the camera footage, the altercati

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure three sampled residents (Resident #1, #17 and #22) were free from abuse, out of 26 sampled residents. On 2/24/24, Resident #2 pushed staff aside and pulled Resident #1 from his/her chair to the floor. Resident #2 struck Resident #1 in the face and on the head multiple times. Resident #2 then stomped on Resident #1's head. Resident #1 sustained a bump and discolored area on his/her forehead. Resident #2's physical and aggressive behavior resulted in six sampled residents (Resident #3, #6, #9, #13, #4, and #15) verbalization of fear for their safety from Resident #2. Additionally, on 2/27/24, Resident #19 struck Resident #17 in his/her face resulting in Resident #17 having a bloody nose and mouth. On 4/3/24, Resident #18 wrapped his/her hand around Resident #22's neck and squeezed until staff intervention. The facility census was 112 residents. The Administrator was notified on 4/1/24 at 2:00 P.M. of an Immediate Jeopardy (IJ) which began on 2/24/24. The IJ was removed on 4/4/24, as confirmed by surveyor onsite verification. Review of the facility policy titled, Abuse and Neglect, dated 1/5/23 showed: -The facility was committed to protecting residents from abuse by anyone. -Physical Abuse was purposefully beating, striking, wounding, or injuring any resident or any manner whatsoever mistreating or maltreating a resident in a brutal or humane manner. -Verbal Abuse was using profanity or speaking in a demeaning or non-therapeutic, undignified, threatening or derogatory manner in a resident's presence. Examples included: mocking, insulting, ridiculing, yelling in an intimidating manner, and threatening. -Mental Abuse was using verbal or non-verbal conduct which would cause or potentially cause a resident to experience intimidation, humiliation, fear, shame, agitation or degradation. This included hovering over a resident with intent to intimidate and threaten. -The facility was committed to protect residents from abuse by anyone, including staff, other residents, consultants, volunteers, agency staff, family members, guardians, friends or any other individuals. 1. Review of Resident #1's facility face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Schizoaffective disorder, (a mental health condition characterized by symptoms such as delusions, hallucinations, and mood disorders that can impact daily functioning). -Impulse disorder, (a mental health condition that is characterized by inability to resist impulses, urges and temptations that may harm oneself or others). -Major depressive disorder, recurrent, (persistent low mood, loss of interest or pleasure, fatigue, feelings of worthlessness and difficulty concentrating, that have severe impact on daily functioning and quality of life). Review of Resident #1's Care Plan, dated 6/7/23, showed: -He/she had the potential for physical or verbal behaviors toward self and others. -Interventions included: education on coping skills; analyzing triggers for aggression and staff intervention to allow time to calm down; administration of medications as ordered; anticipation of resident's needs; separation of parties involved; 1:1 observation. Review of Resident #1's Quarterly Minimum Data Set (MDS - a federally mandated assessment tool used by facilities for care planning), dated 12/18/23 showed: -The resident was cognitively intact. -No behaviors were observed during the assessment period. Review of Resident #2's PASRR (Preadmission Screening and Resident Review - a federally mandated screening process for individuals with serious mental illness and/or intellectual disability/developmental disability related diagnosis who apply or reside in Medicaid Certified beds in a nursing facility; the screening assures appropriate placement of persons known or suspected of having a mental impairment(s) and also that the individual needs of mentally impaired persons can be and are being met in the appropriate placement environment), dated 7/29/22, showed the following information: -He/she had poor insight and required structure and consistently displayed poor/unsafe decision making. -He/she had a history of disorganized behaviors, depression, mania, impulsive behaviors, psychosis, depression, was suspicious and paranoid, abnormal thought processes, verbal and physical aggression, suicide attempts and self harm, -He/she was violent toward medical staff and actions were dangerous to the public. -He/she had a history of becoming violent in public places and threatening to shoot others. -He/she had hit his/her fiancé with a crowbar and thought he/she was dead. -He/she had a guardian appointed. Review of Resident #2's facility face sheet showed he/she was admitted to the facility on [DATE] with the following diagnoses: -Bipolar Disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). -Schizoaffective disorder, bipolar type, (a mental health condition that combines features of schizophrenia, (a severe mental disorder that affects how a person thinks, feels and behaves), and bipolar disorder, (a mental health condition characterized by extreme mood swings), where the individual experiences mood disturbances along with psychotic (a mental state where the individual experiences a break with reality). -Post-traumatic stress disorder, chronic, (long-term, persistent mental health condition that can develop after experiencing or witnessing a traumatic event). -Reactive attachment disorder of childhood, (a rare, but serious condition that can develop in children who have experienced significant neglect, abuse or disruption in early caregiving relationships). -Major depressive disorder, recurrent. Review of Resident #2's Care Plan, dated 9/1/23, showed: -He/she had a long history of mental illness and frequent psychiatric hospital admissions. --Interventions included: use of CALM technique, (Crisis Alleviation Lessons and Methods - to provide safe treatment and humane care to residents in a behavioral crisis), if needed, long term psychiatric management and counseling, if needed; pharmaceutical interventions, if needed and 1:1 observation, if needed. -He/she had a history of behavioral challenges that required protective oversight in a secure setting and had a previous act of physical aggression toward a peer on 1/27/24. --Interventions included: using CALM technique if needed, long term psychiatric management and counseling, if needed; pharmaceutical interventions, if needed, 1:1 observation, if needed, referrals sent out for transfer. Review of Resident #2's MDS, dated [DATE], showed he/she was cognitively intact. Review of a video, dated 2/24/24, showed: -Resident #1 was sitting at a table with Resident #5 getting his/her hair fixed by Certified Medication Technician (CMT) A. -Resident #2 became visible in a chair across the room, taking off his/her shoes and socks. -Resident #2 stood up and the two Hall Monitors (HM A and HM B) stood up and stepped between the residents and it appeared a verbal exchange was taking place between the two residents. -CMT A was still fixing Resident #1's hair. -Resident #2 flipped his/her middle finger at Resident #1. -Resident #2 stood behind Resident #5 and was speaking. -Resident #2 used his/her body to push the two HMs out of the way and started slapping Resident #1, pulled his/her hair and drug him/her to the ground. -CMT A was standing behind Resident #1 using his/her body as a shield. -When Resident #2 pushed the staff out of the way, he/she also slapped at CMT A three times. -Resident #2 gave Resident #1 at least ten slaps on the head and then was on top of him/her. -CMT A stepped aside to call a Code Green. -The three staff were able to get Resident #2 off Resident #1 and put him/her in a hold. -Resident #2 kicked at staff. -CMT A pulled Resident #1 away. -Resident #2 was able to stand up, staff pulled him/her away and let him/her go. -Resident #2 stepped forward and started stomping on Resident #1's head 4 times. -Another staff arrived and removed Resident #2 from the area. Review of the facility's investigation, dated 2/24/24 at 7:49 A.M., showed: -Both residents lived on a locked behavioral unit. -The residents had a verbal altercation earlier in the day. Floor staff intervened and separated the residents so no physical alteration ensued. -The staff thought it was over and did not inform the nurse of the event. -After dinner, the staff were helping Resident #1 with his/her hair. Resident #1 was upset because Resident #2 did not assist the staff with his/her hair. -The two residents started a verbal exchange and the resulting altercation could have been avoided if the staff had separated the residents during their verbal argument. -Resident #2 had the approved CALM hold used to separate him/her from Resident #1. -Resident #1 sustained a hematoma to his/her forehead and some abrasions. He/she was sent to the hospital for evaluation. -Resident #2 received an ordered as needed (PRN) medication and was placed on 1:1 observation. -Resident #2 had previously been in one physical altercation at the facility. Review of Resident #2's Progress Notes, dated 2/24/24 at 6:30 P.M., showed: -Staff responded to a Code [NAME] (used to alert staff to the need for assistance in deescalating a potentially volatile situation), when nurse arrived, staff reported he/she attacked a peer. -When the nurse asked the resident what happened, he/she stated he/she was angry at Resident #1, because Resident #1 was calling him/her names and he/she became mad. He/she said his/her intention was not to hurt the other resident, but to shut him/her up. -He/she was placed on 1:1 observation. Police, guardian, primary care physician, Director of Nursing (DON) and Administrator were notified. During an interview on 2/28/24 at 10:50 A.M., Resident #2 said: -He/she did not want to do Resident #1's hair and told Resident #1 he/she needed to wash and brush his/her own hair. -Resident #1 called him/her multiple names. -He/she had several verbally aggressive encounters with Resident #1 before, but no physical aggression. -He/she should have gone to his/her room and ignored Resident #1 as he/she had done many times before. -He/she approached Resident #1, reached around staff, grabbed Resident #1's hair and pulled him/her to the ground. -Someone called a Code Green. -There were two other staff present. -He/she hit Resident #1 on top of the head, but not on his/her face. -He/she was on top of Resident #1 and staff tried to get him/her off. -When he/she got up, he/she stomped on Resident #1. -He/she was trying to injure Resident #1. -The male staff grabbed him/her and got him/her away from Resident #1 and made him/her sit in a chair. -He/she was in a rage. -He/she asked for a PRN medication and got it. -He/she was asked several times if he/she wanted to go to the hospital and he/she said no. -It took a lot to make him/her mad. -Things that would trigger him/her were talking about his/her kids, being around slow people 24/7 and being told he/she can't do things. -He/she was stuck in a small area with these people. Observation and interview with Resident #1 on 2/28/24 at 11:20 A.M., showed: -He/she had a purple, green, and yellow fading discolored area about two inches in diameter on his/her left forehead at the hairline. -He/she said a staff person was fixing his/her hair when he/she was cussing Resident #2 out and calling him/her a bitch. -He/she had been trying to stop him/herself from calling names, but called Resident #2 all kinds of names. -Resident #2 was at the next table. -The staff told the two of them to stop arguing, but they did not listen. -Resident #2 started the fight, pulled him/her out of his/her chair, pulled his/her hair, punched him/her, and stomped on his/her head. -Staff tried to stop Resident #2 and called a Code Green. -It took a lot of staff to get them apart because Resident #2 was really strong. -He/she stayed in the dining room in a chair and Resident #2 went to a different area. -He/she was moving to a different unit, where he/she thinks he/she would be safe. -He/she didn't know what made Resident #2 so mad. -Resident #2 was bullying people in the dining room during the past weekend. -He/she was afraid of Resident #2. Review of Resident #6's MDS, dated [DATE], showed he/she was cognitively intact. Review of a statement written by Resident #6 on 2/24/24 at 6:35 A.M. showed: -He/she was in the dining room right before Resident #1 was attacked by Resident #2. -The two residents were having a verbal exchange. -Resident #2 told Resident #1 he/she hoped he/she slept with one eye open, because he/she was going to put socks in his/her mouth and pillows over his/her head. -Resident #2 took off his/her socks and shoes, then went over near Resident #1 and Resident #5. -Resident #2 told Resident #5 to stick his/her middle finger at Resident #1 and said, Fuck you, bitch. -Resident #2 attacked Resident #1 and had him/her on the floor, punching him/her in the head and face. During an interview on 2/29/24 at 11:55 A.M., Resident #6 said: -He/she was present when Resident #2 attacked Resident #1. -Resident #2 told Resident #1 he/she would have to sleep with one eye open because he/she was going to stuff some socks in his/her mouth and put a pillow over his/her head. -Resident #2 started taking off his/her shoes and socks, because he/she was going to fight Resident #1. -Resident #1 was getting his/her hair done. -Resident #5 flipped Resident #1 off and called him/her a fucking bitch, because Resident #2 told him/her to. -Staff were between Resident #1 and Resident #2 the whole time. -Resident #2 reached around the staff and pulled Resident #1 down and started beating him/her. -The staff tried to intervene, but Resident #2 was too strong. -Two of the staff tried to help and one got on the walkie-talkie to call a Code Green. A total of three staff were there. -Then another staff member came in and pulled Resident #2 away. -He/she was afraid of Resident #2 and the other residents were afraid of him/her. -When Resident #2 had a behavior, the staff would try to calm him/her, but it didn't always work. -Resident #2 tells him/her to do things, and since he/she is afraid of him/her, he/she does them. -Resident #2 threw water twice and ripped the wig off of one of the nurses. Review of a statement written by Certified Medication Technician (CMT) A on 2/24/24 at approximately 6:25 A.M., showed: -He/she was detangling Resident #1's hair. -The involved residents were in the dining room. -Residents #2, #5 and #6 were in the dining room. -Resident #1 and Resident #2 were having words and calling each other names. -He/she and the other staff asked Resident #2 to please leave Resident #1 alone. -Resident #2 told Resident #5 to call Resident #1 a lot of names and told him/her to put his/her finger up at him/her. -All of a sudden, Resident #2 attacked Resident #1 and stomped his/her head on the floor a couple times. During an interview on 2/29/24 at 12:05 P.M., CMT A said: -Resident #1 and Resident #2 were making remarks to one another. -He/she and the two other staff put their bodies around Resident #1 and stepped between the two residents. -He/she and the other staff thought Resident #2 was just coming over to talk to Resident #5 who was sitting at the table. -Resident #2 reached around the two other staff and started beating Resident #1. -When Resident #2 started hitting, he/she stepped to the side of the room and called a Code Green. During an interview on 2/29/24 at 12:35 P.M., Nurse Practitioner (NP) A said: -He/she was aware of the fight. -Resident #2 had always been in trouble, attention seeking and fighting at his/her previous facility. Review of Resident #9's MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 2/29/24 at 1:24 P.M., Resident #9 said: -He/she was present in the room during the fight. -He/she saw the two residents arguing because of things Resident #1 said. -The staff were trying to stop the whole thing from happening. -Resident #2 pushed the staff out of the way. -Resident #2 pulled Resident #1 out of his/her chair. -He/she saw Resident #2 hitting Resident #1 on his/her head. -He/she was yelling, No, no, stop! and started crying. -He/she went to his/her room at that point. -He/she is scared of Resident #2. During an interview on 2/29/24 at 2:13 P.M., Hall Monitor (HM) A said: -CMT A was working on Resident #1's hair. -Resident #2 was saying Resident #1 needed to learn to do things for him/herself, and was antagonizing him/her. -Resident #1 was telling Resident #2 to leave him/her alone. -Resident #2 said if Resident #1 said anything else, he/she was going to go over there and started taking his/her shoes and socks off. -They were telling Resident #2 it was not worth it and to leave Resident #1 alone. -At that point, they stood behind Resident #1 to keep the two residents apart. They were trying to keep the residents separated. -Resident #2 got up and walked over to them. -When he/she and the other staff were standing between Residents #1 and #2, Resident #2 used his/her body to push them out of the way. -Resident #2 was very strong. -CMT A went to call a Code Green. -Resident #1 was shouting and Resident #2 started stomping. -The nurse came and took Resident #2 away. He/she told Resident #1 not to get up. -Resident #2 wanted to go to the smoke room and said he/she was not going to apologize until Resident #1 apologized first. -Resident #1 did not fight back. -Resident #1 went to the hospital. -Police came later and documented the event. Review of Resident #3's MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 2/29/24 at 10:25 A.M., Resident #3 said: -He/she was in the smoke room and heard Resident #2 state he/she had given Resident #1 what he/she deserved. -He/she was afraid of Resident #2. During an interview on 3/6/24 at 10:04 A.M., the Director of Nursing (DON) said: -Resident #2 hitting Resident #1 was abuse. -He/she did not know if this incident could have been predicted or prevented, but if a Code [NAME] were called sooner, the severity might have been diminished. During an interview on 3/6/24 at 10:15 A.M., the Administrator said: -Resident #2 beat up another resident at his/her previous facility. -The facility did not receive his/her history and behavior notes from the previous facility until after he/she arrived at the current facility. -He/she did not know if this incident could have been predicted or prevented. -Resident #2 was not intimidated by staff and did not fight fairly. -If a Code [NAME] was called sooner, the injury might have been less. -The police came to the facility that day and took a statement. -Resident #1 pressed charges and Resident #2 had a court date assigned. Review of Resident #15's MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 3/7/24 at 12:50 P.M., Resident #15 said: -Resident #2 had never attacked him/her. -He/she was afraid of Resident #2 and would stay away from him/her. -Resident #2 was unreliable; one minute friendly and the next angry. -Resident #2's whole demeanor and the way he/she walked and talked was intimidating. -The previous night, he/she saw Resident #2 rip a nurse's wig off, throw a laptop on the floor and knock medications off the cart. -Resident #2 previously beat up another agency nurse. Review of a written statement by Resident #15 dated 3/12/24 showed: -He/she was not comfortable, nor did he/she feel safe with Resident #2 on the unit. -Resident #2 had beaten 6 people up, 2 of which were agency nurses. -Resident #2 was a menace and unpredictable. -The facility was his/her home and he/she should feel safe and at peace. During an interview on 3/7/24 at 1:05 P.M., Resident #3 said: -The residents were all afraid of Resident #2. -Resident #2 threatened him/her and put a sign on his/her door calling him/her a fat [NAME]. Resident #2 also threatened to rip his/her earring out. -Resident #2 would instigate other residents to do things. -He/she did not see the incident with the agency nurse, but Resident #2 bragged about it and said the nurse was incompetent and a dumb bitch. -Resident #2 was unpredictable, and one would never know when he/she was going to get aggressive. -Resident #2 showed no remorse for his/her actions. Review of Resident #13's MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 3/12/24 at 9:50 A.M., Resident #13 said: -Resident #2 was threatening staff. -Resident #2 previously threatened to kill him/her but did not say why. -Resident did not show any signs when he/she was going to get aggressive, he/she would just do it. -People could not tell when Resident #2 was going to do something. -The residents did not want Resident #2 to come back to the facility. -Since Resident #2 had been gone, the unit was more peaceful and there was less drama. Review of Resident #14's MDS, dated [DATE], showed he/she was cognitively intact. During an interview on 3/12/24 at 10:00 A.M., Resident #14 said: -Resident #2 had previously never hit him/her, but had threatened him/her. -He/she was afraid of Resident #2 because he/she had threatened to hit him/her with his/her walker in the past. -Resident #2 got violent this last time, because he/she thought someone stole his/her things, but nobody had done so. -Resident #2 was yelling and threw some drink pitchers and a chair, and threw the linen cart. -There were staff present; some of them were afraid of the resident. -Resident #2 threatened to hurt the staff and the residents. -When Resident #2 was being taken out of the room, he/she was making threats to get you and kill you to the staff. -He/she was terrified Resident #2 would come back and hurt all of them. -Resident #2 had threatened to stab them and kill them, and had already hurt two agency nurses. During an interview on 3/12/24 at 10:47 A.M., Licensed Practical Nurse (LPN) A said: -Anything could trigger Resident #2. He/she could go off without warning. -Some staff were afraid of the resident, as he/she had made threats toward them. -All of the residents were afraid of this resident. His/her roommate would buy him/her treats to stay on his/her good side. During an interview on 3/12/24 at 11:00 A.M., Certified Nursing Assistant (CNA) B said: -He/she did not think Resident #2 had any real triggers, but would just go off. -Resident #2 did not show any agitation or other signs before he/she would get violent. -Resident #2 just wanted to do what he/she wanted to do, when he/she wanted to do it. Positive reinforcement didn't work with him/her. -Code Greens and CALM techniques had no effect on the resident. He/she would continue to threaten the other residents and staff. -The other residents were terrified Resident #2 was going to return to the facility. During an interview on 3/7/24 at 2:05 P.M., the DON said: -One moment Resident #2 could be really talkative and the next moment, hateful. He/she didn't give a build-up, but it was random and you didn't know what would set him/her off. -Resident #2 was unpredictable and changeable. During an interview on 3/12/24 at 11:30 A.M., Guardian A said: -The resident was a master manipulator. The residents did not want Resident #2 to come back to the facility. -Since the resident had a guardian, the prosecuting attorney would not press charges. During an interview on 3/12/24 at 12:00 P.M., Resident #1 said he/she was afraid of Resident #2. 2. Review of Resident #17's PASSR, dated 11/29/23, showed: -Assistance needed to complete activities of daily living (ADL's - eating, dressing, grooming, bathing, incontinence care). -Assistance needed for transfers, ambulation, fall prevention. -Medical treatment and/or monitoring for chronic conditions. -Behavioral difficulties and/or mental illness symptoms requiring 24 hour monitoring/management. -Lack of community/family supports to maintain functioning at home. -Self injurious behaviors of hitting him/herself in the head. -Physical and verbal aggression toward men. -History of abuse. -Inappropriate sexual comments to staff. -Poor insight and judgement. Review of Resident #17's facesheet showed he/she admitted to the facility 2/16/24 with diagnoses that included: -Chronic Obstructive Pulmonary Disease (a group of lung diseases that block airflow and make it difficult to breathe). -Schizophrenia. -Anxiety Disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that is strong enough to interfere with ones daily activities). -Major Depressive Disorder. -Intermittent Explosive Disorder (repeated sudden bouts of impulsive, aggressive, violent behavior or angry verbal outbursts; with reactions that are too extreme for the situation). -Traumatic Brain Injury (brain dysfunction caused by an outside force, usually a violent blow to the head). Review of Resident #17's admission MDS, dated [DATE], showed the facility was not able to assess cognitive status related to the resident not understanding questions, with severely impaired cognition. Review of Resident #17's care plan, dated 2/26/24, showed: -Resident has an ADL performance deficit related to paraplegia. -- Encourage the resident to participate to the fullest extent possible with each interaction. --Praise all efforts at self care. -Resident has manifestations of behaviors related to his/her mental illness that may create disturbances that affect others; these behaviors include buying, selling, borrowing and trading behaviors with peers. --Administer medication as needed when non pharmacological interventions are ineffective. --Give positive feedback for good behavior. --Notify guardian/physician as needed. Review of Resident #19's PASSR, dated 12/17/14, showed: -Victim of a gang shooting in 1993 which left him/her paraplegic. -Long standing depressive issues, suicidal ideation, and suicide attempts. -Poor concentration and judgement. -Delusions, auditory hallucinations. -Assistance needed with ADL's - toileting, bathing, and dressing. Review of Resident #19's face sheet showed he/she admitted to the facility 1/18/24 with diagnoses that included: -Major Depression. -Schizophrenia. -Anxiety Disorder. -Encephalopathy (a broad term for any brain disease that alters brain function or structure). Review Resident #19's admission MDS, dated [DATE], showed he/she was cognitively intact. Review of Resident #19's care plan, dated 2/26/24, showed: -The resident has an ADL self care performance deficit related to paraplegia. --Encourage the resident to participate the fullest extent possible with each interaction. --Praise all efforts at self care. -Resident has manifestations of behaviors related to his/her mental illness that may create disturbances that affect others; these include yelling at staff, buying, selling, borrowing and trading behaviors with peers. --Administer medication as needed when non-pharmacological interventions are ineffective. --Give positive feedback for good behavior. --Notify guardian/physician as needed. Review of the facility investigation, dated 3/1/24, showed: -The incident happened on 2/27/24. -CNA C notified the DON he/she witnessed Resident #19 hit another resident in the face. -When asked Resident #19 said he/she hit Resident #17 because Resident #17 had not paid him/her for five cigarettes. -When asked Resident #19 said he/she did not hit Resident #17. -Resident #19 denied giving/selling Resident #17 cigarettes. -Resident #17 had a bloody nose and mouth. During an interview on 4/1/24 at 2:30 P.M., Resident #17 said: -He/she did not remember getting in an argument with anyone or being hit in the nose. During an interview on 4/1/24 at 2:40 P.M., Resident #19 said: -He/she remembered hitting Resident #17 in the face. -CNA C saw it. -Resident #17 owed him/her cigarettes. During an interview on 4/1/24 at 2:52 P.M., CNA C said: -He/she was coming through the glass doors to the hall where the residents go out to smoke. -He/she saw Resident #19 hit Resident #17 with a closed fist in the face. -Both of the residents were in their wheelchairs. During an interview on 4/1/24 at 3:00 P.M., the DON said: -During the investigation, Resident #19 denied hitting Resident #17. -Resident #17 did have a bloody nose and mouth, so it looked like the resident was hit. -Resident #19 also denied selling or giving cigarettes to Resident #17. -He/she did have a staff witness the incident, so it was assumed Resident #19 did hit Resident #17. -Education was given again to Resident #19 on not selling or giving items such as cigarettes to other residents. -Education was given again to Resident #17 on not asking for items such as cigarettes, from other residents. During an interview with the Administrator on 4/1/24 at 3:15 P.M., he/she said: -The staff reported to him/her that Resident #19 hit Resident #17 in the mouth or nose. -This reportedly happened right outside the smoking area in the hallway. -The residents have been re-educated on not selling or giving each other items such as cigarettes. -Resident #19 denied hitting Resident #17. -He/she feels as though this was more of a behavior than abuse. 3. Review of Resident #18's PASSR, dated 12/10/20, showed: -Major neurocognive disorder secondary to surgical ablation (removal) related to seizures (Right frontal lobe ablation - right frontal lobe is responsible for higher cognitive functions such as memory, emotions, impulse control, problem solving, social interaction and motor function). -Schizoaffective Disorder. -Major Depression. -Schizophrenia. -Mild Cognitive impairment. -Mood Disorder (Marked disruptions in emotions). -Psychotic disorder with delusions (a belief or altered reality that is persistently held despite evidence or agreement to the contrary, generally in reference to a mental disorder). -Severe physical aggression. -Required outpatient psychiatric follow-up/consultation. -Required secured/behavioral unit. -Required assessment and implementation of behavioral support plan, monitoring of behavioral symptoms and provision of behavioral supports. Review of Resident #18's facility face sheet showed: -Resident admitted to the facility on [DATE], with diagnoses that included: --Epileptic seizures (happens as a result of abnormal electrical brain activity, also known as a seizure). --Violent behavior. --Mood disorder. --Schizoaffective disorder. --Anxiety disorder. --Bipolar disorder (a disorder associated with episodes of mood swings from depressive lows to manic highs). --Unspecified Psychosis. Review of Resident #18's quarterly MDS, dated [DATE], showed he/she had moderately impaired cognition. Review of Resident #18's care plan, dated 4/3/24, showed: -The resident had manifestations of behaviors related to his/her mental illness and brain surgery in 2015 that may create disturbances that affect others. -These behaviors include verbal/physical aggression, poor impulse control, false allegations toward peers, low cognitive ability. --Assisted resident in addressing root cause of change in behavior or mood as needed. --Give