**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), would be provided if such care was needed per the resident's choice, and would only be provided to a resident subject to related physician orders and resident choice. The facility failed to have a system to ensure resident code statuses are obtained, ensure code status matched the resident's wishes, and ensure code statuses were accurately documented. The facility failed to obtain an ordered code status for 2 residents and failed to have congruently documented code status for 2 residents, out of 37 residents investigated for advanced directives. One resident had an order for full code, but a face sheet indicated do not resuscitate (DNR). The resident said he/she wanted to be a full code (Resident #4). One resident had an order for full code, but a face sheet that indicated DNR. The resident's representative said the resident was a DNR (Resident #3). One resident had a face sheet that showed DNR, a signed code status for DNR, but no ordered code status. The face sheet in the code status binder showed full code (Resident #5). One resident had no ordered code status, a signed code status sheet for DNR, and the face sheet showed DNR. The resident representative said the resident is a DNR (Resident #6). The census was 37. The administrator was notified on [DATE] at 10:30 A.M., of an Immediate Jeopardy (IJ) which began on [DATE]. The IJ was removed on [DATE], as confirmed by surveyor onsite verification. 1. Review of the facility's Do Not Resuscitate Order policy, revised [DATE], showed: -Policy Statement: Our facility will not use cardiopulmonary resuscitation and related emergency measures to maintain life functions on a resident when there is a Do Not Resuscitate Order in effect; -Policy Interpretation and Implementation: Do not resuscitate orders must be signed by the resident's Attending Physician on the physician's order sheet maintained in the resident's medical record; -A Do Not Resuscitate (DNR) order form must be completed and signed by the Attending Physician and resident (or resident's legal surrogate, as permitted by State law) and placed in the front of the resident's medical record; -DNR orders will remain in effect until the resident (or legal surrogate) provides the facility with a signed and dated request to end the DNR order; -Verbal orders to cease the DNR will be permitted when two (2) staff members witness such request; -Both witnesses must have heard the request and both individuals must document such information on the physician's order sheet; -The Attending Physician must be informed of the resident's request to cease the DNR order; -The Interdisciplinary Care Planning Team will review advance directives with the resident during quarterly care planning sessions to determine if the resident wishes to make changes in such directives; -The resident's Attending Physician will clarify and present any relevant medical issues and decisions to the resident or legal representative as the resident's condition changes in an effort to clarify and adhere to the resident's wishes. 2. Review of the facility's Cardiopulmonary Resuscitation policy, revised February 2018, showed if the resident's DNR status is unclear, CPR will be initiated until it is determined that there is a DNR or physician's order not to administer CPR. 3. Review of Resident #4's face sheet, showed: -admitted on [DATE]; -DNR code status. Review of the resident's code status sheet, dated [DATE], showed DNR checked and signed by the resident on [DATE]. Review of the resident's admission Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated [DATE], showed: -Moderately impaired cognition; -Diagnoses included heart failure, high blood pressure, atrial fibrillation (irregular heart rate), diabetes and schizophrenia (disorder that affects the ability to think, feel, and behave clearly). Review of the resident's Physician's Orders Sheet (POS), dated [DATE], showed an order dated [DATE], for full code. Review of the facility's Emergency Evacuation binder, printed on [DATE], showed the resident's face sheet with a DNR code status. During an interview on [DATE] at 3:00 P.M., the resident said staff did not talk to him/her about the code status. He/she would prefer to be a full code. 4. Review of Resident #3's face sheet, showed: -admitted on [DATE]; -DNR code status. Review of the resident's Outside the Hospital Do-Not-Resuscitate (OH-DNR) order, dated [DATE], showed DNR checked and signed by the resident on [DATE]. Review of the resident's quarterly MDS, dated [DATE], showed: -Severely impaired cognition; -Diagnoses included high blood pressure, Alzheimer's disease and depression. Review of the resident's POS, dated [DATE], showed an order dated [DATE], for full code. Review of the resident's care plan, in use during the survey, showed: -Problem: Resident is a DNR effective [DATE] per patient and family wishes; -Goal: The facility will respect the resident's decision to be a DNR; -Approach: If there is an absence of vital signs, do not call 911 or initiate CPR. During an interview on [DATE] at 3:20 P.M., the resident's family member said the resident's code status is DNR. He/She spoke to staff last month just to clarify and they went over the code status with him/her. Review of the facility's Emergency Evacuation binder, printed on [DATE], showed the resident's face sheet with a DNR code status. 5. Review of Resident #5's face sheet, showed: -admitted on [DATE]; -DNR code status. Review of the resident's annual MDS, dated [DATE], showed: -Cognitively intact; -Diagnoses included high blood pressure and anxiety. Review of the resident's undated code status sheet, showed DNR checked and signed by the resident. Review of the resident's POS, dated [DATE], showed no order for code status. Review of the facility's Emergency Evacuation binder, printed on [DATE], showed the resident's face sheet with a DNR code status. 6. Review of Resident #6's face sheet, showed: -admitted on [DATE]; -DNR code status. Review of the resident's OH-DNR order, dated [DATE], showed DNR checked and signed by the resident's Power of Attorney (POA) on [DATE]. Review the resident's quarterly MDS, dated [DATE], showed: -Severe cognitively impairment; -Diagnoses included high blood pressure, kidney failure, diabetes, Alzheimer's disease, dementia, depression and schizophrenia. Review of the resident's POS, dated [DATE], showed no order for code status. Review of the resident's care plan, in use during the survey, showed: -Problem: The resident is a DNR; -Goal: The facility will respect the resident's decision to be a DNR; -Approach: If the resident is found unresponsive and has no pulse and not breathing do not initiate CPR and do not call 911. Review of the facility's Emergency Evacuation binder, showed a POS, dated [DATE] through [DATE], with a full code status. No face sheet was found. During an interview on [DATE] at 4:30 P.M., the resident's POA said he/she was aware of the resident's DNR code status and the resident wanted to be a DNR. 7. During an interview on [DATE] at 1:50 P.M., Certified Nurse Aide (CNA) A said if he/she had to find the resident's code status quickly, it is found in the code status binder at the nurse's station. It was the only place he/she knew to look. During an interview on [DATE] at 1:52 P.M., Licensed Practical Nurse (LPN) B said he/she would find the resident's code status on the face sheet. If there is nothing there, he/she would initiate CPR. Observation and interview on [DATE] at 2:02 P.M., Restorative Aide (RA) C said every month he/she receives a print off of all the resident's codes status from their orders and that is where he/she would look for a code status. Every resident has a code status on his/her list. If the resident was a new admit or not on the list, there is a binder at the nurse's station. RA C looked through a binder and did not find any code status and said the binder was a cheat sheet for the nurses. Normally the code statuses would be in the binder. Review of RA C's print off list, showed: -No documentation of Residents #4 and #5 on the list; -Resident #6 showed a DNR code status; -Resident #3 showed a DNR code status. During an interview on [DATE] at 3:22 P.M., Certified Medication Aide (CMT) D said he/she would check the binder at the nurse's station for code statuses. He/she was pretty sure it is updated, but he/she was not responsible for updating it. He/she will also check the Medication Administration Record (MAR) in the medical record. If there was no code status, he/she would get the nurse. During an interview on [DATE] at 5:15 P.M., the Administrator in Training and Director of Nursing (DON) said when a resident is admitted to the facility, they are a full code unless they sign a DNR. It is a part of the admission packet. The code status is also on the POS. If there are changes in the resident's code status, the charge nurse is responsible for updating it in the medical record. If there is a care plan meeting, quarterly or significant change, the code status is reviewed with the resident. They review it and sign it. There is a red piece of paper in front to notify the DON that the code status was changed at the care plan meeting. The MDS coordinator changes the code status since they are present during the care plan meeting. If hospice speaks to the resident about their code status, they are to notify the DON. The charge nurse is expected to change it. They keep a copy of the code status sheet in hard files and it is uploaded to the electronic medical record. In order to find the resident's code status, they look in the electronic medical record, on the header where their picture is found. If the resident is a full code, it is green and DNR is in red. The binder with the code status is not at the nurse's station. The binder with the code statuses are in the facility's emergency evacuation binder. The resident's face sheets are in the binder with their code status at top of face sheet. It is updated quarterly and as needed if new admission or changes. The binder is located in the DON's office. The DON was unsure if staff were aware the binder was in the DON's office. The binder is updated by the DON. It was updated within the last 3 months. The Administrator in Training said she would expect resident's code status on the face sheet, POS and signed code status sheet to all match. They recently had an audit. All residents should have an order for DNR if they are a DNR, but for residents who are a full code, the administrator in training said she would need to follow up with DON. She did not believe they would need an order for full code. If staff were unable to find a resident's code status, they would treat them as full code. During an interview on [DATE] at 5:40 P.M., the Administrator confirmed that POS were not checked during the audit. She would expect staff to check the POS during their audits. It should be reflected on their care plans. All resident's code status are expected to match and have an order on the POS. NOTE: At the time of the abbreviated survey, the violation was determined to be at the immediate jeopardy level K. Based on observation, interview and record review completed during the onsite visit, it was determined the facility had implemented corrective action to remove the IJ violation at the time. A final revisit will be conducted to determine if the facility is in substantial compliance with participation requirements. At the time of exit, the severity of the deficiency was lowered to the E level. This statement does not denote that the facility has complied with State law (Section 198.026.1 RSMo.) requiring that prompt remedial action to be taken to address Class I violation(s).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure one resident was free from physical and verbal abuse and involuntary confinement (Resident #1). On 5/14/23 between 1:00 P.M. and 1:30 P.M., during lunch in the dining room, Certified Nursing Assistant (CNA) CNA A was observed by the Dietary Supervisor (DS), Dietary Aide (DA) B and Residents #3, #6, #2, #5 and #4 either hitting the resident in the head, raising his/her arms to the resident, yelling/cursing at the resident, and/or forcefully grabbing the resident's wheelchair to prevent the resident from exiting the dining room to go to his/her room and lay down. The DS and DA B failed to immediately intervene by separating the resident from the CNA and reporting what they witnessed to Nurse C. The CNA eventually took the resident out of the dining room to the nurse's station where the resident told Nurse C the CNA hit him/her in the head. Nurse C did not immediately separate the resident from the CNA, did not report what the resident said to the Director of Nurses (DON) and did not separate the CNA from residents, pending an investigation. The CNA finished his/her shift which was approximately five more hours. The CNA was assigned to provide care to 13 residents, including Resident #1. In addition, Nurse C called the Psychiatric Nurse Practitioner (NP) after the incident occurred, informing him the resident was aggressive, grabbed the CNA's arm and scratched the CNA, but did not inform him the resident said the CNA hit him/her in the head. The NP increased the resident's risperidone (an antipsychotic medication used to treat behavioral disorders). In addition, the facility policies did not show how the facility would protect the resident once an allegation of abuse was made. Six residents were sampled. The census was 38. The administrator was notified on 6/6/23 at 11:30 A.M. of an Immediate Jeopardy (IJ) which began on 5/14/23. The IJ was removed on 5/25/23, as confirmed by surveyor onsite verification. Review of the facility's Resident Abuse Policy and Procedures, revised on 8/31/18, showed: -Purpose: -This facility maintains a no tolerance policy on any form of abuse towards residents. The resident has the right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Residents must not be subjected to abuse by anyone, including but not limited to, facility staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, visitors and friends, or other individuals; -Definitions: -Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish; -Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or in their hearing distance, regardless of their age, ability to comprehend, or disability; -Physical abuse including hitting, slapping, pinching and kicking. It also includes controlling behavior through corporal punishment; -Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation; -Involuntary seclusion is defined as separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will, or the will of the resident's legal representative; -The facility prime directive towards resident abuse is to develop and operationalize policies and procedures for screening and training all staff, protection of residents and for the prevention, identification, investigation, and reporting of abuse, neglect, mistreatment, in an effort to prevent occurrences of resident abuse; -Training: All staff will be trained through orientation and quarterly in-services that focus on issues related to abuse prohibition practices which include but not limited to: -Appropriate interventions to deal with aggressive and/or catastrophic reactions of residents; -How staff should report their knowledge relating to allegations without fear of reprisal; -What constitutes abuse, neglect and misappropriation of resident property; -Prevention: -Residents, families, volunteers and staff are provided with the necessary information through the New admission Handbook on how and to whom they may report concerns, incidents and grievances without the fear of retribution; and provide feedback regarding the concerns that have been expressed. Individuals can make their concerns anonymously by filling out a grievance form and placing it under the Administrator's door and/or social worker's office door. Identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of the resident property is or likely to occur; -Identification and Investigation: -The direction of an abuse investigation will be determined following the identification of suspicion of alleged abuse including but not limited to suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; -1. Staff, residents, family members and visitors are to report any suspected abuse to any of the following persons: a) Administrator - Grievance Officer; b) Director of Nursing; c) Charge Nurse; d) Social Worker - Grievance Officer; e) Any Member of Management (Minimum Data Set (MDS) Coordinator, Dietary Manager, Human Resource Manager); -2. Investigation shall follow facility's Incident Reporting Policy: -The timeliness of the Investigation: -The facility must begin the investigation in order to collect accurate data related to the incident. Any delay in starting the investigation can cause valuable information to be either lost or altered; -Thoroughness of the Investigation: -Federal law requires the facility to do a thorough investigation of the incident. In order for the facility to provide evidence of the thoroughness of the investigation the information must be recorded. A thorough investigation may require (2) phases of the fact gathering: -Phase I: Must be completed and reported no later that 2 hours after an allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury. If Phase I is not successful in determining a reasonable cause, an extended phase must follow; -Phase II: The investigation should end with the identification of who is involved in the incident, and what, when, where, why and how the incident happened, including probable or reasonable cause. It should also allow the facility to determine if the allegations were true or not; -Each phase of a thorough investigation includes: Data collection and data analysis. Review of the facility's undated policy, Incident Reporting Policy, showed: -All staff are required to understand what constitutes as abuse, neglect, mistreatment of residents, injury of an unknown origin and misappropriation of their property which are outlined in Resident Rights and Abuse & Neglect Policy which are accordance to Federal and State law; -Staff must protect residents from harm, immediately report incidents as required by federal and state law, and begin investigation as soon incident is made known. It is [NAME] Park's responsibility to immediately: -Protect resident(s) from reoccurrence; and -Take any action necessary to treat the ill effect(s) experienced by the resident(s) as a result of the alleged incident(s); -The policy does not show how the resident will be protected from any alleged perpetrator(s). Review of Resident #1's quarterly Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 2/17/23, showed: -Adequate hearing and vision; -Speech Clarity: Unclear speech - slurred or mumbled words; -Makes Self Understood: Usually understands - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to Understand Others: Understood - clear comprehension; -Severely impaired cognition; -Physical behavioral symptoms directed toward others (e.g.; hitting, kicking, pushing, scratching, grabbing, abusing others sexually): Behavior of this type occurred 1 to 3 days (over the past 7 days); -Verbal behavioral symptoms directed toward others (e.g.; threatening others, screaming at others, cursing at others): Behavior of this type occurred 1 to 3 days; -Rejection of care: Behavior not exhibited; -One person physical assistance required for transfers, locomotion on the unit; -Mobility Devices: [NAME] and wheelchair; -Diagnoses of non-traumatic brain dysfunction (brain injury that is not caused by any external force, instead the cause is due to medical conditions and illnesses that disturb the normal functioning of the brain) and stroke. Review of the resident's care plan, undated, showed: -Problems: -Behavioral Symptoms: Resident noted to have physical and verbally aggressive behaviors; -Falls: Resident will attempt to transfer self from wheelchair to bed and bed to wheelchair; -Activities of Daily Living Functional Status: Resident requires assist of 1 with pivot transfer. He/She is nonambulatory and propels himself/herself independently in the wheelchair; -Mood State: Receives antidepressants and antipsychotics for mood disorder; -Approaches: -Monitor/supervise resident in more frequent intervals as needed; -Provide clear and concise boundaries; -Redirect as needed and remove from situations that are harmful to him/her or others; -Maintain a calm environment and approach to the resident; -Maintain a calm, slow, understandable approach with the resident; -Provide assistance with transferring. Encourage resident to ask for assistance; -Monitor behavior every shift; -The resident's care plan did not identify a problem/intervention with the resident frequently requesting/wanting to lay down after he/she finished eating. Review of the facility Administrator's initial report, on 5/15/23 at 12:11 P.M., showed the following: Summary of Alleged Incident: -On 5/14/23, it is alleged CNA A hit Resident #1 in the back of the head with his/her fists and roughly pulled the resident up to the dining room table. The incident was witnessed by the Dietary Supervisor who reported the incident; -Incident Information: -On 5/15/23 at approximately 11:00 A.M., the DON was reviewing another investigation when the DS approached the DON and handed her some paper saying You need to read this. The DON discovered the paper was a statement signed Anonymous and regarded an allegation that CNA A physically assaulted the resident in the dining room during lunch on 5/14/23 (The DS later acknowledged she was the author of the anonymous statement). She said during lunch on 5/14/23, she witnessed CNA A get frustrated with the resident and forcibly push his/her wheelchair into the table. The resident was trying to go to his/her room and the CNA stopped him/her and started wrestling with the resident. The resident put his/her hands up to block the CNA and the CNA started punching the resident in the back of the head. The CNA then grabbed the resident and started swinging the resident around and the resident was halfway out of his/her wheelchair; -At approximately 11:15 A.M. (5/15/23), the DON immediately notified the Administrator and Administrator in Training (AIT) regarding the DS's statement. An investigation was immediately started; -The DS was immediately interviewed over the phone by the Administrator (the Administrator was at home, the DS was at the facility) with the AIT and DON who were present at the facility with the DS. -DA B said he/she saw the resident scratching CNA A when he/she was trying to take the resident to his/her room. The CNA was trying to stop the resident from agitating the other residents while eating and the resident became upset. -CNA A was interviewed by phone. He/She said he/she tried to redirect the resident because the resident was bothering other residents while they were eating and the resident was going to the steam table (a heated table used to keep food hot). The resident was not able to be redirected and since he/she was done eating he/she tried to remove the resident from the dining room. The resident did not want to go and was upset because he/she would not allow him/her to bother the other residents. When he/she tried to remove the resident, the resident started scratching his/her arm and then tried to hit him/her. He/She tried to keep the resident's hands away from him/her so the resident would not injure him/her. He/She said he/she would never hit a resident and he/she was not angry with the resident. He/She said there were dietary staff and residents in the dining room at the time. Once he/she was able to get the resident out of the dining room, he/she took the resident to Nurse C who was behind the nurse's station; -The DON and AIT interviewed 12 residents, None of their statements were consistent with the DS's statement. One resident (Resident #3) said CNA A was grabbing the resident's arm to prevent the resident from hitting him/her. Resident #3 did express the CNA may have been a little too aggressive; -Conclusion: -Due to the inconsistencies of the statements, it could not be determined whether the allegation was founded. However, there was evidence CNA A did not handle the situation appropriately and as a result was terminated. All employees received an inservice about mandated reporting of abuse and anyone failing to report abuse of any kind will also be held accountable. Review of the facility completed investigation e-mailed to DHSS on 5/22/23, showed: -A written statement from the DON dated 5/15/23: When she reported to work on 5/15/23, at approximately 11:00 A.M., as she was exiting the elevator the DS handed her a statement signed anonymous. Upon discovering alleged abuse (regarding CNA A and Resident #1), she immediately notified the AIT, and they notified the Administrator. An investigation was launched; interviewing residents and staff; followed by in-depth inservicing of staff was started on 5/15/23 and is on-going; -The anonymous note was given to the DON by the DS on 5/15/23: On Sunday 5/14/23 at 12:50 P.M. some residents were done eating their food and started to move around the dining room. Resident #1 was trying to go to his/her room. CNA A was upset with the resident and he/she pushed the resident's wheelchair with so much force back to the table. Moments passed and the resident tried leaving out of the dining room again but this time the CNA was really upset and started to wrestle with the resident. The resident then put his/her hands up trying to block CNA A from hitting him/her in the head. The CNA's fists were balled up and he/she was hitting the resident in the head and face. The CNA then started to grab onto the resident's shirt with force slinging the resident around in the wheelchair, pushing on the resident, and handling the resident with the most disrespectful force until the resident was almost on the floor. The CNA then grabbed the resident by the front of his/her shirt and pushed threw the resident back into his/her wheelchair. Then the CNA started to swing the wheelchair forcefully against the door and wall and said to the resident don't play with me I'll lose this job from fucking you up. The resident got very upset and I was yelling at the CNA to leave the resident alone, then Resident #4 was yelling at the CNA to leave the resident alone. The other CNAs were not in the dining room when this happened. A few minutes later people said they wasn't going to report the incident/abuse because they are too short staffed. The CNA told Nurse C the resident was trying to scratch him/her so he/she wouldn't have any consequences following this. I wanted to call the police on the CNA but she figured you all should know first. She is reporting this now. It was very horrible what she witnessed. Signed: A very concerned witness - anonymous; -During the facility investigation the DS confirmed she had written the anonymous note; -The DS's written statement dated 5/15/23, completed after giving the DON the anonymous statement: As some residents were done eating their food and started to move around to leave out of the dining room, Resident #1 kept trying to go to his/her room. CNA A was getting upset with the resident and he/she pushed the resident's wheelchair with so much force against the table. The resident tried leaving again and this time the CNA was very upset and was trying to get the resident to stop but the resident tried to keep going and the CNA balled up his/her fist and hit the resident a few times. She asked the CNA to stop and he/she wasn't listening, then the resident was asking the CNA to stop as well. She then left to go back to the kitchen after being in shock after what she had witnessed. The very next day she reported it to the DON; -A typed statement from the Administrator dated 5/17/23: On 5/15/23 the Administrator (at home) interviewed the DS by phone (DS was at the facility). The following questions were asked during the interview: Question (Q): What staff were present? Answer (A): DA B, CNA A and the DS; Q: How did CNA A hit the resident, how many times, where? A: A few times, in the back of the head with his/her fists; -DA B's undated written statement (per interview with the Administrator, DA B's statement was written and given to Nurse C on 5/14/23): CNA A was taking Resident #1 out of the dining room. The resident started fighting the CNA. The CNA never put his/her hands on the resident. The resident started swinging on the CNA; -A written statement from Nurse C, dated 5/15/23: On 5/14/23, during lunch meal, Resident #1 was brought to the nurse's station by CNA A. This nurse asked the resident again what happened and the resident said the CNA hit him/her. When asked where the CNA hit him/her, he/she said in the head. When asked where in the head, he/she said he/she didn't know. This nurse assessed the resident's head, no redness, swelling, or open areas. This nurse asked the CNA if anyone else was in the dining room during the incident and he/she said DA B. DA B was asked to come to the nurse's station. This nurse asked him/her if he/she had seen the incident between the CNA and resident. He/She said he/she had. When the CNA tried to push the resident out of the dining room he/she started scratching the CNA; -A written statement from the Housekeeping Supervisor (HS) dated 5/17/23: She was at the front desk talking to Receptionist H on 5/15/23 around 7:30 A.M The DS came to the front desk and sat in a chair. The DS stated CNA A was pulling and hitting Resident #1. She asked the DS if she stopped the CNA from hitting the resident and he/she said no. She asked the DS if she called anyone and she said no because Nurse C was standing there. I asked the DS if she called the DON or Administrator and she said that is what she is waiting for them to come in so she can tell them. That was about 7:45 A.M. on 5/15/23; Resident statements, dated 5/15/23: -Resident #2: CNA A was pulling Resident #1's wheelchair and Resident #1 was resisting; -Resident #3: CNA A and Resident #1 were fighting. The CNA was grabbing the resident arms trying to stop the resident from hitting him/her. The CNA was pulling on the resident's wheelchair trying to get the resident out of the dining room. He/She (Resident #3) felt like the CNA was being a little too aggressive; -Resident #5: CNA A was trying to stop Resident #1 from messing with other people and the resident got upset. The resident was then trying to go to the steam table and the CNA tried to pull the resident's wheelchair away. The resident got aggressive and started swinging at the CNA. The CNA was just trying to get the resident out of the dining room. The resident was swinging at the CNA; -Resident #6: He/She saw CNA A pulling Resident #1's wheelchair. The CNA was pulling it kind of hard because the resident was pushing against the CNA. He/She did not see any hitting. Review of the resident's electronic medical record, showed an Events Detail form completed by Nurse C on 5/17/23 at 8:18 P.M., which included the following: -When Occurred: 5/14/23 1:30 P.M.; -Progress Note: At approximately 1:30 P.M. during lunch meal, the resident started propelling around the dining room touching other residents while they were eating. Third assignment CNA requested resident to stop touching others, however behavior continued. He/She attempted to escort the resident out of the dining room. The resident then grabbed his/her arm and started scratching him/her. The resident was brought to nurse's station for close supervision. When asked why he/she (resident) did the above, the resident said they lying on me. Psychiatric Nurse Practitioner (NP) informed of behavior. New order received for risperidone 0.5 milligrams (mg) every morning. Physician and DON informed of behavior and new psych recommendation. Review of the resident's Physician's Order Sheet, showed: -An order dated 2/3/23, for risperidone 1 milligram (mg) daily at hour of sleep (HS) med pass 7:00 P.M. - 11:00 P.M.; -An order dated 5/14/23 for risperidone 0.5 mg daily during the A.M. med pass (7:00 A.M. - 11:00 A.M.). Review of the resident's medication administration record (where nurses initial a medication has been administered per physician orders), for May 2023 and June 2023. showed: -An order for risperidone 0.5 mg at A.M. med pass and initialed as administered daily from 5/15/23 thru 5/31/23, and 6/1/23. During an interview on 5/25/23 at 8:40 A.M., the Administrator said the facility investigation sent to DHSS on 5/22/23 was complete and she had nothing more to add. CNA A is the shower aide but was working the floor as a CNA on 5/14/23. He/She was assigned a group of residents to care for that day, which included Resident #1. CNA A worked his/her 12 hour shift on 5/14/23, from 6:30 A.M. to 6:30 P.M. Review of CNA A's time sheet, dated 5/14/23, showed he/she clocked in at 6:50 A.M. and clocked out at 6:30 P.M. During an interview on 5/25/23 at 10:40 A.M., Resident #1 said staff treat him/her good and no one has been mean or abusive to him/her. He/She said he/she did remember CNA A would not let him/her leave the dining room one day, but could not recall what day that was. He/She wanted to lay down. The CNA grabbed his/her wheelchair and wouldn't allow him/her to leave. That made him/her mad. He/She thinks the CNA may have hit him/her in the front of his/her head, but he/she is not sure. The resident was not afraid of the CNA that day, he/she just wanted to lay down. He/She had not had any problems with the CNA prior to that day. During an interview on 5/26/23 at 9:15 A.M., the DS said on 5/14/23 during lunch, she, DA B and CNA A were in the dining room. Resident #1 was in his/her wheelchair and trying to go back to his/her room. The resident was trying to wheel himself/herself out of the dining room to the hall that leads to his/her room and the CNA was getting frustrated with the resident telling him/her that he/she couldn't leave the dining room. The CNA grabbed the resident's wheelchair hand bars and dragged the resident backwards back into the dining room multiple times. The DS heard a commotion and turned to see the CNA hit the resident. The CNA had his/her fists balled up and hit the resident in the back of the head more than one time. The resident had his/her hands up trying to block the CNA from hitting him/her. The CNA very loudly told the resident you don't know me, I'll lose my job and that he/she did not have time to keep bringing him/her back. The DS told the CNA that's enough, you need to stop it. The resident kept saying he/she wanted to go to his/her room. The resident had slipped down in his/her wheelchair and the CNA grabbed a hold of his/her shirt and pushed the resident back into the wheelchair seat. After that, the CNA took the resident to the nurse's station. The DS did not report what she saw because Nurse C was standing in the hall at his/her cart and she assumed the nurse saw what happened. She did not see the nurse intervene or say anything to the CNA. The DS did not speak to the nurse about what happened, she went downstairs. She is the one that wrote the anonymous letter and gave it to the DON. The DS wrote it anonymously because she wanted to avoid confrontation or retribution. During an interview on 5/25/23 at 9:15 A.M., DA B said on 5/14/23, it was CNA A, the DS, and DA B in the dining room during lunch. The resident had no behaviors while he/she was eating. After the resident finished eating, he/she saw the resident going and talking to other residents. The resident always does this. The resident did not appear to be bothering anyone and the other residents were not complaining. It was after this when the resident told the CNA he/she wanted to go to bed. The CNA told the resident he/she was not going to take him/her to bed. This is when the resident began to get upset. The resident was trying to wheel himself/herself out of the dining room. The resident got to the doorway and the CNA brought the resident back. The resident did not want to come back, saying he/she wanted to go to his/her room. The CNA grabbed the resident's wheelchair by the handles, preventing the resident from leaving. The resident was trying to go one way and the CNA was making him/her go another. That's when the resident began swinging at the CNA. He/She did not see the resident scratch the CNA, but the resident was swinging his/her arms at the CNA who was standing behind the resident's wheelchair. DA B saw the CNA put his/her arms up and the CNA was swinging his/her arms. He/She did not see the CNA hit the resident in the head, but it could have happened because the CNA had his/her arms up too. He/She heard the DS say if the resident wants to go to his/her room, let him/her go to his/her room. The entire incident lasted approximately 6 or 7 minutes. DA B did not say anything to anyone because he/she thought CNA A would tell Nurse C what happened. Review of Resident #6's annual MDS, dated [DATE], showed: -Adequate hearing; -Vision impaired - sees large print, but not regular print in newspapers/books; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Usually understands - difficulty communicating some words or finishing thoughts but is able if prompted or given time; -Ability to Understand Others: Understands - clear comprehension; -Cognitively intact. During an interview on 5/26/23 at 12:38 P.M., Resident #6 said he/she was in the dining room at lunch on 5/14/23. CNA A got real loud with Resident #1 because the resident wanted to stay in the dining room, he/she did not want to leave the dining room. He/She saw the CNA swinging on the resident. The CNA hit the resident, but he/she did not see where he/she hit the resident. The resident was using his/her feet to stop the CNA from pushing his/her wheelchair. The CNA was very aggressive and jerking the resident's wheelchair around. The resident was yelling at the CNA to stop and the CNA was yelling at the resident. Review of Resident #2's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands - clear comprehension; -Cognitively intact. During an interview on 5/25/23 at 11:03 A.M., Resident #2 said he/she was in the dining room on 5/14/23 during lunch. The CNA was trying to pull Resident #1's wheelchair and the resident did not want to be pulled. The resident was putting his/her feet down on the floor to stop the CNA from pulling him/her. Resident #2 thinks the resident was mad because he/she was kind of swinging at the CNA. The CNA did not swing at the resident that he/she saw. Review of Resident #5's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Understands - clear comprehension; -Cognitively intact. During an interview on 5/26/23 at 12:30 P.M., Resident #5 said he/she was in the dining room on 5/14/23 during lunch. Resident #1 was trying to leave the dining room and CNA A kept pulling the resident back into the dining room. The resident seemed to be getting upset as he/she was swinging his/her arms. Review of Resident #4's quarterly MDS, dated [DATE], showed: -Adequate hearing and vision; -Speech Clarity: Clear speech - distinct intelligible words; -Makes Self Understood: Understood; -Ability to Understand Others: Under