**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the re-certification and abbreviated survey, the facility did not ensure that residents were free from abuse, neglect, and exploitation. Specifically, (1) Resident #69 sustained an injury of a laceration to her right leg that required sutures in a resident-to-resident altercation (NY#00215196); and (2) Resident #604 was punched in the head by another resident and suffered a headache and blurred vision (NY#00218990). Both incidents involved the same aggressor (Resident #267). This was evident for 2 of 5 residents reviewed for Abuse (Resident #69 and Resident #604). This deficient practice resulted in actual harm to Resident #69. The findings are: The undated policy for Resident to Resident Abuse documents that the facility will ensure residents' right to be free from verbal and physical abuse and misappropriation of property from other residents. All forms of resident to resident abuse must be reported immediately to the nursing supervisor who will notify the physician, director of nursing, administrator and social worker. Procedures for the aggressor include developing a care plan for residents at risk of abusing other residents that have strategies and interventions to prevent occurrences, developing a behavioral care plan with interventions, and monitoring the resident for aggressive behavior. Procedures for the victim include identifying residents who may be victims of abuse, psychiatrist and/or psychologist evaluations if necessary, and providing in-service education to staff. Resident #267 was admitted to the facility on [DATE] with diagnoses of Psychotic Disorder, Schizophrenia, and Anxiety Disorder due to known Physiological Condition. On 7/18/19 at 8:40 AM and 7/19/19 at 11:11 AM Resident #267 was observed in his room doing activities by himself. Resident was calm. A Quarterly MDS dated [DATE] documented resident #267 is usually understood and usually understands others, cognitively intact, no delusions, mood severity score of 2, no hallucinations, no delusions, no behaviors, independent with ADLs. The resident's active diagnosis includes Psychotic Disorder, Schizophrenia, Autistic Disorder. The resident received antipsychotic medication daily. The CCP titled Behavior symptoms dated 1/29/18 documented wandering, resident has a history of verbally abusive/yelling/screaming, history of physically abusive throwing chairs at others, socially inappropriate, easily agitated when does not get what he wants. Interventions included allow to vent feelings, assess mental status, call resident's mother to help him calm down when agitated, monitor and document changes in behavior, provide verbal and emotional support, psychological consult and treatment as ordered, redirect as needed, remove resident from situations with increased behaviors A Nursing Note dated 1/27/18 documented Resident #267 was screaming and talking to himself at times. Emotional support was provided, and the behavior was redirected. Staff set limits with the resident and encouraged the resident to play with Play Do or color, but the interventions were not effective. The MD ordered Seroquel 50 mg PRN to be given. A Nursing Note dated 1/30/18 documented Resident #267 was transferred to the hospital for aggressive behavior of lifting and throwing a chair on the floor in front of other residents in the dining room because he was frustrated with his computer program running slow. Resident #267 was moved away from other residents and emotional support was provided. Resident #267 was at high risk for hurting self and others. Resident #267 was transferred to [NAME] hospital for unmanageable behaviors. The resident returned to the facility on 1/30/18. There was no documented evidence in the medical record that the facility reviewed or updated the plan of care with interventions to address the resident's aggressive and unmanageable behaviors after the resident returned from the hospital. A Nursing Note dated 2/6/18 documented Resident #267 returned to the facility from an appointment and had a scheduled room change to a different unit. Subsequent nursing notes documented behaviors of screaming, yelling, and becoming upset when he cannot get his way. Resident #267 was not responsive to emotional support and redirection. 1) A nursing note dated 2/11/18 documented Resident #267 began hitting and yelling at staff and residents. The resident became agitated when his tablet was not working. Resident #267 was a danger to himself and others with no self-control. Resident #267 became aggressive in the dining room and inflicted physical harm to Resident #69 via laceration resulting in Resident #69 being transferred to the hospital for suturing. Resident # 267 was transferred to the hospital for psychiatric evaluation. A Nursing note dated 2/11/18 documented Resident #69 was transferred to the hospital at 11:50 AM. Resident had a laceration on right lower leg 7 cm x 1 cm bleeding. Resident #69 was sitting in her recliner chair and Resident #267 held her leg and scratched her causing lacerations. The resident was transferred to the hospital for suturing. A Social Work Note dated 2/11/18 documented that Resident #69 was seen after the incident. The resident was not able to recall the incident or express feelings regarding the incident. The facility Occurrence Report dated 2 /11/18 documented resident #267 is an Autistic patient who became agitated/yelling at patients and staff. Resident #267 is a danger to self and others. Resident #267 follows staff around verbally abusing them. Resident # 267 is a hostile resident with no self-control, may cause hard to self and/or others. Resident #267 got aggressive in the dining room causing another resident physical harm. Resident #267 caused a laceration on resident #69 leading to resident #69 being transferred to the hospital for suturing. Attached to the report were two separate statements from CNA #2. The statements differ in the account of events. In the first written statement dated 2/11/18, CNA #2 reported that around 11:45 AM she was in the dining room when Resident #267 came into the dining room banging his hands on the tables. Resident #267 was hostile and started following her around. Resident #69 was in her recliner chair when Resident #267 began banging her leg and then scratched it. CNA #2 stated Resident #69 was already bleeding when she was able to intervene. In the second written statement dated 2/11/18, CNA #2 reported that between 11:15-11:30 AM she was in the dining room observing the residents. CNA #2 reported resident #267 entered the dining room upset about his iPod not working. CNA #2 told the resident she could not help him, resident #267 began screaming I need You Tube and began banging his fists on the table. CNA #2 reported that resident #267 began following her while banging his fists on other tables. Resident #69 was close to resident #267. Resident #267 then spun around and banged on resident #69's leg, causing resident #69's leg to slip out of the wheelchair and start bleeding. Resident #267 moved to the other side of the room and started to pack his things asking where he was going to be sent. Shortly after this resident #267 went over and sanitized his hands. In a written statement dated 2/11/18, the Licensed Practical Nurse (LPN #1) reported she provided wound care to Resident #69 after the incident. In a written statement dated 2/11/18, the Nurse Practitioner (NP) reported they were called to evaluate Resident #69 after the incident. The NP determined Resident #69 should be transferred to the hospital for stitches since the wound was deep. The NP reported that Resident #267 was sitting in his wheelchair watching television saying he was sorry and that his tablet was not working, and he was agitated about that. The facility investigation summary of the incident dated 2/14/18 documented that on 2/11/18, around 10:30 AM, Resident #267 became upset when his iPod was not working. Certified Nursing Assistant (CNA) #2 was in the dining room when the incident occurred. CNA #2 stated resident #267 began screaming I need You Tube and started banging his fists on the table. Resident #267 followed the CNA around the room and eventually banged his fists on resident #69 leg. CNA #2 intervened and separated the residents. The nursing supervisor was notified. Resident # 267 was sent to the hospital for psychiatric evaluation, and Resident #69 was sent to the hospital for suturing of the lower right leg. The investigation concluded that there was insufficient reason to believe that resident #267 willfully tried to inflict injury on Resident #69 and stated resident #267 has a diagnosis of Autism. Nursing Notes dated 2/15/18 documented Resident #267 returned to the facility from the hospital. The resident was transferred to a different floor and placed on 1:1 (one-to-one) 24-hour supervision. Resident #69 was admitted to the facility on [DATE] with diagnosis that include, but are not limited to: Non-Alzheimer's Dementia, difficulty walking. The admission Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented Resident #69 is sometimes understood and sometimes understands others. The resident had moderately impaired cognitive skills for daily decision making, and there were no signs and symptoms of delirium, delusions, or hallucinations. The behavior of rejecting care occurred four to six days. The resident required extensive assistance for bed mobility and transfer. The resident was totally dependent on staff for locomotion on and off unit, dressing and toilet use. The resident had range of motion impairment on both sides of upper and lower extremities. The resident did not have any skin conditions upon admission. The Comprehensive Care Plan (CCP) titled Cognitive status, for Resident #69, dated 2/1/18 documented the resident has moderately impaired (alert and oriented X (times) 1 to self only) cognition with short- and long-term memory loss. Interventions included assessing the resident's mental status, providing an interpreter as needed, and allowing the resident to express feelings. The CCP titled Behavior Symptoms dated 2/1/18 documented the resident is verbally abusive, physically aggressive, socially inappropriate talking to herself, and resists care. Interventions included: allow resident to vent feelings, assess mental status, monitor and document changes in behavior, redirect as needed, and remove from situations where resident may have increased behaviors. The CCP titled Communication dated 2/1/18 documented the resident has impaired communication related to hearing loss and cognitive impairment, and the resident is Spanish speaking. Interventions included anticipate needs, use short and simple sentences, and non-verbal communication techniques. The resident was observed by the SA (State Agency Surveyor) on 7/16/19 at 11:54 AM and again on 7/23/19 at 9:32 AM. Both times the resident was observed, sitting in her wheelchair, in the dayroom. The resident is Spanish speaking. The resident was observed to speak louder when staff approaches to give assistance. It was observed that once staff gives resident emotional support she calms down. On 7/16/19 at 11:59 AM an interview was held with Resident #69's nephew. The resident's nephew stated he comes to visit his aunt every day to feed her during lunch time since she was admitted to the facility. Prior to the incident on 2/11/18, the resident's nephew stated his aunt never had any altercations or problems with other residents. Resident #69's nephew stated that his aunt is confused and mostly talks to herself and sometimes gets scared when staff try to provide care. The resident's nephew confirmed that his aunt was assaulted by another resident last year. He identified the resident as resident (#267). The facility called him after the incident. The resident's nephew stated his aunt was sent to the hospital and got stitches. The resident's nephew stated his aunt does not remember the incident. He stated that resident #267 was transferred to another unit and he was pleased. He stated that his aunt is confused, so he did not notice any change in his aunt after the incident. On 07/23/19 at 10:56 AM, the Director of Nursing (DON) was interviewed. The DON stated that Resident # 69 is demented and needs total assistance from staff with her Activities of Daily Living (ADL's). The DON stated that Resident #69 is out of bed in the recliner wheelchair in the dayroom and is usually very noisy. The DON stated that if you touch Resident #69 she will scream. The DON stated Resident #69 is very confused and maybe only recognizes her nephew's face. The DON also stated that Resident #267 will lash out when he does not get his way and gets upset quickly. Resident #267 gets very upset when he does not get his way. The DON stated that she was in the building at the time of the incident and became aware of the incident immediately. The DON reported that Resident #267 was upset his iPod was not working. The DON stated that staff were trying to fix his iPod and it was taking too long so resident #267 became upset and started banging on the tables before banging on Resident # 69's leg. The DON stated that the CNA assigned to the dining room separated the residents as soon as she could. The DON stated Resident #69 was sent out to the hospital for stitches after the incident and was evaluated by a psychiatrist. The DON stated that after the incident, staff monitored Resident #69 for any psychological effects from the event, and none were exhibited. Resident #69 continues to have the behavior of screaming out when she is touched, so staff try to position her correctly. The staff also move her out of the room when she gets upset to prevent other residents getting upset. The DON stated that Resident #69 has a very involved family and they did not express any concerns after Resident #267 was moved to another unit. The DON stated that after the incident there was an in-service done with direct staff. The training was done by someone who specializes in Autism. The in-service topics included how to approach a resident in a calm manner. The DON stated that staff are in-serviced on abuse upon hire and annually. Resident #267 was transferred to a different unit and put on 1:1 monitoring for 24 hours a day. The DON stated the interdisciplinary team developed a comprehensive care plan and a solo activity schedule to keep Resident #267 occupied. The DON reported the activity schedule was written on a board, so all staff members knew what Resident #267 was scheduled to be doing throughout the day. The DON reported there were scheduled times for the resident to call his mother, which was identified as a non-pharmacological intervention to calm the resident down. The DON stated that after the incident in February, the structured routine and schedule was working well for the resident, and with 1:1 supervision, the resident was doing well. The DON stated attempts were made to interview Resident #267 about the incident, but the resident would not talk about it. On 07/23/19 at 11:15 AM, an interview was held with CNA #1. CNA #1 stated Resident #267 needs a routine and structure. Since the implementation of the activity schedule, the resident's behavior has improved. CNA #1 stated that the resident can perform his ADLs with supervision. CNA #1 stated that the resident can wash, dress, brush his teeth, make the bed, and eat by himself. CNA #1 stated that Resident #267 has poor impulse control. The CNA reported that after the incident, the resident was not able to recall the incident, but he apologized afterwards. On 7/23/19 at 12:21 PM, an interview with the Registered Nurse (RN #2) was conducted. RN #2 stated that she was in the building during the incident. After the incident, Resident #69's mental status was assessed. As a result of the assessment, the staff keep constant visual contact on the resident to make sure she is safe. The RN stated that staff will monitor to see if any residents try and to get closer to Resident #69 for any reason. RN #2 stated that the resident is vulnerable, and, after the incident, staff need to make sure the resident is safe both physically and emotionally. Per the DON, CNA #2 was not available for interview because they were out on medical leave, and LPN #1 was not available. 2) The undated policy titled Special Assignment (1:1) documents one-to-one/special assignment is provided to residents that exhibit potential to harm themselves or others. A CNA will be scheduled to monitor the resident's behavior and indicate on the monitoring log form any concerns noted. Any behavioral issues will be reported to the charge nurse for intervention and follow up, and period assessment for need will be conducted. Resident #604 was admitted to the facility on [DATE] with diagnosis which include but are not limited to the following: Muscle weakness, difficulty walking, Anxiety Disorder, and Major Depressive Disorder. The Quarterly MDS assessment dated [DATE] documented the resident was understood and understands others, the resident had intact cognition. The resident did not experience any hallucinations, delusions, or symptoms of delirium. The resident did not display any behaviors. The resident required extensive assistance from staff for Activities of Daily Living (ADLs). The resident's diagnoses included: Anxiety Disorder. Resident #604 was discharged from the facility on 12/21/18, therefore no observations were made. The Comprehensive Care Plan (CCP), for resident #604, titled Mood dated 12/22/18 documented the resident was feeling down, depressed, hopeless, feeling bad about self, and had a diagnosis of Anxiety Disorder. Interventions included allowing resident to vent feelings, assessing the resident's mental status, and monitor and document any mood changes. The facility investigation summary report dated 4/27/18 documented, prior to the incident, Resident #267 was sitting in his wheelchair in front of the nursing station asking staff to call his mother. Staff called the resident's mother four times with no answer. Resident #267 became anxious and the MD was notified. The MD instructed staff to redirect and monitor the resident with no new orders given. A CNA offered the resident juice and told the resident they were going to call his mother in a little bit. After a few minutes, the resident asked for more juice and permission to ride his wheelchair into the dining room. Around 12:45 PM resident #267 stood up from his wheelchair in the dining room asking where his mom was and became anxious. Resident #267 walked to the dining room and struck another resident (#604) in the head. Staff immediately responded and separated the residents. Resident #267 received a Haldol injection per the MD order and was transferred to the hospital for agitation. Resident #604 was assessed by the nurse and the MD ordered the resident's transfer to the hospital for evaluation. The investigation concluded that there was insufficient reason to believe that resident #267 willfully tried to inflict injury on Resident #604 because Resident #267 has a diagnosis of Autism. The resident did not sustain injury. In a written statement dated 4/27/18 LPN #2 reported that around 12:40 PM, on 4/27/18, resident #267 asked the nurse to call his mom and the nurse and social worker called the resident's mom four times, but the mom did not answer the phone. In the hallway by the nursing station, Resident #267 got out of his wheelchair and asked, Where is my mom? The CNA offered the resident juice, and the nurse explained she would call his mom back in a little bit. Resident # 267 asked for more juice and permission to ride his wheelchair into the dining room. In the dining room, Resident # 267 became anxious and began asking where his mom was. The staff tried to redirect him, but it was not effective. Resident #267 stood up and punched resident #604 in the head. In a written statement dated 4/27/18 CNA #3 reported around 12:40 PM she went into the dining room and noticed Resident #267 got out of his chair and was very agitated. Resident #267 turned and punched resident #604 in the head and turned away and slapped resident #604 in the head again. CNA #3 stated she tried to calm resident #267 down and the resident got angry and spit on her. Resident #267 apologized to the CNA afterwards. Nursing Notes dated 2/15/18 documented Resident #267 returned to the facility from the hospital after a resident-to-resident altercation. The resident was transferred to another floor and placed on 1:1 (one-to-one) 24-hour supervision. A Nursing Note dated 4/1/18 documented resident #267 was on 15-minute checks. The resident was observed with verbal disturbances of laughing and having conversations with himself. Subsequent Nursing Notes documented Resident #267 displayed behaviors of talking to self and yelling, disrupting other residents. Resident #267 remained on 1:1 supervision and started on Celexa for psychosis. A Social Work Note dated 4/13/18 documented a team meeting was held to discuss resident #267 plan of care. The team discussed the resident's behaviors, recreational needs, and monitoring. The plan was for structured activities and 1:1 monitoring to be continued. Social Work Notes dated 4/18/18 and 4/19/18 documented the resident was approved for a 24-hour aide and supportive services from OPWDD after discharge. The resident could return home and wait for group home placement with a tentative discharge the following week. In the meantime, Resident #267 was transferred Resident #604's unit. The Physician's (MD) note dated 4/19/18 documented Resident #267 was seen by the psychiatrist and the recommendation was made to continue 1:1 monitoring. A Social Work Note dated 4/23/18 documented extended homecare was declined because Resident #267's mother did not want to care for the resident at home. Resident #267 had to remain in the facility until appropriate placement could be obtained. There was no documentation in the record indicating whether the resident received notice or increased support regarding not being able to be discharged home to live with his mother. The April 2018 progress notes were reviewed for resident #604, and there were no behavior notes documented. The MD Note dated 4/27/18 documented the MD was called to the unit to evaluate Resident #604 after she was struck by another resident (#267) around 12:45 PM. Resident #604 had mild edema to the temple and cheek area. Resident #604 complained of left side facial pain and blurry vision. The MD ordered for Resident #604 to be transferred to the hospital for an evaluation. The MD documented Resident #604 had a history of anxiety and was not currently on any medications or followed by psychology or psychiatry. A Nursing Note dated 4/27/18 documented resident #604 was transferred to the hospital status post trauma to the head at 12:45 PM. Resident #604 was the victim of abuse when she was hit/slapped in the head by another resident (#267) suddenly without reason while in the main dining room. Resident #604 complained of left side facial pain and blurry vision. An ice pack was applied to the resident's head. A Social work Note dated 4/27/18 documented Resident #604 was the victim of abuse this afternoon; the resident was hit by another resident (#267) while in the dining room. Resident #604 was expressive and appeared to be saddened about the incident. Resident #604 was counseled and expressed desire to remain on the unit at the time. Psychology follow up was requested. The CCP titled Resident to Resident Altercation dated 4/27/18 documented the resident was a victim of abuse and was hit by another resident (Resident #267). The resident also had verbally abusive behavior and was easily annoyed with a short temper. Interventions included counseling resident to assist with coping with stressful situations, monitoring resident interactions with peers, and psychological evaluation and services. A review of the Resident Status Observation Log dated 4/27/18, for Resident #267, documented the resident exhibited upset, aggressive behavior from 8:30-9:00 AM. At 9:45 AM, it was documented that the resident was repeatedly calling his mother with no answer on the other end. From 12:15-1:15 PM the CNA assigned to resident #267 was on their lunch break, the resident was no longer being monitored 1:1. It is documented that While I was out for lunch [the resident] hit a patient/spat on CNA. A post incident report dated 4/27/18 documented Resident #267 returned from the hospital the same day, 4/27/18. MD ordered resident #267 to be closely monitored to prevent his autistic related behavior from injuring others. An post incident Report dated 4/27/18 documented Resident #604 returned from the hospital on the same day, 4/27/18, with a clear CT scan of head, neck and spine. Resident # 604 was referred to psychological services for emotional support and optometry for blurred vision. A Social work note dated 4/30/18 documented resident #604 was seen by the psychologist today and no recommendations made. A Social Work Note dated 4/30/18, for Resident #267, documented the Social Worker requested 1:1 companion from OPWDD until the resident can be placed into a group home. On 07/23/19 around 11:10 AM, RN #1 was interviewed. RN #1 stated she was the supervisor on the unit at the time. RN #1 stated that Resident #267 got very angry when his mom did not answer the phone and went into the dining room and slapped resident #604 in her face. RN #1 stated that resident #267 calmed down after the incident. RN#1 stated that both residents involved in the incident were sent out to the hospital. RN #1 stated that resident #267 was on 1:1 at the time of the incident, and the CNA watching him was on their lunch break. When asked about who covers the resident when staff goes on lunch break, RN #1 stated the floor staff provide coverage and monitor the resident. She stated there is no one person who relieves the CNA from 1:1 assignment when they go on break. RN #1 stated that resident #267 is allowed to be in his room alone. When questioned about impulsive behavior or unsafe behavior in the resident's room, RN #1 reported that the staff are monitoring every 30 minutes and there had been no episodes since February. RN #1 reported during lunch time, there are 5 CNAs and a nurse in the dining room, which provides enough coverage to monitor residents. RN #1 reported that resident #267 behaviors are episodic and unpredictable. RN #1 stated that the resident was supposed to be discharged that week before the incident, but the resident mother did not want to take him back home. The facility was working on getting him placement in a group home. RN #1 stated that resident #604 is alert and oriented x 3. RN #1 stated that resident # 604 was very anxious and depressed about her placement in the nursing home from the beginning. RN #1 stated that after the incident, Resident #604 was placed on psychotherapy. RN #1 stated that the resident's daughter is very involved and would take her outside and spend time with her. After the incident, RN #1 stated that resident #604 was offered a transfer to a different unit but declined at the time. The facility continued treatment for the resident and planned for a safe discharge. On 07/23/19 at 10:56 AM, the Director of Nursing (DON) was interviewed. The DON stated that most incidents that happen with Resident #267 involve his mother. The DON reported that the resident's mother was not working with the facility on caring for the resident. The DON reported that after this incident, the resident's mother has been more cooperative with the team and is working on getting housing where she can live with the resident at home. The DON reported that to date, Resident #267 has been declined from four group homes and they are still looking for appropriate placement. Per the DON, CNA #3 and LPN #2 were not available for interview. The facility staff did not ensure that the 1:1 supervision was provided, as recommended, in order to prevent further incidents. In addition, Resident #267 was permitted to go into the dining room with other residents without the 1:1 supervision after displaying aggressive behavior and increased anxiety. This put other residents at risk for being abused by the resident. The facility did not protect other residents from being abused by Resident #267. 415.4(b)(1)(i)