**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a Complaint investigation (#NY00359779, and #NY00363581) during an Extended Standard survey completed on 2/3/2025, the facility failed to protect residents from abuse by other residents for three (3) (Resident #17, #71, and #75) of 12 residents reviewed. Specifically, on 11/4/2024, Resident #68 struck Resident #71 in the face with their walker, resulting in a laceration across the bridge of Resident #71's nose, and skin tears to their right cheek and chin. Additionally, on 12/5/2024, 12/10/2024, and 12/11/2024, physical altercations occurred between Residents #17 and #75, who were roommates and remained roommates until after the third altercation on 12/11/2024. This resulted in actual harm to Resident #71. The findings are: The policy titled Abuse/Neglect - Reporting Process, last revised 12/15, documented it is the policy of the facility to treat all residents with kindness, dignity, and consideration. They ensure all residents are free from verbal, sexual, physical, and mental abuse. The policy titled Abuse Preventing and Reporting, last revised 9/23, documented an abusive act is defined as any act of commission or omission that causes potential or actual physical or emotional harm or injury to a resident. Physical abuse is defined as any act or omission which may cause or causes physical pain, harm or injury to the resident or where it is reasonable to believe that pain, harm or injury would result. Physical abuse may include, but is not limited to slapping, pinching, kicking, pushing or rough handling, and/or failure to intervene in a resident altercation that results in physical harm to a resident. 1. Resident #68 had diagnoses that included unspecified dementia with behavioral disturbance, restlessness, and agitation. The Minimum Data Set (a resident assessment tool) dated 10/9/2024 documented Resident #68 was severely cognitively impaired, was usually understood, and usually understands. The [NAME] (a guide used by staff to provide care) dated 1/31/2025 documented Resident #68 was independent with ambulation on the unit, using a rolling walker. The facility could not provide a [NAME] for the time of the abuse 11/4/2024. The comprehensive care plan dated 6/18/2021 documented Resident #68 had a history of physical and verbal aggression, intolerance of noise and of others entering their room, related to dementia. Staff were to assess and anticipate resident's needs, intervene before agitation escalates, guide away from source of distress, and allow to share feelings. On 2/2/2024 a Velcro stop sign was added across entry doorway as needed and the door to their room was to be closed. Resident #71 had diagnoses that included chronic obstructive pulmonary disorder (lung disease that blocks airflow and make it difficult to breath), unspecified dementia without behavioral disturbance, and depression. The Minimum Data Set, dated [DATE] documented Resident #71 was severely cognitively impaired, sometimes understands, was sometime understood, continuously had disorganized thinking and wandered occasionally. The [NAME] dated 1/31/2025 documented Resident #71 was independent with wheelchair mobility on the unit. The facility could not provide a [NAME] for the time of the abuse 11/4/2024. The comprehensive care plan identified as current, dated 6/12/2023, documented Resident #71 had impaired cognitive function related to dementia and to cue, reorient and supervise as needed. The comprehensive care plan documented Resident #71 had a communication problem related to a hearing deficit. Staff were to anticipate and meet needs and to be conscious of Resident #71's position when in groups, activities, and dining room to promote communication with others. The comprehensive care plan did not document that Resident #71 wandered into unsafe places or displayed behaviors directed towards others. Review of the resident-to-resident incident reports for Resident #71 and Resident #68 completed by Registered Nurse #1, and the facility's investigation report completed by the Director of Nursing dated 11/4/2024, revealed at 2:45 PM, Resident #71 was propelling their wheelchair down the hallway when they opened Resident #68's room door and started to enter. Resident #68 met Resident #71 in the doorway, lifted their walker to Resident #71's face, and began pushing them out of their room. Resident #71 began yelling, which alerted staff, who then immediately intervened and separated the two (2) residents. Resident #71 sustained a skin tear to their right cheek and chin and a laceration across the bridge of their nose with a moderate amount of bloody drainage. Bruising was also noted across their nose. Resident #71 was visibly upset and showed moderate signs of pain and discomfort. Tylenol was given, the wounds were cleansed, and steri-strips (thin, sticky bandages applied to skin to help cuts or wounds stay closed) were applied to their right cheek and nose, along with a dry clean dressing to their chin. X-rays were obtained and were negative for any fractures. Resident #68 became aggressive towards staff and was sent to the emergency room for evaluation. The reports documented Resident #68 had a history of aggression towards other residents and staff, had a private room for safety, and the door was kept shut. The resident-to-resident reports and the facility investigation report did not document the stop sign was in place across Resident #68's door at the time of the abuse on 11/4/2024. Interdisciplinary progress notes dated 11/4/2024 through 11/11/2024 documented staff monitored and treated Resident #71's facial injuries (bruising, swelling, laceration, scratches) and administered Tylenol as needed for visible signs of pain. The Medication Administration Record dated 11/1/2024 -11/30/2024 documented Resident #71 was administered Tylenol 500 milligrams nine (9) times for pain between 11/5/2024 and 11/10/2024 after they were struck in the face by Resident #68. Prior to 11/4/2024, Resident #71 had not been receiving pain medication. During observations on 1/27/2025 between 9:42 AM and 10:01 AM, both Residents #71 and #68 were in their rooms, directly across the hall from each other. Resident #68's door was closed and had a stop sign across their doorway. During an interview on 1/29/2025 at 11:44 AM, Licensed Practical Nurse #1 stated Resident #68 did not like people in their personal space and most incidents involving this resident on the unit involved other people entering their room. They stated that if someone got too close to Resident #68, they would become provoked and would attempt to hit the other person. Licensed Practical Nurse #1 stated they did not know if the stop sign was in place on Resident #68's door on 11/4/2024 at the time of the attack. Additionally, they stated Resident #71 had difficulty hearing, so other residents get frustrated when they tried to talk to them. During an interview on 1/29/2025 at 11:51 AM, Certified Nurse Aide #1 stated they were at the nurse's station on 11/4/2024 when they saw Resident #71 wheel down the hallway to Resident #68's room, open the door and enter. They then heard yelling and started to walk down the hallway when they saw Resident #68 push Resident #71 out of their room with their walker. Resident #68 had already closed the door and returned to their room when Certified Nurse Aide #1 arrived at the incident. They stated Resident #71 was bleeding from areas on their face that corresponded with where the walker had hit them. Certified Nurse Aide #1 stated they did not recall if the stop sign was across Resident #68's door on 11/4/2024. The unit had a lot of wanderers who would remove stop signs across doors, and staff did their best to redirect residents. During an observation on 1/30/2025 at 11:18 AM, Resident #68 was in their room, the door was closed and there was no stop sign across the entry way. Resident #71 was in their room across the hall watching television. During an interview on 1/30/2025 at 11:23 AM, Licensed Practical Nurse #1 stated Resident #71 had swelling, bruising to their face and showed signs of pain for days following the incident, requiring Tylenol to relieve the pain. Additionally, they stated they did not know why the stop sign was missing from Resident #68's doorway. They stated other residents frequently go around the unit and remove them, and staff have to look through rooms to find them. During an interview on 1/30/2025 at 11:30 AM, Social Worker #1 stated following the incident on 11/4/2024, Resident #71 was assessed, was holding their injuries and appeared to be in pain. Social Worker #1 stated Resident #68 was assessed and sent to the hospital for evaluation of their increased aggression, and upon their return was seen by the facility provider for their behaviors. Their mood fluctuates because of their dementia. They stated if Resident #68 was in a bad mood, they preferred to be alone and that was why they were care planned to have their door shut. Social Worker #1 stated they did not know if the stop sign was across Resident #68's door on 11/4/2024 at the time of the incident. During an interview on 1/30/2025 at 12:30 PM, Registered Nurse Head Nurse #2 stated there were stop signs across doorways on the memory care unit to deter residents from entering rooms that were not theirs, but residents removed them and hid them. Staff constantly had to check for stop signs and would replace them when they noticed they were missing. During an interview on 1/30/2025 at 1:10 PM, the Medical Director stated Resident #68 was evaluated following an incident that included them having aggressive, assaultive behaviors towards Resident #71. During a telephone interview on 1/30/2025 at 2:06 PM, Registered Nurse #1 stated on 11/4/2024 around 3:00 PM they were paged to the memory care unit. Staff stated they heard screaming and responded to find Resident #68 hitting Resident #71 in the face with their walker. Resident #68 picked the walker up and brought it down on Resident #71's face a couple times. The residents were separated. Resident #71 was assessed, neuro checks were initiated, and first aid was rendered to their facial injuries. Resident #71's Health Care Proxy was called, and they did not want them to be sent to the hospital. The Medical Director was updated and ordered an x-ray of Resident #71's nose and orbitals (eye socket). Registered Nurse #1 that Resident #68 was assessed and was aggressive towards staff, so they were sent to the hospital for an evaluation. Registered Nurse #1 stated that Resident #68 had worsening aggression, behaviors, and confusion in the weeks leading up to the incident. Registered Nurse #1 stated they had been concerned something bad was going to happen. They could just flip a switch. Resident #68 didn't like other people in their personal space and would push people towards the door with their walker if they entered their room. Registered Nurse #1 stated they arrived after the incident and did not know if the stop sign was in place prior to the incident. They stated they had brought their concerns to the Director of Nursing, Administration, and the Medical Director before 11/4/2024 because of Resident #68's history of aggression toward others. Resident #68 had recently been evaluated in the hospital for increased aggression because they were a safety issue to staff and other residents with no findings. Registered Nurse #1 stated Resident #71 was nonverbal, but after the 11/4/2024 incident you could see it on their face, they were worried when wheeling around the unit. During a telephone interview on 1/31/2025 at 8:32 AM, Resident #68's Health Care Proxy stated they were made aware of the incident on 11/4/2024. They were told there was a physical altercation between Resident #71 and another resident, resulting in a minor cut to Resident #71's cheek. They were not aware Resident #71 was hit in the face with a walker. Resident #71's Health Care Proxy stated that if Resident #71 was in their right mind they would have been very upset at the situation and would have been afraid of the person doing this to them. During a telephone interview on 2/3/2025 at 8:40 AM, Risk Management Investigator #1 stated they don't typically investigate resident-to-resident incidents. If it's a reportable incident with a major injury, they may work jointly on the investigation. Risk Management Investigator #1 stated they did not work on this case with the facility and would have expected to be notified. A resident striking another resident with a walker causing cuts and swelling to the face would be considered a major injury. During an interview on 2/3/2025 at 10:40 AM, the Director of Nursing stated they investigated the incident on 11/4/2024 involving Resident #68 and #71. Resident #68 had a history of aggressive behaviors directed towards others. The Director of Nursing stated that Resident #68 was aggressive about Resident #71 entering their room. During the interview, the Director of Nursing reviewed Resident #71's nursing progress notes and stated following the incident, Resident #71 displayed signs of discomfort, was visibly upset, and was medicated for pain. They stated Resident #68 caused harm to Resident #71 during the incident on 11/4/2024. During an interview on 2/3/2024 at 11:46 AM, the Administrator reviewed Resident #71's nursing progress notes and stated, It is safe to say Resident #71 was exhibiting signs of fear and pain following the incident on 11/4/2024 with Resident #68. 2. Resident #17 had diagnoses that included unspecified dementia with mood disturbance, depression, and anxiety. The Minimum Data Set, dated [DATE] documented Resident #17 was moderately cognitively impaired, was usually understood, and usually understands. The [NAME] dated 12/6/2024 documented Resident #17 required an assist of one for ambulation with a rolling walker, was independent for wheelchair mobility on the unit, and required 15-minute checks. Facility could not provide a [NAME] for the day of the altercation, 12/5/2024. The comprehensive care plan dated 9/30/2024 documented Resident #17 had impaired cognition and was dependent on staff for meeting emotional, intellectual, physical and social needs. The care plan documented on 10/23/2024, the resident physically grabbed and slapped another resident in the hallway. Approaches included to invite to scheduled activities and may need one-to-one visits. The care plan documented on 12/5/2024, the resident was hit by another resident due to going through their things; on 12/10/2024 the resident was slapped by another resident who thought resident had taken their walker. Approaches included to cue, reorient and supervise as needed. Additionally, the care plan documented Resident #17 was found crawling on the floor on 12/11/2024. The 15-minute checks were not documented on the comprehensive care plan. Resident #75 had diagnoses that included Alzheimer's disease, Bell's palsy (temporary paralysis or weakness of the facial muscles on one side of the face), and dementia without behavioral disturbance. The Minimum Data Set, dated [DATE] documented Resident #75 was severely cognitively impaired, sometimes understands, was sometimes understood, and had fluctuating disorganized thinking. The [NAME] dated 12/6/2024 documented Resident #75 was independent with a rolling walker for ambulation on the unit. The [NAME] documented on 12/6/2024, 15-minute checks were initiated. The facility could not provide the [NAME] for the day of the altercation, 12/5/2024. The comprehensive care plan dated 6/21/2024 documented Resident #75 had a communication problem related to oral deformity, Bell's palsy, and hearing deficits. Resident #75 had impaired cognitive function related to dementia and could be possessive over other residents. On 9/13/2024, Resident #75 hit another resident. Staff were to anticipate the needs of the resident. Resident #75 wandered and had impaired safety awareness. The care plan documented on 12/5/2024, hit another resident for going through their things and the other resident hit back; on 12/10/2024, Resident #75 slapped another resident due to thinking they took their walker. Approaches included a Velcro stop sign across entry way and to cue, reorient and supervise as needed. Fifteen- minute checks were initiated on 12/5/2024 after the altercation but were not documented on the comprehensive care plan. Review of Resident #17's progress notes dated 12/2/2024 included Social Worker #1 documented a room change occurred on 12/2/2024. The nursing home facility investigative report, dated 12/5/2024 and completed by the Administrator, documented Resident #75 observed Resident #17 going through their belongings and slapped Resident #17 on the face. Resident #17 slapped Resident #75 back, also on the face. The incident was reported to Licensed Practical Nurse #1 by Resident #17, and while they were talking to Licensed Practical Nurse #1 about the incident, Resident #75 approached to tell their side of the story. Residents were new roommates, and both were able to ambulate independently. Resident #17 indicated they did not like their living arrangement. Both residents were placed on 15-minute checks to monitor their whereabouts and to avoid further altercations. The resident-to-resident incident report Resident to Resident Physical Contact for Resident #75 dated 12/10/2024, completed by Registered Nurse Head Nurse #4, documented Resident #75 came out to the dining room and accused Resident #17 of stealing their walker, attempted to take it back, and began hitting Resident #17 on their arms. The residents were separated; 15-minute checks were still in place at the time and continued. Review of Resident #17's nursing progress notes dated 12/10/2024 at 8:15 AM and 8:19 AM included Licensed Practical Nurse #1 documented they witnessed Resident #75 smack Resident #17 because they thought Resident #17 took their walker. They were separated and placed on opposite sides of the dining room. Resident #17 had a red mark on their left arm and was crying. One-to-one was provided to Resident #17 and 15-minute checks continued. The resident-to-resident incident report Resident to Resident Physical Contact for Resident #75 dated 12/11/2024, completed by the Assistant Director of Nursing, documented Certified Nurse Aide #10 saw Resident #75 walking towards their room and when they entered, heard Resident #17 say, It is my bathroom too. Certified Nurse Aide #10 heard a noise and went to check. They observed Resident #17 and Resident #75 crawling around on their bedroom floor. Resident #75 stated Resident #17 pulled them down. The incident report documented Resident #17 and #75, who were roommates, had been having difficulty getting along. To avoid further potential negative interaction, Resident #75 was moved to a private room on another unit. During an interview on 1/27/2025 at 9:51 AM, Resident #17 stated they tended to get upset when they were in group settings. Resident #17 stated they remembered slapping someone because they wouldn't leave them alone, so they had to push them away. Resident #17 appeared paranoid and anxious during the interview. During an interview on 1/29/2025 at 11:40 AM, Licensed Practical Nurse #1 stated Resident #17 and Resident #75 had been arguing for a couple days and had slapped each other. On 12/11/2024 Certified Nurse Aide #10 found them crawling on the floor in their bedroom after slapping each other. They stated Resident #17 seemed afraid of Resident #75. During an interview on 1/29/2025 at 10:29 AM, Certified Nurse Aide #1 stated Resident #17 and Resident #75 were not a good match for roommates because they each thought someone else was always stealing from them and could be very possessive over things. During a telephone interview on 1/30/2025 at 2:17 PM, Registered Nurse #1 stated the two residents became roommates because room changes needed to occur to accommodate male beds on the secure unit. Resident #75 also had room change in September because they had an altercation with their previous roommate. Resident #17 recently moved to the secure unit for safety related to their wandering. Registered Nurse #1 stated they were not surprised when the residents had issues after becoming roommates because they both had issues with other residents in the past. Registered Nurse #1 stated they brought up their concerns with them not being compatible roommates at their weekly interdisciplinary meetings with Administration, the Director or Nursing, therapy, dietician, unit managers, and staffing, but there was no other available bed on the secure unit. Resident #75 was eventually moved after the incident on 12/11/2024, and that had helped Resident #17 with their paranoia. A call was placed to Certified Nurse Aide #10 1/31/2025 at 12:23 PM without success. During an interview on 2/3/2025 at 10:29 AM, the Director of Nursing stated Resident #17 and Resident #75 were put on 15-minute checks following the incident on 12/5/2024 and remained roommates. There were no available beds on the secure unit, and they were attempting to keep both residents on the secure unit. They stated the incident that occurred on 12/10/2024 happened in the dining room, so it did not indicate a room change. The incident on 12/11/2024 was not witnessed, so they only had the residents' account. They eventually moved Resident #75 off the secure unit after the incident on 12/11/2024 to avoid further conflict. NYCRR 415.4(b)(1)(i)