**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of a recorded video, record review and interviews with resident, staff, and a van transportation company, the facility failed to ensure a resident was safely transported to a physician's visit. The facility's contracted transportation company's Van Driver failed to ensure the lift platform was level with the van before rolling Resident # 7 out of the van. The resident fell backwards out of the transport van to a lift platform that was located on the ground approximately 3 feet below the level of the van. Review of the van company's recorded video of the incident revealed the resident could be heard crying and yelling loudly when she hit the ground. Failure to ensure safety when assisting residents onto mechanical van lifts has a high likelihood of resulting in serious resident harm. This was for one (Resident # 7) of three residents reviewed for accidents. The findings included: Resident # 7 was admitted to the facility on [DATE]. The resident's diagnoses in part included a history of stroke. Resident # 7's annual Minimum Data Assessment, dated 8/7/24, coded the resident as cognitively intact. The resident was coded to use a wheelchair, and as needing substantial to maximum assistance to wheel at least 150 feet. Review of Resident # 7's nursing notes revealed an entry on 8/20/24 at 2:58 PM noting It was reported that during transport from an appointment that the resident had a fall. Resident is being transported by EMS (emergency medical services) to the ER (emergency room) for evaluation. A review of hospital records for the dates of 8/20/24 and 8/21/24 revealed the following information. Resident # 7 was seen in the ER on [DATE] following the incident. The physician noted the resident was in no acute distress at the time of the physician's assessment. The physician noted the resident's speech was hard to understand. When she slowed down her speech was not slurred, and she was able to report she had landed on her back inside her wheelchair during a fall from a transport van. The caregiver (transport driver) landed on top of her. The physician further noted, She denies any complaints at this time, no neck pain, no headache, nausea, vomiting, chest pain, reports legs are less painful than they were prior to arrival. A CT (computerized tomography) of her head and cervical spine were ordered and were negative for injury. The resident was discharged back to the facility from the ER on [DATE]. The resident was interviewed on 10/29/24 at 10:47 AM and again on 10/31/24 at 2:40 PM. The resident was observed to talk very fast making it difficult to discern every word. She clearly reported the following information. In August 2024 she had been transported to a doctor's appointment and the Van Driver pushed her out of the van onto the concrete. Before the incident, the Van Driver complained to her that she (the resident) was heavy. Then she fell out of the van. It hurt when she fell, and she had to go to the hospital. An interview was conducted with the Administrator and NA# 1 on 10/31/24 at 3:15 PM. NA (Nurse Aide) # 1 reported and demonstrated the following. NA # 1 had ridden in the van with the contract company to Resident # 7's appointment. Once they arrived at the physician's appointment, she (NA # 1) went into the office to check the resident into the office. She (NA # 1) then came out the door and stood at the doorway while the Van Driver was unlocking and getting Resident # 7 out of the van. She could see the back of the van. The resident and the Van Driver both fell backwards out of the van, and they landed on the lift platform. The wheelchair flipped all the way upside down on top of the resident so that the bottom of the wheelchair seat was facing up in the air and the top of the wheelchair backrest was on the surface of the lift platform. The accident happened very quickly, and she thought the Van Driver had tripped some way and the lift platform was still up in the air when the resident fell backwards. The physician's office staff came to assist with the incident. 911 was called. She called and reported the incident to the facility. She had not observed anything about the Van Driver before the incident which would indicate the Van Driver was not a safe driver. The Administrator reported the facility had used the contracted van company many times and they had given safe and reliable services. The van company had reviewed the incident with her and reported that the Van Driver had not put the lift platform even with the van before rolling the resident out of the van. Instead, the Van Driver had lowered the lift platform all the way to the ground. The van company had reported to the Administrator that there were safety mechanisms in place at the rear of the van, and the Van Driver should have recognized when she met resistance getting the resident out of the van over one of them that there was a possible problem. The Van Company's Director was interviewed on 10/31/24 at 4:53 PM and reported the following information. Their Van Driver had made a mistake and Resident # 7 had fallen out of the transport van. They were very sorry about the incident. They went to check the van at the time of the incident and found nothing mechanically wrong with the lift or the van which led to the incident. The lift was damaged due to the impact of the fall, and it was taken out of service for repair following the incident. She had worked closely with the facility Administrator to try to determine what had happened. There was a video recording from inside of the van which they had watched multiple times to determine what had happened. She and her husband owned the transportation company, and the Director put her husband on the phone call with the surveyor during the interview. Together they reported the following information. The video recorder was facing the rear of the van and therefore the video showed the incident from that angle only. From reviewing the video, they saw NA # 1 had ridden with the resident and the Van Driver. Once they arrived, NA # 1 left the van to go into the doctor's office, and the angle of the video did not pick NA # 1 up until after the incident occurred. After the fall, the video's angle picked up NA # 1 rushing to the back of the van. Upon arrival to the doctor's office, the Van Driver could be seen exiting the van, walking to the rear of the van and letting the lift platform down. The Van Driver then returned inside the van, unlocked the resident's wheelchair's security devices and rolled the resident backwards. While conducting their investigation, they had viewed other transport videos where there had been no incidents. From viewing and comparing the videos where transports were done correctly versus the video where Resident # 7 fell, they were able to see that when the lift platform was even with the van in a safe position to roll residents out, then safety arms on the lift would be visible in all the videos. In viewing the video of Resident # 7's transport, they saw when the Van Driver lowered the lift platform, the safety arms disappeared almost completely. Only a small portion could be seen. This indicated to them that the lift platform had been all the way to the ground instead of level with the back of the van when the resident was rolled backwards. In the video they saw the resident and the Van Driver fall out of the van towards the ground. They estimated that the drop was about 36 inches. They reported they would share the video with the surveyor and a statement from the Van Driver. On 11/1/24 the van company's video was viewed, and the following was observed. Resident # 7 could be seen seated in the rear of the van in a wheelchair. The Van Driver was seated in front and NA # 1 was in the front passenger seat. They came to a stop. NA # 1 stepped out of the van and exited from sight. The video camera no longer was able to capture NA # 1 as she walked into the physician's office to check the resident in. The Van Driver exited the front of the van and opened the back doors of the van. A lift platform could be seen going down at the rear of the van. The arms of the lift faded away from sight as it lowered. There did not appear to be anything in the rear of the van where the lift platform should be. The Van Driver reentered the van and removed the security belts and ties that had kept the resident's wheelchair in place during the transport. She and the resident appeared to be talking. The resident was facing the front of the van and thereby her back was facing the rear of the van. Therefore, the resident could not see where she was headed as she was being rolled backwards in her wheelchair. The Van Driver backed the resident towards the rear of the van. When the Van Driver got to the rear, she appeared to have trouble getting the wheelchair to roll and appeared to be meeting resistance. She readjusted the wheelchair several times pulling it towards her and back again. Then with the last push backwards toward the open rear of the van, the resident fell backwards out of the van in her wheelchair. The Van Driver fell forward out of the van also with the resident. The resident could be heard yelling and crying loudly. After the fall, the resident was out of view from the camera angle. NA # 1 was seen coming into view of the video camera and asking what happened. A gentleman came from one side of the van and physician office staff members were seen coming from the other side to the rear of the van to offer assistance. The wheelchair could be seen lifted up and away. Someone was heard telling the resident they were calling EMS. Someone in the video was heard saying she is on the ground. Once multiple people were attending to the resident, the Van Driver could be seen reentering the front seat of the van and making a phone call to someone. She was heard explaining the incident and stated to the person to whom she was talking that she (the Van Driver) was trying to get Resident # 7 on the lift and couldn't get her. The Van Driver commented, She is so heavy. I was trying to push a little harder. I couldn't rock her because she was so heavy. She then said she tried to rock again and push back again, and the resident fell out of the van and they both hit the ground. The van company also provided a statement from the Van Driver which was in an email from the Van Driver to the Director of the van company on 8/22/24. The emailed statement read as typed, On Tuesday August 20th I [name of van driver] had transported [Resident # 7] to her destination. Once we arrived I locked my breaks, got of my vehicle to go through the proper steps to remove {Resident #7} from the vehicle. The second step was to unfold the lifter and level it so that {Resident # 7} could be placed on the lifter so that I could bring her down to ground level. At the time I didn't realize that I dropped the lifter all the way to the ground instead of keeping it leveled up so that can roll her onto the lifter. Then proceed to unbuckle her restraints so that I could put her onto the lifter upon moving her, not realizing that the lift was ground level, I then proceeded to push her what I thought was on the lifter. Once I started pushing her wheelchair still not realizing that the lifter was down ground level I ended up falling on top of her all the way to the ground. In my mind, I had leveled the lifter but it evident that I didn't, and I fell on top of her going backwards, and we both hit the ground. The van driver ended her statement by saying she had not done anything intentionally to hurt anyone, it had been an unfortunate accident, and she had been properly trained. Interview with the Administrator on 10/31/24 at 3:15 PM revealed the facility identified the incident as needing a plan of correction and they implemented one to ensure residents were safe. The Administrator provided the facility's plan of correction. On 11/1/24 at 11:00 AM the Administrator was notified of immediate jeopardy. The facility's completed corrective action plan was as follows: 1. Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice; On 8/20/2024 resident #7 was being transported by a contracted company to an appointment. During the unloading process, the driver proceeded to lower lift pad to the ground and not level to the van bumper. When the driver proceeded to wheel resident #7 onto lift pad she tripped on safety mechanism and toppled onto resident. This force pushed resident #7 and chair out of the van resulting in a fall in which resident #7 landed on the lift gate landing. On 8/20/2024 resident #7 was not moved until EMS arrived staff helped provide pillows and blankets for dignity until EMS arrived. EMS assisted lowering resident #7 to the ground on the lift gate. Resident #7 was transported to the hospital for further medical treatment. The Driver was suspended on 8/20/2024. The lift gate was damaged during the incident and therefore the van was removed from service until repaired. The driver was drug and alcohol tested on [DATE] with no findings. The driver was interviewed on 8/20/2024 by the contract transport company and maintained that a flap on the van used to keep patients in place failed to drop as expected therefore causing her to trip. On 8/20/2024 the aide who went on transport provided a statement and recollection of the events. She stated she was checking resident #7 into her appointment at the office and was coming out at the time the incident occurred. She stated she saw the driver trip and move forward onto resident #7 at which time the wheelchair tipped backwards and the resident fell. The aide stated that the lift gate was up in the air and that EMS had to assist further lowering it to the ground. On 8/21/2024 the transportation contract company owners came to the facility and brought the van that was part of the incident. The administrator, assistant administrator and owners discussed their findings. The owners stated the van was equipped with video camera that was on the dash and pointed toward the back. They reviewed the video footage however stated it was difficult to fully understand what was happening with the lift gate due to resident #7 and her chair being in the center. They stated they also reviewed footage of her earlier transportations for the day and noticed that the sides of the lift gate were not in visible sight as they had been on her earlier transports for the day. The owners maintain that those flaps only stay up if the lift gate is not level. The driver had received certification upon hire on safety as it relates to ensuring the lift gate is even with the van bumper prior to unrestraining a patient and proceeding with unloading. The owners had implemented a remediation plan of their own after reviewing the tapes starting 8/21/2024. All transports that have a single driver must call dispatch prior to removing the patient from the van to confirm all safety techniques including having the lift gate level are in place prior to unloading a patient. Resident #7 returned to the facility on 8/21/2024 with no injuries. Resident #7 statement was obtained on 8/21/2024 and she stated she remembered talking to the driver and the driver tripped on something causing her to fall backward with the driver on top of her. On 8/21/2024 a trauma screen was performed on resident #7 and she reported no concerns from the incident. On 8/23/2024 during care resident #7 reported the incident again and another trauma screen was completed and she was concerned about future transportation. On 9/12/2024 resident #7 had her first appointment out of the facility since the incident the aide went with her and provided support of her safety during the transport process. Resident #7 expressed no further concern related to transport. The facility failed to ensure resident #7 was safe during the unloading process of transport resulting in fall from the van. 2. Address how the facility will identify other residents having the potential to be affected by the same deficient practice; Any residents receiving transports are affected by this practice. The transport company implemented 8/21/2024 that when working alone all drivers will be required to confirm the lift is floor level by walking on the lift and notifying their administration, prior to unloading all residents, that lift is level and safe. 3. Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur; All drivers received education by the transport company owners on Passenger Assistance Safety which includes lift operating procedures and safety harnesses. This was completed 8/22/2024. This was supplied to the facility by the transport company on 8/22/2024. Any new driver will receive education by the transport company in orientation and will be sent to administrator as needed. The center contracts with no other transportation company and therefore no further education was required from other companies. 4. Indicate how the facility plans to monitor its performance to make sure that solutions are sustained; The Quality Assurance Committee (Regional Director of Clinical Services, administrator, Director of Nursing, Assistant Director of Nursing) met on 8/22/2024 to review the findings and initiated a plan. Unit secretary or designee will ride on transport for an audit of 2 transports weekly x 4 weeks, weekly x 8 weeks to ensure the lift gate is level prior to wheeling patient off the van and driver has made all safety checks prior to unloading a patient. The audits will be reported to Quality Assurance for further review quarterly x 2. Include dates when corrective action will be completed. Completion date: 8/23/2024 The facility's corrective action plan was validated by the following: Beginning on 10/29/24 at 9:54 AM a tour of the facility was conducted. Multiple residents, who were interviewed, did not report a problem with safety or transportation. The facility provided documentation they had communicated and worked with their contracted van company to implement their plan of correction. There was documentation the van company provided education to their van drivers and the drivers completed a two day course entitled Passenger Assistance Safety and Sensitivity driver certification program, which included instruction on lift operating procedures, wheelchair and occupant securement training. The van drivers had a certificate of completion awarded from the Community Transportation Association of America. The facility provided evidence of their audits as outlined in their plan of correction. Their audits included checking for ramp and boarding safety, patient securement, and patient assistance. Resident # 7 was part of their audits, and the audit showed the resident had been transported safely following the incident to another office visit. It was confirmed with the Administrator that they only used this transportation company currently for transportation needs, and there had been no further incidents. The facility's correction date of 8/23/24 was validated on 11/1/24.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews with staff, family, residents, the physician and the facility's psychiatric provider, the facility failed to protect a cognitively impaired and dependent resident (Resident # 3) from abuse by another cognitively impaired resident (Resident # 2). Resident # 2 was known by staff to display behaviors which included paranoia, delusions, aggression with staff, and exit seeking behaviors. Resident # 2 entered Resident # 3's room while staff were attending to other residents during an evening meal and assaulted Resident # 3 by pulling Resident # 3's wheelchair over on the floor resulting in Resident # 3 landing on the floor; hitting and kicking Resident # 3 in the head; beating Resident # 3 with a meal tray and; hitting Resident # 3 with the door by swinging a door back and forth onto Resident # 3's body while Resident # 3 was on the floor. Resident # 3 sustained a laceration near his eye, multiple areas of bruising, and fear that the incident would occur again. This was for one of three residents sampled for abuse. The findings included: Resident # 2 was admitted to the facility on [DATE] following a hospitalization from 8/28/23 to 9/18/23. According to the hospital Discharge summary, dated [DATE], Resident # 2's diagnoses included hypertension, coronary artery disease, heart failure, atrial fibrillation, history of prostate cancer, failure to thrive with moderate malnutrition. The hospital discharge summary also noted the following. Prior to hospital admission on [DATE] Resident # 2 had resided at home and a neighbor had found Resident # 2 to be confused. He was also febrile. During hospitalization Resident # 2 was determined to have pneumonia which was treated and resolved. Also, while hospitalized Resident # 2 displayed behavioral problems. It was documented Resident # 2 had removed his clothing and barricaded himself and his wife in the hospital room with a trashcan. He was physically restrained at one point and started on antipsychotic medications during hospitalization. On the hospital discharge summary, the physician noted Resident # 2 could have possible dementia, and his antipsychotic medications were to be continued after his hospital discharge. According to facility room assignment reviews, Resident # 2 was admitted to a room in the facility where he resided with his wife. Physician orders revealed Resident # 2 was prescribed Seroquel 25 mg (milligrams) at bedtime for agitation on 9/18/23. (Seroquel is an antipsychotic medication.) Review of the facility record revealed on 9/19/23 Resident # 2 was seen by the facility medical physician who noted Resident # 2 seemed to have delirium while hospitalized , and antipsychotics were started. The physician noted he would try to wean the resident off antipsychotics over the next few days. Resident # 2's admission Minimum Data Set assessment, dated 9/24/23, coded Resident # 2 as severely cognitively impaired. Resident # 2 was assessed to be ambulatory with a walker and displayed the behavior of refusing care. Resident # 2's care plan, reviewed on 10/2/23, included information that Resident # 2 was at risk for complications related to cognitive impairment secondary to his advanced age. Staff were directed to observe for changes in his cognition over time. The care plan also noted he received antipsychotic medications, was at risk for elopement, and that psychiatric services would be provided as needed. On 10/4/23 the physician noted in a progress note that he was following up on Resident # 2's medical issues and his psychosis. The physician further noted there had been no recent agitation issues with the resident. Per physician orders, on 10/7/23 Resident # 2's Seroquel dosage was changed to ½ tablet (12.5 mg) at bedtime. This indicated a dose reduction. Per physician orders on 10/16/23 the dosage was increased back to 25 mg at bedtime. (This dosage amount remaining ordered through 3/9/24). Resident #2's physician noted in a progress note, dated 10/17/23, the following. He was seeing Resident # 2 because of severe agitation in the last couple of days. The resident had a urinalysis completed which was negative, and Resident # 2 had known dementia. The physician directed the resident's daily Seroquel dosage be administered at 6:00 PM rather than at bedtime. On 11/6/23, the Director of Nursing (DON) noted in a nursing note Resident # 2 had stated suicidal ideations but had no plan or means to carry out his ideation. The DON further noted a psych referral would be sent. Interview on 3/21/24 at 4:45 PM with the DON revealed at the time of 11/6/23 Resident # 2 refused to see a psychiatrist, and therefore the psychiatric evaluation did not take place at that time. Resident # 2's physician noted in a progress note, dated 11/19/23, that he was seeing Resident # 2 for a two- month post hospitalization visit for senile dementia and other medical reasons. The physician noted Resident # 2 had an appropriate affect and was in no apparent distress. The physician further documented Resident # 2 would be maintained on Seroquel. Resident # 2's physician noted in a progress note, dated 12/19/23, In follow up of dementia, he does get agitated quite frequently and sometimes have outburst where he resists on seeing the doctor, but today he does not remember anything at all and has really no concerns or complaints while I am in the room. The physician further noted, I will continue Seroquel at this time for agitation. On 12/23/23 a quarterly Minimum Data Set assessment was completed showing the following assessment. Resident # 2 was moderately cognitively impaired, wandered and rejected care 1 to three days during the assessment period, and was ambulatory. Review of physician orders revealed an order on 1/11/24 for a geriatric psychiatric consult for Resident # 2. Review of Resident # 2's medical record revealed a document noting a hearing had been held and Resident # 2 had been deemed incompetent. This document was stamped as filed on 2/2/24. On 2/2/24 the facility's Social Services Director noted there had been a court appointed guardian arranged for Resident # 2. On 2/3/24 at 1:48 AM Nurse # 1 documented in a nursing note the following about Resident # 2. Around 2300 (11:00 PM) resident came up to the nurses' station and started yelling at another nurse and getting in her face. Resident was yelling that it was all the other nurse's fault. Writer got in between resident and nurse and was attempting to calm down the resident. Resident stated the girl he murdered was alive and her and her boyfriend are trying to murder him. Resident stated we needed to call the highway patrol to come protect him. Resident was eventually able to be redirected and clamed down. MD (Medical Doctor) was made aware and PRN (as needed) one time order for Haldol IM (intramuscular) was put in place in case of any more agitation. Resident is now resting in bed. (Haldol is an antipsychotic medication) Nurse # 1 was interviewed on 3/20/24 at 11:00 AM and reported the following. Resident # 2 was not always agitated. Every once in a while he would become confused. She thought Resident # 2 had a history of being in the military police. Routinely he was pleasant around other residents. He knew where his room was and never wandered into other residents' rooms. She never feared for other residents' safety because of any of Resident # 2's behaviors, and he was typically easily redirected if he became confused. On 2/3/24 he had been yelling at another nurse while telling her it was her fault that someone was trying to come kill him. She intervened and gave him a snack. He calmed down and went to bed. She never had to administer the Haldol that was ordered. On 2/11/24 at 4:21 AM Nurse # 2 documented in a nursing note the following about Resident # 2. Resident came to nursing station to use phone to call police. 'I killed my wife.' CNA (certified nursing assistant and I checked and {resident's wife] is asleep. On 2/12/24 at 10:19 PM Nurse # 3 noted the following in a nursing note about Resident # 2. Resident noted with increased confusion this evening refusing medication and ranting of someone coming go kill him, and his wife. Resident was easily redirected. MD notified. Safety measures in place. Nurse # 3 was interviewed on 3/20/24 at 7:30 PM and reported the following. She did not often care for Resident # 2. Initially when she did care for him, he seemed pleasant. One day he was ranting that someone was trying to kill him and stealing his money. She placed a note in the chart, talked to the physician who instructed to monitor Resident # 2. Resident # 2 had refused his medications that day. There was another episode which occurred during the first two weeks of March, 2024 during which he was ranting and trying to leave the facility. He was easily redirected. She would take him by his hand and walk him to his room. Based on his behaviors, she never feared he would hurt another resident. She had never witnessed him hurt or touch any resident. She was not aware of any psychiatric referrals ordered and not completed for the resident. On 2/13/24 at 1:53 AM Nurse # 1 noted the following in a nursing note about Resident # 2. Resident confused said he got a emergency call that stated the jets are on the way to murder him and his wife. Able to calm resident down by talking to him. Resident calm but refusing to go back to his room or bed stated he will leave [his wife] down there alone to get murdered. Resident calm sitting nurses station eating a snack. Resident # 2's physician noted in a progress note, dated 2/19/24, Baseline, very confused and paranoid, in no apparent distress. He has times where he thinks somebody has to murder him and his wife. He can ambulate with a walker Under the physician's plan for the date of 2/19/24, the physician noted he would continue the Seroquel for his behaviors and psychosis and refer to psychiatry. Review of Resident # 2's facility medical record revealed no documentation Resident # 2 was ever seen for a psychiatric consult. On 2/23/24 at 9:29 AM Nurse # 4 noted the following in a nursing note about Resident # 2. Resident complied with medication administration. Increasingly more agitated as the morning goes on. He is unable to verbalize what we can help him with. He wants to leave to find the 'hotel.' Asked how to contact police. Nurse # 4 further noted the physician was contacted and resident was being redirected. On 2/23/24 at 11:32 AM Nurse # 4 noted the physician had ordered lab work for the resident. On 2/26/24 at 1 PM a nursing note was entered documenting the staff had talked with Resident # 2's guardian and informed the guardian Resident # 2 was continuing to refuse lab work to be done. On 2/26/24 at 3:16 PM Nurse # 4 noted the following in a nursing note about Resident # 2. Resident had been exit seeking. Continuing to redirect with very little effect. Resident has continued to refuse to give a urine sample for UA (urinalysis). Change of shift report communicated that we are to re-attempt once the resident has calmed down. During last exit seeking attempt resident stated when he gets back, he will come back with a 'gun.' Resident was returned to room. Put music on for resident that seemed to calm resident. Safety measures in place. Nurse # 4 was interviewed on 3/20/24 at 11:10 AM and reported the following. She worked part time and worked with Resident # 2 about one time per week. At times he appeared frustrated as if he could not say what he wanted to convey. When he mentioned the gun, she knew he had past military experience. He indicated he would not do anything with a gun if he had one. His confusion did not occur on a daily occurrence, and generally he was easy to redirect. She would allow him to voice concerns, deescalate and play music for him. That seemed to help. He never gave any indication he would harm anyone. She never saw him threaten anyone. He never wandered into other residents' rooms or tried to hurt them. She never thought anyone was in danger based on Resident # 2's behaviors. On 2/27/24 at 1:11 PM Nurse # 5 noted in a nursing note that Resident # 2 had been agitated, confrontation, and had lifted his walker and attempted to throw out the glass door. Nurse # 5 further noted diversional conversation was provided and Ativan 1 mg per a one time order was administered and was effective. The resident became calm. Nurse # 5 was interviewed on 3/20/24 at 12:57 PM and reported the following. Resident # 2 was not agitated on a daily basis. He was in the dayroom on 2/27/24 when he became upset on that date. He was typically redirectable. On that day, he took medication and was okay. He calmed down. She had never seen him threaten anyone or harm anyone. He never gave any indication he would hurt anyone. She was not aware of why a psychiatric evaluation had not been done for Resident # 2. Review of physician orders revealed on 2/27/24 Resident # 2 was started on Depakote extended release 250 milligrams twice per day. (Depakote is a medication used as a mood stabilizer). On 3/1/24 Nurse # 6 completed a SBAR communication form (a situation, backgroumd assessment, and recommendation request form). The nurse checked on the form Resident # 2 was having increased verbal and physical aggression, and a danger to self or others. According to the record, after the completion of the form Resident # 2 was sent to the hospital for evaluation. Nurse # 6 was interviewed on 3/21/24 at 11:49 AM and reported the following. She was the staff development coordinator for the facility. Her office was on a different unit than the unit on which Resident # 2 resided. On 3/1/24 she had been in her office when Resident # 2 came walking down the unit where she worked. He was dressed in his coat and toboggan to leave, and his wife was following him. The nurse talked to him and he commented, We are getting out of here. He then told his wife, If you are not coming with me then you are going to pay for this. She knew around the date of 2/28/24 there had been an incident where he had had thrown his walker at an exit door and held his walker up towards staff who were trying to intervene. It had taken about 10 minutes to get him calmed down on that day. She was also aware he had refused lab work to be done. Therefore, she called EMS (Emergency Medical Services) to transfer him to the hospital on 3/1/24. It was her hope that they could medically find if something was causing his confusion and agitation. At the time she did not feel he posed a danger to others, but only to himself because he wanted to leave the facility. She had never seen him threaten or harm another resident when he was agitated. Review of hospital emergency department records, dated 3/1/24, revealed the following. The physician noted Resident # 2 presented for aggressive behavior. Patient was noted to be throwing his walker and furniture at staff attempting to take his wife and leave the facility. On exam patient is moderately confused, oriented to self, reports his wife was being attacked by hospital staff. The physician further noted during his assessment Resident # 2 was calm and cooperative, labs had been done without any significant abnormalities. According to the record, he was returned to the facility with no changes in orders or a psychiatric consult being done. On 3/6/24 Resident # 2's care plan was updated to reflect that Resident # 2 had behaviors related to dementia with psychosis. Some of the interventions included to assign staff that were familiar with the resident when possible and to assure Resident # 2 he was safe if he became distressed. Review of physician orders revealed on 3/9/24 an order for Seroquel 25 milligrams every 12 hours. This indicated an increased dosage. Resident # 2's physician noted in a progress note, dated 3/11/24, Resident # 2 had experienced some syncope episodes. The physician noted that Seroquel was one medication that could contribute to orthostatic hypotension. He further noted Resident # 2 did not respond well to Lorazepam and he would be a good candidate for a lockdown unit. The physician further noted, continue with a referral for psychiatry for further monitoring. On 3/11/24 Resident # 2's Seroquel was discontinued. On 3/12/24 at 7:40 PM Nurse # 7 noted, Late Entry, Resident became aggressive and had an altercation with another resident. Resident was sent to local ER per MD order. RP notified. Review of the facility's investigation into Resident # 2's altercation revealed Resident # 3 was the other Resident involved in the 3/12/24 altercation. A review of Resident # 3's record revealed his diagnoses included in part stroke with hemiplegia/ hemiparesis, dysphagia, and intellectual disability. Resident # 3's quarterly Minimum Data Set assessment, dated 3/2/24, included the information that he was totally dependent on staff for transfers and required substantial to maximum assistance to roll in bed. He was assessed to reject care from staff at times but had no other behaviors on the assessment. According to the record, Resident # 3 resided in the room diagonally across from Resident # 2's room. According to staffing sheets, Nurse # 5 had cared for Resident # 2 from 7 AM to 3 PM on 3/12/24 before the altercation occurred. Nurse # 5 was interviewed on 3/20/24 at 12:57 PM and reported the following. She had also cared for Resident # 2 on the previous day of 3/11/24 and he had been fine on 3/11/24. On 3/12/24 he was also fine all day until he had a moment at the end of the shift. She did not recall the incident in its entirety, and it was brief. She had been seated at the nursing station at the time. Both Resident # 2 and Resident # 3 were in the dayroom which was located adjacent to the nursing station. The dayroom could not be viewed if a staff member was seated. She had been charting and she heard a noise. She stood up and saw that Resident # 2 had moved Resident # 3's wheelchair. Resident # 2 had also said something, but she did not recall what he had said. To her knowledge, Resident # 3 had not done anything, and Resident # 3 was okay. Resident # 3 had just been moved up from where his wheelchair had been. Resident # 2 did seem agitated at the time. She thought she recalled either the Activity Director or the Facility Scheduler had been present at the time and separated Resident # 2 and Resident # 3. She recalled the Activity Director saying Resident # 2 needed his walker. She had gone to Resident # 2's room, obtained his walker, and then walked with Resident # 2 back to his room. He calmed down while she walked with him back to his room. She recalled him saying, I like you because you have a dog. He had not given any indication that he would hurt anyone or become volatile. That was the last time she saw him. She did not report anything to the oncoming Nurse (Nurse # 7) because she recalled Nurse # 7 was standing at the medication cart when the incident moment occurred. The NA (Nurse Aide # 1), who had cared for Resident # 2 during the day shift of 3/12/24, was interviewed on 3/20/24 at 1:30 PM and reported the following. She was familiar with Resident # 2 and knew that at times he felt someone was out to get him. He had never hurt another resident or indicated he would. He never went into other residents' rooms. At times he had stopped in the doorway at the room adjacent to his own and spoken to the residents who resided there in a friendly manner to tell them hello. There were times he would say he felt trapped and would pull on the exit doors to get out. On 3/12/24 during the day shift he had been in the dayroom at one time and was trying to get out. She gave him some cookies and he calmed down. She had never witnessed any incident in the dayroom with Resident # 3. The Activity Director was interviewed on 3/20/24 at 2:10 PM and reported the following. Resident # 2 participated in activities and would talk to other residents in a pleasant manner. He never showed aggression to any residents. On occasion he would say he could not go outside because there was someone out there who was going to get him and his wife. He was not agitated when he mentioned it, and the remark would just seem to come from nowhere. She did not recall an incident at the change of day shift to evening shift on 3/12/24. She did recall Resident # 2 did not have his walker and mentioned this to the nurse. The Scheduler was interviewed on 3/20/24 at 2:18 PM and reported the following. She had been in an office which was near the nursing station at the change of day shift and evening shift on 3/12/24. She recalled Nurse # 5 saying Resident # 2's name and saw her stand up. She (the Scheduler) did not see anything that happened. She left her office when she heard Nurse # 5 say Resident # 2's name to check on things. Resident # 3 was in his wheelchair a couple feet away from Resident # 2 in the dayroom. They were not interacting, and she did not recall Resident # 2 not being calm. Resident # 3's roommate (Resident # 5) was interviewed on 3/20/24 at 9 AM. According to Resident # 5's Minimum Data Set assessment, dated 3/2/24, Resident # 5 was cognitively intact. Resident # 5 reported the following about the evening of 3/12/24 during the interview. Supper meal trays had been served on 3/12/24. He (Resident # 5) was in his bed. Resident # 3 was in his wheelchair watching television when Resident # 2 came into their room. Resident # 2 grabbed Resident # 3's wheelchair and pulled it backwards onto the floor. Resident # 3 fell out of the wheelchair. The intruding resident hit, kicked, and stomped Resident # 3's head. Resident # 2 took Resident # 3's meal tray and beat the heck out of him (Resident # 3). Resident # 2 also took the door to the entrance of their room and hit Resident # 3 with it while Resident # 3 was on the floor. Resident # 2 did this by swinging the door back and forth on Resident # 3's body. Resident # 2 then used the bathroom door to do the same thing. Resident # 2 threw the lid of Resident # 3's supper plate at Resident # 5, but it had missed him and hit the bed. He (Resident # 5) had never seen Resident # 2 before. He (Resident # 5) could not get out of bed by himself to help. He had used his call bell. It seemed like it took 10 to 15 minutes for the staff to come. The nurses did get there and took Resident # 2 away and Resident # 3 was sent to the hospital. On 3/20/24 at 10:00 AM the speech therapist accompanied the surveyor to interview Resident # 3, who was observed to speak in short phrases and at times had unclear words due to his stroke. According to the speech therapist, she had worked with Resident # 3 and was effectively able to communicate with him. Resident # 3 was observed at the time to have a bruised right eye and a small scar where a laceration had healed to the right of his eye. He spoke in short sentences and conveyed the following. The resident, who attacked him, had never been in his room before. He had seen him in a room across the hall from his before the incident. The resident had come in his room and started kicking and hitting him in the face. Resident # 3 pointed to his face as he spoke and to his bruised eye. The resident, who attacked him, used the door to hit his head and it hurt his head. He was afraid now because he worried it could happen again. After the interview, it was confirmed with Resident # 3 and the speech therapist that Resident # 3's comments were understood correctly by the surveyor. Both indicated they had been understood correctly. NA # 2 had been assigned to care for both Resident # 2 and Resident # 3 on the evening shift of 3/12/24. NA # 2 was interviewed on 3/20/24 at 10:15 AM and reported the following. She usually cared for Resident # 3 and described him as a very sweet man. On 3/12/24 she had worked from 7 AM to 7 PM. She had cared for Resident # 3 all during the day and at 3:00 PM assignments were changed for the evening. Resident # 2 was also added to her assignment. She did not consistently care for Resident # 2. To her knowledge Resident # 2 had never threatened or hurt another resident prior. Around 4:00 PM she had seen Resident # 2 walking around the nursing desk. At supper time on 3/12/24 she had been in another resident's room helping them eat their meal. While assisting to help this other resident eat, she thought she heard Resident # 3's voice. Then she heard a noise as if something was falling. She went to look to see what had occurred and found Resident # 2 in Resident # 3's room. Resident # 3 was on the floor curled up in a fetal position. Resident # 2 was swinging the bathroom door back and forth and using the door to hit Resident # 3 in the back. Resident # 3 was crying and there was blood everywhere. She yelled, stop-stop. Resident # 3 raised his arm to swing at her and then exited the room. She looked down the hall and did not see anyone, so she screamed for help. A Nurse Aide on the adjacent hall heard the scream and alerted her nurse. Then other staff came and helped. Nurse # 7 had been assigned to care for Resident # 2 on the evening shift of 3/12/24. Nurse # 7 was interviewed on 3/20/23 at 12:38 PM and reported the following. She routinely worked with Resident # 2 and he was confused every day and would become agitated. He would talk about needing a gun and needing to protect the place where he was. He talked about being in the special military police. He would tell the Nurse Aides at night not to come into his room to care for his wife. He saw himself as the caregiver for his wife and that he was in charge. He had been known to say he would hurt those girls (meaning the aides) if they didn't stop coming into his room. She (Nurse # 7) would have to talk to him and convince him to allow for the staff to care for his wife. Although he would talk to staff about guns, he would not talk to residents about them, and she never knew him to hurt or threaten to hurt another resident prior to 3/12/24. She did not recall anything that had occurred happening between Resident # 2 and Resident # 3 at the beginning of the evening shift or where Resident # 2 was at the beginning of the shift. At the time of the incident, she had been in another resident's room providing care with the door closed. She heard yelling. When she got to the room, other nurses had already arrived. Resident # 2's wife was wandering, and she redirected her and then stayed with Resident # 3 until he was taken to the hospital. NA # 3 was interviewed on 3/21/24 at 10:20 AM and reported the following. She had been working on an adjacent hall to Resident # 2's hall on the evening of 3/12/24 when she heard NA # 2 screaming. She ran to the room and saw NA # 2 trying to get Resident # 2 out of Resident # 3's room. Resident # 2 was agitated when she (NA # 3) arrived but when he saw her (NA # 3), he calmed down and said, There's my sweet heart. She then took him calmly by the hand and led him to his room without a problem, sat him down with his meal tray before him and closed the door. She went back to help with Resident # 3 and try to stop the bleeding while NA # 2 got multiple nurses. They came right away. Nurse # 8 was a nurse who had responded on the date of the incident of 3/12/24 and had been working on the adjacent unit. Nurse # 8 was interviewed on 3/21/24 at 2:30 PM and reported when she heard the call for help, she responded and found Resident # 3 crying on the floor. There was blood in his eyes and his ears . She was familiar with Resident # 2 and was shocked he had attacked Resident # 3. She did not think he had the strength to do what he had done. Nurse # 9, who had been working on another unit and had responded on 3/12/24, was interviewed on 3/21/24 at 3:00 PM. Nurse # 9 reported the following. She heard that they were calling all the nurses to Resident # 2's unit. She ran to Resident # 3's room and saw he had blood in his eyes, ears, and on his arm. One of the Nurse Aides reported he had been beaten. She called 911 for the police and EMS to be dispatched. The facility Social Worker came and stayed with Resident # 2 while she was making calls and getting the paperwork ready for transfer for both residents. Then she took over staying with Resident # 2 until emergency services arrived. At the point where she started watching Resident # 2, he was agitated again and asking if she was going to shoot him while telling her she was an idiot and no good. She had worked with Resident # 2 previously and never known him to be paranoid or have behaviors when she had worked with him previously. He had always been pleasant. Resident # 2's guardian was interviewed on 3/21/24 at 9 AM and reported the following. She had known Resident # 2 and his wife for 37 years and knew them well. He and his wife were very active prior to his September 2023 hospitalization. She described Resident # 2 as very sweet and charitable towards others. He had no history of violent behavior. Historically he had worked for the military police and analyzed spy photographs. In September 2023 he was hospitalized and then he and his wife were placed in the facility. It was during the hospitalization that she first became aware of any confusion. The hospital physician had talked to her and informed her that Resident # 2 was hallucinating and thinking that he and his wife were being kidnapped. She was appointed his guardian in February 2024. She visited two to three times per week. She noticed he was becoming more and more confused, and to her, it appeared to be happening rapidly. He was having a harder time completing sentences. Some days she visited, and he was completely fine. Other days he was paranoid and would talk about being under surveillance through his clock, the smoke detector, or television. She felt as if his memories were becoming mixed up in his head. He never appeared aggressive to her. He appeared fearful. On the day of the incident, she had talked to him about two hours before the altercation. He had been in a great mood and had given no indication he could hurt anyone. She was totally shocked and felt as if he could be placed on the right medications, then he could be helped. She did not recall anyone at the facility talking to her about a psychiatric consult until after the incident. Review of hospital records for Resident # 2 revealed he had a psychiatry consult on 3/13/24 after he was hospitalized . The psychiatric NP (Nurse Practitioner) noted, Patient currently reports he doesn't know where he is or why he is not home. He states they took him out after he had to beat somebody up .He appears confused discussing enemies, traitors, and enemy cots. At the time of the survey, Resident # 2 remained hospitalized . Review of Resident # 3's 3/12/24 emergency department records revealed he was assessed to have a small laceration lateral to the right eye which was closed with skin glue and steri- strips, a skin tear to the elbow, and several abrasions and bruises to the forehead. A CT of Resident # 3's head revealed no fracture or hemorrhage. After treatment, he returned to the facility. The facility Social Service Director was interviewed on 3/20/24 at 4:50 PM and reported the following. She had never witnessed Resident # 2 be aggressive with another resident prior to 3/12/24 or wander into another resident's room. She confirmed a psychiatric consult had never been obtained for Resident # 2 and the referral had been inadvertently missed, but she was unsure how it had been missed. Resident # 2's physician was interviewed on 3/21/24 at 9:45 AM and reported the following. From Resident # 2's initial entry into the facility he had made crazy statements. Although Resident # 2 never received a psychiatric consultation, he (the medical physician) was seeing him and overseeing his medications. The highest likelihood of his psychosis[TRUNCATED]