**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews with Police Officer, staff, Resident, Psychiatric Nurse Practitioner, and Physician, the facility failed to protect a Resident's right to be free from staff to resident abuse perpetrated by Nurse Aide (NA) #3 while giving care to a resident with a history of being combative. On 03/08/2025 during morning rounds, Medication Aide #2 observed Resident #9 in his bed with scratches on the left side of his forehead, side of face, nose and left eye redness (bruising). This affected 1 of 4 Residents reviewed for abuse (Resident #9). The findings included: Resident #9 was admitted to the facility on [DATE] with diagnoses including cerebral infarct (stroke). The quarterly Minimum Data Set (MDS) dated [DATE] had Resident #9 coded as cognitively intact and needed total care with activities of daily living (ADL). There were no behaviors or moods reported. His vision was severely impaired, and he was also always incontinent with bowel and bladder. The care plan dated 01/24/2025 had a focus of Resident #9 needing total assistance with ADL, was incontinent of bowel and bladder, had a history of behaviors: verbal insults towards staff, will refuse medication at times, verbal aggression towards staff during ADL care, behaviors (striking out at staff and roommate) and cussing at staff during care. Review of the Initial Allegation Report (2-hour report) dated 03/08/2025 revealed an allegation of abuse. The incident was reported at 7:15 AM. The details of the report stated Nurse #1 was informed that Resident #9 had an injury to his forehead, nose, and left eye. Visible injuries include scratches to the forehead, side of head, and left eye redness noted (initial stages of bruising). He complained of pain with palpitation to nose and left eye. Resident #9 stated that this morning around 6:45 AM, She told me to turn on the bed and I did not want to, then she hit me in the face. The resident denied any other injuries or complaints of pain other than his nose and left eye. The incident was reported to the local law enforcement. Immediate interventions include suspension of the accused nurse aide, facial x- ray, and neurological checks. Currently, there was no ongoing risk to other residents. We are conducting a thorough investigation to ensure the safety and well-being of everyone in our care. A review of a witness statement from Nurse #1 dated 03/08/2025 revealed at around 6:45 AM Medication Aide #2 came to her and reported Resident #9 had visible injuries to his forehead, side of head and left eye. The resident complained of pain from his nose and left eye area. She asked what happened and he stated, she hit me. The Nurse asked when it happened and if he knew her name. The Resident stated it just happened this morning. She told me to turn in the bed and he did not want to then she hit him in the face. The resident stated just his head and face hurt. A telephone interview with Nurse #1 was conducted on 03/19/2025 at 9:43 AM. The nurse stated she worked the night shift from 7:00 PM to 7:00 AM and worked in facility that night but was not Resident #9's nurse. On 03/08/2025, around 6:45 AM, Med Aide #2 reported to her to look in on Resident #9 because he had scratches on head and believed he was hit. She went to Resident #9's room and saw he had small scratches to the left side of his forehead, nose and eye. His eye was swollen and it would not fully open. She told Resident #9 he had an injury to his head and asked if he remembered what happened and he said, she hit me. The Nurse also asked if he remembered who hit him and stated, she told him to roll over in bed and he did not want too and then she hit me. She did not know if it was a slap or punch. He could not say a name but stated, she worked with him that night. The Nurse also stated his injuries were fresh because the scratches had not clotted yet and were easy to clean. The Nurse asked Resident #9 if she could touch the areas, and he allowed. She used normal saline to clean his face and offered a cold pack, but he refused. He said he was not in pain. The areas stopped bleeding when cleaned. The wounds did not look as if he could inflict them on himself and he never had a history of making anything up. He can be combative at times. The NA that worked with him that night was NA #3. The Nurse stated she asked if it was okay to leave him and if he felt safe, he stated he did. She went to find NA #3 and she had left the building. She then called the Unit Manager on-call supervisor. A review of a witness statement from Medication Aide (Medication Aide #2) no date revealed on March 08, 2025, as she was in the middle of her morning med pass and giving medicine to a resident. She heard Resident #9 yelling and then he stopped. When this Med Aide went into his room, she noticed blood and cuts on his face. She immediately notified Nurse #1 on duty. A telephone interview with Medication Aide #2 was conducted on 03/19/2025 at 4:11 PM. Medication Aide #2 stated she was the med aide on 03/07/2025 at 11:00 PM to 03/08/2025 at 7:00 AM. On 03/08/2025 at approximately 5:45 to 6:00 AM, she and NA #2 were getting supplies from the supply room. As they passed Resident #9's room, his roommate, Resident #69, yelled out for help. He wanted his television turned on. She observed Resident #9 at that time, and he was fine and did not have any scratches or bruises. She went to get the medications for Resident #69 and came back to the room and while giving him his medications, NA #3 came in and told Resident #9 she was there to change his brief. Resident #9 and NA#3 were calm, and he allowed her to assist him. She left the room and went to another resident's room to give medications. While in the Residents room, she heard Resident #9 yell out but could not understand what he was saying. It was not out of the ordinary for him to yell out and he did not yell after that. She exited the resident's room and saw NA #3 walk by and figured she took care of Resident #9's needs. NA #3 looked normal and did not seem angry. She went to her next resident room to administer medications and after she finished administering medications to that resident, she went to peek in on Resident #9. She observed scratches on his face and forehead, he had scratches on his left side of his eye and left inner eye. The scratches were fresh, and she noticed blood on his face. She asked the resident what happened to his face, and he did not say anything. She then went to get Nurse #1. The nurse went into Resident #9's room and took care of the resident, and she went back to administering medications. The Medication Aide also stated Resident #9 was alert and oriented and he cannot see very well. To her knowledge, he had never made false allegations against staff and his nails were short and neat. The Medication Aide further stated she worked with Resident #9 regularly after the incident and he had not had any behavior changes. He did not appear to be afraid, had not had any sleeping changes and he still yells out if he needed something. A telephone interview with NA #2 was conducted on 03/19/2025 at 12:31 PM. The NA stated he worked 7:00 PM o 3/07/25 to 7:00 AM on 03/08/2025 and he was familiar with the care for Resident #9. Resident #9 needed total assistance with activities of daily living (ADL) care. The morning of 03/08/2025 he saw NA #3 walk in the room and within a minute he heard her tell Resident #9 to roll over to be changed and she did sound agitated. Within another minute he heard sounds like a hand hitting a hand and was walking away from the room. He would usually go in and see what was going on, but NA #3 was not the type of person that you confront when she was upset. When she (NA #3) left the room, he and Medication Aide #2 went in and observed blood coming down Resident #9's left or right temple. Medication Aide #2 asked if he was okay, but he did not hear what the Resident said because they left to find a nurse and went in opposite directions. The NA also stated he had not observed NA #3 abusing residents or treating them roughly in the past. A review of the witness statement from NA #3 dated 03/08/2025 revealed she was assigned to rooms 64-70 and she did her roll call at 11:30 PM. All of her residents were accounted for and did her 1st round at 12:30 AM. Resident #9 was not soiled at all, and he doesn't like to be bothered throughout the night. She doesn't get too close to him because he is a fighter and he can't see and is afraid at times, but she checked on him every round. At 5:30am she asked if she could check him to see if he needed to be changed and he said, Yes. As she was changing him, she talked with him, so he knew what she was doing, so he didn't get afraid and fight her. He let her change him and she left the room. She didn't see anything on him because he didn't let anybody get close to him. He wasn't upset at all when she changed him. A telephone interview with NA #3 was conducted on 03/19/2025 at 2:28 PM. The NA stated she came in on overtime on 03/07/2025 for a 11-7 shift. It was a pleasant night. She was in a good mood and Resident #9 was in good spirits as well. She went in to do her rounds and the last round was around 5:30 AM. He was fine when she left the room around 5:45 AM. The NA also stated she would always announce what she was going to do and loud enough for him to hear her. The Resident is half blind, so you must tell him what you are there for. She told him she was there to check and change his brief and he allowed it. There were no other interactions with the Resident. She left and she did not return to the room. The NA also stated she feels she was being set up at the facility because she and Resident #9 got along well, and she would never do anything like this. A review of an x-ray dated 03/08/2025 revealed a history of injury and pain, 4 views of facial bones with no prior studies. There were no definite displaced or depressed facial fractures. A review of the local Police Department incident/investigation report dated 03/08/2025 revealed on 03/08/2025 the Police Officer #1 was dispatched to [name of the facility] in reference to an elderly man who was assaulted by an employee. When he arrived, he and Officer #2 walked to Resident #9's room where he spoke to the resident. Resident #9 stated that earlier that morning a he-she hit him in the face and scratched his head. He asked the resident who it was and what they were doing. He was having a hard time communicating but was able to inform me that she was there to give him a bath and when she asked him to sit up, he didn't move fast enough for her, and she struck him. Officer #1 asked Resident #9 if it was possible that it was an accident and if she apologized and doctored him up afterwards and he stated No, she was mean. I observed a bruised left cheek below his eye, a small amount of dried blood in his tear duct, and a long scratch going from the top of his left eye to the top of his head. It was easy to see due to the resident not having hair on his head. A telephone interview with Police Officer #2 was conducted on 03/18/2025 at 2:49 PM. Officer #2 stated they were called in on 03/08/2025 for alleged abuse of a Resident from a staff member. They went to the Residents room and asked if he could tell them what happened and he stated he was hit by a he/she, because he did not move fast enough and that it just happened. The Resident just said he was hit and did not explain how he was hit. The Resident also showed signs of an altercation with bruises and scratches that were visible on his face. There was no arrest yet and the case was still open. A telephone interview with Nurse #2, the 7:00 PM to 7:00 AM nurse on 03/08/2025 was conducted on 03/19/2025 at 1:42 PM. The nurse stated she did work the night shift when the incident occurred and was Resident #9's nurse. That morning (3/08/25), she was completing her night rounds and did not see or hear anything but was told about it after it happened. The Nurse stated the last time she was in Resident #9's room was in the middle of her shift around 1:00 AM. Resident #9 did not have any bruising or scratches. A review of a witness statement from Nurse #3, no date, revealed at the start of my shift on 03/08/2025, as charge nurse (7:00 AM to 7:00 PM), it was reported to him a potential abuse involving Resident #9. Upon going to assess Resident #9, he was adamant he was hit. He had visible injuries to forehead, left eye and head. When asked when and by whom, the Resident stated, early this morning by this girl. Emotional support was offered to Resident #9, and first aid was offered. A telephone interview with Nurse #3 was conducted on 03/19/2025 at 9:23AM. The Nurse stated he still worked at the facility as 7:00 AM to 7:00 PM charge nurse. An incident happened on Saturday morning, 03/08/2025 at end of the night shift. Nurse #1 reported to him that suspected abuse may have happened to Resident #9 and went to his room a little after 7:00 AM to assess him. He noticed he had injuries including and a bruise on his left eye and scratches on his face. He did not complain of pain at that time. Resident #9 allowed him to apply an ice pack to the bruise on his face. He did a full assessment and body check and there were no other issues found. The resident stated, That girl hit me, when asked what girl he said it was the girl working with him that night. He could not give her name. The Resident worked with NA #3 that night shift. The Nurse also stated he had not seen NA #3 treat or had any reports of her treating the residents any other residents ruff or would have reported it. The Nurse also stated Resident #9 had dementia and got agitated at times and refuses his care. The Resident's behavior had not changed since the incident and, he had not complained about the pain. An interview with the Unit Manager was conducted on 03/20/2025 at 1:01 PM. She stated the incident was reported to her by phone between 7:00 AM and 7:30 AM because she was the on-call Nurse that weekend. Nurse #1 reported Resident #9 had a developing bruise on the inner left eye and small scratches on his forehead, left side of nose and face. Resident #9 had a history of being combative with staff in the past. The Unit Manager also stated she told Nurse #1 to start neurological checks and then she contacted the provider and DON. The provider gave orders for a facial x-ray and there were no fractions found. She also contacted the Responsible Party (RP) to say that there was an alleged abuse involving Resident #9. The DON completed the reports and notified authorities. The DON stated she would handle the investigation. The Unit Manager further stated the Resident had not had any change of behavior or sleep habits. When she went to visit him on that Monday, 03/10/2025, he was his normal self and stated he was okay and did not have any pain or discomfort. An observation and interview with Resident #9 were conducted on 03/18/25 at 02:03 PM. Resident #9's face was observed to be free from bruising and scratches. He stated he did not have any pain. The Resident stated he was hit by a girl that worked at the facility. She asked him to lie down so she could change him, and he guessed it wasn't fast enough for her, and she started hitting him in the face and head. He did not remember who she was, but it was the person that was working with him that night. He stated he feels safe at the facility, he was mad, but the incident did not bother him at all anymore because she must have been crazy. He has not seen the NA at the facility since the incident. He was already seeing psychiatric services but not for this issue. He also stated he still can sleep without any issues and his moods had not changed. An interview with Resident #69, Resident #9's roommate was conducted on 03/18/2025 at 02:13 PM. The Resident stated he did not hear or see anything because he was asleep. A follow up interview with Resident #9 was conducted on 03/19/2025 at 12:02 PM. The Resident stated he could not see how she was hitting him but knew she was hitting him. The Resident also stated there was no need to go to the hospital when it happened, and he was fine. A review of the Trauma Informed Screen completed 03/11/2025 revealed Resident #9 was in a recent confrontation with a staff member. Resident #9 stated he was, OK. There were no anxiety issues, the Resident denied any mental anguish or anxiety. X-ray of face was obtained and is included. The resident was also followed up by the provider and that note is also included. A review of a social services note dated 03/11/2025 revealed he met with Resident #9 in his room. Questions concerning Trauma Inform Screen and discussions of altercation with staff member. Resident #9 stated he was, OK and has no anxiety issues. The Resident also stated he was not in need of any other psychological services at present and was thankful for his visit. An interview with the Social Worker (SW) was conducted on 03/21/2025 at 9:09 AM. The SW stated he was made aware of the incident with Resident #9 that happened the past weekend (03/08/2025). He went down to Resident #9's room to check on him and to make sure he was not in any distress or suffering from trauma. He completed the screen for trauma, and it did not show any trauma. He stated he was okay; he was not fearful or in any pain. A telephone interview with the Psychiatric Nurse Practitioner was conducted on 03/20/2025 at 10:36 AM. She stated she visits Resident #9 twice a month on Wednesdays for his combative behaviors and diagnosis of vascular dementia with behavioral disturbances. On 03/12/2025 Resident #9 had a scheduled chronic visit and med review. He was in his bed, asleep and easily aroused. He was calm and content, alert and oriented. He stated he did not have any anxiety or issues sleeping and eating well. When asked if there were any issues, he wanted to discuss, he stated, no, and did not mention the incident. On 02/26/2025, he was ordered a new as needed (PRN) order for 0.5 milligrams Ativan for agitation prior to the incident and it was not administered within that look back period of 14 days. He had a history of being agitated and striking out at times during care. He can identify people by voices. Resident #9 had not had a history of fabrications. He was still alert and oriented even though he is blind. The Nurse Practitioner also stated Resident #9 did not have any notable bruising or scratches visible or complained of pain on 03/12/2025 when she visited him. A review of a physician note dated 03/12/2025 revealed Resident #9 was stable and there were no new complaints. His skin was normal temperature and normal color. Summary from 03/08/2025 revealed resident noted with multiple scratches to forehead, left side of scalp, and on the inner corner of his left eye. Bruising was noted to left eye and nose as well. When asked what happened the resident stated that he was told by a nursing assistant to turn over and he did not want to and when he said that he did not want to she hit me in the face. The resident reported pain to the left side of face and nose. The area was cleansed with wound cleanser and patted dry. The provider was notified and gave telephone order for an x-ray of nose and left orbit and neurological checks were implemented. A telephone interview with the Physician was conducted on 03/20/2025 at 1:44 PM. The Physician stated she was new to the facility but did visit Resident #9 on 03/12/2025 as her note indicated. She did not observe any facial bruises or scratches on his face and there were no complaints of pain. If there was, she would have addressed it in her note. She also stated she could not say if the scratches could have been self-inflicted due to the incident because she did not see the areas when the incident happened. The physician also stated she would expect all residents at the facility to be free from abuse. A review of the investigation Report (5-day report) dated 03/14/2025 revealed the alleged employee (NA#3) was suspended starting 03/08/2025 through the duration of the investigation. After investigation, NA #3 was terminated. Skin audits were completed on the residents with BIMS scores less than or equal to 11. Interviews completed with resident with BIMS greater than and equal to 12. Statements were received from the resident, resident's roommate, and other staff that were present during the day of the incident. Staff were re-educated on the abuse policy. Employees were re-educated about abuse and the importance of timely notification to management. Weekly skin checks will be continued on in-house residents. No other residents were noted to be in any immediate danger. An interview with the Director of Nursing (DON) was conducted on 03/20/2025 at 1:31 PM. The DON stated she received a call from her Unit Manager a little after 7:00 AM on 03/08/2025 and reported Resident #9 had been hit in the face and had some scratches and bruise under the left eye forming with fresh blood. The DON asked which NA was scheduled and was told NA #3 and her shift ended at 7:00 am and she had already left the facility. The DON had the Unit Manager take NA #3 off the schedule and look for a replacement. She then called NA #3 and asked if she had Resident #9 the last shift and if anyone was in the room with her. She stated she did have him last night and no one else was in the room with her when she finished his care. She said he can fight you and be combative at times, but it went ok and there were no issues. NA #3 emailed her the statement. The DON called her back and told her he was hit in the face and was observed with fresh blood and a bruise that was forming. The DON informed the NA #3 she would investigate the incident and get back to her. The DON had the Unit Manager contact the physician and got an order for an x-ray and no fractures were found. Skin was assessed for Resident #9 and no other issues aside from the face scratches and redness, bruise to left eye. He did not require treatment for his face, it resolved on its own. He also did not require pain medication, just an ice pack. The DON stated she completed the Initial Report and called 911 and reported it to police and their investigation was ongoing. The DON received a statement from Nurse #1. The abuse and neglect education began on 03/08/2025 by Nurse #3. Resident #9 or any other resident were not in immediate danger. He was not showing any emotional distress and stated he was fine and did have a psychiatric visit on 03/12/2025. He has not complained of pain since the incident and did not require further treatment for his face. The DON indicated she reported the incident to the Administrator. The DON also stated she called NA #3 and let her know the allegation was substantiated and had to let her go. There were no previous issues with Resident #9 and NA #3 ever reported. The Resident did have a history of striking out at staff but that was no excuse. The DON stated she expected her staff not to abuse residents and for her residents to be free of abuse and feel safe at the facility. An interview with the Administrator was conducted on 03/20/2025 at 3:52 PM. The Administrator stated he was called by the DON on 03/08/2025 who reported there was a situation with Resident #9 and NA #3. She stated it looked like the NA, that worked that night, may have abused the resident. The nurses evaluated the resident for any other issues to his body and skin. There were scratches and a bruise on his left eye and there were x-rays completed and there were no fractures found. The resident did not complain of pain after the day of the incident and his bruising and scratches went away quickly. The Administrator also stated he made sure the DON completed the initial review and reported the incident to the police who were in the building while he was on the phone with her. He also reminded the DON that the NA could not work there until the investigation was completed. The NA had not been in the facility since that morning at 6:50 AM. The Administrator also stated the RP was made aware. The investigation was substantiated. The staff member was fired but there were no prior issues with NA #3 before the incident and there were no problems between her and Resident #9. There was no abuse found by the alert and oriented Residents that completed questionnaires and interviews. The staff were questioned about what happened and they received witnesses' statements. They educated the staff that they must report abuse as soon as possible and that abuse is not supposed to happen and will continue to educate staff about abuse. The Administrator stated he expected the residents to be free from abuse.