**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation, and review of the facility policy, the facility failed to adequately assess residents' skin and failed to ensure adequate care and services were provided to residents to prevent the development and worsening of pressure ulcers. This resulted in Actual Harm for Resident #135 when the facility staff failed to adequately assess the resident's skin and failed to implement timely interventions for a pressure ulcer until the ulcer reached an advanced stage. Actual Harm also occurred for Resident #01 when the facility staff failed to assess the resident's skin and the resident developed an unstageable pressure to the right heel caused by a removable splint device. This affected two (Residents #135 and #01) of the three residents reviewed for pressure ulcers. The facility census was 128. Findings include: 1. Review of the medical record for Resident #135 revealed an admission date of 03/18/24 with diagnoses including muscle weakness, need for assistance with personal care, and type two diabetes mellitus. Review of the Minimum Data Set (MDS) assessment for Resident #135 dated 06/27/24 revealed the resident had intact cognition, had no pressure ulcers present, but was at risk for the development of pressure ulcers. Review of the care plan for Resident #135 most recently revised on 06/21/24 revealed the resident was at increased risk for pressure ulcer development. Interventions included the following: administer treatments as ordered and monitor for effectiveness, offer and assist with toileting on rounds and as needed, pressure reducing mattress to bed. Review of the weekly skin assessments for Resident #135 revealed there were no weekly skin assessments completed for the resident from 06/14/24 until 07/05/24. Review of the hospital emergency department visit note for Resident #135 dated 06/23/24 revealed the resident had superficial stage one sacral decubitus ulcers which did not appear infected with no surrounding erythema or discharge. Review of the nurse progress note for Resident #135 dated 06/23/24 timed 7:27 P.M. revealed Resident #135 returned to the facility from the hospital emergency department with no new orders. There was no skin assessment completed upon Resident #135's return from the hospital on [DATE]. Review of the shower sheet for Resident #135 dated 06/26/24 revealed the resident had an area of redness to his sacral area. Review of the nurse progress note for Resident #135 dated 07/02/24 a State Tested Nursing Assistant (STNA) called the nurse to the resident's room. The nurse arrived and noted an area to the resident's right buttocks which had eschar (dry, black, firm tissue which formed on full thickness wounds.) The resident voiced complaints of pain to his buttocks and the nurse administered as needed pain medication. The nurse notified the physician and the wound physician and received and implemented a treatment order for the wound to the resident's right buttocks. Review of the physician's orders for Resident #135 revealed wound treatment order for the pressure ulcer to the resident's buttocks was not initiated until 07/02/24. Review of the wound physician visit note for Resident #135 dated 07/05/24 revealed the resident had an unstageable pressure ulcer to the right buttocks which measured 8.8 centimeters (cm) in length by 4.7 cm in width with the depth unable to be determined because 50 percent (%) of the wound bed was covered with 50 percent slough (a yellow or white material that accumulates in a wound bed and is made up of dead cells, pus, and other debris.) The wound had a moderate amount of drainage. Interview on 08/27/24 at 11:10 A.M. with Unit Manager (UM)/Licensed Practical Nurse (LPN) #330 confirmed the facility had not completed skin assessments for Resident #135 from 06/14/24 through 07/05/24. UM/LPN #330 further confirmed Resident #135 was assessed to have stage one pressure ulcers present to the sacral area during a hospital visit on 06/23/24, and the facility staff did not assess the resident's skin upon the resident's return from the hospital on [DATE]. UM/LPN #330 confirmed the facility staff did not identify and implement a treatment for Resident #135 until 07/02/24 when the resident presented with an unstageable pressure ulcer with eschar to the right buttocks, and by that time the resident's pressure ulcer had already reached an advanced stage. Review of the facility policy titled Pressure Ulcer Risk Assessment revised March 2005 revealed if pressure ulcers were not treated when they were discovered, they could quickly get larger, become very painful for the resident, and often become infected. Once a pressure ulcer developed, it could be extremely difficult to heal. Staff should routinely assess and document the condition of the residents' skin per the facility wound and skin care program for any signs and symptoms of irritation or breakdown. Staff should immediately report any signs of a developing pressure ulcer to the supervisor. Staff should assess resident's skin for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 2. Review of the medical record for Resident #01 revealed an admission date of 03/07/24 with diagnoses including schizoaffective disorder, unspecified psychosis, and displaced bimalleolar fracture of the right lower leg. Review of the MDS assessment for Resident #01 dated 07/27/24 revealed the resident had mildly impaired cognition, had no pressure ulcers present, but was at risk for the development of pressure ulcers. Review of the care plan for Resident #01 dated 03/26/24 revealed the resident was at increased risk for pressure ulcer development. Interventions included the following: administer treatments as ordered and monitor for effectiveness, assist with turning and repositioning on rounds and as needed to relieve pressure areas, low air loss mattress to bed. Review of the hospital progress notes for Resident #01 dated 06/20/24 through 07/20/24 revealed the resident had a surgical procedure to the right ankle which required an ortho-glass splint with an ace wrap. Review of facility progress notes, physician's orders, and assessments for Resident #01 dated 07/20/24 to 08/16/24 revealed there was no documentation of a splint to the resident's right leg, ankle, or foot. Review of the wound physician visit note for Resident #01 dated 08/16/24 revealed the resident had an unstageable pressure ulcer which measured 3.1 centimeters in length by 2.6 cm in width covered with eschar to the right heel related to a medical device, a cast boot which was first identified on 08/15/24. Observation on 08/27/24 at 3:50 P.M. revealed Resident #01 had a dime-sized pressure ulcer to the right heel which was covered in eschar. Telephone interview on 08/28/24 at 11:40 A.M. with Wound Physician (WP) #601 confirmed facility staff reported Resident #01 had a cast or splint present to his right foot when he returned from the hospital following surgery on 07/20/24. WP #601 confirmed staff reported when the cast or splint was removed on 08/15/24 staff discovered a new pressure ulcer was present to the resident's right heel. Interview on 08/28/24 at 11:48 A.M. with UM/LPN #330 confirmed there was no documentation of a cast, splint, or other device being present on Resident #1's right foot following the resident's return from the hospital on [DATE]. Interview on 08/28/24 at 2:20 P.M with Registered Nurse (RN) #431 confirmed Resident #01 returned from the hospital on [DATE] with a hard, splint type device in place to the right lower leg and heel which was held in place by an ace bandage. RN #431 confirmed the splint device was removable, but the staff had not removed the device until 08/15/24 when RN #431 removed the splint in order to remove the sutures Resident #01 had in place to the right ankle. RN #431 confirmed staff discovered Resident #01 had developed an unstageable pressure ulcer to the right heel underneath the splint. Review of the facility policy titled Pressure Ulcer Risk Assessment revised March 2005 pressure ulcers were usually formed when a resident remained in the same place position for an extended period of time causing increased pressure or a decrease in circulation to an area, which destroys tissue. Pressure could also come from splints, casts, bandages, or wrinkles in the bed linen. This deficiency represents noncompliance investigated under Complaint Number OH00157073 and Complaint Number OH00156967 and Complaint Number OH00156451.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the facility's investigation, review of witness statements, review of the hospital records, and policy review, the facility failed to ensure residents were free from resident-to-resident abuse. This resulted in Actual Harm on 05/31/24 when Resident #52, a resident with a known history of aggressive behaviors towards other residents, intentionally ran over Resident #14 with his wheelchair. Subsequently, Resident #14 was sent to the local hospital where she was diagnosed with a closed fracture of the right tibial plateau initial encounter. The facility also failed to ensure Resident #60 was free from resident- to-resident abuse when Resident #52 intentionally ran into the resident with his wheelchair causing the two residents to become involved in a physical altercation. This affected two (#14 and #60) out of three residents reviewed for abuse. The facility census was 126. Findings include: 1) Review of Resident #14's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included vascular dementia, difficulty in walking, muscle weakness, chronic obstructive pulmonary disease (COPD), osteoarthritis, psychotic disturbance, mood disturbance and anxiety, congestive heart failure, adult failure to thrive, anxiety disorder, alcohol dependence, retention of urine, acute kidney failure, schizoaffective disorder, and major depressive disorder. Review of Resident #14's activities of daily living (ADL) care plan dated 12/15/23 and revised 06/17/24, revealed Resident #14 required assistance with ADLs and Resident #14 does ambulate with her walker but is often non-complaint with using her walker and is a fall risk. Interventions included Resident #14 had a rollator walker and a wheelchair, but she did not use them daily, staff to assist with completion of ADLs on a daily basis and Resident #14 required weight bearing assistance with ambulation. Review of Resident #14's annual Minimum Data Set (MDS) assessment dated [DATE], revealed the resident to be cognitively intact. Review of Resident #14's late entry progress note dated 05/30/24 at 10:30 A.M., revealed Resident #14 returned from the hospital with a right tibia fracture and a urinary tract infection (UTI). New medications were updated on the medication administration record (MAR) and sent to Nurse Practitioner (NP) #550. Review of Resident #14's progress note dated 05/30/24 at 11:43 A.M., revealed Resident #14 was in the hallway trying to get her food order for lunch. Another resident (facility identified #52) ran over Resident #14 with his wheelchair and her leg was dislocated in the wheelchair and the resident hitting her head. NP #550 was at the facility and was aware and new orders were placed to initiate neurological checks, to get x-rays, and for Resident #14 to be sent out for evaluation. Review of Resident #14's hospital After Visit Summary (AVS) dated 05/30/24 revealed Resident #14 was seen due to her being an assault victim with diagnoses listed as assault, fall initial encounter, closed fracture of the right tibial plateau and urinary tract infection (UTI) without hematuria. Resident #14 was treated with antibiotics and pain medications, placed in a knee immobilizer and released back to the facility. Review of Resident #14's progress note dated 06/03/24 revealed another resident rolled into the resident with their wheelchair, resident expressed pain, the physician was called, and the resident was sent to the hospital on [DATE] where she was diagnosed with right tibia fracture and a UTI. Resident #14 had orders for Tramadol (narcotic pain relief), Norco (narcotic pain relief) and ibuprofen. The other resident (Resident #52) was moved to a different unit. Review of Resident #14's progress note dated 06/14/24 revealed Resident #14 had a follow up appointment scheduled with orthopedics on 06/18/24 at 2:00 P.M. 2) Review of Resident #60's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included COPD, acute and chronic respiratory failure with hypoxia, anemia, insomnia, sepsis, schizoaffective disorder and hypertension. Review of Resident #60's most recent MDS assessment dated [DATE], revealed the resident to be cognitively intact. Review of Resident #60's progress note dated 04/05/24 at 7:31 P.M. revealed the State Tested Nurse Aide (STNA) (unknown and the facility was unable to verify) was observed separating the residents (the facility identified Resident #52 as being the other resident) and the STNA and Licensed Practical Nurse/Unit Manager (LPN/ UM) #167 deescalated the situation. Head to toe skin assessments were completed and no injury was notified. The physician and Resident #60's guardian were notified. Review of Resident #60's Interdisciplinary Team (IDT) note dated 04/12/24 at 4:24 P.M., revealed Resident #60 was involved in a physical aggressive incident on 04/05/24. Another resident (facility identified as Resident #52) aggressively rolled into Resident #60 with their wheelchair. Resident #60 then kicked the resident in the stomach. The two began to throw blows with closed fists. The residents were immediately separated and assessed for injuries. No injuries were noted at the time of initial assessment. Resident #60 was continually monitored with no complaints, signs, or symptoms of pain. The aggressor was placed on one-on-one, and no further incidents of aggression were noted. Review of the medical record for Resident #52 revealed the resident was admitted to the facility on [DATE]. Diagnoses included schizophrenia, non-pressure chronic ulcer of other part of right foot, malnutrition, diabetes mellitus, schizoaffective disorder, cannabis dependence, depression, anxiety disorder and COPD. Review of Resident #52's physician order dated 02/19/24 revealed Resident #52 resided on a secured unit. Review of Resident #52's quarterly MDS assessment dated [DATE] revealed the resident to be cognitively intact. Review of Resident #52's progress note dated 04/05/24 at 7:02 P.M., revealed STNA (unknown and the facility was unable to verify) was observed separating the residents and the STNA and LPN/UM #167 deescalated the situation. Head to toe skin assessments were completed with no injuries. The physician and Resident #52's guardian were notified. Review of Resident #52's behavior care plan dated 04/09/24 and revised 06/10/24, revealed Resident #52 exhibited verbal and aggressive behaviors at times. Interventions included medications as ordered, caregivers to provide an opportunity for positive interaction, consult behavioral services as needed, explain all procedures to the resident before starting and allow the resident time to adjust to changes, intervene as necessary to protect the right and safety of others, divert attention, remove from the situation, and monitor behavior episodes and attempt to determine underlying causes. Review of Resident #52's Psychiatric Consent to Treat, dated 04/26/23 revealed Resident #52 refused the consent. Interview of the IDT meeting note dated 04/12/24 at 4:35 P.M. revealed Resident #52 was a [AGE] year-old male with a history of schizoaffective disorder, depression, and schizophrenia. Resident #52 initiated the incident of physical aggression on 04/05/24. Resident #52 aggressively rolled his wheelchair into the back of another resident (facility identified as Resident #60). The other resident then kicked Resident #52 in the stomach. Both residents started throwing blows and were immediately separated and assessed for injuries. Skin assessment, neurological assessment, and pain assessments were initiated. No injuries or pain were noted. Resident #52 was placed on one-on-one. No further incidents of aggression were noted since the incident. Review of Resident #52's progress note dated 05/09/24 at 2:13 P.M. revealed Resident #52 had increased agitation, aggressively rolled his wheelchair on other residents, was cursing residents out, called other residents names and attempted to jump on them. Resident #52 did not eat for three days and refused his medications. The nurse redirected Resident #52, but it was unsuccessful. The physician was notified, and Resident #52 had a new order in place to send Resident #52 to the hospital for a psychiatric evaluation. All management staff were notified. Review of Resident #52's progress note dated 05/09/24 at 6:00 P.M., revealed transportation arrived to pick Resident #52 up and the resident refused to go to the hospital for a psychiatric evaluation. Review of Resident #52's progress note dated 05/30/24, revealed Resident #52 intentionally ran another resident (facility identified as Resident #14) over with his wheelchair. Resident #52 had no new injuries noted and refused to allow staff to take vital signs. NP #550 was made aware, and a new order was given to send Resident #52 out to the hospital for evaluation. Review of Resident #52's progress note dated 06/12/24 at 2:04 P.M., revealed Resident #52 returned to the facility from the hospital. A head-to-toe assessment was completed with no skin issues. The resident was in a pleasant mood with no complaints of pain or discomfort. Review of Resident #52's one-on-one observation forms dated 04/05/24 to 05/30/24, revealed Resident #52 was on a one-on-one monitoring from 04/05/24 at 10:15 A.M. to 04/12/24 at 12:45 A.M., on 05/09/24 from 1:00 A.M. to 05/10/24 at 12:45 P.M. and again on 05/30/24 from 10:00 A.M. to 10:30 A.M. Review of the facility's Self-Reported Incident (SRI) dated 04/05/24 at 3:37 P.M. for an alleged physical abuse, revealed Resident #52 and Resident #60 were involved in a physical altercation and both residents were separated for continued safety measures. Resident #52 was observed to be yelling aimlessly in the hallway in an aggressive manner. Resident #60 was exiting his room and Resident #52 was observed to roll into Resident #60. Resident #60 then turned and struck Resident #52 and Resident #52 grabbed Resident #60 by his collar as the two struck each other. Both residents were separated, and Resident #52 was placed on one-on-one monitoring. The SRI was unsubstantiated. Review of the facility's SRI dated 05/31/24 at 10:01 A.M. for alleged physical abuse, revealed Resident #52 was observed being aggressive towards Resident #14. Both residents were separated and continued safety measures. Resident #14 was knocked down on the ground and was taken to the emergency room for further evaluation. All responsible parties were made aware of the incident. Resident #52 was observed, to be unprovoked, and to use his wheelchair to intentionally knock over Resident #14. Resident #14 complained of pain in her right leg following the incident and was transferred to the emergency room for further evaluation. Resident #14 was transferred to the hospital and was diagnosed with a right tibia fracture and urinary tract infection. Resident #52 was transferred to the men's unit and was transferred to the hospital for psychiatric evaluation. The SRI was unsubstantiated by the facility as evidence indicated abuse did not occur. Review of STNA #138's witness statement dated 05/31/24, revealed STNA #138 was at the nurse's station charting when she noticed Resident #52 roll away from the nurse's station in the direction of Resident #14 and then rolled over her. When STNA #138 stood up, she noticed that Resident #14 was under Resident #52's wheelchair and Resident #14 began to complain of right knee and leg pain. The nurse on duty then began to administer aid to her after separating the two residents. Interview on 06/17/24 at 12:37 P.M. with LPN/UM #167 and the Director of Nursing (DON) revealed, LPN/UM #167 observed Resident #52 going down the hallway and Resident #60 was coming out into the hallway on 04/05/24. LPN/UM #167 stated he went to his office and staff called him out to the hallway and he witnessed Resident #52 holding onto Resident #60's collar and Resident #52 was swinging at him. LPN/UM #167 stated Resident #60 had his leg out kicking Resident #52. LPN/UM #167 stated Resident #52 was the aggressor in the incident because he intentionally rolled over Resident #60 with his manual wheelchair. LPN/UM #167 also stated Resident #52 had an additional incident on 05/31/24. LPN/UM #167 reported Resident #52 was in the hallway talking to the staff and Resident #52 ran over Resident #14 with his manual wheelchair. Resident #14 was sent to the hospital, and she was diagnosed with a closed fracture of the right tibial plateau. LPN/UM #167 stated Resident #14 was able to walk independently without a mobility device prior to the incident and she was walking without assistive device at the time of the incident. LPN/UM #167 reported Resident #14 was not able to walk since Resident #52 ran her over with his manual wheelchair on 05/31/24 and Resident #14 had a knee immobilizer that was put in place at the hospital on her right leg. Interview with STNA #138 on 06/17/24 at 12:49 P.M. revealed STNA #138 was behind the nurse's station charting and Resident #52 was mumbling but it was not towards anyone. STNA #138 stated Resident #14 was at the medication cart and Resident #14 went to walk past Resident #52 and he aggressively rolled her over with his manual wheelchair. STNA #138 stated that she ran out to assist Resident #14 and the nurse and physician came to assess Resident #14 before staff moved her to a wheelchair. STNA #138 stated Resident #14 was taken to her room and placed into bed until she was sent to the hospital. A telephone interview with NP #550 on 06/17/24 at 12:59 P.M., revealed she was at the nurse's station getting a report on the residents when she heard Resident #14 saying stop! stop! and she observed Resident #14 walk in front of Resident #52. NP #550 stated Resident #52 rolled Resident #14 over with his manual wheelchair and it did not appear accidental. NP #550 reported Resident #52 did not appear remorseful and NP #550 stated Resident #14 was ambulating with no assistive device at the time of the incident. NP #550 stated Resident #14 was sent out to the emergency room, and she sustained a fracture to her right leg as a result of the incident. NP #550 reported Resident #52 was sent out for a psychiatric evaluation on 05/31/24. NP #550 stated Resident #14 currently required a wheelchair and could not walk due to the fracture. Observation of Resident #14 on 06/17/24 at 1:13 P.M. revealed the resident was sitting in her room in a wheelchair wearing an immobilizer on her right knee. Interview with Resident #14 at the same time, revealed Resident #14 could not recall the date of the incident but stated a man was sitting in his manual wheelchair near the nurse's station and he decided to run her over with his manual wheelchair. Resident #14 stated the man was going back and forth over her with his manual wheelchair and she had pain in her right leg after the incident. Resident #14 reported the man was cursing prior the incident, but he was not cursing at her. Resident #14 stated she was able to walk prior to the incident and Resident #14 stated she was walking without an assistive device on the date of the incident, but she was not able to walk after the incident. Resident #14 stated she had a knee brace that she received at the hospital after she broke her leg. Observation of Resident #52 on 06/17/24 at 4:17 P.M. revealed Resident #52 was rolling himself in the hallway in his manual wheelchair by picking up his feet and using his arms to maneuver the wheelchair. Interview with Resident #52 at the same time, revealed Resident #52 accidentally hit Resident #14 with his manual wheelchair on 05/31/24. Resident #52 stated he did not intentionally hit Resident #14 and he denied any prior incidents or altercations at the facility. Observation of Resident #60 on 06/18/24 at 10:26 A.M. revealed Resident #60 was sitting in the common area on the unit. Resident #60 was observed to get up and ambulate independently. Interview with Resident #60 at the same, revealed the resident did not want to discuss the incident between him and Resident #52. Interview on 06/18/24 at 10:30 A.M. with the DON, verified the progress note on 05/09/24 stated Resident #52 attempted to run over residents with his wheelchair. The DON stated Resident #52 denied psychiatric care on 04/05/24 and he was ordered to go out to the hospital on [DATE] but he refused. The DON stated Resident #14 was placed on one-on-one monitoring from 04/05/24 to 04/12/24 and again on 05/09/24 to 05/10/24. Review of the facility's abuse investigation and reporting policy dated December 2016, revealed all reports of resident abuse shall be promptly reported to local, state and federal agencies as defined by current regulations and thoroughly investigated by facility management. This deficiency represents non-compliance investigated under Complaint Number OH00154689.

Based on record review, observation, resident interview, staff interview, review of hospital reports, and review of facility policy, the facility failed to ensure staff safely assisted residents with transfers. This resulted in actual harm when a staff person was pushing Resident #73 via wheelchair without the footrests in place. Resident #73 fell face forward and sustained a laceration to his head requiring emergency hospital transfer and sutures. This affected one (Resident #73) of three reviewed for accidents. The facility's census was 133. Findings include: Review of the medical record for Resident #73 revealed an admission date of 02/11/22 with diagnoses including quadriplegia, anxiety disorder, bipolar disorder, and schizoaffective disorder. Review of the Minimum Data Set (MDS) for Resident #73 dated 04/01/23, revealed the resident was cognitively intact and was totally dependent upon the assistance of two staff with transfers and was non-ambulatory. Review of the fall risk assessment for Resident #73 dated 02/04/23 revealed the resident was at risk for falls. Review of the care plan for Resident #73 updated 04/11/23, revealed the resident was at risk for falls related to dependence on staff for transfers/mobility. Interventions included be sure the resident's call light is within reach and encourage the resident to use it for assistance as needed, education for safety of foot pedals to be on and resident sitting in an upright position in wheelchair, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, follow facility fall protocol, and physical therapy to evaluate and treat as needed. Review of the nurse progress note for Resident #73 dated 03/24/23 per Licensed Practical Nurse (LPN) #250, revealed the nurse was at the nurse's desk and heard a loud thump noise and when she stood up, she saw the resident lying face down on the floor in front of his wheelchair. Resident #73 had a gash above his right eye, which was bleeding. The nurse applied pressure to the laceration and called 911. Emergency personnel arrived and wrapped Resident #73's head with an ace wrap and took the resident to the hospital. Review of hospital notes for Resident #73 dated 03/24/23 revealed the resident presented to the hospital with complaint of head injury and laceration over the right eyebrow from a fall at the facility. The resident was quadriplegic from a past history of trauma and he accidentally fell to the ground from his wheelchair and struck his head, causing bleeding from a laceration above the right eyebrow. Resident #73 received a tetanus shot and the laceration above the right eyebrow was noted to be six centimeters (cm) in length and required closure with ten sutures. Observation on 04/24/23 at 9:23 A.M. of Resident #73 revealed the resident was sitting in his custom high-back manual wheelchair with footrests in place and the resident's feet were positioned on the footrest. Resident #73 had a healing laceration noted above his right eyebrow which was approximately six cm in length. Interview on 04/24/23 at 9:23 A.M. with Resident #73 confirmed on 03/24/23, he was up in his wheelchair in the common area outside the therapy gym. His legs were not on the footrests, and they had been pushed to the side because he was getting ready to have therapy soon. Resident #73 confirmed Business Office Manager (BOM) #425 approached him in the hall because he had requested to have someone from administration discuss his finances. Resident #73 confirmed he did not want to discuss financial matters in the common area and BOM #425 suggested they talk in the resident's room. Resident #73 confirmed BOM #425 did not place the footrests back in position and did not place his feet on the footrests, and his feet were still dangling when BOM #425 began to push his wheelchair. Resident #73 confirmed he has quadriplegia and is unable to move his extremities. Resident #73 confirmed because his feet were not on the footrests, when BOM #425 pushed his wheelchair forward it caused him to fall face forward out of the chair and onto the floor. Resident #73 confirmed he did not lose consciousness and he felt a large amount of blood coming from a gash on his head. Resident #73 confirmed the nursing staff provided first aid and called 911. He went to the hospital and had to have a tetanus shot and stitches to close the gash to his right eyebrow. Interview on 04/24/23 at 1:40 P.M. with the Administrator, [NAME] President of Clinical Services (VPCS) #975, and Licensed Practical Nurse (LPN) #640 confirmed the facility conducted an investigation of Resident #73's fall on 03/24/23. Interview confirmed Resident #73 had quadriplegia and was unable to move his extremities himself. The resident used a high back custom wheelchair with footrests for mobility. Resident #73 was unable to propel his wheelchair himself. Interview confirmed BOM #425 pushed the resident's wheelchair forward without the footrests in place and the resident's feet were left dangling, causing Resident #73 to fall forward and sustain a laceration about his right eye, in which required hospitalization and sutures. Interview confirmed the facility's investigation determined the root cause of Resident #73's fall on 03/24/23, was due to an untrained staff member transporting him from one place to another without ensuring a safe transfer. Interview confirmed the facility's follow up intervention was to have LPN #635 provide education to BOM #425 on 04/25/23 to allow clinical staff to transfer residents. Interview on 04/24/23 at 2:30 P.M. with LPN #250 confirmed she was at the nurse's station on 03/24/23 when she heard a loud thump and stood up and saw Resident #73 on the floor face down in front of his wheelchair. Resident #73's footrests were not in place but had been pushed to the side. Resident #73 had a laceration to his head with a copious amount of blood. LPN #250 confirmed she applied pressure to the resident's head and called 911. LPN #250 confirmed Resident #73 said he fell face forward when a staff person pushed his wheelchair forward without his feet on the footrests and they got caught on the floor, which caused him to fall face forward out of his chair. Review of the facility policy titled, Falls Clinical Protocol, dated March 2018 revealed the facility would assess the resident's risk for falls, and the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling. This deficiency is based on incidental findings discovered during the course of the complaint investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility self-reported incident (SRI), review of facility investigations, observations, staff and resident interviews, and review of a facility policy, the facility failed to ensure residents were free from abuse. This resulted in Actual Harm for when Resident #118 was physically abused by Resident #72 and subsequently required hospital evaluation/treatment for a right wrist fracture, and when Resident #117 was physically abused by Resident #95 and subsequently required hospital evaluation/treatment for a broken jaw. Additionally, the facility failed to ensure Resident #19 was free from staff-to resident abuse and failed to ensure Resident #41 and #53 were free from resident-to-resident abuse which placed the residents at risk for more than minimal harm that did not result in actual harm to the residents. This affected five (#19, #41, #53, #118, and #117) of 11 residents reviewed for abuse. The facility census was 121. Findings include: 1. Review of the medical record revealed Resident #118 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia with behavioral disturbance, unspecified Alzheimer's disease, unspecified anxiety disorder, hypertension, peripheral vascular disease, and mild receptive-expressive language disorder. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #118 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #118 was a one-person assist and required extensive assistance with bed mobility, transfers, and toileting, and supervision with dressing, eating, locomotion, and personal hygiene. Review of care plan dated 07/11/22 revealed Resident #118 had potential to exhibit physical and verbal behaviors to staff and other residents related to dementia with behavioral disturbance. Interventions included medications as ordered, anticipate needs, minimize potential for disruptive behaviors with tasks/diverting attention, and provide activities program. Additionally, Resident #118 had pain related to right upper arm related to fracture. Interventions included administer pain medications as ordered, assess pain level, assess for non-verbal signs of pain, offer medications prior to painful treatments offer relaxation techniques, assist to change positions as needed, and monitor for effects of pain medications. Review of hospital records dated 10/29/22 revealed emergency medical services (EMS) reported to the hospital that Resident #118 was in an altercation with another resident at the facility and was pushed down. Resident #118 presented to the emergency room (ER) with arm splinted by EMS. When the ER removed the splint, Resident #118's arm had a noticeable deformity to the right elbow. Resident #118 was holding his right elbow and grimacing with pain. On 10/29/22 the hospital completed diagnostic testing including x-rays to right humerus, right shoulder, right wrist, and bilateral elbows, and computerized tomography (CT) scans without contrast to head and cervical spine. Results of x-rays showed probable fracture to right radial head and proximal ulna. CT results showed no abnormalities. Review of progress notes revealed on 10/29/22 Resident #118 had an unwitnessed fall that may have involved a incident with another resident on the men's unit. Resident #118 was found getting up off the floor and complained of pain to his right arm. Resident #118's right arm did have some swelling at elbow, and the resident was walking with unsteady gait. Paramedics were called and the resident went to the hospital for evaluation and treatment. Review of SRI dated 10/31/22 revealed upon investigation, the facility substantiated allegations of resident-to-resident physical abuse on 10/29/22, when Resident #118 was pushed to the ground in the dining room by Resident #72 and sustained fracture to his right arm. On 10/29/22 it was noted that Resident #118 was observed getting himself up off of the floor in the dining room area. He presented with complaint of pain to his right elbow. Per the investigation, there had been an altercation between Residents #118 and #72, as Resident #72 had admitted to pushing Resident #118 down to the ground. Resident #118 was sent to the emergency room for his pain and swelling in the right elbow. Resident #72 was placed on one-on-one (1:1) supervision. Resident #118 was found to have a fracture to his right arm and returned back to facility with his right arm placed in a brace and sling in place. Staff were interviewed and no staff witnessed the altercation. No residents witnessed the altercation either. Review of the medical record revealed Resident #72 was admitted to the facility on [DATE]. Diagnoses included unspecified dementia with behavior disturbance, paranoid schizophrenia, generalized anxiety disorder, and schizoaffective disorder bipolar-type. Review of the most recent MDS assessment dated [DATE] revealed Resident #72 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #72 was a one-person assist and required extensive assistance with bed mobility, transfers, and toileting, and supervision with dressing, eating, locomotion, and personal hygiene. Review of care plan dated 10/31/22 revealed Resident #72 had a history of being physically aggressive and physically throwing chairs related to schizoaffective disorder-bipolar type and unspecified bipolar disorder. On 10/30/22 Resident #72 exhibited physical behaviors/aggression towards another resident causing injury. Interventions included medication as ordered, assist to develop appropriate methods of coping/interaction, intervene as necessary to protect the rights/safety of others, monitor behaviors to determine underlying cause, and provide activities to accommodate the resident. Review of witness statement dated 10/31/22 at 9:20 A.M. revealed Registered Nurse (RN) #126 stated The aides and I were talking in the hallway when we heard a commotion coming from the dining room. When I got to the dining room, (Resident #118) was getting up off the floor and (Resident #72) was standing there and shouting 'He's always bothering me'. When asked neither resident was able to verbalize what happened. The nurse stated she did not report the incident as a potential abuse allegation because she did not see anything happen. RN #126 charted that it might have been an incident between two residents because the two residents were present when the unwitnessed incident occurred. Observation on 11/14/22 at 12:38 P.M. revealed Resident #118 was seated in dining room eating lunch. Resident #118's right arm had a cast wrapped with ace bandage from wrist to mid upper arm. During an interview on 11/16/22 at 10:55 A.M. Corporate Registered Nurse (RN) #211 stated the nurse on duty reported to management that Resident #118 had fallen 10/29/22 and RN #126 did not indicate that the incident might have involved another resident. Corporate RN #211 stated she was reviewing the fall on 10/31/22 and interviewed Resident #118 who stated another resident (#72) had pushed him down. During an interview with the other resident, Resident #72 admitted to pushing Resident #118 because he was tired of dealing with him. During an interview on 11/16/22 at 11:09 A.M. the Director of Nursing (DON) stated she was notified on the weekend of 10/29/22 that Resident #118 was injured after a fall in the dining room and was sent out for treatment. When the DON came in on Monday, 10/31/22 she reviewed the progress notes and discovered there was a possible altercation between two residents. Upon interviewing the residents, Resident #72 indicated that he hit Resident #118 because Resident #118 thought the chairs in the dining room were his and accused Resident #72 of sitting in his chair. The DON stated staff collected statements and also notified the police. The local police seem to feel like the facility was a nuisance, so they did not come out. The DON stated Resident #72 was placed on 1:1 supervision until he could be evaluated by psych. Resident #118 was moved to a new room. Corporate RN #211 interviewed all staff and, there were no witnesses. The DON stated staff interviewed and assessed all residents, and there was no other harm noted. The DON stated the QAPI committee reviewed the incident because it was not reported appropriately, and Corporate RN #211 was completing daily audits of nursing notes since 10/31/22. The DON stated Resident #72 was normally a very calm, sweet person, and he had never shown any violent behaviors before the incident or after. During an interview on 11/17/22 at 2:25 P.M. the DON stated the interdisciplinary team concluded after investigation that based on the history of Resident #118's fixation on ownership of chairs, the cause of the unwitnessed incident on 10/31/22 between Residents #118 and #72 was related to Resident #118 making statements to Resident #72 about sitting in his chair. Resident #72 became upset and pushed Resident #118 down. The intervention for Resident #118 was to place his name on his chair. This intervention was proven ineffective because the resident moved the chair from the common area to his room and was temporarily using a wheelchair for mobility while his arm healed. Once the staff discovered the incident was related to a resident-to-resident altercation, Resident #72 was placed on 1:1 until he was evaluated by psych services. During an interview on 11/23/22 at 8:04 A.M. RN #66 stated the unwitnessed incident between Resident #72 and #118 was initially reported to management as a fall on 10/29/22. RN #66 was notified on the night of 10/29/22 that Resident #118 had fallen and was sent out for possible injury, and RN #66 did not find out until 10/31/22 that there had been an incident with another resident. RN #66 tried to interview staff to determine what had happened, and the nurse involved, RN #126, was suspended for not reporting suspicions of abuse. All residents were assessed for abuse on 10/31/22 and Resident #72 was placed on 1:1 pending psychiatric evaluation. Resident #72 was sent out for evaluation because he was visibly upset and pacing, and Resident #72 was removed from 1:1 supervision when he came back. The staff were going to put Resident #118's name on a chair in the dining room once his injuries healed and he no longer needed to use the wheelchair, to prevent further incidents from happening. Staff suspected Resident #118's fixation on ownership of dining room chairs had started the incident. 2. Review of the medical record review revealed Resident #117 was admitted to the facility on [DATE]. Diagnoses included dementia with behaviors, chronic obstructive pulmonary disease, Alzheimer's disease, hypertension, anxiety, and major depressive disorder. Review of the MDS assessment dated [DATE] revealed an assessment for cognitive status was not able to be completed as resident was unable to answer questions. Resident #117 had behaviors directed towards others and behavioral symptoms not directed towards others, occurring one to three days during the seven-day assessment period. Resident #117 required limited assist for bed mobility, transfers, and supervision for toileting and eating. Resident #117 was assessed with no loss of liquids or solids from mouth when eating, did not hold food in mouth or checks, and no complaints of difficulty when chewing or swallowing. Resident #117 weight was documented at 135 pounds. Resident #117 had weight loss of more than five percent in last month or loss of ten percent or more in last six months. Review of the plan of care for Resident #117 dated 07/14/22 revealed the resident exhibits behavioral symptoms that are not easily altered and potentially harmful to resident or others related to cognitive impairment and dementia with behaviors, poor impulse control and urinating on the floor and other residents furniture. Interventions include administer medications as ordered, monitor for adverse side effects, monitor mood, affects and behaviors, and psychology services as needed. Review of the plan of care for Resident #117 dated 11/03/22 revealed a risk for pain and alteration in comfort related to recent dislocation of jaw with altercation. Resident #117 had fluctuating cognitive deficits due to Alzheimer's disease, increasing difficulty to process current situations and safety awareness. Interventions include administer pain medications as ordered, monitor for breakthrough pain, and monitor for effects of analgesic administered. Review of the plan of care for Resident #117 dated 11/03/22 revealed a self-care deficit in eating related to chewing problems, resident has been diagnosed with a fracture jaw and in at risk for unintended weight loss. Interventions include diet per physicians' orders, adaptive diet as ordered, report immediately an difficulty chewing or swallowing, refer to speech therapy and occupational therapy, and reassess eating ability quarterly. Review of the plan of care for Resident #117 dated 11/08/22 revealed a risk for infection/complications due to laceration to forehead. Interventions include administer medications as ordered, evaluate pain, monitor for signs and symptoms of infection, and monitor vital signs. Review of the nurses' progress notes dated 11/02/22 at 5:12 P.M. revealed Resident #117 was observed exiting Resident #95's room by a State Tested Nursing Assistant (STNA). Resident #117 was noted to be bleeding from forehead and distraught. First aide was provided by RN #57, vitals were obtained and range of motion was unchanged. Review of the nurse's progress note dated 11/02/22 at 10:33 P.M. for Resident #117 revealed resident was noted to be in a physical altercation with another resident and was assessed, physician was notified of resident laceration to the forehead by another resident . Incident was report to the state, police, resident's physician and emergency contact. Orders were obtained to send the resident to the hospital for evaluation and treatment. Resident #117 was unable to communicate what happened in the incident with the other resident. Review of the After Care Visit Summary from the hospital dated 11/02/22 for Resident #117 revealed instruction orders for liquid diet only and follow up with oral maxillofacial trauma surgery tomorrow morning related to jaw fracture. Review of the hospital progress notes dated 11/02/22 for Resident #117 revealed resident was punched in the head by another resident without loss of consciousness. Review of the radiology reports for a CT scan of the head revealed an acute displaced fracture of the right mandibular condyle. Further review of the progress note revealed a consult with a facial trauma physician was completed with recommendations to wait a week for repair of jaw and continue with a liquid diet. No other injuries were noted. Review of the SRI dated 11/02/22 at 6:52 P.M. revealed after investigation, the facility substantiated allegations of resident-to-resident abuse. The incident happened on 11/02/22 at 5:12 P.M. when Resident #95 reported Resident #117 entered Resident #95's room and would not leave. Resident #95 was trying to push Resident #117 out of the room. Resident #117 started to get Resident #95 off of him and an altercation occurred resulting in Resident #95 hitting Resident #117 in the head. A statement from Resident #95 admitting to the altercation with Resident #117 resulting in a fracture that required hospitalization and follow up care. An audit of like residents on the unit revealed no reports of feeling unsafe or had a physical altercation with any residents in the last week. Resident #95 was placed on 1:1 monitoring until he can be evaluated by psychology services. The police, the physician and the power of attorneys were notified of the incident. Review of the nurse's progress note dated 11/03/22 at 12:05 P.M. revealed Resident #117 returned to the facility with orders for liquid diet for six weeks until 12/15/22 related to dislocated jaw. Review of the nurses' progress note dated 11/03/22 at 12:11 P.M. revealed Resident #117 has a follow up appointment for treatment of a dislocated jaw on 12/15/22. Review of the nurse's progress note dated 11/03/22 at 2:34 P.M. revealed a thorough investigation and review of Resident #117 medical records including interviews with staff and residents revealed Resident #117 was in another residents' room watching television when he began going through the other residents' belongings and the other resident hit him. The STNA noted Resident #117 coming out of the room holding his face. The STNA assisted Resident #117 to the nurse for assessment. Resident #117 was noted as having a laceration to his forehead and pain to his jaw. Resident #117 was unable to state what happened to him when questioned. Resident #117 was sent to the hospital for evaluation and treatment. Resident #117's emergency contact was notified along with psych services. Resident #117 was moved off the men's secured unit a different secured unit. Resident #117 care plans have been updated. The dietician was notified of the new diet orders and the fractured jaw. Social services will follow up with resident. Resident #117 does not display any psychosocial issues at this time. Review of the After Care Visit Summary dated 11/07/22 for Resident #117 revealed a follow up appointment was completed with a follow up appointment in six weeks for treatment of facial injury due to closed fracture of condylar process of the mandible. Review of the active physician orders for Resident #117 revealed a pureed diet with thin liquids dated 11/11/22, speech therapy three times a week for thirty days dated 11/07/22, and oxycodone concentrate 100 milligrams/milliliter (mg/ml) give five mg by mouth every four hours as needed for pain for thirty days dated 11/03/22. Review of the medical record revealed Resident #95 was admitted to the facility on [DATE]. Diagnoses included schizophrenia, diabetes, dementia, cognitive decline, hypertension, and bipolar disorder. Review of the quarterly MDS assessment dated [DATE] revealed Resident #95 had intact cognition. Resident #95 was not coded with any behaviors. Resident #95 required extensive assist with bed mobility, transfers, and toileting. Resident #95 was independent with eating. Review of the plan of care for Resident #95 revealed the resident exhibits verbal and physically aggressive behaviors toward staff and residents related to schizophrenia, cognitive decline, bipolar disorder, and dementia with behaviors. Can become physically aggressive towards other residents and staff members when he feels his territory/space has been intruded upon/residents wandered into his room without his permission. Interventions include administer medications as ordered, monitor/document for side effects and effectiveness, anticipate the resident's needs, consult behavioral services as needed, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, remove from situation and take to alternate location as needed, monitor behavior episodes and attempt to determine underlying cause. Review of the plan of care revealed Resident #95 exhibits behavioral symptoms that are not easily altered and potentially harmful himself and others. Interventions include resident noted to break/disassemble the furniture in his room, stop sign to doorway to help prevent other residents from entering. Give medications per physician order, monitor for adverse reactions of medications, monitor mood, affect, and behaviors with all hands on care and contacts, approach in a calm manner, allow resident to calm down before attempting to continue with care, attempt to identify and resolve basis for voiced/demonstrated anger and verbally abusive behaviors. Review of the progress notes for Resident #95 at 11/02/22 at 5:18 P.M. revealed resident admitted to punching another resident in face due to the other resident wandering into his room without consent and laying in his bed. Skin assessment completed, no complaints of pain. Police were notified. Review of the progress note dated 11/02/22 at 10:39 P.M. revealed Resident #95's physician and guardian were notified of the resident-to-resident incident. Resident #95 placed 1:1 to ensure no further incident. Psych services and social services to follow up with resident. Resident #95 is calm and watching television with his 1:1. Review of the progress notes dated 11/03/22 at 1:51 P.M. for Resident #95 revealed through a thorough investigation and a review of the resident's medical record including staff and resident interviews, it was noted that Resident #95 and another resident was watching television together and the other resident began searching through Resident #95 belongings, the resident asked him to stop, and he would not and Resident #95 stated I hit that [explicit term], he shouldn't have been watching television and not going through my [explicit term] belongings. Resident #95 was placed 1:1 and physician, guardian and psych services were notified of incident. Resident #95 was assessed by the nurse without any findings. As an intervention Resident #95 has a stop sign placed in front of door, and management staff presence has been increased on the men's unit. Resident #95 care plan was updated. Resident has not displayed any aggression since incident and continues 1:1. Review of the progress notes for Resident #95 dated 11/03/22 at 5:32 P.M. revealed the resident has been sent out to hospital for a psych evaluation, unit manager aware, physician aware, call placed to guardian no answer received voicemail left, will continue to monitor. Review of the psychology notes dated 11/09/22 for Resident #95 revealed the resident is alert and oriented to person, place, and time. Resident #95 stated he continues to hear voices. Further review of management notes revealed an investigation was completed and it was noted that Resident #95 hit Resident #117. Resident #95 was placed on 1:1 monitoring continuing. Observation on 11/14/22 at 1:02 P.M. revealed Resident #117 sitting at table in dining room eating pureed food without assist, no signs and symptoms of pain observed. Interview 11/22/22 at 8:54 A.M. with Behavioral Specialist #226 from psych services verified he has meet with Resident #95 regarding the altercation between the resident and Resident #117. Resident #95 has a history of physical abuse and has been physically abused himself. Resident #95 continues to receive services three times a week. Observation on 11/23/22 at 11:19 A.M. revealed Resident #95 continues to have 1:1 monitoring in place. Interview on 11/23/22 at 12:51 P.M. with Office Staff #225 verified Resident #117 does not have any scheduled surgery in the near future for repair of fractured jaw. Interview on 11/23/22 at 1:17 P.M. with RN #57 revealed the nurse assigned to Resident #117 on 11/02/22 (day of altercation) and stated Resident #117 was observed by staff exiting Resident #95's room holding his face. RN #57 stated Resident #117 does not have the ability to communicate what happened, just indicated that he was in pain. RN #57 obtained vital signs and contacted the physician for additional orders. RN #57 notified the DON and the Resident #117's emergency contact before transferring the resident to the hospital for evaluation. RN #57 stated Resident #95 admitted to punching Resident #117 in the face and was immediately placed into 1:1 monitoring. RN #57 stated Resident #117 returned to the facility the next day and was moved to another building. RN #57 stated Resident #95 remains on one-to-one monitoring. Interview on 11/23/22 at 1:45 P.M. with the DON verified the incident involving Resident #117 and Resident #95 was investigation and determined to be resident to resident abuse. 3. Review of the medical record revealed Resident #19 was admitted to the facility on [DATE]. Diagnoses included metabolic encephalopathy, unspecified schizoaffective disorders, type II diabetes, generalized anxiety disorder, unspecified major depressive disorder, unspecified personality disorder, and unspecified intellectual disabilities. Review of the most recent Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #19 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #19 was a one-person assist and required supervision with all activities of daily living (ADL's). Review of SRI revealed after investigation, the facility substantiated allegations of staff-to-resident emotional /verbal abuse. The incident happened on 11/16/22 at 5:55 P.M. Resident #19 reported on 11/17/22 that night nurse, Registered Nurse (RN) #88, kicked his prosthetic leg across the room following a fall. Upon interview, RN #88 admitted to kicking Resident #19's prosthetic leg because it was in his way. Resident #19's roommate (Resident #92) witnessed RN #88 kicking prosthetic leg. During an interview on 11/23/22 at 8:23 A.M. RN #66 stated the incident involving RN #88 and Resident #19 was first reported to staff on 11/17/22. RN #88 was doing two-hour rounds and found Resident #19 sitting on the floor in the bathroom against the wall. Upon interview Resident #92, Resident 19's roommate, stated RN #88 told Resident #19 to quit being a crybaby and kicked his prosthetic leg across the room. Resident #19 was not wearing his prosthetic leg at the time the incident occurred. When the nurse was questioned, RN #88 stated he kicked the leg because it was in his way. RN #66 stated RN #88 was immediately fired and the facility called the police. 4. Review of the medical record revealed Resident #41 was admitted to the facility on [DATE]. Diagnoses included paranoid schizophrenia, unspecified psychosis, and history of traumatic brain injury. Review of the most recent MDS assessment dated [DATE] revealed Resident #41 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #41 required supervision and no physical assistance with ADL's. Review of the care plan dated 10/05/22 revealed Resident #41 had a mood problem related to history of traumatic brain injury, psychosis, and paranoid schizophrenia. Interventions included medication as ordered, reinforce strengths and positive coping skills, behavioral health consults as needed, encourage to verbalize feelings, institute 15-minute checks for 24 if changes in behavior demonstrate risk, and monitor/report behaviors. Review of SRI revealed after investigation, the facility substantiated resident-to resident physical abuse. The unwitnessed incident occurred on 11/08/22. Resident #96 stated the altercation started because Resident #41 (roommate) was going through his things. The facility was unable to determine who started it. Both residents sustained minor scratches and bruises and after times Resident #41 had a black eye. On 11/08/22, Resident #41 was moved to a private room on the same unit, and Resident #96 was moved to another unit on 11/09/22. Review of Resident #41's progress notes revealed both Residents #41 and #96 were in their shared room when a physical altercation took place. Resident #41 stated that Resident #96 socked him in the back of the head. Staff separated and assessed each resident. Resident #41 had a reddened area noted to the middle of his forehead, a scratch noted to the right side of his nose, and swelling noted to his right eye. Resident #41 stated that he was having some pain but didn't need medication. Review of the medical record revealed Resident #96 was admitted to the facility on [DATE]. Diagnoses included hypothyroidism, emphysema, glaucoma, and hypertension. Review of the most recent MDS assessment dated [DATE] revealed Resident #96 was cognitively intact, had no behaviors, did not wander, and did not reject care. Resident #96 was a one-person assist and required extensive assist with bed mobility and transfers, and supervision with locomotion, eating, dressing, toileting, and personal hygiene. Review of care plan dated 07/20/22 revealed Resident #96 required the safety of residing on a secured unit due to impaired safety decisions and poor safety awareness. Interventions included provide activities of interest, provide redirection as needed, an resident to be supervised on a secures unit. Review of progress note dated 11/08/22 revealed Resident #96 got into a physical altercation with another resident while in his room. Resident #96 stated that resident was going through his drawer. The residents were separated and assessed. Resident #96 had a scratch noted to the left side of his neck and denied pain. Observation on 11/14/22 revealed Resident #41 had a visible purple bruise noted to his right eye. During an interview on 11/23/22 at 8:15 A.M. RN #66 stated he was on the unit when the incident happened and did not see the incident. Resident #41 came out his room, and sat down hardin the area, visibly upset. RN #66 walked up and asked what was wrong. Resident #41 pointed to Resident #96 and said Resident #96 had hit him. RN #66 asked and Resident #96 stated he hit Resident #41 because he was In my [explicit term]. Resident #41 stated he hit Resident #96 back. Upon assessment it was noted Resident #41 had a slight scratch on his nose and complained of pain to his nose. Resident #41 was worried because he had a history of previous fracture. The facility ordered an x-ray, completed 11/08/22,and it was negative for nasal fracture. By this time there was a noticeable bruise forming to Resident #41's right eye. The residents were placed in separated rooms, Resident #41 was moved to a private room and on 11/09/22, Resident #96 was moved to another building/unit. This was during the first week the facility had started their increased management presence on the unit in response to the incidents on the men's unit. 5. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included type II diabetes, unspecified anxiety disorder, hypertension, unspecified epilepsy, and schizoaffective disorder bipolar type. Review of the most recent MDS assessment dated [DATE] revealed Resident # 53 had severely impaired cognition, had no behaviors, and did not reject care. Resident # 53 was a one-person assist and required extensive assistance with bed mobility, was independent with eating, and required supervision for transfers, dressing, toileting, and personal hygiene. Review of care plan dated 05/26/22 revealed Resident #53 had a behavior problem related to schizoaffective disorder and anxiety. Interventions included medication as ordered, anticipate needs, intervene as necessary to protect the safety of others, and monitor behaviors. Additionally, Resident # 53 was at risk for impaired psychosocial well-being related to witnessed aggressive events and other resident conflicts. Interventions included medication as ordered, monitor for adverse reactions, 1:1 counseling as needed, private room, and refer to psych services as needed. Review of progress notes revealed on 11/14/22 around 1:00 P.M. Resident #53 was verbally aggressive and spit on staff as she went into his room to collect his lunch tray. Around 3:40 P.M. the aide reported to the nurse Resident #90 had entered Resident #53's room and hit him. Resident #53 confirmed that Resident #90 had struck him but was unable to provide details regarding the altercation. Review of the medical record revealed Resident #90 was admitted to the facility on [DATE]. Diagnoses included moderate hypoxic ischemic encephalopathy, pseudobulbar effect, diffuse traumatic brain injury, unspecified bipolar disorder, unspecified schizophrenia, and unspecified anxiety disorder. Review of the the most recent Minimum Data Set assessment dated [DATE] revealed Resident #90 had moderately impaired cognition, had no behaviors, did not wander, and did not reject care. Resident #90 was a one-person assist and required extensive assistance with bed mobility, transfers, and toileting, and[TRUNCATED]