**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the facility investigation, review of emergency medical service (EMS) and police reports, review of the county coroner case documentation, and review of facility policy, the facility failed to prevent resident to resident abuse. Actual harm occurred on 09/23/25 when Resident #29 was discovered in a resident room behind a closed door and Resident #53 was discovered in the same room behind a drawn privacy curtain laying supine on a sheet on the floor with towels secured tightly around the neck. Resident #53's head was purple in color, skin was cool to touch, with blood in her mouth, petechia to her skin, and no respirations or pulse were present. Resident #29 later admitted strangling Resident #53. The county coroner case documentation listed the cause of Resident #53's death as a homicide by means of strangulation. This affected one (#53) of three residents reviewed for abuse in a facility census of 71. Findings include:1. Review of the medical record revealed Resident #29 admitted to the facility on [DATE]. Diagnoses included schizophrenia, chronic obstructive pulmonary disease, hypertension, and brief psychotic disorder. Review of the resident census revealed Resident #29 was initially admitted to the secured dementia unit and then moved to the secured second floor behavior unit on 07/17/25. Review of the Minimum Data Set (MDS) assessment dated [DATE] the resident was assessed with clear speech, usually understood and understands others, moderate cognitive impairment, no recorded behaviors, no range of motion impairment, and independent with ambulation. Review of the resident's care plan dated 07/25/25 revealed a the nursing plan of care was revised to address Resident #29's cognitive loss/disorientation/impaired judgement related to diagnosis of schizophrenia. Interventions included: Follow doctor's orders for appropriate treatment, review the medication regimen with the physician to assess and rule out possible side effects or contraindications related to medications or food products, verbalize you will help him/her Stay in control, assure the resident he is protected, safe, and secure and in a protected environment. On 08/21/25 Resident #29 was evaluated by psychiatry services. Resident #29 was documented to be pleasant, calm and engaged throughout the entire evaluation. Psychoactive medications were reviewed and no behaviors were documented. Review of Resident #29 medical record lacked documentation indicated he exhibited aggressive behaviors towards staff or residents while residing at the facility. Review of the resident census revealed Resident #29 was returned to the dementia unit on 09/05/25. 2. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included major depression, bipolar disorder, muscle weakness, cognitive communication deficit, insomnia, anxiety disorder, polyneuropathy, and anemia. Resident #53 resided on the secured dementia unit since 01/24/25. Review of the MDS assessment dated [DATE] revealed Resident #53 had clear speech, usually understood and understands, severe cognitive impairment, no recorded behaviors, and was independently ambulatory. On 08/28/25 a quarterly secure unit admission assessment noted Resident #53 to be appropriate for the dementia unit due to a mental health condition. The unit would benefit the resident due to a smaller unit that allowed for staff interventions Review of a facility investigation revealed on 09/23/25 at approximately 9:30 P.M. Registered Nurse (RN) #400 attempted to locate Resident #29 for medication administration. RN #400 was unable to locate Resident #29 in his room or common area and requested Certified Nurse Aide (CNA) #301 to assist in finding him. RN #400 and CNA #301 proceeded to walk down the unit corridor and discovered Resident #55's room door closed. CNA #301 opened the door. Resident #29 was observed standing inside the door rocking from side to side with perspiration on his forehead. CNA #301 observed the curtain pulled around the first bed in the room and proceeded to open the curtain. Resident #53 was observed lying on the floor placed on a sheet in the supine position. Her face was deep purple with blood coming from her mouth. A bath towel and pillowcase were wrapped tightly around her neck. RN #400 yelled for help and Licensed Practical Nurse (LPN) #500 responded to the room. CNA #302 was located at the nursing station and responded to the room. Once CNA #302 observed Resident #53 on the floor she immediately returned to the nurses' station and called Emergency Medical Services (EMS). LPN #500 directed staff to stay with Resident #29 and take him to the unit dining room. LPN #500 assessed Resident #53 and checked her for a radial pulse with no pulse palpable. Resident #53's skin was noted to be cold and clammy, and no respirations were detected. LPN #500 and RN #400 determined the room was a crime scene. LPN #500 stood outside the room until EMS and Police arrived while RN #400 contacted the Director of Nursing (DON) to inform her of the incident. EMS assessed Resident #53, pronounced the resident deceased , and police assumed control of the scene. Resident #29 was placed in police custody. Preliminary autopsy results were obtained and revealed Resident #53's cause of death was a homicide due to strangulation. The incident remains under police investigation and Resident #29 remains in police custody. Review of CNA #302's written stated dated 09/23/25 at 9:00 P.M. noted CNA #302 was at the nurses' station when she heard RN #400 and CNA #301 yelling for help. CNA #302 got up to see what was wrong and saw Resident #53 was lying on the floor. CNA #302 ran back to the nurses' station and RN #400 yelled Call the police. RN #400 took Resident #53's vitals and confirmed she did not hear Resident #53's heart and felt for a pulse. Resident #29 was completely calm standing in the room and was saying he had to do it. Review of EMS report dated 09/23/25 noted at 9:41 P.M. and EMS call was received. Injury was listed as suffocation/asphyxiation. EMS was on scene at 9:51 P.M. Narrative notes document the EMS was dispatched to the facility for an unconscious person. Notes stated someone was possibly strangled. The crew confirmed with dispatch that law-enforcement was on scene. Upon arrival the crew was led to room [ROOM NUMBER] (Resident #55's room). This room was reported to belong to someone not involved in the incident. There was a police officer at the door to the room where the incident occurred. Crew entered the room to find a [AGE] year-old female on the floor in the prone position with her arms under her body and a towel around her neck. With law-enforcement standing nearby the law enforcement officer was notified that we needed to remove the towel. It took great effort to remove this as it was extremely tight. The knot being in the back at the base of her head. Once it was loosened it was noted there was also part of a sheet tied around her neck with this knot more to the side near her right ear. This also took great effort to loosen as it was pulled very tight. Once loosened a carotid pulse was checked noting it to be absent. Signs of obvious death were present. Interview with CNA #300 on 09/25/25 at 6:35 A.M. revealed he went to the dementia unit on 09/23/25 at approximately 9:15 P.M. to ask RN #400 if she wanted some food for lunch. RN #400 was at the dementia unit nurses' station obtaining medications from behind the nurses' station. RN #400 was then walking in the hall to look for Resident #29. CNA #300 remained at the nurses' station talking with LPN #500, CNA #302, and Floor Technician (FT) #700. RN #400 and CNA #301 yelled for help from Resident #55's room door entry. CNA #300 and LPN #500 ran to the room. CNA #300 observed Resident #29 standing inside the room and next to the entry door. Resident #53 was on the floor near bed one. Resident #53 had towels around her neck, her face was purple, her lips were dark purple, her eyes were closed, and CNA #300 saw veins coming out of her head. CNA #300 stayed by the room while RN #400 instructed a CNA to be 1:1 with Resident #29. LPN #500 entered the room to check Resident #53's pulse. CNA #300 heard RN #400 yell Call 911. CNA #302 was at the nursing station and called 911 from the station. CNA #300 heard LPN #500 state Resident #53 was with no pulse and her skin was cold. CNA #300 went out to open the facility door for police and EMS. Interview with RN #400 on 09/25/25 at 7:10 A.M. revealed on 09/23/25 at approximately 8:45 P.M. she was at the dementia unit nurses station gathering Resident #29's medications for administration. RN #400 stated she had seen Resident #29 ambulating in the hall 30 to 35 minutes prior to gathering medications. Resident #53 was last observed in the hall approximately 20 to 25 minutes prior to gathering medications. RN#400 proceeded to Resident #29's room and Resident #29 was not in the room. RN #400 looked in the dementia unit dining room and Resident #29 was not in the dining room. RN #400 observed CNA #301 in front of the dementia unit nurses' station and requested her to assist in looking for Resident #29. Both RN #400 and CNA #301 walked together down the hall. When RN #400 and CNA #301 reached Resident #55's room they noted the room door was closed. RN #400 stated the room door was usually open. CNA #301 opened the door. Resident #29 was standing inside the door rocking side to side with perspiration dripping from his face and a washcloth in his hand. CNA #301 noticed the privacy curtain to bed one was pulled around the bed and proceeded to pull the curtain back. Resident #53 was observed on the floor lying on a bed sheet. Her head was deep purple and thick towels were wrapped around her neck. RN #400 immediately yelled for help. RN #400 listened to Resident #53's back with a stethoscope and was unable to hear lung sounds or a heartbeat. Resident #53 appeared deceased and RN #400 considered the incident a crime scene. LPN #500 and CNA #300 arrived at the room. RN #400 yelled for CNA #302 to call 911. RN #400 told CNA #303 to take Resident #29 to the dining room and stay with him providing one on one observation. RN #400 then notified the DON via phone. Resident #29 was later observed calmly seated in the dementia unit dining room with a flat affect. RN #400 stated the police arrived at the facility within minutes. One officer stayed with Resident #29 and CNA #303. On 09/29/25 at 12:41 P.M. an additional interview with RN #400 revealed EMS arrived 10-15 minutes after the initial notification. CNA #301 called initially and was informed later the call was disconnected. 911 returned a call to the facility and LPN #500 took the second call. Telephone interview on 09/25/25 at 10:42 A.M. with CNA #301 revealed she last observed Resident #29 walking in the dementia unit corridor with Resident #53, Resident #55 and Resident #70 on 09/23/25 at 8:20 P.M. CNA #301 proceeded to go on break and leave the dementia unit. Between 8:30 and 8:40 P.M. CNA #301 returned to the dementia unit nursing station. RN #400 asked CNA #301 if she had seen Resident #29. CNA #301 walked with RN #400 down the dementia unit hall and discovered Resident #55's room door was closed. CNA #301 opened the door and observed the first bed privacy curtain pulled, which was unusual due to no current resident residing in this bed. From under the curtain the CNA saw a cover (sheet) on the floor. The CNA pulled the curtain and stated Oh my God twice. RN #400 was behind CNA #301 and asked what was wrong and entered the resident room. CNA #301 stated Resident #53 was on the floor. She observed Resident #29 to be sweaty. CNA #301 recalled a CNA #303 from a different unit stayed with Resident #29 in the dining room after the incident. Interview on 09/29/25 at 6:40 A.M. LPN #500 stated on 09/23/25 at approximately 8:50 P.M. the received a staff call off so he went to the dementia unit to report the call off to RN #400. He observed RN #400 gathering Resident #29's medications at the nurses' station and she proceeded to look for the resident. LPN #500 did not see either Resident #29 or Resident #53. At 9:05 P.M. while standing at the nurses' station LPN #500 heard RN #400 yell out for help. LPN #500 responded to the room RN#400 was yelling from. LPN #500 entered the room and observed Resident #29 standing inside the door and rocking side to side. Resident #29 appeared to have sweat on his face. Resident #53 was observed on the floor laying supine on a sheet. LPN #500 told RN #400 to take Resident #29 from the room and have someone sit with him until police arrived. LPN #500 proceeded to assess Resident #53. Resident #53's skin was cold and clammy with petechiae on her skin. She had what appeared to be a towel tightly wrapped around her neck with blood coming from her mouth. Her face and head were deep purple in color. LPN #500 stated he thought it was a different resident at first due to her appearance. The resident was also covered with a blanket from her mid back to her feet. LPN #500 stated he attempted to obtain a radial pulse and could not. He also observed no respirations were present. LPN #500 proceeded to exit the room, close the door, and remain outside the room until EMS and police arrived. Review of Police incident report dated 09/23/25 documented the incident occurrence from 9:10 P.M. to 9:44 P.M. on 09/23/25. Time of arrival to the scene was 9:46 P.M. Offense description was listed as Murder and Nonnegligent Manslaughter with weapon/force used coded as asphyxiation. Arrestee recorded on 09/23/25 at 11:39 P.M. and listed Resident #29. Victim listed Resident #53. Offense was murder and strangulation. Narrative notes documented when the officer arrived on scene he saw a group of nurses and aids in Resident #55's room. Upon entering the room Resident #53 was unresponsive, lying face down on the floor, with a towel wrapped around her neck. The nurse told officers the room where the incident happened belonged to Resident #55. Resident #55 was not in the room at the time of the incident. She said the door was closed and when the nurses opened it, Resident #29 was standing in the room rocking back and forth. They pulled back the privacy curtains and found Resident #53 unresponsive on the floor. The suspect, Resident #29, was sitting with one of the nurse aides and a resident at a table in the lounge area. The officer asked Resident #29 what happened today and he responded I don't know, she was down and choked me, stabbed me, then took off. The officer repeated Resident #29's statement questioning who choked and stabbed him. Resident #29 stated, No she didn't choke me, he choked me and stuck me. I don't know his name. The officer asked him if he was hurt at all. Resident #29 said No I'm alright, she was breathing when I was in there. I couldn't do anything to her. One of the residents sitting at the table asked Resident #29 if he was going home after this. Resident #29 responded No, I am going to prison, death row. The officer asked him why Resident #53 was on the floor right now. Resident #29 said She's dead, I guess. She wasn't dead. The officer questioned Resident #29 if he touched Resident #53. He responded Oh yeah. The officer asked him where and Resident #29 said Around the neck. The DON walked into the room and introduced herself to the officer. Resident #29 turned around and said to the DON You see, I killed her. The DON mentioned to me that Resident #29 was in jail for a long time, but she didn't know for what kind of crime. Review of the local county coroner case summary of death of Resident #53 dated 09/24/25 revealed anatomic diagnoses included: petechial hemorrhages involving the face and forehead, bilateral upper and lower petechial conjunctival hemorrhages, facial congestion, faint shallow ligature [NAME] on the anterior neck consistent with cloth ligature, deep right-sided strap muscle hemorrhage, anterior cervical soft tissue hemorrhage, cerebral vascular congestion, and faint purple contusion on right anterolateral neck, distally. Cause of death: Strangulation (minutes). Cause of injury noted as strangled with cloth ligature. Manner of death Homicide. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, last reviewed 05/2025, revealed residents have the right to be free from abuse. The policy defines abuse as the willful infliction of injury resulting in physical harm. The policy defines serious bodily injury as an injury involving extreme physical pain; involving substantial risk of death. The policy defines willful to mean the individual must have acted deliberately. This deficiency represents non-compliance investigated under Master Complaint Number 2627173 and Complaint Number 2626970, Complaint Number 2626838, Complaint Number 2626237. Review of the medical record revealed Resident #29 admitted to the facility on [DATE]. Diagnoses included schizophrenia, chronic obstructive pulmonary disease, hypertension, and brief psychotic disorder. Review of the resident census revealed Resident #29 was initially admitted to the secured dementia unit and then moved to the secured second floor behavior unit on 07/17/25. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed with clear speech, usually understood and understands others, moderate cognitive impairment, no recorded behaviors, no range of motion impairment, and independent with ambulation. Review of the resident's care plan dated 07/25/25 revealed the nursing plan of care was revised to address Resident #29's cognitive loss/disorientation/impaired judgement related to diagnosis of schizophrenia. Interventions included: Follow doctor's orders for appropriate treatment, review the medication regimen with the physician to assess and rule out possible side effects or contraindications related to medications or food products, verbalize you will help him/her Stay in control, assure the resident is protected, safe, and secure and in a protected environment. On 08/21/25 Resident #29 was evaluated by psychiatry services. Resident #29 was documented to be pleasant, calm and engaged throughout the entire evaluation. Psychoactive medications were reviewed, and no behaviors were documented. Review of Resident #29 medical record lacked documentation indicating he exhibited aggressive behaviors towards staff or residents while residing at the facility. Review of the resident census revealed Resident #29 was returned to the dementia unit on 09/05/25. Review of the medical record revealed Resident #53 was admitted to the facility on [DATE]. Diagnoses included major depression, bipolar disorder, muscle weakness, cognitive communication deficit, insomnia, anxiety disorder, polyneuropathy, and anemia. Resident #53 resided on the secured dementia unit since 01/24/25. Review of the MDS assessment dated [DATE] revealed Resident #53 had clear speech, usually understood and understands, severe cognitive impairment, no recorded behaviors, and was independently ambulatory. On 08/28/25 a quarterly secure unit admission assessment noted Resident #53 to be appropriate for the dementia unit due to a mental health condition. The unit would benefit the resident due to a smaller unit that allowed for staff intervention. Review of a facility investigation revealed on 09/23/25 at approximately 9:30 P.M., Registered Nurse (RN) #400 attempted to locate Resident #29 for medication administration. RN #400 was unable to locate Resident #29 in his room or common area and requested Certified Nurse Aide (CNA) #301 to assist in finding him. RN #400 and CNA #301 proceeded to walk down the unit corridor and discovered Resident #55's room door closed. CNA #301 opened the door. Resident #29 was observed standing inside the door rocking from side to side with perspiration on his forehead. CNA #301 observed the curtain pulled around the first bed in the room and proceeded to open the curtain. Resident #53 was observed lying on the floor placed on a sheet in the supine position. Her face was deep purple with blood coming from her mouth. A bath towel and pillowcase were wrapped tightly around her neck. RN #400 yelled for help and Licensed Practical Nurse (LPN) #500 responded to the room. CNA #302 was located at the nursing station and responded to the room. Once CNA #302 observed Resident #53 on the floor she immediately returned to the nurses' station and called EMS. LPN #500 directed staff to stay with Resident #29 and take him to the unit dining room. LPN #500 assessed Resident #53 and checked her for a radial pulse with no pulse palpable. Resident #53's skin was noted to be cold and clammy, and no respirations were detected. LPN #500 and RN #400 determined the room was a crime scene. LPN #500 stood outside the room until EMS and Police arrived while RN #400 contacted the Director of Nursing (DON) to inform her of the incident. EMS assessed Resident #53, pronounced the resident deceased , and police assumed control of the scene. Resident #29 was placed in police custody. Preliminary autopsy results were obtained and revealed Resident #53's cause of death was a homicide due to strangulation. The incident remains under police investigation and Resident #29 remains in police custody. Review of CNA #302's written statement dated 09/23/25 at 9:00 P.M. noted CNA #302 was at the nurses' station when she heard RN #400 and CNA #301 yelling for help. CNA #302 got up to see what was wrong and saw Resident #53 was lying on the floor. CNA #302 ran back to the nurses' station and RN #400 yelled Call the police. RN #400 took Resident #53's vitals and confirmed she did not hear Resident #53's heart and felt for a pulse. Resident #29 was completely calm standing in the room and was saying he had to do it. Review of the EMS report dated 09/23/25 noted at 9:41 P.M. an EMS call was received. Injury was listed as suffocation/asphyxiation. EMS was on scene at 9:51 P.M. Narrative notes document the EMS was dispatched to the facility for an unconscious person. Notes stated someone was possibly strangled. The crew confirmed with dispatch that law-enforcement was on scene. Upon arrival the crew was led to room [ROOM NUMBER] (Resident #55's room). This room was reported to belong to someone not involved in the incident. There was a police officer at the door to the room where the incident occurred. Crew entered the room to find a [AGE] year-old female on the floor in the prone position with her arms under her body and a towel around her neck. With law-enforcement standing nearby the law enforcement officer was notified that we needed to remove the towel. It took great effort to remove this as it was extremely tight. The knot being in the back at the base of her head. Once it was loosened it was noted there was also part of a sheet tied around her neck with this knot more to the side near her right ear. This also took great effort to loosen as it was pulled very tight. Once loosened a carotid pulse was checked noting it to be absent. Signs of obvious death were present. Interview with CNA #300 on 09/25/25 at 6:35 A.M. revealed he went to the dementia unit on 09/23/25 at approximately 9:15 P.M. to ask RN #400 if she wanted some food for lunch. RN #400 was at the dementia unit nurses' station obtaining medications from behind the nurses' station. RN #400 was then walking in the hall to look for Resident #29. CNA #300 remained at the nurses' station talking with LPN #500, CNA #302, and Floor Technician (FT) #700. RN #400 and CNA #301 yelled for help from Resident #55's room door entry. CNA #300 and LPN #500 ran to the room. CNA #300 observed Resident #29 standing inside the room and next to the entry door. Resident #53 was on the floor near bed one. Resident #53 had towels around her neck, her face was purple, her lips were dark purple, her eyes were closed, and CNA #300 saw veins coming out of her head. CNA #300 stayed by the room while RN #400 instructed a CNA to be one-on-one with Resident #29. LPN #500 entered the room to check Resident #53's pulse. CNA #300 heard RN #400 yell Call 911. CNA #302 was at the nursing station and called 911 from the station. CNA #300 heard LPN #500 state Resident #53 had no pulse and her skin was cold. CNA #300 went out to open the facility door for police and EMS. Interview with RN #400 on 09/25/25 at 7:10 A.M. revealed on 09/23/25 at approximately 8:45 P.M. she was at the dementia unit nurses station gathering Resident #29's medications for administration. RN #400 stated she had seen Resident #29 ambulating in the hall 30 to 35 minutes prior to gathering medications. Resident #53 was last observed in the hall approximately 20 to 25 minutes prior to gathering medications. RN#400 proceeded to Resident #29's room and Resident #29 was not in the room. RN #400 looked in the dementia unit dining room and Resident #29 was not in the dining room. RN #400 observed CNA #301 in front of the dementia unit nurses' station and requested her to assist in looking for Resident #29. Both RN #400 and CNA #301 walked together down the hall. When RN #400 and CNA #301 reached Resident #55's room they noted the room door was closed. RN #400 stated the room door was usually open. CNA #301 opened the door. Resident #29 was standing inside the door rocking side to side with perspiration dripping from his face and a washcloth in his hand. CNA #301 noticed the privacy curtain to bed one was pulled around the bed and proceeded to pull the curtain back. Resident #53 was observed on the floor lying on a bed sheet. Her head was deep purple, and thick towels were wrapped around her neck. RN #400 immediately yelled for help. RN #400 listened to Resident #53's back with a stethoscope and was unable to hear lung sounds or a heartbeat. Resident #53 appeared deceased , and RN #400 considered the incident a crime scene. LPN #500 and CNA #300 arrived at the room. RN #400 yelled for CNA #302 to call 911. RN #400 told CNA #303 to take Resident #29 to the dining room and stay with him providing one on one observation. RN #400 then notified the DON via phone. Resident #29 was later observed calmly seated in the dementia unit dining room with a flat affect. RN #400 stated the police arrived at the facility within minutes. One officer stayed with Resident #29 and CNA #303. On 09/29/25 at 12:41 P.M. an additional interview with RN #400 revealed EMS arrived 10-15 minutes after the initial notification. CNA #301 called initially and was informed later the call was disconnected. Nine-one-one (911) returned a call to the facility and LPN #500 took the second call. Telephone interview on 09/25/25 at 10:42 A.M. with CNA #301 revealed she last observed Resident #29 walking in the dementia unit corridor with Resident #53, Resident #55 and Resident #70 on 09/23/25 at 8:20 P.M. CNA #301 proceeded to go on break and leave the dementia unit. Between 8:30 and 8:40 P.M. CNA #301 returned to the dementia unit nursing station. RN #400 asked CNA #301 if she had seen Resident #29. CNA #301 walked with RN #400 down the dementia unit hall and discovered Resident #55's room door was closed. CNA #301 opened the door and observed the first bed privacy curtain pulled, which was unusual due to no current resident residing in this bed. From under the curtain the CNA saw a cover (sheet) on the floor. The CNA pulled the curtain and stated Oh my God twice. RN #400 was behind CNA #301 and asked what was wrong and entered the resident room. CNA #301 stated Resident #53 was on the floor. She observed Resident #29 to be sweaty. CNA #301 recalled CNA #303 from a different unit stayed with Resident #29 in the dining room after the incident. Interview on 09/29/25 at 6:40 A.M. LPN #500 stated on 09/23/25 at approximately 8:50 P.M. they received a staff call off so he went to the dementia unit to report the call off to RN #400. He observed RN #400 gathering Resident #29's medications at the nurses' station and she proceeded to look for the resident. LPN #500 did not see either Resident #29 or Resident #53. At 9:05 P.M. while standing at the nurses' station LPN #500 heard RN #400 yell out for help. LPN #500 responded to the room RN #400 was yelling from. LPN #500 entered the room and observed Resident #29 standing inside the door and rocking side to side. Resident #29 appeared to have sweat on his face. Resident #53 was observed on the floor laying supine on a sheet. LPN #500 told RN #400 to take Resident #29 from the room and have someone sit with him until police arrived. LPN #500 proceeded to assess Resident #53. Resident #53's skin was cold and clammy with petechiae on her skin. She had what appeared to be a towel tightly wrapped around her neck with blood coming from her mouth. Her face and head were deep purple in color. LPN #500 stated he thought it was a different resident at first due to her appearance. The resident was also covered with a blanket from her mid back to her feet. LPN #500 stated he attempted to obtain a radial pulse and could not. He also observed no respirations were present. LPN #500 proceeded to exit the room, close the door, and remain outside the room until EMS and police arrived. Review of Police incident report dated 09/23/25 documented the incident occurrence from 9:10 P.M. to 9:44 P.M. on 09/23/25. Time of arrival to the scene was 9:46 P.M. Offense description was listed as Murder and Nonnegligent Manslaughter with weapon/force used coded as asphyxiation. Arrestee recorded on 09/23/25 at 11:39 P.M. and listed Resident #29. Victim listed Resident #53. Offense was murder and strangulation. Narrative notes documented when the officer arrived on scene, he saw a group of nurses and aids in Resident #55's room. Upon entering the room Resident #53 was unresponsive, lying face down on the floor, with a towel wrapped around her neck. The nurse told officers the room where the incident happened belonged to Resident #55. Resident #55 was not in the room at the time of the incident. She said the door was closed and when the nurses opened it, Resident #29 was standing in the room rocking back and forth. They pulled back the privacy curtains and found Resident #53 unresponsive on the floor. The suspect, Resident #29, was sitting with one of the nurse aides and a resident at a table in the lounge area. The officer asked Resident #29 what happened today and he responded, I don't know, she was down and choked me, stabbed me, then took off. The officer repeated Resident #29's statement questioning who choked and stabbed him. Resident #29 stated, No she didn't choke me, he choked me and stuck me. I don't know his name. The officer asked him if he was hurt at all. Resident #29 said No I'm alright, she was breathing when I was in there. I couldn't do anything to her. One of the residents sitting at the table asked Resident #29 if he was going home after this. Resident #29 responded No, I am going to prison, death row. The officer asked him why Resident #53 was on the floor right now. Resident #29 said She's dead, I guess. She wasn't dead. The officer questioned Resident #29 if he touched Resident #53. He responded, Oh yeah. The officer asked him where and Resident #29 said Around the neck. The DON walked into the room and introduced herself to the officer. Resident #29 turned around and said to the DON You see, I killed her. The DON mentioned to me that Resident #29 was in jail for a long time, but she didn't know for what kind of crime. Review of the local county coroner case summary of death of Resident #53 dated 09/24/25 revealed anatomic diagnoses included: petechial hemorrhages involving the face and forehead, bilateral upper and lower petechial conjunctival hemorrhages, facial congestion, faint shallow ligature [NAME] on the anterior neck consistent with cloth ligature, deep right-sided strap muscle hemorrhage, anterior cervical soft tissue hemorrhage, cerebral vascular congestion, and faint purple contusion on right anterolateral neck, distally. Cause of death: Strangulation (minutes). Cause of injury noted as strangled with cloth ligature. Manner of death Homicide. Review of the facility policy titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident Property, last reviewed 05/2025, revealed residents have the right to be free from abuse. The policy defines abuse as the willful infliction of injury resulting in physical harm. The policy defines serious bodily injury as an injury involving extreme ph

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, review of a self-reported incident, review of an incident report, review of hospital records, review of staff statements, staff interview, staff job description, and policy review, the facility failed to ensure staff assisted a resident with safe ambulation, report a resident fall, and ensure a resident was assessed for injuries prior to moving the resident after a fall, and ensure the resident's fall was thoroughly investigated. Additionally, the facility failed to implement fall prevention interventions. This resulted in Actual Harm on 02/12/25 when staff assisted Resident #47 to the bathroom without his walker, staff then picked the resident up off the floor after a fall, toileted the resident, and then walked the resident back to bed further increasing the risk for injury then never reported the fall to the nurse. The oncoming nursing shift later found the resident had bruising to the left lower lip and redness to the left side of the face and a displaced intertrochanteric fracture of the left femur, requiring surgical repair and hospitalization from 02/12/25 through 02/18/25. This affected one (#47) of three residents reviewed for falls. The facility census was 74. Findings include: Review of the medical record for Resident #47 revealed an admission date of 01/18/24. Diagnoses included hemiplegia and hemiparesis following cerebral infarction, type two diabetes mellitus, atrial fibrillation, difficulty walking, muscle weakness, osteoarthritis of unspecified hip, hypertension, anxiety disorder, bipolar disorder and vascular dementia. A diagnosis of displaced intertrochanteric fracture of the left femur was added on 02/18/25. Review of the annual Minimum Data Set (MDS) assessment completed 01/21/25 revealed the resident had severe cognitive impairment. The resident required substantial/maximal assistance for toileting, supervision/touching assistance for transfers and ambulation. Review of a fall risk assessment dated [DATE] revealed the resident was at high risk for falls. Review of a physical therapy discharge assessment dated [DATE] revealed the resident could ambulate 150 feet with front wheeled walker and supervision/stand by assist requiring ten percent verbal cues for proper use of walker. Discharge recommendations included the use of a front wheeled walker for ambulation. Review of the physician orders for 02/2025 revealed no orders for assistive mobility devices. Review of the care plan initiated 01/18/24 and last revised on 01/22/25 revealed the resident was at risk for falls due to decline in functional mobility, diagnoses of anxiety, depression and vascular dementia, an elevated body mass index, restlessness, osteoarthritis of the hip, incontinent, use of psychotropic medications and weakness. Interventions included to be sure the resident's call light was within reach and encourage the resident to use it for assistance as needed. The resident needed prompt response to all requests for assistance. Physical/Occupational evaluation and treatment as indicated. The resident required the assistance one staff for transfers and assistance with toileting as needed. There was no documentation in the care plan for the resident to use a walker. Review of the staff schedule for 02/11/25 revealed Certified Nursing Assistant (CNA) #110 and CNA #112 were assigned to care for residents on the memory care unit including Resident #47 from 02/11/25 at 7:00 P.M. through 7:00 A.M. on 02/12/25. Review of a nurse progress note dated 02/12/25 at 7:50 A.M. revealed the nurse was notified by a nursing assistant that Resident #47 was not able to sit up or get up for breakfast on his own. The nursing assistant went to help the resident and when she touched his leg he yelled out in pain. The progress note stated that when the nurse was notified, the nurse further assessed Resident #47's skin and leg. Resident #47 had swelling to his left hip/leg, and his left leg was rotated outward. Resident #47 also had a swollen bottom lip on the left side, and red bump on his left cheek. The nurse notified nurse practitioner and received a STAT order for a left hip/pelvis X-ray and the rest of his leg if needed. The nurse progress note continued to say Resident #47 was complaining of pain and discomfort, was given medication (scheduled Tylenol), vital signs were within normal limits and the resident will continue to be monitored. Review of a self-reported incident (SRI) report dated 02/12/25 at 10:00 A.M., a facility incident report and subsequent investigation revealed the resident had bruising to left lower lip, left cheek, and noted increased pain to left hip. Resident #47 was unable to give description. Full assessment head to toe completed. Left leg had increased pain and resident was unable to move left leg. Left leg also noted had shorten appearance to it. The nurse contacted the physician and received orders for a STAT x-ray. Physician and guardian notified. Review of the SRI summary of incident revealed the resident was found with an area of discoloration to the left lower lip and left cheek and leg pain. The nurse assessed the resident, and a stat x-ray was ordered showing a left femur fracture. Upon investigation it was reported that staff had assisted the resident to the bathroom in the early morning hours of 02/12/25 and his legs buckled and he went to the floor. The staff assisted the resident off the floor and onto the toilet and back to bed. The staff noticed the resident had difficulty walking and the resident was unable to tell staff what was wrong. The staff were educated on reporting any fall immediately upon discovery. Disciplinary action was taken as appropriate. Further review of the incident report and investigation revealed no documentation regarding what fall interventions were in place prior to the resident's fall including type of footwear worn and environmental conditions of the room. There were also no statements or interviews from the day shift nursing assistant receiving report from the night shift nursing assistant, there was no statement from the nursing assistant who discovered the injury, and no documentation if the resident was using his walker at the time of the fall. Review of a late entry nurses note dated 2/12/2025 at 10:09 A.M. revealed the resident had bruising to left lower lip, left check, left side of head and noted increased pain to left hip. Resident unable to recall events. Full assessment head to toe completed. Left leg has increased pain and resident was unable to move left leg. Left leg also noted with shortened appearance. Nurse contacted physician and received order for STAT X-ray. Review of a nurses note dated 02/12/25 at 11:06 A.M. revealed the results of the x-ray included an acute-appearing fracture of the intertrochanteric left femur. There was a mild displacement of the distal fragment. There were no gross lytic or blastic lesions in the bones. There was no abnormal radiopaque foreign body. There was no dislocation. The joint spaces were unremarkable. Resident was sent out 911. Will continue to monitor. Responsible party was notified. The nurse practitioner and management notified. Review of a late entry nurses note for 2/13/25 at 9:20 A.M. revealed the Interdisciplinary Team (IDT) met to discuss resident related to fall dated 02/12/25. Resident was being assisted to the toilet when his knees buckled causing him to fall to the floor. An x-ray was completed related to leg pain and results showed a left femur fracture. Resident was sent to the emergency room for evaluation and treatment. Review of an undated and unsigned statement by Certified Nursing Assistant (CNA) #110 taken over the phone by the Director of Nursing (DON) revealed on the morning of the resident's accident, CNA #112 and CNA #110 walked the resident to the bathroom. CNA #110 stated the resident made it to the toilet, he went down saying he could not do it. The resident went to the ground, and we let him catch his breath. Afterward, we proceeded to lift him up and place him on the toilet. After the resident was done, we walked him back to bed. Review of an undated and unsigned statement by CNA #112 revealed on the night of the resident's incident, CNA #110 and CNA #112 walked the resident to the bathroom because he had a bowel movement. As they walked the resident to the toilet, the resident buckled to the floor. CNA #110 and CNA #112 helped the resident off the floor. Once the resident caught his breath they continued to take him to the toilet. CNA #110 and CNA #112 cleaned the resident up after using the toilet and walked the resident back to bed. CNA #112 noticed the resident was walking funny and asked him what happened, and the resident stated he did not know. Review of an undated unsigned statement for Registered Nurse (RN) #260 taken by Assistant Director of Nursing (ADON) #214 revealed no staff had reported a fall for Resident #47 on the 12-hour night shift from 02/11/24 into 02/12/25. Review of a skin assessment dated [DATE] revealed Resident #47 's left leg and hip were swollen and turned outward. The resident had a bruised and swollen lip and a red bump on the left cheek. Review of a hospital documentation dated 02/12/25 revealed the resident was admitted to the hospital on [DATE] at 11:53 A.M. The resident presented with a fall and hip pain from an unwitnessed fall at the nursing home. The outpatient x-ray showed fracture of the left intertrochanteric femur and mild displacement of distal fragment. The resident was unable to provide any history and believed it was 1978. The resident underwent imaging and found to have a severely comminuted intertrochanteric fracture through the proximal left femur with varus deformity of the proximal left femur. There was mild hemorrhage in the soft tissue surrounding the deformity. The resident denied pain. Review of the hospital imaging/diagnostics report dated 02/12/25 revealed a computed tomography (CT) of the left hip was completed. The resident had an acute severely comminuted intertrochanteric fracture through the proximal left femur with varus deformity of the proximal left femur. There was underlying diffuse osteopenia and mild hemorrhage in the soft tissues surrounding the proximal left femoral fracture deformity. The resident was also noted with mild underlying bilateral hip osteoarthrosis with underlying diffuse osteopenia. Review of the resident's care plan revised on 02/18/25 revealed the resident was at risk for falls and potential injury. Interventions included a low bed, maintain a clear pathway, mat on floor next to bed, non-slip material in chair, turn and reposition, Broda chair per therapy recommendation, call light in reach and encourage use, prompt response for requests for assistance. Review of the care plan for alteration in musculoskeletal status related to the fracture revealed an intervention for an abductor pillow while in bed. Review of corrective action counseling statements dated 02/19/25 for CNA #110 and CNA #112 revealed counseling completed for failure to follow instruction or to perform work according to procedure or policy. Review of a training in-service dated 02/19/25 revealed 74 staff received education on the fall policy. Observation on 03/20/25 at 9:39 A.M. of Resident #47 revealed the resident was in bed with his eyes closed. The bed was in the lowest position but was not a low bed. Resident #47's hip abductor was not in place and there was no floor mat next to the bed. Further observation revealed there was no nonslip material in place in the resident's wheelchair. Interviews on 03/20/25 at 9:39 A.M., CNA #272 verified the resident's hip abductor was not in place and was located in the resident's closet. CNA #272 verified there was no fall mat in place next to the resident's bed. CNA #272 was unaware the resident required a fall mat. CNA #272 verified the resident's bed was in the lowest position. Interview on 03/20/25 at 9:42 A.M., CNA #276 verified there was no nonslip material in place in the resident's wheelchair. CNA #276 revealed another resident must have moved it. Interview on 03/20/25 at 10:09 A.M., CNA #110 revealed on 02/12/25 before 6:00 A.M. CNA #112 assisted him with walking Resident #47 to the bathroom without his walker. CNA #110 revealed they got to the bathroom and the resident began to buckle. CNA #110 revealed CNA #112 and himself were on each side of the resident and lowered the resident to the ground on his buttocks with his legs in front of him in front of the toilet. CNA #110 revealed they got the resident back up and put him on the toilet. CNA #110 revealed the resident had not hit his head. CNA #110 stated four times the resident had not fallen; he was lowered to the ground. CNA #110 verified the incident was not reported to the nurse. During the interview CNA #110 revealed he told CNA #402 on the oncoming shift about lowering Resident #47 to the ground. CNA #110 revealed he was unaware that lowering a resident to the floor was considered a fall. CNA #110 stated he had been educated by the DON. Interview on 03/20/25 at 10:56 A.M., CNA #276 revealed on 02/12/25 her shift started around 7:00 A.M. CNA #276 revealed around 7:30 A.M. Resident #47 requested assistance getting up. CNA #276 revealed as she went to assist the resident, the resident stated, my hip, my hip. CNA #276 revealed seeing a bruise on the resident's lip. CNA #276 revealed she requested the nurse to the room to assess the resident. CNA #276 revealed she wrote a statement. Interview by telephone on 03/20/25 at 11:04 A.M. and 2:49 P.M. was attempted unsuccessfully with CNA #402. Interview on 03/20/25 at 11:11 A.M., the DON revealed on 02/12/25 Resident #47 was found with unexplained injuries and a self-reported incident was reported. The DON revealed she was not in the building on 02/12/25. The DON revealed Resident #47 had a fracture to the left hip/femur. The DON revealed the resident was sent to the hospital where he received surgical repair and returned to the facility on [DATE]. The DON revealed during the investigation it was found that the resident had been assisted to the bathroom by CNA #110 and CNA #112. While in the bathroom the resident's legs buckled and he fell. The staff assisted him up and onto the toilet then walked him back to bed. The DON verified CNA #110 and CNA #112 never reported the fall and received written counseling action. The DON stated CNA #110 and CNA #112 stated the resident fell and never indicated he had been lowered to the floor. CNA #110 and CNA #112 stated if a resident was not injured then why would they report the incident to the nurse. The DON revealed staff were educated to report all falls even if lowered to the floor or change in plane. The DON revealed CNA #110 and CNA #112 stated the resident may have hit his head during the fall. The DON revealed not knowing what kind of footwear the resident was wearing at the time of the fall or if there were any contributing environmental factors. The DON revealed the resident was not care planned for gait belt use but maybe they should have used a gait belt. The DON revealed the incident occurred around 5:00 A.M. The DON verified there was missing information in the investigation, she claims she asked the questions and should have written down all the questions asked and their responses. Further interview with the DON revealed the nursing assistants stated the fall happened around 5:30 A.M. and the oncoming shift noticed around 7:30 A.M. The DON revealed the resident had an x-ray around 11:06 A.M. and was admitted to the hospital at 11:53 A.M. on 02/12/25. The DON verified she could not find a statement by CNA #276 and never interviewed CNA #402 who received report from CNA #110. Further interview on 03/21/25 at 1:18 P.M. the DON verified there was no documentation in the incident report or the investigation whether staff had the resident using his walker at the time of the fall. The DON revealed per therapy the resident should have been using his walker, and it was the safest way to walk Resident #47. The DON revealed the resident would need reminded to use his walker and often would refuse to use the walker. The DON verified there was no documentation in the medical record the resident had refused to use his walker at the time of the fall on 02/12/25. The DON further revealed the use of a walker was not required to be in the physician's orders or care plan. Interview on 03/20/25 at 12:26 P.M., CNA #112 revealed on 02/12/25 around 5:00 A.M. to 5:30 A.M. Resident #47 was in bed and had a bowel movement. CNA #112 revealed CNA #110 and herself walked with the resident to the bathroom to clean him up. CNA #112 revealed they were not using a gait belt or the resident's walker because the resident could walk on his own. CNA #112 revealed they were walking behind the resident and the resident's legs buckled and CNA #110 and herself grabbed the resident's arms and lowered him to the floor on his bottom with his legs in front of him facing the toilet and his back to the door. CNA #112 revealed she had not noticed the resident hitting his head or face on anything. CNA #112 revealed waiting for the resident to catch his breath and then they got him up on the toilet, cleaned him up and walked him back to bed. CNA #112 revealed the resident was walking funny. CNA #112 revealed asking the resident what was wrong with his leg and the resident replied, I don't know. CNA #112 revealed not noticing any bruising or red marks on the resident's face. CNA #112 revealed the incident was not reported to the nurse because the resident had not voiced having pain. CNA #112 revealed the DON educated her for not reporting the incident. Interview follow-up on 03/20/25 at 12:51 P.M., the DON revealed she had just spoken with CNA #112 and CNA #112 told her the resident fell and had hit his head. The DON was not sure why CNA #112 and CNA #110 were inconsistent with their statements when reporting to the surveyor that the resident was lowered to the floor and had not hit his head as she had spoken with both of them earlier in the same day and they told her the resident fell, hit his head, and was not lowered to the floor. Observation and interview on 03/20/25 at 12:58 P.M., the DON verified Resident #47 was not in a low bed. The DON revealed the resident's bed was in the lowest position. The DON revealed the care plan should have stated the bed should be in the lowest position instead of a low bed. The DON revealed a low bed would not be appropriate for Resident #47. Interview on 03/20/25 at 1:15 P.M., ADON #214 revealed initiating the investigation for Resident #47. ADON #214 revealed RN #260 was contacted and knew nothing about a fall from the previous shift. ADON #214 revealed going with RN #300 to assess Resident #47 for a second time around 8:00 A.M. to 8:30 A.M. on 02/12/25. ADON #214 revealed the resident was moaning in pain. The resident had rotation of the left leg with swelling and winced when touched. ADON #214 revealed the resident had bruising on the lip and a red mark on the left cheek. ADON #214 revealed RN #260 and RN #300 were not aware what happened to the resident. ADON #214 revealed attempts were made to contact CNA #110 and CNA #112, but no response was received. Interview on 03/20/25 at 1:08 P.M., Physician #100 revealed he had been notified Resident #47 had a fracture from a fall. Physician #100 revealed typically there would not be a fracture from being lowered to floor unless the resident had osteoporosis. Physician #100 revealed the resident had no bone density test results indicating osteoporosis. Interview on 03/20/25 at 3:29 P.M., RN #260 revealed working the memory care unit on the 12-hour shift from 02/11/25 through 02/12/25. RN #260 could not recall what time she last saw the resident during the shift. RN #260 revealed earlier in the shift the resident was walking around per his normal. RN #260 revealed the nursing assistants never reported the resident had fallen. Interview on 03/20/25 at 3:34 P.M. RN #300 revealed on 02/12/25 CNA #276 was assisting residents with breakfast when Resident #47 asked for assistance to get out of bed. CNA #276 reported the resident stated ow when she tried to assist him. RN #300 revealed CNA #276 called her to the resident's room. RN #300 revealed Resident #47's left leg and hip were rotated outward, there was redness and bruising on the left side of the lip, and redness on the left side of his face. RN #300 revealed the nurse practitioner was notified with new orders received for an x-ray. RN #300 revealed Resident #47's scheduled medications including Tylenol were administered. RN #300 revealed the x-ray technician reported the resident most likely had a fracture. RN #300 revealed 911 was called while awaiting the final x-ray report. RN #300 revealed emergency medical services (EMS) were already in the building when the final x-ray results were received showing the fracture. Interview on 03/21/25 at 1:12 P.M., Physical Therapist (PT) #700 revealed Resident #47 had discharged from therapy with a recommendation for a front wheeled walker. PT #700 revealed staff had been instructed for the resident to use the walker and may require verbal cues to use the walker. PT #700 revealed the resident had dementia and would forget and often get up without his walker. PT #700 revealed the resident should have used the walker with staff. Review of the Certified Nursing Assistant job description revealed the nursing assistant would report all changes in the resident's condition to the nurse supervisor/charge nurse as soon as practical. Report all accidents and incidents observed on the shift they occur. Further review of the job description revealed to follow physician orders and follow directions of the physical therapist. Also, assist resident to walk with or without self-devices as instructed. Review care plans daily to determine if changes in the resident's daily care routine have been made on the care plan. Review of the facility policy Fall Policy, revised 01/03/25, revealed the facility would assure proper review of resident fall risk and implementation of interventions to attempt to prevent or reduce falls and injuries related to falls. Tracking would be done on an incident where a fall has occurred. A fall is when a resident is observed on the floor or when a resident was lowered to the floor with or without injury. Appropriate medical care would be provided as needed, including calling for emergency transport to the emergency room if indicated. Nursing notes would reflect the fall, assessment, care and monitoring provided and notifications. Care plans would be updated with new and discontinued interventions when reviewed and following a fall as appropriate. This deficiency represents non-compliance investigated under Master Complaint Number OH00163072 and OH00162984.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility policy, review of the Self-Reported Incidents (SRI) database, facility investigation, review of hospital records, resident interviews, and staff interviews, the facility failed to prevent resident-to-resident physical abuse. This resulted in actual harm when Resident #01, a resident with known history of resident-to-resident abuse incidents, struck Resident #02 in the face causing a hematoma (a pool of clotted blood that forms in the tissue) to her face and a closed fracture of the right orbital floor (one or more bones around the eyeball break, often from a blow to the face). Additionally, the facility failed to ensure Resident #03 was free from resident-to-resident physical abuse when Resident #01, who was supposed to be on one-to-one monitoring, struck Resident #03 in the back several times, while Resident #03 was asleep. This affected three (#01, #02 and #03) of six residents reviewed for abuse. The current census is 79. Findings include: 1. Review of the SRI dated 08/14/24 revealed the incident was reported on 08/09/24 at 6:35 P.M., when Resident #01 was seen grabbing Resident #02's hair and punching her in the face. Per the SRI, the facility separated the residents, sent Resident #02 to the hospital, then upon return placed both residents in 15-minute checks until Resident #02 was transferred to another unit. Per the SRI report, the police were notified but no report was made, and no charges were filed. The SRI was unsubstantiated for abuse due to Resident #01's diagnosis of dementia. Review of the facility's investigation into the alleged resident-to-resident abuse dated 08/09/24 to 08/16/24 revealed per the investigation, two nurses and one aide were interviewed after the incident, and there was no information regarding what led up to the incident noted in the interviews. Per the aide's written statements dated 08/09/24, Resident #01 and Resident #02 were sitting in their wheelchairs in the hallway and the aide witnessed Resident #01 grabbing Resident #02 by the hair and punching her in the face. Per the nurses' interviews the aide reported the incident immediately and Resident #02 was able to report to one nurse she was punched by Resident #01 in the face. No other resident interviews were included in the investigation reports. An assessment of Resident #02 revealed the resident had facial swelling and bruising to the right side of her face. Per the investigation Resident #02 was sent to the hospital and was diagnosed with facial swelling and an orbital fracture to her right eye. a. Review of Resident #01's medical record revealed an admission date of 01/24/24. Diagnoses for Resident #01 included: bipolar disorder, vascular dementia, delirium, and metabolic encephalopathy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and portrayed physical behaviors towards others during the review period. Review of Resident #01's care plans dated May 2024 and revised on 08/16/24 revealed a focus for behaviors such as physical aggression towards others. Interventions include psychological evaluation, medications per order, talk to resident when being aggressive, and intervene by talking calmly and taking resident to a quiet area when behaviors are observed. Review of the SRI dated 02/22/24 revealed at 8:40 P.M., staff witnessed Resident #01 striking another resident in the face. Per the SRI there was no marks on either resident, and no injuries were noted in the documentation. Per the SRI, staff witnessed Resident #01 near the other resident's room, and he struck her in the mouth with his hand. Per the SRI, the other resident was interviewed and stated she had not done anything to upset Resident #01. Per the SRI, Resident #01 was sent to the hospital for testing, was positive for a urinary tract infection, and was referred to the Senior Wellness Group. The other resident was moved to another unit. Review of Resident #01's behavior assessment dated , 02/23/24 at 12:05 A.M., revealed the resident was having wandering and hitting behaviors. Interventions included redirection and one-to-one interventions. Per the assessment the interventions were effective. Review of Resident #01's physician orders revealed on 06/18/24, the resident was ordered to be seen by psychiatric services. There was no documentation of Resident #01 being seen by a psychiatrist noted in the record until 08/14/24 when the psychologist saw the resident. The order was discontinued on 08/15/24. Review of Resident #01's behavior assessment dated [DATE] at 6:44 P.M., revealed the resident was having cursing, threatening others, and grabbing behaviors. Interventions included redirection and were effective. No behavior assessment was noted in Resident #01's medical records for 08/09/24 for behaviors towards Resident #02. Review of Resident #01's behavior assessment dated [DATE] at 3:15 P.M., revealed Resident #01 was having pacing, wandering, and disrobing in public behaviors. Interventions include one-to-one interventions, redirection, and toileting. Per the assessment the interventions were effective. b. Review of Resident #02's medical record revealed an admission date of 04/21/23. Diagnoses for Resident #02 included: dementia, dysphagia, anemia, antisocial personality disorder, and bipolar disorder. Review of the comprehensive MDS assessment dated [DATE], revealed the resident had impaired cognition and had no documented behaviors at the time of the review period. Review of Resident #02's care plans dated 04/24/24 revealed the resident did not have any behaviors of aggression towards others. Per the care plan there were no behaviors relating to abuse. Review of Resident #02's assessments revealed the resident denied pain during the assessments dated from 06/01/24 to 08/09/24. Review of the vital sign monitoring revealed on 08/09/24 at 8:13 A.M., the resident denied any pain. On 08/10/24 at 8:43 A.M., Resident #02 reported a pain level of 4 out of 10 (10 rated as the highest pain). On 08/11/24 at 8:26 A.M., Resident #02 reported a pain level of 5 out of 10. Review of the progress note dated 08/09/24 at 6:40 P.M., revealed Resident #02 was being sent to the hospital for evaluation of facial swelling due to an altercation with another resident. Review of Resident #02's hospital documentation dated 08/09/24 at 9:19 P.M., revealed the resident was treated for a hematoma to her face and a fractured orbital space. The hospital diagnosed Resident #02 with a closed fracture of the right orbital floor. Discharge orders included to start taking cephalexin 250 milligrams orally three times a day for 10 days, and to apply ice packs to affected area. Resident #02 was discharged from the hospital back to the facility on [DATE]. Review of the progress note dated 08/10/24 at 2:20 A.M., Resident #02 returned from the hospital to the facility. Observations on 09/04/24 at 10:02 A.M., revealed Resident #02 was observed on another unit than Resident #01. During an attempt to interview Resident #02 on 09/05/24 at 10:05 A.M., Resident #02 did not answer any questions. During the interview attempt, the resident did not appear to be in distress. Interview on 09/04/24 at 10:10 A.M. with State Tested Nurse Aide (STNA) #300 revealed she was the aide that had cared for Resident #02 after she returned from the hospital on [DATE]. Per STNA #300 the resident had bruising under her eye and some swelling. STNA #300 stated she did get the resident ice to place on her face after she reported pain. Interview on 09/04/24 at 11:20 A.M. and on 09/17/24 at 11:02 A.M., with Social Worker (SW) #333 revealed after the incident Resident #02 was moved to another unit when she returned from the hospital on [DATE]. Per SW #0333, the resident denied any concerns, stating she could not recall what happened or why it happened, and stated she felt safe in the facility. SW #333 stated she did interview Resident #02 on 08/12/24 and the resident stated she had no pain from the incident. Interview on 09/04/24 at 2:15 P.M., with the Director of Nursing (DON) revealed the DON was notified on 08/09/24 around 7:00 P.M., after the incident with Resident #01 and Resident #02 occurred. The DON stated due to Resident #01's dementia abuse could not be substantiated. The DON stated he felt Resident #01 had a 'focus' on Resident #02 which caused the resident to strike her. The DON stated Resident #01 had a 'fixation' on Resident #02 and once she was moved off the unit, there was no other behaviors from Resident #01 to any other resident until the incident on 08/13/24. The DON did not explain what he meant by fixation and there was no other history per records or interviews of Resident #01 and Resident #02 having any issues prior. The DON stated he felt by moving Resident #02 off the unit he had fixed the problem; the DON did not reveal the previous issues Resident #01 had with another resident. The DON verified there was no interviews or assessment included in the investigation regarding the behaviors or factors which could have provoked the incident. The DON stated despite previous allegations of resident-to-resident abuse regarding Resident #01, the DON felt placing Resident #01 back into 15-minute checks was sufficient to ensure the safety of the other remaining residents on the unit. Interview on 09/17/24 at 11:45 A.M. with the DON verified Resident #01 was seen by the psychologist in the facility which was a Certified Nurse Practitioner (CNP), and a social worker who was employed by the psych services. Interview on 09/17/24 at 9:33 A.M., with Licensed Practical Nurse (LPN) #100 revealed she assessed Resident #02 on 08/10/24, after she transferred from another unit. LPN #100 stated the resident did complain of slight pain in her face and was provided ice for discomfort per hospital paperwork. 2. Review of the SRI dated 08/14/24 revealed Resident #03 reported to the nurse on 08/13/24 at 11:38 P.M., Resident #01 had struck him multiple times in the back. Per the SRI the facility reported the incident on 08/14/24 at 10:15 P.M. Per the SRI the facility unsubstantiated the abuse due to Resident #01's dementia. Review of the facility's investigation dated 08/14/24 revealed on 08/13/24 at 11:38 P.M., Resident #03 came to the nurse's station and reported to the nurse that Resident #01 had hit him 5 times in the back. Per the investigation Resident #03 was assessed for injuries and his back was noted to be bruised and swelling. The facility staff reported they separated the residents and notified all parties of the incident. The staff and residents were interviewed. Per the interviews Resident #01 had returned from the hospital and showed no behaviors prior to the incident. All other residents were assessed for injuries, and none were found. Resident #03 refused to be sent to the hospital for evaluation and Resident #01 was placed on one-to-one monitoring until he was transferred to a behavioral facility on 08/14/24. a. Review of Resident #01's medical record revealed a re-admission date of 01/24/24. Diagnoses for Resident #01 included: bipolar disorder, vascular dementia, delirium, and metabolic encephalopathy. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and portrayed physical behaviors towards others during the review period. Review of Resident #01's care plans dated May 2024 and revised on 08/16/24 revealed a focus for behaviors such as physical aggression towards others. Interventions include psychological evaluation, medications per order, talk to resident when being aggressive, and intervene by talking calmly and taking resident to a quiet area when behaviors are observed. Review of Resident #01's behavior assessment dated [DATE] at 3:15 P.M., revealed Resident #01 was having pacing, wandering, and disrobing in public behaviors. Interventions include one-to-one interventions, redirection, and toileting. Per the assessment the interventions were effective. Review of Resident #01's progress notes revealed on 08/12/24 at 10:35 A.M., the interdisciplinary team added the intervention of 15-minute checks for the resident. The medical record contained no evidence of 15-minute checks being completed. Review of Resident #01's behavior assessment dated [DATE] at 11:38 P.M., revealed Resident #01 was having behaviors of crawling around on the floor. Interventions of redirection were ineffective. No behavioral assessments dated 08/13/24 were noted in Resident #01's medical records after the incident with Resident #03. Review of Resident #01's progress note dated 08/13/24 at 5:34 P.M., Resident #01 was sent to the hospital due to critical laboratory values. Per the note dated 08/13/24 at 11:04 P.M., Resident #01 had returned from the hospital and was being monitored. No behavioral assessments dated 08/13/24 were noted in Resident #01's medical records after the incident with Resident #03. Review of the psych service note dated 08/14/24 at 9:33 A.M., signed by the social worker for psych services revealed the plan listed on the note was to have Resident #01 be seen by psych services 6 visits in 3 months to reach the goal of increasing interpersonal interactions and activities. Therapeutic interventions attempted were listed as supportive therapy. No mention of the aggressive behaviors was noted in the progress note. Review of Resident #01's behavior assessment dated [DATE] revealed the resident exhibited behaviors of being combative with care, hitting and grabbing. Interventions attempted were redirection, one-to-one intervention, and change in scenery. Per the assessments the interventions were ineffective. No documentation was noted in the records in regard to what the staff did if the interventions were ineffective. Review of Resident #01's physician orders revealed on 09/03/24, Resident #01 was to be on one-to-one supervision at all times. No orders predating the 09/03/24 order for one-to-one supervision was noted in the medical record for Resident #01. Observations made on 09/04/24 at 9:44 A.M. and 09/17/24 at 11:00 A.M., of Resident #01 revealed the resident to be resting in his room, and the resident did not respond to questions. A staff member was observed throughout the survey to be sitting in Resident #01's room watching the resident as a one-to-one intervention. b. Review of Resident #03's medical record revealed an admission date of 10/28/22. Diagnoses for Resident #03 included: chronic obstructive pulmonary disease, heart failure, cognitive communication deficit, and vascular dementia. Review of the comprehensive Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had intact cognition and had no behaviors during the review period. Review of Resident #03's care plans dated 09/22/23 revealed no focus for behaviors of aggression towards others or himself. Review of Resident #03 medical record revealed no documentation of Resident #03's injuries after the incident on 08/13/24 at 11:52 P.M. No monitoring of the bruising or skin assessment was included in the records. Per Resident #03's vital signs no reports of pain were recorded in the records. Observation and interview on 09/04/24 at 11:03 A.M. with Resident #03 revealed the resident denied any further incidents with Resident #01, after he returned to the facility. Resident #03 could not provide details of the incident on 08/13/24. Interview on 09/04/24 at 3:30 P.M., with Clinical Nurse Manager (CNM) #500 and Regional Registered Nurse (RRN) #555 and the DON revealed after the incidents occurred on 08/09/24 and 08/13/24, all staff were interviewed after the incident regarding the details of each incident. The DON verified there were no assessments or documentation of Resident #01's behaviors prior to the incident. CNM #500 stated Resident #01 was assessed by the facility's psychologist on 08/08/24 and 08/13/24 and was stable with no behaviors. RRN #555 stated the resident was not on one-to-one monitoring despite a history of aggressive behaviors towards other residents due to the psychiatric evaluation of being stable on 08/08/24 and 08/13/24. The DON and CNM #500 verified 15-minute checks were not documented in the records and stated on 08/13/24, Resident #01 returned to the facility around 11:00 P.M., and was not documented as being observed until 11:45 P.M., after Resident #03 had reported he was being hit by Resident #01. Interview on 09/17/24 a 11:45 A.M. with the DON verified Resident #01 was seen by the psychologist in the facility which was a Certified Nurse Practitioner, (CNP), and a social worker who was employed by the psych services. Review of the policy titled, Abuse, Mistreatment, Exploitation, and Misappropriation of Resident Property, dated October 2022, revealed abuse is defined as instances of abuse, irrespective of mental or physical condition causing harm, pain, and/or mental anguish. The policy stated in order to prevent abuse the facility will complete ongoing assessments of behaviors. To protect other residents increased supervision of the alleged perpetrator and/or immediate transfer out of the facility. Per the policy the facility will complete ongoing assessments and care planning for appropriate interventions for monitoring the residents with behaviors. If a resident is accused or suspected of resident-to-resident abuse the facility will ensure all other residents are protected as determined by the circumstances which can include increased monitoring of accused residents and/or the immediate transfer or discharge of the resident. This deficiency represents non-compliance with control numbers OH00156980 and OH00156909.