**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy and facility documentation review, and staff interviews it was determined that the facility failed to ensure residents were free from abuse when staff failed to implement supervisory measures allowing Resident CL3 to physically assault and cause significant injuries to the head and upper extremities of Resident CL2, resulting in an immediate jeopardy situation. Findings include: Review of facility policy titled, Safety and Supervision of Residents without revision date under subheading, Individualized, Resident-Centered Approach to safety revealed Number 3 The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Review of CL2's clinical record revealed 5 day Medicare MDS (Minimum Data Set -periodic assessment of resident needs) dated [DATE] indicating a BIMS (Brief Interview of Mental Status) of 10 out of 15. The score indicates Resident CL2 had moderate cognitive impairment. Review of CL2's clinical record revealed diagnoses including but not limited to following: Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and muscle weakness; Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle). Review of CL3's clinical record revealed hospital documention prior to admission on [DATE] to facility which indicated under History of Present illness; .Presents to the ED (Emergency Department) with subsequent 302 petition (involuntary psychiatric admission petition) filed by wife through VCC for agitated and aggressive behavior, threatening purportedly to kill himself and his wife brandishing a knife in furtherance thereof, who subsequently to being brought to the ED by police, having little recollection of events prompting his presentation Review of Resident CL3's clinical record revealed a Quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated [DATE] indicating a BIMS (Brief Interview of Mental Status) score of 03 out of 15 which reflectsa severe cognitive impairment. Review of CL3's clinical record progress note dated [DATE] (14:26/2:26 p.m.) revealed, Residents daughter brought butter knife from residents room and asked that the kitchen not put knives on the residents tray because he was trying to cut himself with it. Resident was assessed and no bruising or skin tears noted. Kitchen staff also called and made aware that resident is not to have plastic or metal knives on his tray. Resident will be placed on Q1hr checks. Review of CL3's clinical record revealed a Psychiatric Evaluation and Consult document dated [DATE], which under section titled Impression and Plan, Staff reports he was collecting knives in his drawer so now he is not receiving knives on his tray. Review of CL3's clinical record revealed the resident was on safety checks every one hour, which was initiated on [DATE]. The last documented evidence of Q (every) hour supervision check was completed on [DATE]. Review of Resident CL3's [DATE] MAR (Medication Administration Record) and TAR (Treatment Administration Record) revealed an intervention of checking Q (every) shift for safety, No knives plastic or metal on meal trays was discontinued as of [DATE]. Review of Resident CL3 clinical record revealed an eMAR (Medication Administration Record) Progress note dated [DATE] revealed resident came out to med nurse swinging his cane. Review of Resident CL3's clinical record revealed a social work progress note date [DATE], revealing, SW (social worker) contacted spouse and notified (spouse) that [Resident] is displaying aggressive behaviors and we are transferring him to [psychiatric facility] in DE (Delaware) to be evaluated. Clinic record of Resident CL3 revealed resident was transferred to a psychiatric facility for treatment on [DATE] and returned to the facility on [DATE]. Review of Resident CL3's clinical record including psychiatric hospital admission summary dated [DATE] which revealed under History of Present Illness; the patient was getting agitated, aggressive, threatening other residents with the cane. Review of clinical record of Resident CL3 including care plan goals and interventions failed to reveal goal(s) to address resident's physical aggression or interventions for aggression, knife hoarding, or threatening behavior using a walking cane. Review of clinical record of Resident CL3 revealed progress note dated [DATE], which indicated, Nursing staff responded to room following roommate yelling for help. Resident found to be hitting his roommate. Resident was removed from the room. Police notified; Residents wife now present in agreement for Resident to get psych help. MD (Medical Doctor) notified, 911 was called. Resident send to [local hospital] ER (Emergency Room) for evaluation. Review of facility documentation including witness statement by staff member revealed heard screaming from room [ROOM NUMBER]. Help, immediately went to open the room door because his roommate closed it. I saw him standing over his roommate in the wheelchair, he was (hitting) him with the (cane) and punching him. He was covered with blood. Immediately called the nurse. Review of witness statement by LPN revealed, Around 1730, I was called to the room [ROOM NUMBER] by the CNA (certified nurse aide). On entry to the room [ROOM NUMBER]A was noted standing over (resident) 301B yelling 'where is my wife. Resident in 301B was sitting in his wheelchair, face covered in blood with multiple hematomas to the left, right, and top of head. (Resident) 301A (AKA CL3) continued to be aggressive constantly repeating, 'I hate him because he did something to my wife. Review of CL3's care plans failed to reveal 1 hour supervision checks. The care plan interventions did not include prohibiting resident to have knives as a result of an incident on [DATE], when resident was reportedly cutting self with meal knife. The care plan interventions failed to address behavior specific interventions including attempting to hit staff member with walking cane. Residents CL2 and CL3 were shared a room at the end of hallway, 113 feet 4 inches from the nursing station, and direct supervision. Review of hospital emergency room documentation for Resident CL2 under Reason for Visit (chief complaint) indicated, Head injury and Assault victim. Further review of hospital record revealed under ED Provider Note section the following; [AGE] year old male with past medical history of dementia brought to ED (emergency Department) after assault. Patient was assaulted by his demented roommate. Patient was struck multiple times by a cane. Patient has extensive facial trauma (contusions) with facial lacerations. Significant bruising to bilateral upper extremities. Additional review of hospital record revealed under Summary of Hospitalization the following notation under subsection Hospital Course. who presented from NH (Nursing Home) with SOB (Shortness of breath) and found to be in acute heart failure after he was assaulted by his roommate at his nursing home. Pt (Patient) found to be Hypoxia (oxygen deficiency in arterial blood) upon admission, put on oxygen up to 8L (liters) as his renal function continued to worsen with diuretic usage to help his acute heart failure flare. Further review of hospital record revealed Resident CL2 expired at the hospital on February 3, 2023. Review of Resident CL2's clinical record revealed attending physician discharge summary revealed, under Final Diagnosis the notation of head trauma - hit by another resident. An Immediate Jeopardy situation was identified on [DATE], at 6:10 p.m. and the Immediate Jeopardy template was presented to the Nursing Home Administrator and corporate compliance nurse, Employee E3 at 6:41 p.m. on [DATE], regarding the facility's failure to ensure the residents were free from abuse by providing supervision for Resident CL3 who has a history of violent behavior. The facility submitted and completed an immediate action plan which included whole house audit to determine residents with behaviors are identified; Facility staff would audit residents with behaviors to ensure care plans goals and interventions current to address specific behaviors; Education provided to nursing staff regarding supervision of residents and education regarding abuse/neglect. The education was held prior to start of work shift and continued until all staff were inserviced. The facility policy on behavior monitoring, supervision, care plans, and abuse/neglect were reviewed and updated as deemed necessary. Random audits of resident behaviors and nursing interviews with five staff per week (x4 weeks then x2 months) were conducted and will continue till completed. The action plan was accepted on [DATE], at 8:51 p.m. On [DATE], a review of audits, documentation of completed employee education, and interviews with 38 and non licensed staff members revealed the facility had completed the interventions developed for the action plan. The Immediate Jeopardy was lifted on [DATE], at 4:54 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy. Review conducted of the clinical records affected by the abusive inaction caused by insufficient supervision which alllowed Resident CL3 to physically abuse Resident CL2 but also had the potential to cause significant harm, physical pain, or mental/emotional anguish. 483.13 Resident behavior and facility practices 10-1-1998 edition 28 Pa Code 201.14(a) Responsibility of Licensee 28 Pa. Code: 201.18(b)(1)(3) Management 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, facility policy and facility documentation review, and staff interviews it was determined that the facility failed to ensure to initiate or implement adequate supervisory measures for Resident CL3 to prevent life threatening injuries to CL2, resulting in an immediate jeopardy situation. Findings include: Review of facility policy titled, Safety and Supervision of Residents without revision date under subheading, Individualized, Resident-Centered Approach to safety revealed Number 3 The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Review of CL2's clinical record revealed 5 day Medicare MDS (Minimum Data Set -periodic assessment of resident needs) dated [DATE] indicating a BIMS (Brief Interview of Mental Status) of 10 out of 15. The score indicates Resident CL2 had moderate cognitive impairment. Review of CL2's clinical record revealed diagnoses including but not limited to following: Dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability) and muscle weakness; Congestive Heart Failure (excessive body/lung fluid caused by a weakened heart muscle). Review of CL3's clinical record revealed hospital documention prior to admission on [DATE] to facility which indicated under History of Present illness; .Presents to the ED (Emergency Department) with subsequent 302 petition (involuntary psychiatric admission petition) filed by wife through VCC for agitated and aggressive behavior, threatening purportedly to kill himself and his wife brandishing a knife in furtherance thereof, who subsequently to being brought to the ED by police, having little recollection of events prompting his presentation Review of Resident CL3's clinical record revealed a Quarterly MDS (Minimum Data Set - periodic assessment of resident needs) dated [DATE] indicating a BIMS (Brief Interview of Mental Status) score of 03 out of 15 which reflectsa severe cognitive impairment. Review of CL3's clinical record revealed a progress note dated [DATE] (14:26/2:26 p.m.) revealed, Residents daughter brought butter knife from residents room and asked that the kitchen not put knives on the residents tray because he was trying to cut himself with it. Resident was assessed and no bruising or skin tears noted. Kitchen staff also called and made aware that resident is not to have plastic or metal knives on his tray. Resident will be placed on Q1hr checks. Review of CL3's clinical record revealed a Psychiatric Evaluation and Consult document dated [DATE], which under section titled Impression and Plan, Staff reports he was collecting knives in his drawer so now he is not receiving knives on his tray. Review of CL3's clinical record revealed the resident was on safety checks every one hour, which was initiated on [DATE]. The last documented evidence of Q (every) hour supervision check was completed on [DATE]. Review of Resident CL3 clinical record revealed an eMAR (Medication Administration Record) Progress note dated [DATE] revealed resident came out to med nurse swinging his cane. Review of Resident CL3's [DATE] MAR (Medication Administration Record) and TAR (Treatment Administration Record) revealed an intervention of checking Q (every) shift for safety, No knives plastic or metal on meal trays was discontinued as of [DATE]. Review of Resident CL3's clinical record revealed a social work progress note date [DATE], revealing, SW (social worker) contacted spouse and notified (spouse) that [Resident] is displaying aggressive behaviors and we are transferring him to [psychiatric facility] in DE (Delaware) to be evaluated. Clinic record of Resident CL3 revealed resident was transferred to a psychiatric facility for treatment on [DATE] and returned to the facility on [DATE]. Review of Resident CL3's clinical record including psychiatric hospital admission summary dated [DATE] which revealed under History of Present Illness; the patient was getting agitated, aggressive, threatening other residents with the cane. Review of Clinical record of Resident CL3 revealed progress note dated [DATE], which indicated, Nursing staff responded to room following roommate yelling for help. Resident found to be hitting his roommate. Resident was removed from the room. Police notified; Residents wife now present in agreement for Resident to get psych help. MD (Medical Doctor) notified, 911 was called. Resident send to [local hospital] ER (Emergency Room)for evaluation. Review of facility documentation including witness statement by non licensed Employee E5 revealed heard screaming from room [ROOM NUMBER]. Help, immediately went to open the room door because his roommate closed it. I saw him standing over his roommate in the wheelchair, he was (hitting) him with the (cane) and punching him. He was covered with blood. Immediately called the nurse. Review of witness statement by Licensed Employee E4 revealed, Around 1730, I was called to the room [ROOM NUMBER] by the CNA (certified nurse aide). On entry to the room [ROOM NUMBER]A was noted standing over (resident) 301B yelling 'where is my wife. Resident in 301B was sitting in his wheelchair, face covered in blood with multiple hematomas to the left, right, and top of head. (Resident) 301A (AKA CL3) continued to be aggressive constantly repeating, 'I hate him because he did something to my wife. Review of CL3's care plans failed to reveal 1 hour supervision checks. The care plan interventions did not include prohibiting resident to have knives as a result of an incident on [DATE], when resident was reportedly cutting self with meal knife. The care plan interventions failed to address behavior specific interventions including attempting to hit staff member with walking cane. Residents CL2 and CL3 were shared a room at the end of hallway, 113 feet 4 inches from the nursing station, and direct supervision. Review of CL2's hospital emergency room documentation under Reason for Visit (chief complaint) indicated, Head injury and Assault victim. Further review of hospital record revealed under ED Provider Note section the following; [AGE] year old male with past medical history of dementia brought to ED (emergency Department) after assault. Patient was assaulted by his demented roommate. Patient was struck multiple times by a cane. Patient has extensive facial trauma (contusions) with facial lacerations. Significant bruising to bilateral upper extremities. Additional review of hospital record revealed under Summary of Hospitalization the following notation under subsection Hospital Course. who presented from NH (Nursing Home) with SOB (Shortness of breath) and found to be in acute heart failure after he was assaulted by his roommate at his nursing home. Pt (Patient) found to be Hypoxia (oxygen deficiency in arterial blood) upon admission, put on oxygen up to 8L (liters) as his renal function continued to worsen with diuretic usage to help his acute heart failure flare. Further review of hospital record revealed Resident CL2 expired at the hospital on February 3, 2023. An Immediate Jeopardy situation was identified on [DATE], at 6:10 p.m. and the Immediate Jeopardy template was presented to the Nursing Home Administrator, and the Executive Director at 6:41 p.m. on [DATE], regarding the facility's failure to ensure the residents were free from neglect when licensed staff failed to provide supervision for a resident with a history of violent and aggressive behavior. The facility submitted and completed an immediate action plan which included whole house audit to determine residents with behaviors are identified; Facility staff would audit residents with behaviors to ensure care plans goals and interventions current to address specific behaviors; Education provided to nursing staff regarding supervision of residents and education regarding abuse/neglect. The education was held prior to start of work shift and continued until all staff were inserviced. The facility policy on behavior monitoring, supervision, care plans, and abuse/neglect were reviewed and updated as deemed necessary. Random audits of resident behaviors and nursing interviews with five staff per week (x4 weeks then x2 months) were conducted and will continue till completed. The action plan was accepted on [DATE], at 8:51 p.m. On [DATE], a review of audits, documentation of completed employee education, and interviews with 38 licensed and non licensed staff members revealed the facility had completed the interventions developed for the action plan. The Immediate Jeopardy was lifted on [DATE], at 4:54 p.m. after confirmation the immediate action plan was implemented, and the Nursing Home Administrator and the Director of Nursing were informed the residents were no longer in immediate jeopardy. 28 Pa. Code 211.5(f) Clinical records Previously cited [DATE], [DATE], [DATE] 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services Previously cited [DATE], [DATE], [DATE] 28 Pa code 211.10 (c) Resident care policies Previously cited [DATE], [DATE], [DATE] 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1)(3) Management 28 Pa. Code: 201.18(e)(1) Management 28 Pa. Code: 211. 12(c) Nursing services