**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and facility investigation, and staff interviews, it was determined that the facility failed to implement adequate safeguards in the locked dementia care unit to protect residents from abuse and physical altercation for two of 17 residents (Residents R25 and R94) resulting in actual harm of a laceration to the thumb and transport to the emergency room for treatment of sutures (stitches) for one Resident R94. Findings include: Review of the facility policy entitled, Staffing - [NAME] Lane dated 1/6/23, indicated that there will always be a minimum of two nursing staff on the hall when at least one resident is there. Review of facility policy entitled Resident Abuse, Neglect and Misappropriation of Property dated 1/6/23, indicated that it is the facility policy to prevent, report and investigate any and all allegations of abuse and neglect relative to all residents in the facility's care. The policy also revealed, that the definition of abuse will be defined per the CFR 488.301, 488.355 and the HCFA State Operations Manual Appendix P which defines abuse means the willful infliction of injury, .with resulting physical harm, pain, or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of CMS Guidelines 483.12 (a)(1) Freedom from Abuse, Neglect and Exploitation defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes .physical abuse . Also under the guidance under Abuse: Sections 1819 and 1919 of the Social Security Act provide that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility must provide a safe resident environment and protect residents from abuse. Review of Resident R25's clinical record revealed an admission date of 7/24/12, with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), with behavioral disturbance, anxiety, depression and alcohol, cannabis and inhalant dependence, in remission. Review of Resident R25's Annual Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 8/9/23, revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R25 scored a 9, indicating cognitive impairment. Review of a nursing note, dated 3/10/23, at 4:07 p.m. documented that Resident R25 had hands on another resident ripping the resident's shirt. Review of a nursing note, dated 7/23/23, at 8:20 p.m., revealed Resident R25 grabbed ahold of another resident's sweatshirt. Review of a nursing note, dated 8/16/23, at 7:00 p.m., revealed Resident R25 was noted holding a closed fist and yelling at roommate in hallway. Review of Resident R25's clinical record revealed a nursing note, dated 8/19/23, revealed that Nurse Aide (NA) Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirts with Resident R25's one hand held back as if preparing to punch Resident R94. NA Employee E3 was unable to separate the residents and called for assistance. Resident R25 had swelling and bleeding to inner right lower lip. Review of Resident R94's clinical record revealed an admission date of 5/1/22, with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), with behavioral disturbance, depression, cognitive impairment and high blood pressure. Review of Resident R94's Quarterly MDS, dated [DATE], revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R94 scored a 6, indicating severe cognitive impairment. Review of a nursing note, dated 7/7/23, at 5:04 p.m. revealed a NA observed Resident R94 strike another resident while ambulating beside the resident, punched with a closed fist to the other residents left upper arm. Review of a nursing note, dated 7/26/23, at 4:02 a.m. revealed that Resident R94 was having increased agitation tonight with another resident and staff. Resident refusing care yelling at staff and being confrontational with other residents in hallway. Review of Resident R94's clinical record revealed a nursing note, dated 8/19/23 at 10:58 p.m. that NA Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirt's with Resident R25's one hand held back as if preparing to punch Resident R94, NA Employee E3 was unable to separate the residents and called for assistance. When assistance arrived they were able to separate the residents and Resident R94 stepped backward and fell onto his/ her buttocks. Review of information submitted by facility dated 8/20/23, revealed that on 8/19/23, Resident R25 had a physical altercation with Resident R94. When staff intervened to separate the residents, Resident R94 fell backwards onto their buttocks. Resident R25 had a split lip with bleeding and swelling to right lower lip. Resident R94 was taken to the emergency room for evaluation after the altercation with Resident R25. Review of a facility incident report, dated 8/19/23, revealed that Resident R94 was sent to the emergency room at 9:30 p.m. due to complaints of a two centimeter laceration to the right thumb, and received three sutures for the laceration, right side of face was red with superficial abrasions to bridge of nose, right temple and right upper eyelid. Resident R94's right eye was reddened and complained of pain to the right eye. Review of the facility investigation notes revealed that it was determined that staff left the hall and went to an adjoining unit for approximatley three and a half to four minutes, leaving the residents unattended. Upon return to the hall, this staff member intervened in the altercation. The staff member provided a witness statement with false information resulting in termination. During an interview on 10/19/23, at 11:00 a.m. the Nursing Home Administrator and Director of Nursing confirmed that NA Employee E3 willfully left the 300 hall (Willow Lane) without any staff on 8/19/23, for approximatley three and a half to four minutes when Resident R25 and Resident R94 were engaged in a physical altercation. The facility failed to implement adequate safeguards to ensure residents are free from abuse for cognitively impaired residents in a locked dementia care unit resulting in actual harm of a laceration with sutures to Resident R94. 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(d)(3)(4)(5)Nursing services 28 Pa. Code 211.12(f.1)(1) Nursing services

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policies, clinical records, and facility documentation, and staff interviews, it was determined that the facility failed to provide a safe environment by not providing adequate supervision to protect residents from injury during a resident to resident altercation between two of 17 residents (Residents R25 and R94), that resulted in actual harm of a laceration to the thumb and transport to the emergency room for treatment of sutures (stitches) for one resident (Resident R94). Findings include: Review of the facility policy entitled, Staffing - [NAME] Lane dated 1/6/23, indicated that there will always be a minimum of two nursing staff on the hall when at least one resident is there. Review of facility policy entitled Resident Abuse, Neglect and Misappropriation of Property dated 1/6/23, indicated that it is the facility policy to prevent, report and investigate any and all allegations of abuse and neglect relative to all residents in the facility's care. The policy also revealed, that the definition of abuse will be defined per the CFR 488.301, 488.355 and the HCFA State Operations Manual Appendix P which defines abuse means the willful infliction of injury, .with resulting physical harm, pain, or mental anguish. Willful as used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of Resident R25's clinical record revealed an admission date of 7/24/12, with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), with behavioral disturbance, anxiety, depression and alcohol, cannabis and inhalant dependence, in remission. Review of Resident R25's Annual Minimum Data Set (MDS-a periodic assessment of resident care needs), dated 8/9/23, revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R25 scored a 9, indicating cognitive impairment. Review of a nursing note, dated 3/10/23, at 4:07 p.m. documented that Resident R25 had hands on another resident ripping the resident's shirt. Review of a nursing note, dated 7/23/23, at 8:20 p.m. revealed Resident R25 grabbed ahold of another resident's sweatshirt. Review of a nursing note, dated 8/16/23, at 7:00 p.m. revealed Resident R25 was noted holding a closed fist and yelling at roommate in hallway. Review of a nursing note, dated 8/19/23, revealed that Nurse Aide (NA) Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirt's with Resident R25's one hand held back as if preparing to punch Resident R94. NA Employee E3 was unable to separate the residents and called for assistance. Resident R25 had swelling and bleeding to inner right lower lip. Review of Resident R94's clinical record revealed an admission date of 5/1/22, with diagnoses that included dementia (condition of impaired ability to remember, think, or make decisions that interferes with everyday activities), with behavioral disturbance, depression, cognitive impairment and high blood pressure. Review of Resident R94's Quarterly MDS, dated [DATE], revealed under Section C: cognitive patterns, questions from C0500 BIMS Summary Score: Resident R94 scored a 6, indicating severe cognitive impairment. Review of a nursing note, dated 7/7/23, at 5:04 p.m. revealed a NA observed Resident R94 strike another resident while ambulating beside the resident, punched with a closed fist to the other residents left upper arm. Review of a nursing note, dated 7/26/23 at 4:02 a.m. revealed that Resident R94 was having increased agitation tonight with another resident and staff. Resident refusing care yelling at staff and being confrontational with other residents in hallway. Review of Resident R94's clinical record revealed a nursing note, dated 8/19/23 at 10:58 p.m. that NA Employee E3 had come out of a resident room to find Resident R25 engaged in an altercation with Resident R94. Resident R25 was seated in the wheelchair and Resident R94 standing in front of Resident R25, both residents had grabbed each other's shirt's with Resident R25's one hand held back as if preparing to punch Resident R94, NA Employee E3 was unable to separate the residents and called for assistance. When assistance arrived they were able to separate the residents and Resident R94 stepped backward and fell onto his/ her buttocks. Review of information submitted by facility dated 8/20/23, revealed that on 8/19/23, Resident R25 had a physical altercation with Resident R94. When staff intervened to separate the residents, Resident R94 fell backwards onto their buttocks. Resident R25 had a split lip with bleeding and swelling to right lower lip. Resident R94 was taken to the emergency room for evaluation after the altercation with Resident R25. Review of a facility incident report, dated 8/19/23, revealed that Resident R94 was sent to the emergency room at 9:30 p.m. due to complaints of a two centimeter laceration to the right thumb, and received three sutures for the laceration, right side of face was red with superficial abrasions to bridge of nose, right temple and right upper eyelid. Resident R94's right eye was reddened and complained of pain to the right eye. Review of the facility investigation notes revealed that it was determined that staff left the hall and went to an adjoining unit for approximatley three and a half to four minutes, leaving the residents unattended. Upon return to the hall, this staff member intervened in the altercation. The staff member provided a witness statement with false information resulting in termination. During an interview on 10/19/23, at 11:00 a.m. the Nursing Home Administrator and Director of Nursing confirmed that NA Employee E3 left the 300 hall (Willow Lane) unsupervised without any staff on 8/19/23, for approximatley three and a half to four minutes when Resident R25 and Resident R94 were engaged in an altercation. The facility failed to implement adequate supervision to protect cognitively impaired residents from a physical altercation in a locked dementia care unit resulting in actual harm of a laceration requiring sutures to Resident R94. 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(d)(3)(4)(5)Nursing services 28 Pa. Code 211.12(f.1)(1) Nursing services