**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, interview, and observations, the facility failed to ensure 4 residents (Resident #30, Resident #75, Resident #31, and Resident #57) were free from abuse of 65 potential residents. Resident #30 grabbed Resident #75 and Resident #57 and pushed and choked Resident #31. Resident #57 struck Resident #30 in response to Resident #30's aggressiveness. Resident #75 and Resident #57 expressed being fearful of Resident #30, resulting in psychosocial harm for Residents #75 and #57. The findings include: Review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, dated 2/1/2023, showed .Abuse, neglect .will not be tolerated by anyone, including .patients .The patient has the right to be free from abuse, neglect .The center administrator is responsible for assuring that patient safety, including freedom from risk of abuse or neglect holds the highest priority .Abuse: the willful infliction of injury .pain or mental anguish .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .Physical Abuse: includes hitting, slapping .Mental Abuse: includes, but is not limited to .harassment .PREVENTION POLICY .The center will provide supervision and support services designed to reduce the likelihood of abusive behaviors .All supervisory partners who receive reports of and/or identify inappropriate behaviors will take immediate steps to correct such behaviors .Patients with needs and behaviors that might lead to conflict with partners or other patients will be identified by the Care Planning team, with interventions and follow through designed to minimize the risk of conflict .The Interventions .will include .Identification of patients whose personal histories render them at risk for abusing other patients or partners .Assessment of appropriate interventions strategies to prevent occurrences .Monitoring the patient for any changes that would trigger abusive behavior .Reassessment of the protective strategies on a regular basis .PROTECTION POLICY .Staff will respond immediately to protect the alleged victim .Any individual found to be in danger of injury will be removed from the source of the suspected abusive behavior including, but not limited to room or staffing changes, if necessary, to protect the patient(s) from the alleged perpetrator .Examining the alleged victim for any sign of injury, including a physical examination or psychosocial assessment if needed .Increased supervision of the alleged victim and patients . Resident #30 was admitted to the facility on [DATE], with diagnoses including Blindness Right Eye, Dementia with Anxiety, Insomnia, and Weakness. Review of Resident #30's comprehensive care plan dated 6/27/2022, showed .Diagnosis of dementia with anxiety disorder, restlessness and agitation .Combative behavior towards staff with rejection of care. Patient known to inappropriately grasp at objects and wander related to poor eyesight. Anxiety and agitation worse in PM [evening] . with approach dated 1/19/2023, .Redirect patient when he is seen wandering or grasping into or at inappropriate objects . Review of Resident #30's quarterly Minimum Data Set (MDS) assessment dated [DATE], showed Resident #30 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Resident #30's vision was highly impaired. Resident #30 had no mood indicators or behavioral symptoms toward others documented and rejection of care occurred 1 to 3 days in the past 7 days. Resident #30 used a wheelchair as a mobility device. Further review revealed Resident #30 required extensive assist of one staff member for locomotion on unit, eating, and personal hygiene. Medical record review of Resident #30's Behavior Monitoring sheet for December 20, 2022, revealed .grabbing others . Review of Resident #30's Psychiatric Periodic Evaluation dated 1/2/2023, showed .Staff state patient has had several episodes of increased anxiety and agitation over the last few days. This is not unusual for patient, but behavior appears to have increased .he has been combative and very agitated with staff during care . Review of Resident #30's nursing progress note by Licensed Practical Nurse (LPN) #4 dated 1/4/2023 at 4:30 PM, showed Resident #30 .was agitated and having behaviors. Pt [patient] was witnessed to have multiple verbal outbursts. Also kicking and swinging arms while in common area, around other residents .was removed from the area and taken to his room .Resident continued with behaviors . Review of Resident #30's nursing progress note by LPN #5 dated 1/4/2023 at 6:06 PM, showed .noted to be agitated this shift arguing with staff and other residents throwing trash in hallway floors . Medical record review revealed two events documented on Resident #30's Behavior Monitoring sheet on 1/4/2023. First entry at 6:56 PM, Certified Nurse Aide (CNA) #2 documented cursing at others and the second event documented at 6:57 PM, by CNA #2, Cursing at others. Review of Resident #30's nursing progress note by LPN #2 dated 1/4/2023 at 7:15 PM, showed Resident #30 .APPEARS AGITATED AND AGRESSIVE [aggressive] DURING TRANSFER BACK TO BED . Review of Resident #30's nursing progress note by Registered Nurse (RN) #2 dated 1/5/2023 at 9:42 PM, showed Resident #30 .has exhibited increased agitation and behaviors towards staff, and was tested for UTI [urinary tract infection] Patient is currently receiving abt [antibiotic therapy] r/t [related to] uti [urinary tract infection] . Review of Resident #30's nursing progress note by LPN #6 dated 1/7/2023 at 4:22 PM, showed Resident #30 .up in the chair roaming the halls . Medical record review revealed two events documented on Resident #30's Behavior Monitoring sheet on 1/7/2023. First entry at 6:24 PM, CNA #3 documented cursing at others and the second event documented at 6:25 PM, by CNA #3, Disrobing in public. Medical record review of Resident #30's Behavior Monitoring sheet revealed on 1/15/2023 at 2:04 AM, LPN #2 documented, cursing at others. Review of Resident #30's Psychiatric Periodic Evaluation dated 1/17/2023, showed .Patietn [Patient] delusional, exit seeking, and aggressive with redirection at times . Medical record review of Resident #30's Behavior Monitoring sheet revealed on 1/17/2023 at 7:29 PM, NA #4 documented, grabbing others. Medical record review of Resident #30's Behavior Monitoring sheet revealed on 1/19/2023 at 12:20 PM, CNA #2 documented, cursing at others for 5 minutes. At 12:21 PM, CNA #2 documented, hitting others. At 8:37 PM, LPN #2 documented, cursing at others for 20 minutes. Review of Resident #30's nursing progress note by RN #1 dated 2/13/2023 at 3:22 PM, revealed .is agitated and aggressive .[NAME] [propels] self in chair, needs to be redirected numerous times out of other resident rooms . Medical record review of Resident #30's Behavior Monitoring sheet revealed on 2/13/2023 at 4:49 PM, Nurse Aide (NA) #4 documented, grabbing at others for 20 minutes. Redirect, One on one, provide calm environment interventions were documented as not effective. At 4:52 PM, NA #4 documented hitting others for 15 minutes and One on one, provide calm environment interventions were not effective. At 4:54 PM, NA #4 documented, cursing at others and One on one, provide calm environment interventions were not effective. At 4:56 PM, NA #4 documented amended and more data available, however, no further notes noted. Telephone interview on 3/15/2023 at 7:15 PM, when asked to clarify the 2/13/2023 note, NA #4 stated, .This was the night two other CNAs come and got me to help because [RN #1] asked them to come and get me to get him [Resident #30] off a lady [Resident #31] that he had pushed his feet on the back of her wheelchair and grabbed her by the back of her shirt and was choking her . When asked to further clarify the amended note, NA #4 stated, .I was asked to change the note and not put all that in there . When asked who asked him to change the note, NA# 4 replied, .I don't remember . NA #4 further stated, .that was not the first time he [Resident #30] tried to choke somebody . When asked to provide further information and details, NA #4 stated he could not recall, .exactly Review of Resident #30's nursing progress note by RN #1 dated 2/14/2023 at 6:26 PM, revealed .Resident [#30] increased agitation and aggressive. Going in others rooms. Difficult to redirect. Cursing staff and other residents . Review of Resident #30's social services progress note by Social Worker (SW) #1 dated 2/24/2023 at 4:30 PM revealed Resident #30 .has restlessness, trouble concentrating on things, and can be easily agitated at times . Review of Resident #30's progress note by the Director of Activities dated 2/27/2023 at 11:12 AM, revealed Resident #30 .propels around in his w/c [wheelchair] as he likes pulling himself along the handrails and door facings (pulling off corner protectors) and at times will pull on other resident chairs and needs redirection several times during the day as he goes in other resident rooms due to his poor eyesight. Pt [patient] can get agitated from time to time during redirection and will reach out to grab clothing or your hands when doing so and can be hard to redirect . Resident #30 can .be disruptive as he propels himself into others, pulls their W/C [wheelchair] or pulls the table clothes [cloths] off the tables with items on them due to his poor eyesight . Review Resident #30's quarterly MDS assessment dated [DATE], showed Resident #30 had a BIMS score of 3, indicating severe cognitive impairment. Resident #30's vision was highly impaired. Resident #30 had mood indicators of feeling tired; having little energy for several days in the last 14 days; trouble concentrating on other things, such as newspaper or watching television nearly every day in the last 14 days; moving or speaking so slowly that other people noticed or being so fidgety or restless that he had been moving around a lot more than usual for half or more of the days; and being short-tempered, easily annoyed for half or more of the days in the past 14 days. Resident #30 had behaviors of hallucinations and delusions. Physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms directed toward others occurred 1 to 3 days in the past 7 days. Rejection of care occurred 1 to 3 days in the past 7 days. Resident #30 used a wheelchair as a mobility device. Further review revealed Resident #30 required extensive assist of two or more staff members for locomotion on unit, eating, and personal hygiene. Observations of Resident #30 on 3/13/2023 during the afternoon hours of 1:00 PM - 5:00 PM and on 3/14/2023 during the morning hours of 8:00 AM - 11:00 AM, revealed the resident sitting in a reclined Broda chair (rolling chair that reclines with a footrest), in the hallway outside his room, reclined at a 30-45-degree angle, with his feet on the floor, quiet and sleeping. During observation on 3/14/2023 at 2:00 PM, the resident had been moved to his room with the door closed. During an interview on 3/14/2023 at 3:15 PM, the Administrator stated .There are people that are intimidated . by Resident #30's behaviors.He'll get in a mood, and he'll pull himself .I've heard people complain because he'll go around the whole floor .We've tried to redirect him . During an interview on 3/14/2023 at 3:22 PM, LPN #8 stated Resident #30 .with his vision impairment .likes to try to go in rooms . The staff .must redirect . During an interview on 3/14/2023 at 3:42 PM, the Director of Activities mentioned Resident #30's behavior when he .was pulling on someone's wheelchair . When asked if other residents complained about Resident #30's behavior, the Director of Activities stated .most of them [the residents] don't . complain and she stated that the other residents understood that Resident #30 was blind, and Resident #30 didn't realize what he was doing. During an interview on 3/15/2023 at 10:17 AM, Housekeeper #1 stated Resident #30 .be out in the hallways .He don't mean no harm .he might grab .he grab somebody's chair to scoot through the hallway . Housekeeper #1 stated there was an incident involving Resident #30 and an unidentified resident where Resident #30 .grabbed her chair and she hit him .I think she's gone .they sent her to [another nursing home] .She got irritated with him [Resident #30]. Housekeeper #1 stated .he [Resident #30] can't hurt nobody .he's blind .he'll grab and try to feel . During an interview on 3/15/2023 at 10:29 AM, Housekeeper #2 stated .He [Resident #30] can't see but he can still be a little aggressive .He's got that strength .be resistant . Housekeeper #2 denied knowing of any instances of Resident #30 hurting anyone. Resident #75 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Chronic Obstructive Pulmonary Disease, Major Depressive Disorder, Anxiety Disorder, Anemia and Chronic Kidney Disease. Review of Resident #75's Quarterly MDS dated [DATE] showed a BIMS score of 15 which indicated the resident was cognitively intact. The resident exhibited no behaviors, required extensive assistance of 1 staff for bed mobility, and supervision of 1 staff for ambulation, dressing, toilet use and personal hygiene. Review of Resident #75's Care Plan dated 5/17/2021 showed .receives psychotropic medication for depression, insomnia, and anxiety . Review of Resident #75's Psychotherapy Progress Note dated 2/15/2023, revealed .Patient is seen today for current significant symptoms of depression and anxiety. Patient processed anxious feelings and stressors due to medical issues .Clinician plans to continue psychotherapy and recommends medication evaluation/treatment as needed for significant symptoms of depression and anxiety due to patient is minimally stable/requires ongoing interventions at this time . Review of Resident #75's Psychotherapy Progress Note dated 2/28/2023, reveals .Patient is seen today for current significant symptoms of depression and anxiety. Patient processed anxious feelings and stressors due to medical issues. She reports efforts to cope with getting out of bed/out of room and engaging in walking with walker activities .Clinician plans to continue psychotherapy and recommends medication evaluation/treatment as needed for significant symptoms of depression and anxiety due to patient to minimally stable/requires ongoing interventions at this time . During an interview with Resident #75 on 3/13/2023 at 3:59 PM, Resident #75 stated that Resident #30 comes down the corridor and tries to make it out the door. Resident #75 stated Resident #30 was losing his eyesight and he rolled his chair and pushed on it and jerked the fire alarm and made it sound. Resident #75 stated Resident #30 .He's hurting quite a few people . Resident #75 mentioned an incident she thought occurred three weeks ago. Resident #30 was behind Resident #31 and pushing and got hold of Resident #31's shirt and it took 2 staff members to separate Resident #30 from Resident #31. Resident #75 stated that she heard Resident #31 say Stop .leave me alone . Resident #30 was pushing Resident #31's wheelchair with his feet. Resident #31 was admitted to the facility on [DATE] with diagnoses including Chronic Kidney Disease, Severe Dementia, and Anxiety Disorder. Review of Resident #31's Annual MDS assessment dated [DATE] showed a BIMS score of 4, indicating the resident had severe cognitive impairment. The resident exhibited no behaviors and required extensive assistance of 2 staff for bed mobility and transfer, extensive assistance of 1 staff for dressing, eating, toilet use and personal hygiene, and required limited assistance of 1 staff for locomotion. Review of Resident #31's comprehensive care Plan dated 1/9/2023 showed .Cognitive Deficit .BIMS score indicates severe impairment with difficulty communicating as evidenced by Dementia Dx [diagnoses] and Hard of hearing . The resident was not interviewable. During an interview on 3/14/2023 at 3:03 PM, the Administrator was informed of the allegation of abuse involving Resident #30 against Resident #31 which was witnessed by Resident #75. The Administrator stated .I have not heard about this . and stated .We weren't aware of it . The Administrator stated that there was a previous allegation involving Resident #30 and a person of a name similar to Resident #31's last name. The Administrator stated that .APS [Adult Protective Services] came .State Survey came in . The Administrator was also informed that Resident #75 stated she was fearful of Resident #30 because of his behavior and the Administrator expressed that he was not aware of this. The Administrator stated .He [Resident #30] pulls himself down the hallway .he can't see very well . During an interview on 3/14/2023 at 3:18 PM, the Assistant Director of Nursing (ADON) was asked about the allegation of abuse regarding Resident #30 against Resident #31, and she responded .I've never heard that .There was one time he [Resident #30] had a few behaviors and we had a urinalysis drawn . The ADON described the previous behaviors as .He [Resident #30] was yelling .trying to go in and out of the dining room .pushed bedside table .but wasn't anyone around . During an interview on 3/14/2023 at 3:24 PM, the ADON stated that after Resident #30 completed the antibiotics in January 2023, there have been .no more issues . The ADON stated that the behaviors shown prior to the antibiotics were that Resident #30 had .shown anxiety and .pushed a table out of the way . During an interview on 3/14/2023 at 3:29 PM, the Administrator stated that he spoke with Resident #75 regarding Resident #30 moving down the hallway and he stated that Resident #75 identified only one staff member being present and identified the nurse by RN #1's first name. During an interview with RN #1 on 3/14/2023 at 3:36 PM, RN #1 denied seeing an altercation between Resident #30 and Resident #31. The RN stated .I've never seen him [Resident #30] get aggressive .I've not had any trouble .He's not had any behaviors with me . The RN stated that she does not normally work on Resident #30's floor, but that she worked on that floor .a couple of weeks ago . During an interview with Resident #75 on 3/15/2023 at 10:10 AM, Resident #75 confirmed her fear of Resident #30 .I feel he's a threat .violence . Resident #75 stated .He's [Resident #30] grabbed my arms and jerked me .finally I just don't come near his wheelchair . Resident #75 stated that this behavior by Resident #30 has happened .several times .I don't know what the dates were . Resident #75 stated she .did not tell the staff . about the incident where Resident #30 grabbed her arms and jerked her. During an interview on 3/15/2023 at 11:39 AM, the Administrator stated .the incident she [Resident #75] described that she was fearful did not occur . The Administrator stated that he interviewed Resident #75 who told him one staff member was involved in the incident and not two staff members. The Administrator stated he spoke with the nurse Resident #75 identified as being present during the incident who was identified as RN #1. The Administrator stated .the nurse [RN #1] said the incident didn't occur . Review of Resident #31's nursing progress note dated 3/15/2023 at 1:05 PM, revealed .This nurse [RN #3] reported, to daughter, allegation of abuse with an undetermined time frame . Interview with 27 residents with BIMS scores of 9 or higher were conducted on 3/15/2023 between 8:35 AM - 1:30 PM, with one additional complaint of abuse reported by Resident #57 against Resident #30. Resident #57 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Diabetes, Adjustment Disorder with Mixed Anxiety with Depressed Mood, Major Depressive Disorder and Post-traumatic Stress Disorder. Review of Resident #57's quarterly MDS assessment dated [DATE], showed a BIMS score of 15 indicating the resident was cognitively intact. The resident required extensive assistance of 1 staff for bed mobility, transfer, locomotion, dressing, toilet use, and personal hygiene. Resident Mood Interview showed Resident #57 had feelings of being down, depressed, or hopeless and poor appetite or overeating for 2-6 days over the last 2 weeks. Rejection of care behavior occurred 1 to 3 days in the past 7 days. There were no other behaviors noted. Resident #57 used mobility devices of cane/crutch and wheelchair. Review of Patient #57's comprehensive care plan with a start date of 5/1/2020, edited 1/2/2023, showed .Psychotropic medication use r/t [related to] Psychiatric Diagnoses- stress or trauma inducing event that may affect patient's mood/behavior .Goal .Patient will be protected from re-traumatization as much as possible .7/30/2020 .Patient reports h/o [history of] stress or trauma .may affect patient's mood/behavior .Goal .Patient will be protected from re-traumatization as much as possible .Avoid actions that may trigger memories of trauma/stress inducing event . Review of Resident #57's Psychiatric Periodic Evaluation dated 2/27/2023, showed .On exam, patient is up in wheelchair. She is attempting to find social services. Appears anxious. She is trying to find out when psychotherapy comes to visit .Denies depression, but states 'I just have some things I want to tell her' .Patient still exhibiting symptoms of anxiety and occasional depression . Review of Resident #57's Psychotherapy Progress Note dated 2/28/2023, showed .Patient is seen today for current significant symptoms of depression and anxiety. Social worker referral due to patient request for psychotherapy .Patient processed anxious feelings and stressors .She also processed difficulty expressing her feelings to others due to trust issues .Clinician plans to continue psychotherapy and recommends medication evaluation/treatment as needed for significant symptoms of depression and anxiety due to patient is minimally stable/requires ongoing interventions at this time . During an interview with Resident #57 on 3/15/2023 at 12:04 PM, the resident stated Resident #30 came into her room multiple times. Resident #57 stated there was an incident where two staff members came into her room to get Resident #30 out of her room. These 2 staff members told Resident #57 to wait in the hallway while the staff members removed Resident #30 from Resident #57's room. The 2 staff members removed Resident #30 from Resident #57's room and returned Resident #30 to his room. The 2 staff members returned to Resident #57's room to clean up the mess Resident #30 made in the room. While Resident #57 waited outside her room, Resident #30 came back out of his room and came toward Resident #57 as she waited in the hallway. Resident #30 attempted to stand up and grabbed the arm of her wheelchair and then touched her right arm and moved his hand up her arm. Resident #57 hit Resident #30 on his hand with her grabber device. The staff intervened and told Resident #57 she could not hit Resident #30 and the staff removed Resident #30. Resident #57 stated she was fearful of Resident #30 because she did not know his capabilities. Resident #57 felt like she was abused by Resident #30 and had the right to defend herself from Resident #30 and did not feel comfortable with Resident #30. Resident #57 was aware if she held her door handle, Resident #30 could not come in her room. Resident #57 stated she did not want to have to think about defending herself from Resident #30 and needed to think of her own well-being. Resident #57 was fearful at night that Resident #30 would come into her room so she would move her bedside table in front of her so Resident #30 could not get to her as quick. Resident #57 stated she told staff members about Resident #30, and they were aware of his behaviors. Resident #57 did not know the date or time of the incident in which she defended herself from Resident #30 and struck him and could not remember the names of the staff members who intervened because they were not wearing name badges. Resident #57 stated she knew of another resident who resided in the room that belonged to Resident #31 and Resident #75 who was also fearful of Resident #30. Resident #57 stated when she was socializing with Resident #75, Resident #75 returned to her room when she saw Resident #30 coming down the hallway. Resident #57 stated Resident #75 stopped their conversation and went into her room to get away from Resident #30. During an interview with the Administrator and the Regional [NAME] President on 3/15/2023 at 3:51 PM, the Administrator stated that the investigation into the abuse allegation involving Resident #30 and Resident #75 was .still ongoing . The Regional [NAME] President stated that 23 other residents had been interviewed by staff and no other abuse complaints had been reported. The Administrator and Regional [NAME] President were asked if they had interviewed Resident #57, and they confirmed that the facility had not interviewed Resident #57. The Administrator and Regional [NAME] President were notified that Resident #57 reported an altercation with Resident #30 and reported that she was fearful of Resident #30. The Regional [NAME] President and Administrator confirmed that the facility was not aware of an incident between Resident #57 and Resident #30. Review of Resident #57's progress note by RN #3 dated 3/15/2023 at 4:43 PM, showed .Resident reports being fearful of another resident. Resident assessed and is safe and without s/s [signs and symptoms] of increased anxiety at this time. NP made aware. Psych to [be] made aware to assess resident. Will continue to observe for increased anxiety . During an interview on 3/15/2023 at 6:40 PM, the Administrator stated that Resident #30 was moved to another unit and staff has been assigned to monitor him. The Administrator stated that Resident #30 was moved because there was not another private room available for Resident #57 and .because the social worker talked to her [Resident #57] and she did say she was fearful . of Resident #30.