**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, and interviews, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 residents (Resident #6 and Resident #74) of 26 residents reviewed for abuse. The facility's failure to prevent resident to resident altercations resulted in actual harm for Resident #6. On 6/27/2024, Resident #283 struck Resident #6 with a water pitcher causing a laceration and bruising to the left eye on 12/15/2023 and Resident #74 when Resident #31 struck resident #74 with a walker causing a small cut to Resident #74's right earlobe and a skin tear to the resident's left hand, which resulted in actual HARM to Residents #6 and #74. The findings include: Review of the facility policy titled, Abuse, Neglect and Misappropriation of Property, revised 4/14/2022, revealed .organizations intention to prevent the occurrence of abuse .all alleged Abuse, Neglect, exploitation, injuries of unknown origin, and Misappropriation of resident property is investigated .are reported immediately .Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish . Review of the medical record revealed Resident #283 was admitted to the facility on [DATE] with diagnoses including Schizoaffective Disorder, Bipolar Type, Cognitive Communication Deficit, Unspecified Psychosis, Mood Disorder, and Alzheimer's. Review of a comprehensive care plan for Resident #283 initiated 4/28/2022, revealed .Behavioral .at risk and/or active behavior problems .Physically Aggressive Verbally Aggressive .cursing, hitting and screaming .related to being easily agitated and difficult to redirect .staff will .Provide non-confrontational environment .Anticipate care needs .provide them before the resident becomes overly stressed .Allow resident adequate time to verbalize his feelings .praise him when he verbalizes them in a calm tone .Intervene as needed to protect the rights and safety of others; approach in calm manner, divert attention, remove from situation .take to another location as needed .report changes in behavioral health status to MD [medical doctor] . Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #283 scored a 7 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident had severe cognitive impairment. Further review revealed no behaviors were observed, and the resident received antipsychotic and antianxiety medications during the assessment period. Review of the Behavioral Progress Notes for Resident #283 dated 11/9/2023, revealed . Depakote [medication used to stabilize mood] 250 milligrams [mg] TID [three times a day] .Klonopin [medication used to treat anxiety] 1 mg TID .Geodon [medication used to treat Bipolar Disorder] 40mg q [every] AM [morning] and 40mg q PM [night] .judgement poor .insight poor .continue current psych treatment . Review of the Nurse's Progress Notes for Resident #283 dated 11/15/2023, revealed . impatient with poor impulse control and verbal outbursts are common . Review of the comprehensive care plan for Resident #283 revised 12/15/2023, revealed the resident was involved in a resident to resident altercation. The interventions included .Separate resident immediately to reduce interactions with other resident's [residents] when he is agitated .one on one prn [as needed] .social services as needed . Review of the Social Work Notes for Resident #283 dated 12/15/2023, revealed .SSD [Social Service Director] was notified by DON [Director of Nursing] that a resident to resident [altercation] took place .[Resident #283] .struck .[Resident #6] .in the dining room with a water pitcher .[Resident #283] was sorry for his actions .[Resident #6] .was making inappropriate gestures .order from NP [Nurse Practitioner] to refer [Resident #283] to in-patient psych [psychiatric] related to resident to resident [altercation] . Review of the Nurse's Notes for Resident #283 dated 12/15/2023, revealed .resident [Resident #283] stated to the nurse .[Resident #6] .flipped me off so I hit him with my pink water pitcher .' Review of the facility investigation dated 12/15/2023, revealed a resident-to-resident altercation between Resident #283 and Resident #6 had occurred. A staff nurse was assisting a resident to the dining room. When the staff nurse entered the dining room a resident at the facility informed the nurse Resident #283 hit Resident #6 with a water pitcher. Resident #283 and Resident #6 were immediately separated. Resident #283 had a history of outbursts and aggressive behavior. Resident #283 was placed on 1:1 supervision until the resident was admitted to an inpatient psychiatric facility (admitted to an inpatient psychiatric facility on 12/15/2023 and did not return to the facility). Resident #6 sustained a small laceration/bruise above his left eye. No changes in Resident #6's behavior were observed. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Dementia, Major Depression, Anxiety, and Schizoaffective Disorder, Bipolar Type. Review of a comprehensive care plan for Resident #6 initiated 3/2/2018 and revised 12/15/2023, revealed .Behavioral .at risk for behaviors identified as verbal aggression, declining care, being short tempered, placing self on floor .staff will .Anticipate care needs and provide them before I become stressed .Monitor behavior to determine underlying cause . Consider location, time of day, persons involved .Provide non-confrontational environment .Refer to Psych NP as needed .Refer to Social Services as needed .Report to Physician any changes in behavioral status . Review of the Behavioral Progress Notes for Resident #6 dated 11/23/2023, revealed . thought process impaired, memory impaired, judgement poor .insight poor .Depakote 500 mg in the morning Remeron [medication used to treat depression] 7.5 mg at bedtime .maintain stabilization . Review of a quarterly MDS assessment dated [DATE], revealed Resident #6 was unable to complete the BIMS assessment, the resident was rarely/never understood, which indicated the resident had severe cognitive impairment. Further review revealed no behaviors were observed, and the resident did not receive antipsychotic medications during the assessment period. Review of a comprehensive care plan for Resident #6 revised 12/15/2023, revealed the resident was involved in a Resident-to-resident altercation. The interventions included .Care for abrasion to left eye, per order .Evaluate and monitor for pain and distress .Interview and monitor resident for psychosocial wellbeing . Review of the Nurse's Notes for Resident #6 dated 12/15/2023, revealed .resident was involved in an altercation with another resident .[Resident #6] .is pleasant and calm .no s/s [signs and symptoms] of distress . Review of the Nurse's Notes for Resident #6 dated 12/15/2023, revealed .house NP .was notified of resident-to-resident altercation .NP saw resident .new order .Tylenol [medication used to treat pain] 650 mg every 6 hours as needed .for pain . Review of the NP Notes for Resident #6 dated 12/15/2023, revealed .resident involved in a resident-to-resident altercation .small cut .bruise .above .left eye .painful to touch .Tylenol 325mg 2 tabs PO [by mouth] every 6 hours as needed . Review of the Physician's Orders for Resident #6 dated 12/15/2023, revealed .Acetaminophen [Tylenol] .325 mg .2 tabs [tablets] every 6 hours as needed .clean laceration with normal saline and pat dry, monitor s/s of infection . Review of a Skin Integrity Assessment for Resident #6 dated 12/15/2023, revealed .a 2.5 [centimeter (cm)] x [by] 0.1 [cm] x 0 laceration to the resident's left eyebrow with a small amount of blood .first aid applied . During an interview on 7/31/2024 at 9:21 AM, the NP stated Resident #6 was hit in the head with a water pitcher by Resident #283 on 12/15/2023. The NP assessed Resident #6 after the altercation, the resident received a small cut above the left eye with bruising and the resident was ordered Tylenol for pain. The NP confirmed Resident #6 was physically harmed by Resident #283 when he was hit in the head with a water pitcher. Review of the medical record revealed Resident #31 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, Bipolar Disorder, Mood Disorder, Delusions, and Depression. Review of a comprehensive care plan for Resident #31 initiated 12/5/2022, revealed .Behavioral .at risk for behavior problems .screaming and yelling out .easily agitated and sometimes is difficult to re-direct .staff will .Anticipate care needs .provide them before the resident becomes overly stressed .allow him to express how he feels; praise him for any positive communication . Review of a quarterly MDS assessment dated [DATE], revealed Resident #31 scored a 00 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review revealed no behaviors were observed, and the resident received antipsychotic medications during the assessment period. Review of the Nurse's Note for Resident #31 dated 6/18/2024, revealed .Psych NP rounded today .New orders received .decrease Risperdal [medication used to treat Bipolar Disorder] to 0.25 mg at bedtime . Review of a comprehensive care plan for Resident #31 revised 6/27/2024, revealed the resident was involved in a resident-to-resident altercation. The interventions included .individualized signage on door to identify his room .Psychosocial Follow-up for 72 hours .Separate residents immediately . Review of the Nurse's Notes for Resident #31 dated 6/27/2024, revealed .Resident exhibited aggressive verbal and physical behaviors towards others .placed on [every] 15 minute checks with direct supervision .Psych NP advised to attempt psych placement for increased behaviors . Review of a facility investigation dated 6/27/2024, revealed a resident-to-resident altercation between Resident #31 and Resident #45 had occurred. Certified Nursing Assistant (CNA) I reported to the charge nurse Licensed Practical Nurse (LPN) E she heard loud noises from Resident #74's room. When CNA I entered the room, the CNA observed Resident #31 and Resident #74 arguing. Resident #31 made contact (hit) with Resident #74 using his walker. LPN E was called to the room by CNA I and witnessed CNA I separating the two residents. Resident #74 was observed to have a 1 cm skin tear to his left hand and a 0.5 cm skin tear to the right earlobe. Resident #31 had no injuries, and the residents were immediately separated. Resident #74's injuries were assessed and the wounds to the left hand and right earlobe were treated by LPN E. A psychological evaluation was performed on both residents with no psychological harm identified. Review of the Behavioral Progress Notes for Resident #31 dated 6/30/2024, revealed . memory impaired .judgement poor .insight poor .recent agitation, aggression .Cymbalta [medication used to treat Depression] 60 mg qd [daily] .Risperdal 0.5 mg q AM .0.25mg q hs [bedtime] Depakote 500 mg BID [twice daily] .Remeron 15mg q hs . Resident #31's Risperdal dosage was increased after the altercation (gradual dose reduction (GDR) was ordered on 6/18/2024). Review of the SSD Notes dated 7/1/2024, revealed .[Resident #31] was evaluated after the physical altercation .in no distress, had no concerns and there were no other incidents . Review of the medical record revealed Resident #74 was admitted to the facility on [DATE] with diagnoses including Dementia, Psychosis, Mood Disorder, and Alzheimer's. Review of a quarterly MDS assessment dated [DATE], revealed Resident #74 scored a 6 on the BIMS assessment which indicated the resident had severe cognitive impairment. Further review showed no behaviors were observed, and the resident received antipsychotic medications during the assessment period. Review of a comprehensive care plan for Resident #74 revised 6/27/2024, revealed .Mood State . Resident .is experiencing disturbed thought processes .secondary to .medical condition .staff will .1:1 visit with social services as needed . Allow resident to express their feelings .Consult with psychiatry/psychology as needed .Encourage and assist to activities .Notify MD with significant changes .resident was involved in a resident-to-resident altercation .Psychosocial Follow-up for 72 hours .Separate residents immediately . Review of the Nurse's Notes for Resident #74 dated 6/27/2024, revealed .No s/s of fear or distress noted .at baseline with emotional status. Resident denies any pain or discomfort . Review of the Physician's Orders for Resident #74 dated 6/27/2024, revealed .clean .skin tear to left hand and right ear lobe . Review of the Interdisciplinary Team (IDT) Notes for Resident #74 dated 6/28/2024, revealed, .IDT met and reviewed .Resident is often confused and has periods of agitation .reviewed and discussed recent interactions with others .no s/s of distress . Review of the SSD Notes for Resident #74 dated 7/1/2024, revealed . SSD followed up with resident .regarding the incident that occurred on Friday [6/27/2024] with .[Resident #31] .Resident stated that he is fine and no issues or concerns with the incident .stated .no other incidents have occurred with the .[Resident #31] . During an interview on 7/30/2024 at 9:00 AM, CNA I stated she witnessed the resident-to-resident altercation between Resident #31 and #74 on 6/27/2024. CNA I was walking down the hallway and heard what sounded like a .scuffle . coming from Resident #74's room. When the CNA entered the room Resident #31 had entered Resident #74's room, Resident #74 was exiting the bathroom, Resident #74 told Resident #31 to leave his room, and Resident #31 hit Resident #74 with his walker which resulted in an injury to the right ear lobe. CNA I immediately intervened and had Resident #31 put the walker down. When Resident #31 lowered the walker, Resident #74 hit Resident #31, and the walker caused a skin tear to Resident #74's left hand. LPN E was notified of the incident, and the LPN treated the injuries to Resident #74's left hand and right ear. CNA I removed Resident #31 from Resident #74's room, neither resident remembered the altercation when asked about it later in the shift, and no other behaviors were observed. CNA I also stated she had not observed Resident #31 in any altercations since the 6/27/2024 incident. During an interview on 7/30/2024 at 2:49 PM, LPN E stated she was working when the resident-to-resident altercation occurred between Resident #31 and Resident #74 on 6/27/2024. LPN E stated she was familiar with Resident #31 and Resident #74. The LPN was called to Resident #74's room by CNA I. CNA I informed the LPN Resident #31 had entered Resident #74's room. Resident #74 was coming out of the bathroom and saw Resident #31 in the room and told Resident #31 to leave. Resident #31 lifted his walker and hit Resident #74, scratching Resident #74's right earlobe before the CNA could stop him. Resident #74 attempted to punch Resident #31 to protect himself and hit the walker causing the skin tear to Resident #74's left hand. LPN E stated Resident #31 gets confused about what room is his and he entered Resident #74's room unintentionally. When the LPN entered Resident #74's room, CNA I had separated the residents. Both residents were assessed by LPN E, Resident #74 received a minor scratch on his right earlobe, there was a Scant amount . of blood. The earlobe was cleansed, and no further treatment was required. Resident #74 received a skin tear to the left hand , the hand was cleansed and required 2 steri-strips (wound closure tape). Resident #31 sustained no injuries and was taken back to his room immediately by CNA I and placed on 1:1 supervision for 72 hours. Both residents were monitored closely after the incident and 15 minutes after the altercation, neither resident could recall the incident. LPN E stated Resident #31 was usually easy to redirect when he had behaviors. Resident #31 had a GDR of Risperdal in June 2024 prior to the altercation .this might have caused the incident . LPN E stated Resident #31's Risperdal was increased back to the original dosage, and the resident had not had any further altercations or incidents. During an interview on 7/30/2024 at 3:11 PM, LPN F stated she was the Behavioral Health Nurse at the facility and was familiar with Resident #31. LPN F stated Resident #31 had a GDR of the Risperdal in June 2024, several days prior to the 6/27/2024 altercation between Resident #31 and Resident #74. LPN F did not witness the incident, but recalled Resident #74 received a minor injury to his earlobe. Resident #31's Risperdal was increased back to the original dosage, and the resident had not had any further altercations since the 6/27/2024 incident. During an interview on 7/31/2023 at 5:40 PM, the Interim Director of Nursing (IDON) stated she was not employed at the facility when the altercation took place between Residents #283 and #6. The IDON reviewed the medical record for Residents #283 and #6 and confirmed Resident #6 received an injury when Resident #283 hit the resident in the head with a water pitcher. Further interview revealed the IDON was not employed at the facility when the altercation took place between Residents #31 and #74. The IDON reviewed the medical record for Residents #31 and #74 and confirmed Resident #74 received an injury when Resident #31 hit the resident with the walker.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of a facility investigation, observation, and interview the facility failed to prevent abuse of 3 residents (#5, #1, #9) of 13 residents reviewed for abuse of 19 sampled residents. The facility's failure to prevent resident to resident altercations resulted in actual harm for Resident #5 when Resident #4 grabbed Resident #5's wrist and twisted her arms and wrist and caused Resident #5 to cry out in pain. The findings included: Review of a facility policy Abuse, Neglect and Misappropriation of Property last reviewed 10/17/2022, showed .it is the organization's intention to prevent the occurrence of abuse, neglect, exploitation, injuries of unknown origin, and misappropriation of resident property .Abuse is defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Resident #5 was admitted to the facility on [DATE], with diagnoses including Dementia with Behavioral Disturbance, Acute Respiratory Disease, Psychosis, Alzheimer's Disease, Major Depressive Disorder and Anxiety Disorder. Review of Resident #5's comprehensive care plan dated 4/29/2021, showed .Behavioral .may be at risk and/or have active behavior problems such as socially inappropriate, wandering in and out of others rooms, pilfering .may become verbally abusive, sexually inappropriate or .may resist care due to dx [diagnosis] of dementia .staff will encourage me not to push against the door handle on exit door, address wandering behavior by walking with resident, redirect from inappropriate areas, engage in diversional activities .consult with psychiatry/psychology as needed . Review of Resident #5's quarterly Minimum Data Set (MDS) dated [DATE], showed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe cognitive impairment. Delusions were observed during the assessment period. The resident had verbal behavioral symptoms directed toward others 1 to 3 days, behavioral symptoms not directed toward others daily and wandering daily during the assessment period. Review of Resident #5's Nursing Progress Note dated 1/4/2023, showed .wanders/pilfers needs frequent redirection .Makes delusional statements .often wanders during the meal and must be redirected back to it . Review of Resident #5's Nursing Progress Note dated 1/6/2023, showed .has increased behaviors this shift. Showing aggressive behaviors. Redirection unsuccessful . Review of Resident #5's Nursing Progress Note dated 1/9/2023, showed .usual wandering/pilfering behaviors. Redirected PRN [as needed]. No aggressive behaviors . Review of Resident #5's Behavioral Medicine Progress Note dated 1/10/2023, showed .nsg [nursing] reports increased anxiety, restlessness some aggression .Add Ativan [antianxiety medication] 0.5 mg [milligram] qd [every day] PRN X [times] 14 days. Hold for any sedation/dizziness . Review of Resident #5's Nursing Progress Note dated 1/11/2023, showed at 1:01 PM, .PRN Lorazepam [antianxiety medication] 0.5 mg [milligrams] given due to increased agitation and aggressive behaviors . Review of Resident #5's Nursing Progress Note dated 1/13/2023 at 2:31 PM, showed .Increased intrusive wandering, holding door shut to prevent this nurse from entering room. Verbally aggressive when redirected, angry affect, pacing rapidly. Difficult to redirect. Ativan given per PRN order at 1:13 PM for increased agitation/anxiety. Effective, calmer at this time . Review of Resident #5's comprehensive care plan revised on 1/23/2023, showed .Behavioral .demonstrates inappropriate behaviors including: intruding in personal space and hugging other residents .assist resident away from other residents as needed .determine the cause for inappropriate behavior and refer to a physician for intervention, encourage participation in structured activities as appropriate, observe for triggers of inappropriate behaviors and alter environment as needed . Review of Resident #5's Nursing Progress Note dated 1/23/2023, showed .up ambulating .in hall with usual gait .smiling/laughing today . Review of a facility investigation dated 1/31/2023, showed staff were in the dining room cleaning up after lunch and heard Resident #4 yelling at Resident #5. The staff immediately left the dining room to see what was happening. Resident #4 was observed holding the wrist of Resident #5 and Resident #5 was observed on her knees with Resident #4 twisting and pulling Resident #5's wrist and arms. Resident #4 was yelling at Resident #5 and Resident #5 was crying. Staff immediately separated the residents. Resident #4 was placed on 1 on 1 supervision. Resident #5 was taken to the activity/dining room and supervised by staff. Resident #5 was assessed by the nurse with no visual signs of injury, and no complaints of pain. Both were interviewed by the police and no charges were filed. Resident #4 had verbal and physical altercations towards the staff, but no recent indications of physical altercations with other residents. Resident #4 was sent to the emergency room for medical evaluation. Resident #4 reported Resident #5 was a thief and that Resident #4 was trying to keep Resident #5 from taking his belongings. There had been a previous incident of Resident #5 going in Resident #4's room and taking his coat, but no coat was found in the hallway at the time of the incident. Both residents were seen by the Nurse Practitioner, and both were interviewed by Social Services. Review of Resident #5's Behavioral Medicine Progress Note dated 1/31/2023, showed .follow-up visit for evaluation .mood: euthymic .affect: congruent .per exam patient is alert with no noted agitation or aggression .no noted depression . Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Parkinson's Disease, Speech Disturbance, Schizoaffective Disease Bipolar Type, Major Depressive Disorder, Anxiety Disorder, Chronic Obstructive Pulmonary Disease, Type 2 Diabetes Mellitus, and Cognitive Communication Deficit. Review of Resident #4's annual MDS dated [DATE], showed a BIMS score of 12 indicating Resident #4 had moderate cognitive impairment. The resident exhibited potential indicators of psychosis, and verbal behavioral symptoms directed toward others 4 to 6 days during the assessment period. Review of Resident #4's comprehensive care plan revised on 12/5/2022, showed . At risk and/or active behavior problems: Physically Aggressive, Verbally Aggressive .As Evidenced By: cursing, hitting, and screaming at others .Administer and monitor the effectiveness and side effects of medications as ordered .intervene as needed to protect the rights and safety of others . Review of Resident #4's Behavioral Medicine Progress Note dated 12/6/2022, showed .nsg. [nursing] reports some verbal outbursts, agitation, insomnia .Elder is alert with no noted aggression or agitation. No noted anxiety today. Nsg to notify MD/NP [Medical Doctor/Nurse Practitioner] for any ms [mental status] change .risk/benefit analysis of current psychotropic medications assessed; benefits outweigh risks of potential negative side effects at this time . Review of Resident #4's Behavioral Medicine Progress Note dated 12/10/2022, showed .nsg. reports increased labile mood, aggression, agitation, delusions, threatening staff .noted frequent delusions .noted increased anxiety .rec [recommend] to send out to Geri-psych if placement is available . Review of Resident 4's Nursing Progress Note dated 12/11/2022, showed .elder is striking out at staff, trying to throw coffee cups at staff, kicking doors screaming profanity .[Psychiatric Nurse Practitioner (NP)] gave order for one time 1 mg [milligram] Clonazepam [antianxiety medication] X [times] 1 dose . Review of Resident 4's Nursing Progress Note dated 12/14/2022, showed .Up in w/c [wheelchair] awaiting smoke break. Continues with usual demanding behaviors and episodes of yelling out. Redirected/reoriented PRN [as needed] . Review of Resident 4's Nursing Progress Note dated 12/24/2022, showed .Elder was upset this AM [morning] about not being able to go smoke at 8:00 AM .explained that scheduled smoke break was at 9:00 AM .became combative and aggressive towards staff .[Psychiatric NP] was notified of behaviors and new order was received for 20 mg/ml [milliliters] Geodon [antipsychotic medication used to treat agitation] IM [injection given into the muscle] one time dose to be given. Dose was given and resident has settled down . Review of Resident 4's Nursing Progress Note dated 12/26/2022, showed at 5:15 AM .yelling and demanding to go to the front office .pulling on exit door .'Open the door you bitch.' He then then threw a glass of water and attempted to kick this writer . Review of Resident #4's Behavioral Medicine Progress Note dated 1/16/2023, showed .follow-up visit for evaluation and management of GAD [General Anxiety Disorder] .alert on exam with no noted aggression or anxiety .reevaluation completed in reference to appropriateness of schizoaffective dx [diagnosis]. It is clinicians' impression that dx continues to be accurate .counseling/coordination of care re: medication compliance and medication risks. Benefits as well on POC [plan of care] with staff re: psych admission .2 weeks: Recent medication change or Adjustment . Review of Resident #4's Nursing Progress Note dated 1/31/2023 at 12:55 PM, showed .Appr [approximately] 12:25 PM, resident [Resident #4] was observed holding another resident's arms in the hallway. Staff immediately intervened. Resident [Resident #4] remained anxious stating the other resident had taken his coat. Resident [Resident #4] verbalizing paranoid statements about other residents stealing his belongings. While interviewing resident [Resident #4] he recalls the incident but says it happened in his room last summer. Resident [Resident #4] assessed and placed 1:1 [one to one supervision] . Review of a facility investigation dated 1/31/2023, showed staff were in the dining room cleaning up after lunch and heard Resident #4 yelling at Resident #5. The staff immediately left the dining room to see what was happening. Resident #4 was observed holding the wrist of Resident #5 and Resident #5 was observed on her knees with Resident #4 twisting and pulling Resident #5's wrist and arms. Resident #4 was yelling at Resident #5 and Resident #5 was crying. Staff immediately separated the residents. Resident #4 was placed on 1 on 1 supervision. Resident #5 was taken to the activity/dining room and supervised by staff. Resident #5 was assessed by the nurse with no visual signs of injury, and no complaints of pain. Both were interviewed by the police and no charges were filed. Resident #4 had verbal and physical altercations towards the staff, but no recent indications of physical altercations with other residents. He was sent to the emergency room for medical evaluation. Resident #4 reported Resident #5 was a thief and that he was trying to keep her from taking his stuff and that she took his coat. There had been a previous incident of Resident #5 going in Resident #4's room and taking his coat, but no coat was found in the hallway at the time of the incident. Both residents were seen by the Nurse Practitioner, and both were interviewed by Social Services. Review of Resident #4's Social Service Progress Notes dated 2/1/2023 at 1:04 PM, showed .Worked with IDT [intradisciplinary team] and resident's conservator related to resident's recent increase in behaviors. I have made several referrals for .to behavior units and Gero-psych units .and no facility is able to accept him .psych continues to follow .here at facility .does have a UTI [urinary tract infection] which is being treated . Observation of Resident #5 on 7/27/2023 at 11:20 AM, showed the resident up in the hallway. Resident #5 was well-groomed, awake, alert, smiling and pleasant. During an interview with Resident #5 on 7/27/2023 at 11:20 AM, she stated no to if anyone had every mistreated or hurt her. She was smiling and began to pat this surveyor's hand and smiled. She did not speak in sentences but did answer yes and no questions appropriately. When asked if she was afraid of anyone at the facility she stated no. When asked if she was happy here, she stated yes. When asked if anyone every bothered her or hurt her arms she looked at her arms, looked back up, smiled, and stated no. During an interview with Certified Nursing Assistant (CNA) #1 on 7/27/2023 at 11:30 AM, she stated .he [Resident #4] isn't very nice, he is very demanding, he has outbursts toward staff and residents, especially staff .he could be very verbally aggressive to staff and residents .[Resident #5] is very sweet does her own thing she will wander around and occasionally goes into other resident rooms but very easily redirected. She rarely sits down .there are sometimes she gets mad. Her mood will change, she will get aggressive it is like she goes into a different place in her mind, we just let her cool off and she is fine .I am not aware of her ever hitting staff or residents .she was just walking around the hall .we were picking up lunch trays, she had left the dining room walking down the hall .[CNA #2] and I were picking up trays .[Resident #4] was in his room .he is inpatient he wants what he wants right then, he was agitated. He wanted something, milk, go smoke, I don't remember what it was that particular day .he was sitting in his doorway, [Resident #5] was just walking. We heard her yell out. [Resident #4] has her by both of her wrist twisting. She was crying, trying to get away from him. He was hurting her, she was crying, and she doesn't just yell out or cry .he was willfully holding her wrist. He didn't like her because she was always walking around, he would say she would go in his room and steal stuff, but I am not aware of her ever doing that. [CNA#2] got them separated prying his hands off of her and we kept them separated and I went and got the nurse .[Resident #5] was very upset. She was shaking, but by the time I got back with the nurse she had settled down. There was not any bruising on her wrist but they were a little red, but for what he did she really didn't have any marks on her, I was surprised .after she settled down she just was at her baseline .she wasn't afraid or withdrawn, I didn't see any change in her .I think he was hurting her or she was scared because she was yelling out and yelped out . During an interview with CNA #2 on 7/27/2023 at 12:00 PM, she stated .if he doesn't get his way he gets angry he will get aggressive with staff and residents .I don't have any knowledge of him actually hitting another resident mostly he yells .she does have a temper, she can be combative with staff .we have always been able to redirect her before she has had an altercation with other residents. She does cry sometimes there is another resident on the unit she thinks is her husband and she will say he wants a divorce and she will be crying or if she talks about her son not visiting she will cry .[Resident #4] was in his room, she [Resident #5] was finished and left the dining room, we were finishing in the dining room and we heard her yell we jumped up and ran out of the dining room she was saying 'help me' .I went down the hall he was half way in the hall out of his room he was twisting her arms she was on the floor on her knees beside his chair and he was twisting her arms, and he would not let go .I tried to tell him to let her go. He was hurting her. He started yelling calling her names and I told [CNA #1] to go get the nurse, he finally let go and I took her to the dining room. The nurse was there and I took [Resident #5] out of his sight .she was upset on the way up the hall but by the time we got to the dining room, I put on music, got her something to drink and she had already calmed down .he was willfully trying to hurt her .I think he said she was trying to steal his stuff. I don't think she had even been in his room but according to him everyone was always trying to steal his stuff .he was intentionally holding her wrist trying to hurt her .I told him to go to his room and calm down, I didn't want him coming to the dining room .he did continue to yell and scream but I am not aware of him being physically aggressive with any other resident after that . During an interview with Licensed Practical Nurse (LPN) #1/Behavioral Health Manager (BHM) on 8/1/2023 at 10:30 AM, she stated .[Resident #4] has a traumatic brain injury he has very explosive behavior, he makes paranoid statements. Usually, he can be redirected. He takes his medications well, he very much wants to make his presence known, he is not [NAME] in personality. He is followed by the Psych NP. We do telehealth 3 times a month with all the residents receiving services and one day a month he comes to the facility. He was following both residents prior to the incident .I am not aware of previous resident to resident altercations with [Resident #4] .on 1/31/2023 at approximately 12:35 PM, he was observed holding on to [Resident #5]'s wrists. He was verbalizing paranoid statements saying she had stolen his coat .staff intervened, and he was placed on one on one. Normally she forgets anything within 2 minutes, there was no residual emotional effect. At the time of the incident, she was crying he had her wrists and was twisting and pulling on them. He was yelling at her, she was yelling and crying. The CNAs physically removed his arms from her. They removed her from the area to the dining room and within a few minutes she was fine .at the moment there was emotional trauma. She had no physical injuries .she was seen by the Psych NP within an hour or so and there were no new orders .our corporate Social Service Director [SSD] was filling in and noted on 2/1/2023 no emotional distress and no trauma .she was at her baseline .during the following days there was no indication of any emotional distress or trauma .he would act out usually at smoke break time .he remained on 1:1 and was taken out to the smoke shack to change his environment . During an interview with LPN #2 on 8/2/2023 at 8:15 AM, she stated .I did an assessment on [Resident #5] she did not show any non-verbal signs of pain and she did not verbalize being in any pain. There was no redness, bruising or skin tears observed .I did do a head to toe assessment .she was not tearful, afraid, or withdrawn .she stopped whimpering almost immediately when the CNAs separated them .the CNA already had her walking down the hallway to the dining room .she did not show any signs of distraught, fear, anxiety, no emotional or physical distress .she was at her baseline the rest of my shift .I was not aware of him being aggressive with residents before .he didn't have any other behaviors the rest of the day .he does repeat himself and does get loud and demanding of staff, but that is about it .He was sent out within a few days after the incident to in-patient psych . During an interview with the Director of Nursing (DON) on 8/2/2023 at 4:30 PM, she stated .after this incident [Resident #5] was transitioned off of the unit and has thrived well with no further incidents .we have hired additional staff in the activities department .we are able to offer more activities to the residents including bringing off the unit for group activities bringing one or two residents at a time .both residents are seen by our Psych NP .it was a witnessed abuse .[Resident #5] was in distress, she was on her knees in the floor beside his wheelchair crying with him twisting her arms . The DON confirmed the facility failed to prevent abuse of Resident #5 resulting in psychological distress and harm to Resident #5. Resident #1 was admitted to the facility on [DATE], and readmitted on [DATE], with Acute Respiratory Failure, Chronic Obstructive Pulmonary Disease, Dementia without Behavioral Disturbance, Mood Disturbance, Anxiety, Schizophrenia, Type 2 Diabetes Mellitus, Bipolar Disorder, and Parkinson's Disease. Review of Resident #1's' quarterly MDS dated [DATE], showed a BIMS score of 12 indicating moderate cognitive impairment. Potential indicators of psychosis of hallucinations, and delusions during the assessment period. The resident had verbal behavioral symptoms directed toward others, behavioral symptoms not directed toward others and wandering 4 to 6 days during the assessment period. Review of Resident #1's Physician Progress Note dated 11/29/2022, showed .he is admitted to [facility] from [hospital] 1/5/2021, where he was treated for pneumonia. He has been stable. He is alert with confusion and delusion. He is often resistant to care refuses all blood draws, showers, etc. Ambulates with walker. He states he feels well .poor insight, delusional. Mental status confused and abnormal affect .not oriented to time and place .recent memory abnormal and remote memory abnormal .Schizophrenia .continue Haldol [antipsychotic medication], olanzapine [antipsychotic medication], Depakote [anticonvulsant medication used to treat mood disorders] . Review of a facility investigation dated 12/3/2022, showed Resident #1 was hit on the hand by Resident #3 after a verbal altercation. Review showed no injury to Resident #1 and Resident #1 did not complain of pain and no mental anguish was apparent to either resident. Resident #3 was placed on 1 to 1 supervision. The facility investigation revealed a nurse saw Resident #3 strike Resident #1 with a walker after a verbal altercation. Continued review of the facility investigation revealed a CNA was coming down the hall at approximately 7:00 PM and heard screaming and yelling around the corner in front of the nurses' station. Resident #1 and Resident #3 were screaming at each other. They were trying to hit each other with a walker that belonged to Resident #1. The CNA got between the two residents to redirect. The nurse was on the phone at the nurses' station when Resident #3 became agitated with Resident #1 and was not easily redirected by staff and began yelling at Resident #1. Resident #3 was noted to be kicking at Resident #1 and took Resident #1's walker and began striking him with it. Resident #3 was admitted to the facility on [DATE], with diagnoses including Chronic Kidney Disease Stage 3, Schizoaffective Disorder, Seizures, Anxiety Disorder, Pseudobulbar Affect, Psychosis, Bipolar Disorder, Major Depressive Disorder, Non-ST (NSTEMI) Myocardial Infarction, Alzheimer's Disease, and General Anxiety Disorder. Review of Resident #3's Behavioral Medicine Progress Note dated 11/22/2022, showed .of note, pt. [patient] back from Geri-psych [geriatric psychiatric unit] due to schizoaffective d/o [disorder] exacerbation .no noted psychomotor agitation or aggression. He appears to be tolerating tx. [treatment] changes from Geri-psych so far .1 week s/p [status post] psych hospitalization . Review of Resident #3's 5-day MDS dated [DATE], showed a BIMS score of 9 indicating moderate cognitive impairment. The resident exhibited potential indicators of Psychosis as evidenced by Delusions. Resident #3 exhibited verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others 1 to 3 days, during the assessment period. Review of Resident #3's Nursing Progress Note dated 11/23/2022 at 8:33 AM, showed .observed ambulating on hallways without AD [assistive device] and appeared to be unsteady. Staff attempted to educate patient regarding safety and not to ambulate by himself, patient had a behavioral outburst after staff told him not to walk by himself without a walker and a therapist . Review of Resident #3's Nursing Progress Note dated 11/23/2022 at 9:13 AM, showed .observed walking without AD at face [fast] pace. Unable to redirect/ Therapy has also tried to redirect. Elder ran outside and down the hallways trying to skip backwards .[psych NP] notified of erratic behavior. One time dose of Geodon [antipsychotic medication] IM [intramuscular] 20 mg ordered and given with somewhat positive effects . Review of Resident #3's Nursing Progress Note dated 11/28/2022, showed .cont. [continue] to walk and run the halls .refusing some meds .placed one on one for the day after verbal outburst in smoke shack . Review of Resident #3's Nursing Progress Note dated 11/30/2022 at 2:17 PM, showed .elder up out of his wheelchair several times today. He has had several outbursts of screaming. Refuses to take more than 5 pills pulled most meds given and gave them except the vitamins. V/S [vital signs] within normal limits . Review of Resident #3's Nursing Progress Note dated 11/30/2022 at 2:53 PM, showed .resident easily agitated this shift. Demanding that I go obtain food from a local restaurant 'right now.' Explained that I was unable to accommodate his request today but would check with him regarding food later in the week. He then threw his money on the ground stating 'fine then I just won't eat' then raced off in his w/c [wheelchair]. Resident's money secured and returned to business office for safe keeping until resident calms . Review of Resident #3's comprehensive care plan revised on 12/3/2022, showed .Behavioral .has the potential to demonstrate behaviors including physical aggression, agitation .bipolar disorder and schizophrenia .1:1 until discharge to hospital or seen by psych/MD and determine to be safe around others, assist resident away from other resident and others as needed, determine the cause for inappropriate behavior and refer to a MD or hospital as needed .Geri-psych referral .social services or designee to follow up for psychosocial affects from negative encounter . During an interview with Resident #1 on 7/26/2023 at 11:35 AM, when asked about the incident with Resident #3 he stated .he accused me of looking at him and tried to kick me between the legs, but he didn't make contact .I don't know where my walker was, that was a while ago .I never hit anybody .I do remember he did hit my legs with a walker, but it wasn't hard and it didn't hurt .he has started to come in my room, but the staff has gotten to him before he made it in the door . During the interview Resident #1 stated he was not afraid, he was happy at the facility, and he received good care. During an interview with LPN #3 on 7/26/2023 at 7:00 PM, she stated .that was my first night here .I was seated behind the nurses station. [Resident #3] came out of his room .[Resident #1] was on the hall. The nurses' station door was shut and [Resident #1] came to the door and was saying something. [Resident #3] came up and was talking to me at the same time. They started talking to each other. I don't know what was said, I was on the phone, but I could see them over the counter .out of the blue [Resident #3] took [Resident #1's] walker and started rolling it on the floor towards [Resident #1] and bumping [Resident #1] on the legs. [Resident #1] was against the door and I couldn't open it .The CNA heard the commotion and separated them. I assessed both residents and there were no injuries. [Resident #1] didn't have any redness on his legs, skin tears, or bruising .I did not see [Resident #1] retaliate in any way .[Resident #3] said [Resident #1] called him a liar, and he didn't like that .I only saw him hit him with the walker .[Resident #3] was in a wheelchair .I never saw him raise the walker off of the floor .he was just pushing it towards him and bumping his legs and feet .[Resident #1] just doesn't like men in general .he was at his baseline when I worked again in a couple of days .he has never mentioned the incident to me again .he thinks he owns the building and that he writes us our checks . During an interview with CNA #3 on 7/26/2023 at 7:25 PM, he stated .they had gathered around the nurses' desk [Resident #3] swears and hollers .they were both talking before the altercation but it did not appear they were arguing .they were not raising their voices .[Resident #3] took [Resident #1's] walker and was hitting his legs .the walker was not up in the air he was in a wheelchair .he might have raised the walker off the floor a little but it looked like he was just pushing it across the floor .when I saw what was going on I separated them .neither one was hurt .[Resident #1] was willfully pushing the walker at [Resident #3] trying to hit his legs and he was successful before I could get to them .I never saw [Resident #1] hit [Resident #3] . During an interview with the DON on 8/2/2023 at 8:50 AM, she stated .the incident occurred on 2nd shift .I received a phone call, that a resident-to-resident altercation/incident had occurred. This was my first resident to resident altercation .[Resident #3] had a hold of [Resident #1]'s walker .they were having a tug of war with the walker .[Resident #3] was the one who initiated the altercation .the staff reported [Resident #3] did push the walker into [Resident #1]'s legs and feet .witnesses reported the incident was a willful action on the part of [Resident #3] to hit [Resident #1] .skin assessments were completed with no negative findings . During an interview with the DON on 8/2/2023 at 4:30 PM, she confirmed the facility failed to prevent abuse of Resident #1. Resident #9 was admitted to the facility on [DATE], with diagnoses including Depression, Anxiety Disorder, Alzheimer's Disease, Peripheral Vascular Disease, and Cognitive Communication Deficit. Review of Resident #9's quarterly MDS dated [DATE], showed a BIMS score of 0 indicating severe cognitive impairment, with no behaviors observed during the assessment period. Review of Resident #9's comprehensive care plan revised on 4/14/2023, showed .at increased risk for wandering and elopement .diagnosis of dementia .periods of increased confusion, forgetfulness, disorientation, impaired cognition, impaired decision making, and decreased safety awareness .complete elopement risk assessment per facility protocol, discuss with resident/family risk of elopement and wandering, if missing from facility, follow elopement protocol .if .wandering in potentially unsafe areas or situation, redirect to safer area, leave safe and reassess regularly, take photograph of resident to maintain on file for identification purposes .update elopement binder . Review of Resident #9's Nursing Progress Note dated 4/15/2023, showed .increased agitation noted. CNA attempted to clean him up due to incont. [incontinent] episode of bowels, resident was hitting a [and] kicking staff, small cut to left knuckle from hitting staff during care. Staff unable to redirect, this nurse attempted to redirect resident with ineffective results, resident is safe in bed at this time, refused to allow staff to put on clothes, bed at low position, call light in reach . Review of Resident #9's Nursing Progress Note dated 4/17/2023, showed .Intrusive wandering. Redirected out of others' rooms often. Pleasant demeanor noted . Review of Resident #9's comprehensive care plan revised on 4/17/2023, and showed .safety alarms as permitted, such as wander guard . Review of Resident #9's Nursing Progress Note dated 4/20/2023, showed .patient becomes combative w/[with] care during shower X 3 assist. Patient swinging soiled brief in attempts to hit at staff and threw brief in floor w [with] stool splatting out including walls .this [TRUNCATED]