**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, www.wunderground.com, Electrical Company invoice, observation and interview, the facility failed to provide adequate supervision to prevent an accident for 2 (Resident #5 and Resident #10) of 6 sampled residents reviewed for accidents. The facility failed to ensure adequate supervision to prevent an exit seeking, wandering, cognitively impaired resident (Resident #10) with a Brief Interview for Mental Status (BIMS) score of 9, assessed to be an elopement risk, from leaving a safe environment and exiting the facility to an unsafe environment. Resident #10 (wearing a wander guard bracelet) exited a double door connected to the door alarm/wander guard system that malfunctioned on [DATE] at an unknown time until [DATE] at 2:00 AM. No alarm was activated when Resident #10 exited through the double doors. Resident #10 walked approximately 618 feet down a sidewalk, an embankment, and into a street to a house in the nearby community. Resident #10 knocked on the door and stated, I am trying to find my house. A member of the house (a previous male employee) recognized Resident #10 and drove her back to the facility at approximately 2:15 AM. The staff were unaware Resident #10 was missing from the facility. Resident #10 reported to the nurse when she returned that she fell down the hill. Resident #10 had dirt on the back of her clothes. Resident #10 reported to the Nurse Practitioner (NP) on [DATE] that she bit her tongue when she fell, and a small laceration to right side of her tongue was noted. The facility also failed to provide supervision to ensure an environment free of accidents for Resident #5, a vulnerable high fall risk resident, receiving blood thinner. On [DATE] at 2:05 PM, Resident #5 had a witnessed fall which resulted in a head injury. The Conservator was notified of the fall via email. At 5:00 PM Resident #5's blood pressure had decreased to 90/62. Licensed Practical Nurse (LPN) A (Hospice nurse) noted Resident #5 was pale in color, with slurred speech, an abrasion/ raised area to forehead, weak grip, shallow breathing, was tense and moaning, hypotensive with an irregular heart rate, and Resident #5 stated he was cold. On [DATE] and [DATE] staff noted in a nursing note: Resident #5 had blood in his mouth and was combative with care and restless. Resident #5 expired in the facility on [DATE], 3 days after the fall. The facility's failure to provide adequate supervision for vulnerable residents resulted in Resident #10's elopement and Resident #5's accident which placed the residents in Immediate Jeopardy (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident) with actual harm. The Administrator was notified of the Immediate Jeopardy (IJ) for F-689 on [DATE] at 4:33 PM related to Resident #10 in the conference room. The Administrator and the Senior [NAME] President were notified of the IJ on [DATE] at 6:33 PM related to Resident #5 in the conference room. The facility was cited at F-689 at a scope at severity of J, which is Substandard Quality of Care. The Immediate Jeopardy began [DATE], continued through [DATE], and was removed on [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-689 was received on [DATE]. The corrective actions were validated onsite by the surveyors on [DATE] through observation, review of records, audit review, education review, and staff interviews. The facility's noncompliance at F-689 continues at a scope and severity of D for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Review of the facility policy titled, Incident and Accident Process, dated 1/2024 revealed, .An incident or accident is defined as 'any occurrence that is outside the norms or any happening that is not consistent with the routine operation of the center or care of a particular patient .All patient incidents should be documented in the EHR [electronic health record] .When any incident results in injury, as defined below, and/or there is evidence of negligence, they must be reported to clinical risk management .Significant injury including: Fracture or dislocation of bones or joints, Closed head injury with altered consciousness, and Subdural hematoma .Any condition requiring medical treatment outside the center that is inconsistent with the routine management of the patient's preexisting condition(s) .The DON [Director of Nursing] should review all incidents for accuracy and complete documentation .is data complete and thorough and paints a picture of what happened .Was the care plan updated to reflect the incident .Is additional investigation needed to determine the exact events of the incident .What can be done to avoid similar incidents recurring on this or any patient in the center . Review of the undated facility policy titled, MISSING PATIENT PROCEDURE, revealed, .In the event a patient is discovered missing from the building, the following policies and procedures shall govern the situation .Person discovering that a patient may be potentially missing or not accounted for shall report the situation to their immediate supervisor .If the patient has not lawfully left the center, an immediate search of the building shall take place (corridor by corridor) at the direction of the charge nurse. Every patient's room bathroom, closet, or storage area will be thoroughly searched .Concurrent with the internal search, an external search of the grounds and adjacent areas shall be scanned for a wandering patient .including street and side street proximal to the center the charge nurse shall delegate this task .The Administrator and Director of Nurses shall be notified of situation immediately as well .When a missing patient has been found, an incident report and detailed description of the search shall be completed and forwarded to the DON and Administrator .All staff should be alert as to the whereabouts of all patients at all times to the extent possible and should be familiar with these procedures . 2. Review of the medical record revealed Resident #10 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease with late onset, Dementia without Behavioral Disturbance, psychotic disturbance, mood disturbance, and anxiety. Review of the care plan for Resident #10 revealed, .Problem Start Date XXX[DATE] Elopement: At risk for complications r/t [related to] impaired cognition due to dementia, wanders .Goal Target Date XXX[DATE] Will have elopement risk minimized through next 120 days or next review. Will remain in safe confines of center unless supervised by staff/representative .Approach Start Date XXX[DATE] apply and maintain wanderguard as need for accidental or self removing .Approach Start Date XXX[DATE] check wanderguard placement & function as ordered. Replace one month prior to expiration date .Approach Start Date XXX[DATE] Redirect and reassure patient during episodes of exit-seeking . The care plan for Resident #10 revealed at risk for elopement since [DATE]. Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt [patient] noted to pace hallways this night when asked what she was doing she stated she didn't know and felt like walking .when oriented to time of night pt stated maybe i [I] should sleep . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Frequently requires redirection by staff. Occasionally delusional . Review of the Elopement Risk dated [DATE] for Resident #10 revealed, .Has patient exhibited wandering or exit seeking behavior in the last 90 days .No .Is patient cognitively impaired with poor decision making skills .Yes .Does patient have indications of dementia or a diagnosis of dementia .Yes .Elopement Risk Score: 0.0 . The progress notes revealed Resident #10 was pacing the halls and expressed she did not know why, which placed this resident to be at risk for an elopement. Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt wandering in hallway earlier looking for daughter going room to room redirected returned to her room and 10 mins. [minutes] later doing same thing .easily redirected but doesn't last long. since med d'c 'd [discontinued] pt is more alert but some paranoia noted along with wandering in the evening and night .will monitor . Review of the Elopement Risk dated [DATE] for Resident #10 revealed, .Has patient exhibited wandering or exit seeking behavior in the last 90 days .No .Is patient cognitively impaired with poor decision making skills .Yes .Does patient have indications of dementia or a diagnoses of dementia .Yes .Elopement Risk Score: 0.0 . The progress notes revealed Resident #10 was wandering the halls and searching for family which placed the resident to be at risk for an elopement. Review of the Progress Notes dated [DATE] for Resident #10 revealed, .NP, notified of Pt's increased paranoia and not sleeping at night. New order noted for Trazadone [antidepressant] 25mg [milligram] PO [by mouth] q [every] HS.[hour of sleep] Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt wanders halls looking for daughter or trying to figure out 'what i am supposed to do' redirected multiple times by staff . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt wandering in hallway off and on during the night looking for family .redirected and then 30 mins. later same thing .will monitor . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt in hallways last night looking around then would go into room a few mins later looking around again .off and on all night .when asked what are you looking for stated 'i dont know' would go back to room and lay down .will monitor . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt up at night looking up and down hallways .then will dart back in room .when asked if pt needs something stated 'i'm [stated I'm] just looking .will monitor . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt paranoid and packing clothes up unable to redirect .will monitor . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Staff report behaviors such as packing to leave and wondering [wandering] -state . Review of the Elopement Risk dated [DATE] for Resident #10 revealed, .Has patient exhibited wandering or exit seeking behavior in the last 90 days .Yes .Is patient cognitively impaired with poor decision making skills .Yes .Does patient have indications of dementia or a diagnosis of dementia .Yes .Elopement Risk Score: 1.0 Level: The patient is at risk for elopement. Proceed with appropriate safety intervention . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Episodes of wandering up et [and] down halls looking for family . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 had Brief Interview for Mental Status (BIMS) score of 9 which indicated moderately impaired cognition. Continued review of the MDS revealed Resident #10 wandered 1-3 days over the last 7 days. Continued review of the MDS revealed Resident #10 required supervision with locomotion on unit and no setup or physical help from staff for locomotion off unit. Continued review of the MDS revealed Resident #10 was able to walk 10 feet - 150 feet independently. Review of the care plan for Resident #10 revealed, .Problem Start Date XXX[DATE] .Behavioral Symptoms .At risk for altercation in behaviors r/t refusal of plan of care .Pt has wandering, delusions, and hallucinations .Approach Start Date XXX[DATE] .promote safety .Remind patient that words and actions have impact; redirect as needed .Remove patient from triggering situations when possible; respect personal space and rights . The behavior care plan for Resident #10 revealed she wandered and was delusional which placed the resident at risk for elopement. Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Pt had walked to other unit .was frantically and repeatedly asking for . her ex husband [named Ex-husband] . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .wanders throughout building looking for family members .will continue to monitor . Review of the Order History for Resident #10 revealed XXX[DATE] .Wanderguard: check for placement and skin integrity under band nightly .Wanderguard .expiration date Jun [June] 2023; check skin for placement, skin integrity, and functionality daily . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Pt is noted with increased confusion and pacing . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Continues to wander in hallway and requires some redirection . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt wanders halls looking for family members or locations . Review of the Elopement Risk dated [DATE] for Resident #10 revealed, .Has patient exhibited wandering or exit seeking behavior in the last 90 days .No .Is patient cognitively impaired with poor decision making skills .Yes .Does patient have indications of dementia or a diagnoses of dementia .Yes .Elopement Risk Score: 0.0 . The progress notes revealed Resident #10 was wandering the halls and searching for family which placed the resident to be at risk for an elopement. Review of the Progress Notes dated [DATE] for Resident #10 revealed, .increased confusion/paranoia noted this week .pacing and looking for husband or family .rummaging/hoarding items primarily on bed .refuses to allow staff to remove items . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Staff state that patient continues with occasional behaviors (packing to leave and wandering) . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .Pt noted in room packing stating that she is going home that the Md [medical doctor] okayed it . Review of the Elopement Risk dated [DATE] for Resident #10 revealed, .Has patient exhibited wandering or exit seeking behavior in the last 90 days .No .Is patient cognitively impaired with poor decision making skills .Yes .Does patient have indications of dementia or a diagnosis of dementia .Yes .Elopement Risk Score: 0.0 . The progress notes revealed Resident #10 was wandering the halls, searching for family, and packing to leave which placed the resident to be at risk for an elopement. Review of the Progress Notes dated [DATE] for Resident #10 revealed, .pt exited building .walked to near by house .was returned to facility by member of the community .pt reports falling on hill outside door .no injury or pain noted .NP and daughter .notified .pt resting in bed at this time .will continue to monitor . Review of the POST FALL REPORT dated [DATE] revealed, .pt stated fell while outside on the hill . Review of the Progress Notes dated [DATE] for Resident #10 revealed, .PT SEEN BY NP .THIS AM .PT REPORTED TO HAVE BITTEN HER TONGUE WHEN SHE FELL .NP ORDERED WARM SALT WATER WRINSES [rinses] FOR THIS .PT CALM, NOT EXIT SEEKING .WILL CONT [CONTINUE] TO MONITOR . Review of the NP Progress Notes dated [DATE] for Resident #10 revealed, .Patient is seen today for follow up after exiting the facility early this morning and a self reported fall upon her return. Per staff, the patient did have dirt on the back of her clothes consistent with a fall as she had reported .Patient's daughter and daughter-in-law did arrive and the patient did report to them that her tongue was sore. Patient states that she thinks she bit it. No other injuries noted. Family is concerned about insomnia and requests that the patients night time sleep medicine 'trazadone' be increased . Review of the Order History dated [DATE] - [DATE] for Resident #10 revealed .Wanderguard: check for placement and skin integrity under band nightly .Wanderguard .expiration date Jun [June] 2023; check skin for placement, skin integrity, and functionality daily . Review of an invoice from Electrical Company revealed, the Senior [NAME] President (SVP) called the company on [DATE] at 6:10 AM and stated need electrical work at exit door on South end exit today. Continued review of the invoice revealed Electrical Company OO arrived at the facility on [DATE] and relocated exit light and power to exit panel and lock to an unswitched circuit. Review of the www.wunderground.com [weather underground] website the weather on [DATE] was a low of 67 degrees, high of 79 degrees, with 1.35 inches of rain for the day. During an interview on [DATE] at 4:20 PM the Director of Nursing (DON) stated, .we have an investigation on [Named Resident #10] exiting the building . Observation in the dining room on [DATE] at 10:57 AM, revealed Resident #10 was sitting at a table playing bingo. After the activity she followed staff out of the activity and goes straight to her bed to lay down and cover up. During an interview on [DATE] at 8:00 AM, the Administrator stated, .we were unable to determine what time she left .I don't know which house exactly she went to, but I have an address and phone number of the previous employee that brought her back to the building . During an interview on [DATE] at 9:05 AM, Family Member (FM) X stated, .They called me in the middle of the night said she [Resident #10] got out the door because the electricity went out or something .She wandered to a house in the neighborhood .I understood she either knocked on the door or rung the doorbell .that is the only time I knew she ever got out of the building .She went down an embankment .she said she fell .might have got some minor scratches .I went and looked where she walked out you could see in the mud where she slipped .I am so glad she didn't wander where them 2 bull dogs were chained up .a gentleman from the house she walked to brought her back .I know by 3:16 AM she was back in the building .The staff didn't even realize she was gone .she went out the double door close to her room .I don't have any idea the last time the staff had seen her .I was told the alarm didn ' t sound it wasn't working or something .I went down to the facility and the alarm was not working on the door .The facility said they would get the door fixed immediately but I couldn't understand why that was the only safety device they had in place to monitor the residents . During a telephone interview on [DATE] at 12:15 PM, Licensed Practical Nurse (LPN) Z stated, .I was working the night [Named Resident #10] left the building .I was not aware she was missing .She knocked on a door of a house near by .a CNA that use to work here was living there and he recognized her and brought her back to the facility .She had gotten up a couple of times .wandering a few times that night .I am not sure what time she left the building .I usually give her medicines between 7:00 PM - 9:00 PM .we were aware she was missing when the building got the phone call .We turned the light switch off to help the residents rest and that disengaged the door. She was more confused when she came back .mud and grass on her bottom .she said she slide down the hill . She didn't have any injuries .I contacted the person on call but I can't remember who that was .I spoke to the [Named Administrator] as well .I know the doors are checked by the maintenance department .they had someone to come out and repair the wiring to the door .we did a check for all the residents being in the building after she exited the building . During a telephone interview on [DATE] at 12:19 PM, LPN AA stated, .I was working that night when [Named Resident #10] got out of the building .the phone at the facility rang and someone asked if we had a resident missing .and then the doorbell rang and a gentleman had brought [Named Resident #10] back .We didn't know she was missing .She was a little scared and confused .she had some mud on her bottom and leg .[Named Resident #10] knocked on the neighbors door and said something about work she had to do in the basement .I am not sure how he got her back to the facility . During a telephone interview on [DATE] at 12:23 PM, CNA BB, stated, .[Named Resident #10] was having a hard time sleeping that night .[[DATE] the night Resident #10 eloped from the facility]kept wanting her son, wanting to leave to catch the bus .She went to sleep I thought .later I thought I heard a door closing .I thought the sound came from the vending machine .then an employee that use to work here brought her back to the building .she had walked to his family's house down the road .She had mud on her clothes, it had rained that day .we didn't see no visible injuries .I think that light switch was connected to the door and when we turned the lights off the door wasn't working .I usually do a round to check on everybody at 10:30 PM, 12:00 AM, or 1:00 AM .I don't remember what time it was I performed a check on her . During an interview on [DATE] at 1:50 PM, LPN Q stated, .If we had a missing wander guard or a missing resident, we would immediately do a head count . During an interview on [DATE] at 2:10 PM, the Administrator stated, .the door shorted out when the light switch was turned to the off position .we had an electrician come out to fix the door the next day .Initially the staff did not know she was gone .the staff said they heard a sound like a door slamming .two of the CNAs started checking the unit and that is when they realized [Named Resident #10] was missing . During an observation and interview on [DATE] at 4:15 PM, the Administrator and this Surveyor walked off the potential footage Resident #10 walked when she exited the facility on [DATE]. Resident #10 exited the 200 hall double doors, walked along a sidewalk, potentially walked down an embankment into the road. Resident #10 continued to walk to the fifth house to the right and knocked on the door. The potential footage walked was approximately 618 feet. The Administrator was asked if an interview was obtained from the former employee who brought Resident #10 back to facility, and he replied, No. During a telephone interview on [DATE] at 4:15 PM, Former Employee EE stated, .[Named Resident #10] walked to our house and knocked on the door around 2:00 AM .She was really confused and said she was trying to find her house, she was needing to go home .I had taken care of her before when I worked at the facility as a nurse aide .I helped to calm her down and got her into my car .in the meantime my family was calling the facility to make sure they had a missing resident .an employee came to the door to get her .They didn't know she was missing .She had one of those ankle bracelets on but [Named LPN Z] said it must have been broken . During a telephone interview on [DATE] at 4:34 PM, CNA GG stated, .[Named Resident #10] did get out of the building .I don't remember the time or if we knew really what time she left .she knocked on a neighbors door .I don't know if we knew she was gone or not .she would walk around the building independently . During an interview on [DATE] at 12:00 PM, the DON stated, .I would expect if a resident exited the building the nurse would do a full body assessment .chart the last time the resident was observed in the building .the alarm on the door did not sound when [Named Resident #10] went out the side door .I know the light switched contributed to her exiting the building .I did not interview [Named Former Employee EE] .I would expect my staff to know a resident was missing . Record review revealed there was no documentation for the last time Resident #10 was observed in the facility. ________________________________________ 3. Review of the medical record revealed Resident #5 was admitted to the facility on [DATE] with diagnosis which included Alzheimer's disease, Dementia, and Long Term Use of Anticoagulants. Review of the Quarterly MDS dated [DATE] revealed Resident #5 had a BIMS score of 4 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #5 required extensive assist with bed mobility, transfer, locomotion on unit and off unit, and dressing. Further review of the MDS revealed Resident #5 received an anticoagulant (blood thinner) over the last 7 days. Review of fall event dated [DATE] revealed Resident #5 had a witnessed fall in the hallway while leaning over in his wheelchair. Resident #5 sustained an abrasion noted to his forehead with the witnessed fall. Review of the neuro check sheet revealed the frequency to be performed was every 30 minutes times (x) 4, every 1 hour x 4, every 4 hours x 4, and every 8 hours x 6. Review of the neuro checks for [DATE] - [DATE] revealed missing documentation on [DATE] at 3:00 PM for the neuro check. Review of the Medication Administration Record (MAR) from [DATE] to [DATE] revealed Resident #5 received Eliquis (blood thinner) 2.5 mg by mouth twice a day. Review of the Progress note dated [DATE] for Resident #5 revealed, .PT WAS WITNESSED LEANING OVER IN WHEELCHAIR AND FELL TO THE FLOOR. PT NOTED TO HAVE AN ABRASION NOTED TO FOREHEAD. [Named Conservator B] MADE AWARE, [Named NP C] AWARE . The progress note does not reveal if Conservator B was made aware of the risk of a fall with head injury while receiving a blood thinner for Resident #5. Review of the Physician Progress Notes dated [DATE] for Resident #5 revealed, .Routine visit for patient [with] progressive dementia, Afib [Atrial Fibrillation] .per Nursing fell last week bending over reaching for glasses Abrasion to R [right] forehead . Review of the care plan for falls for Resident #5 revealed .Problem Start Date [DATE] .At risk for falls r/t [related to] Hx [history] of falls, Alzheimer's and Dementia with decreased safety awareness, Delusional disorder .Goal .Patient will have fall risks minimized through 120 days or next review XXX[DATE] Encourage me to ask for assistance when picking items up off the floor XXX[DATE] Encourage me to ask for assistance when wanting to leave the dining room XXX[DATE] I will go from my low bed to mats and crawl in the floor in my room at times. I will do this instead of using my call light for assistance XXX[DATE] place bed control out of reach so that I do not adjust my bed to unsafe level XXX[DATE] Encourage patient to use non-skid footwear during transfers/ambulation .Encourage to use call light for needed assistance . The care plan interventions to prevent falls were not appropriate for Resident #5. Resident #5 had a BIMS score of 4 with the inability to remember to ask for assist or the ability to put non-skid footwear on prior to transfers and no ambulation occurred over the last 7 days of the MDS look back period. Review of the 5-day MDS assessment dated [DATE] for Resident #5 revealed a BIMS score of 4 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #5 required substantial/maximal assistance with sit to stand, chair/bed to chair transfer, and walking 10 feet was not attempted. Further review of the MDS revealed Resident #5 received an anticoagulant over the last 7 days. Review of the MAR dated [DATE]-[DATE] revealed an order for Eliquis 2.5 mg by mouth twice a day administered from [DATE]-[DATE]. Review of Hospice D's Visit Note Report dated [DATE], revealed Resident #5 was admitted to hospice with primary diagnoses of Cerebral Atherosclerosis and secondary diagnoses of Dementia. Review of the Visit Note Report revealed Resident #5 was confused, able to verbalize his name, self-propels in wheelchair short distances, and 3 or more falls in past 3 months. Review of Hospice D's Visit Note Report dated [DATE], revealed Resident #5 was being changed by CNA; the Hospice nurse assisted with Resident #5 transferring from bed to the wheelchair. Resident #5 stood, and nurse pivoted patient to the chair. Continued review of the Visit Note Report revealed Resident #5's vital signs were within normal limits (blood pressure (b/p) 122/68, Pulse (P) 88, Respirations (R) 16, Temperature (T) 97.2). Review of the Hospice D's Visit Note Report dated [DATE] for Resident #5 revealed, .CHAPLAIN HOSPICE EVALUATION .Narrative .ESCORTED PATIENT TO DINING AREA HE EVENTUALLY RESPONDED. HE WAS ABLE TO ANSWER SOME QUESTIONS. PATIENT STATED HE WAS A CHRISTIAN. HE STATED HE WAS FROM [NAME]. HE SMILED AND SEEMED PROUD THAT HE WAS A FIREFIGHTER .THIS CHAPLAIN OFFERED PRAYER AND PATIENT SAID SURE .PATIENT DID STATE HE WAS MARRIED AND HAD 2 CHILDREN. HIS FAMILY DOES NOT SEEM TO BE ENVOLVED [involved] IN HIS CARE XXX[DATE] 01:33 PM . Review of the Progress Notes dated [DATE] for Resident #5 revealed, .2:05PM .PT [patient] WAS LEANING FORWARD IN WHEELCHAIR REACHING TO THE FLOOR AND FELL OUT OF CHAIR HITTING HEAD ON FLOOR CREATING AN ABRASION. [Named Conservator B] AWARE AND NP .[Named NP C] AND HOSPICE AWARE WITH NO NEW ORDERES [orders] AT THIS TIME . The facility's progress notes did not reflect Conservator B was made aware of Resident #5's routine administration of a blood thinner and the risks of a fall with a head injury. Review of the care plan for falls for Resident #5 revealed .At risk for falls r/t [related to] Hx [history] of falls, Alzheimer's and Dementia with decreased safety awareness, Delusional disorder .Goal .Patient will have fall risks minimized through 120 days or next review XXX[DATE] Encourage me to ask for assistance when picking items up off the floor XXX[DATE] Encourage patient to use non-skid footwear during transfers/ambulation .Encourage to use call light for needed assistance . The circumstance of Resident #5's fall on this date ([DATE]) was identical to the fall on [DATE] with a post fall care plan intervention not being appropriate to prevent further falls. Review of the neuro checks dated [DATE] for Resident #5 revealed: a. 1:30 PM B/P 124/60, P 114; b. 2:00 PM B/P 102/87, P 66; c. 2:30 PM 105/60, P 55; d. 3:00 PM 130/55, P 67; e. 4:00 PM 107/89, P 66; f. 5:00 PM 90/62, P 76; g. 6:00 PM 98/40, P 50; h. 7:00 PM 90/46, P 43; i. 11:00 PM 90/52, P 70. Review of the Progress Notes dated [DATE] for Resident #5 revealed, .6:50PM .PT NOTED TO HAVE A DECLINE THIS AFTERNOON HOSPICE HERE TO EVAL PT WITH NEW ORDERS. CONSERVATOR AWARE OF DECLINE . Review of Hospice D's Visit Note Report dated [DATE] for Resident #5 revealed, .Vital Signs .Pulse 98 .Blood Pressure 88/52 .PT HAD FALL HYPOTENSIVE [TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, facility investigation review, medical record review, observation, and interview the facility failed to provide an environment free from abuse for 5 of 9 sampled residents (Resident #1, Resident #2, Resident #6, Resident #7 and Resident #8) reviewed for abuse. On [DATE] Resident #2, a vulnerable, severely cognitively impaired, ambulatory female resident wandered into Resident #1's room. Resident #1, an alert male resident with a Brief Interview for Mental Status (BIMS) score of 15 and an extensive psychiatric history, willfully hit Resident #2 multiple times on her head and back. On [DATE] Resident #7, a vulnerable, severely cognitively impaired, female resident in a wheelchair, bumped into Resident #1's wheelchair in the dining room. Resident #1 was verbally abusive and called Resident #7 derogatory names. The facility's failure to recognize and intervene with Resident #1's continued physical and verbally abusive behaviors toward residents placed Resident #2 and Resident #7 in Immediate Jeopardy (IJ), (a situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident). The facility failed to prevent an incident physical abuse when Resident #6 and Resident #8 were involved in a resident-to-resident altercation on [DATE] which did not rise to an IJ level. The facility failed to report the resident-to-resident altercation that occurred between Resident #6 and Resident #8 on [DATE] to the appropriate agencies. The Administrator was notified of the IJ on [DATE] at 6:38 PM in the Conference room. The facility was cited at F-600 at a scope and severity of K, which constitutes Substandard Quality of Care. The Immediate Jeopardy began [DATE], continued through [DATE], and was removed on [DATE]. A partial extended survey was conducted on [DATE] through [DATE]. An acceptable Removal Plan, which removed the immediacy of the Jeopardy for F-600 was received on [DATE]. The corrective actions were validated onsite by the surveyors on [DATE] through observation, review of records, audit review, education review, and staff interviews. The facility's noncompliance at F-600 continues at a scope and severity of E for monitoring of the effectiveness of the corrective actions. The facility is required to submit a Plan of Correction. The findings include: 1. Abuse, Neglect, Misappropriation of Property and Exploitation, dated [DATE], revealed .Abuse, Neglect .will not be tolerated by anyone, including staff, patients .The patient has the right to be free from abuse, neglect .Abuse: the willful infliction of injury .intimidation, or punishment with resulting physical harm, pain or mental anguish .It includes verbal abuse .physical abuse, and mental abuse .Willful .means the individual must have acted deliberately .Verbal Abuse: the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents .or within their hearing distance regardless of their .ability to comprehend .Physical Abuse: includes hitting, slapping, pinching and kicking .PREVENTION POLICY .The center will provide supervision and support services designed to reduce the likelihood of abuse 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 designed to meet the needs of such patients will include .identification of patients whose personal histories render them at risk for abusing other patients or partners .Assessment of appropriate intervention strategies to prevent occurrences .Monitoring the patient for any changes that would trigger abusive behavior .Dementia management program as needed .Any patient event that is reported to any partner by patient, family .any person will be considered an allegation of either abuse, neglect .Any allegation (or) indication of possible willful infliction .Any partner having either direct or indirect knowledge of any event that might constitute abuse, neglect .must report the event immediately, but not later than 2 hours after forming the suspicion if the events that cause the suspicion involve abuse .it is the policy of this facility that abuse allegations (abuse, neglect .mistreatment .) are reported per Federal and State Law .The investigation is conducted immediately .When it is identified that an alleged incident may have occurred .As soon as any partner has knowledge and reports an alleged event .When there is a question as to whether to conduct an investigation, it is best to do so .The results of all investigations will be completed within five working days of the incident .all necessary corrective actions will be taken .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 .to protect the patient (s) from the alleged perpetrator .Increased supervision of the alleged victim and patients . Review of the undated facility policy titled, PATIENT RIGHTS, revealed, .the patient/resident's right to live in an environment which is individualized for them .Your sense of well being and your safety during your stay here are of the utmost importance to us .your care is planed with a group of professionals holding your well-being as their primary concern .Your plan of care will include an assessment of your strengths and needs. The ultimate goal is to assist you to achieve and/or maintain the highest level of functioning . 2. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses which included Delusional Disorders, Schizoaffective Disorder, bipolar type, Hallucinations, Anxiety Disorder, and Major Depressive Disorder. Review of the care plan for Resident #1 revealed, .Start Date XXX[DATE] Problem: At risk for alteration in behaviors .Pt [patient] has delusions, hallucinations, talks to himself, verbal and physical behaviors toward others, short tempered, easily annoyed, impatient .Approach: Remove patient from triggering situations when possible; respect personal space and rights Start date XXX[DATE] . Review of the Physician Progress Notes dated [DATE] for Resident #1 revealed schizoaffective disorder .does not tolerate dosage [medication dosage] decrease. Review of the Progress Notes dated [DATE] for Resident #1 revealed, .PT [Patient] IS ALERT WITH HALLUCINATIONS NOTED . Review of the Nurse Practitioner (NP) Progress Note dated [DATE] for Resident #1 revealed, .Patient is delusional - reports his mother is coming to get him to take him home for extended work they need to do with children . Review of the Nurse Practitioner Progress Note dated [DATE] for Resident #1 revealed, .Patient is found sitting up in his wheelchair .Delusional .Reports 'I am now the governor and I have served 15 terms' . Review of the Progress Notes dated [DATE] for Resident #1 revealed, .A patient entered [Named Resident #1]'s room and was attempting to sit in his electric wheelchair. [Named Resident #1] was afraid the patient was going to get hurt so he yelled for patent to leave his room and [Named Resident #1] struck the patent with his hand on the head and back . Review of the facility investigation revealed on [DATE] at 6:00 PM, Resident #2 wandered into Resident #1's room. Resident #1 yelled at Resident #2 to get out of his room and while she was at his bedside, he struck the resident with his open hand on the head and back. A nurse aide heard the commotion and immediately intervened. The victim Resident #2 was removed from the room and provided increased observation. The nurse performed a skin assessment on both residents with no injuries noted. A stop sign was placed on Resident #1's room to intervene wandering behavior. The facility investigation revealed the staff were trained on abuse policy and procedures. The staff should be with Resident #2 during mealtimes. A Velcro stop sign was affixed to Resident #1's doorway. The Quality Assurance Performance Improvement (QAPI) will oversee question and answers regarding abuse policy and procedures. The staff will monitor patients for behaviors that may increase their risk for physical abuse. The QAPI committee will confirm compliance with Stop Sign usage. Both residents will continue to be seen by Psych services. Review of the PSYCHOTHERAPY PROGRESS NOTE dated [DATE] for Resident #1 revealed, .Pt .was able to discuss incident yesterday of increased agitation/low frustration tolerance leading to an incident with another resident who came into his room, trying to use his electric w/c [wheelchair] .(pt. Experiencing grandiose baseline delusions) leading to broader issues with interpersonal skills (impulsivity/agitation) .Pt will reduce inappropriate behaviors by 50 % [percent] during review period, substituting with more appropriate patterns of interaction . Review of the Progress Notes dated [DATE] for Resident #1 revealed, .NO ABNORMAL BEHAVIORS. NO YELLING OR CRUSING [cursing] NOTED . Review of the Progress Notes dated [DATE] for Resident #1 revealed, .PT IS ALERT WITH DELUSIONAL BEHAVIORS NOTED AT TIMES . Review of the Progress Notes dated [DATE] for Resident #1 revealed, .Patient takes meds for schizoaffective bipolar type Still with delusions/hallucinations . Review of the Progress Notes dated [DATE] for Resident #1 revealed, .PT IS ALERT WITH DAILY DELUSIONS (HE OWNS MULTIPLE SPORT CARS, HOUSES, OR HE IS KIN TO FAMOUS PEOPLE .) ALL AT BASELINE . Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15 which indicated no cognitive impairment. Continued review of the MDS revealed Resident #1 experienced delusions and other behaviors not directed toward others. Review of the PSYCHIATRIC PERIODIC EVALUATION dated [DATE] for Resident #1 revealed, .New/Ongoing Target sx's [symptoms] .Pressured Speech, Impulsive Action, Compulsivity . Review of the PSYCHIATRIC PERIODIC EVALUATION dated [DATE] for Resident #1 revealed, .Pt [patient] has a persistent, chronic mental illness that requires ongoing therapeutic intervention to prevent exacerbation of presenting behaviors/psychological symptoms and to sustain baseline stability and overall well-being . Review of the care plan for Resident #1 revealed, .Problem: At risk for alteration in behaviors .Pt [patient] has delusions, hallucinations, talks to himself, verbal and physical behaviors toward others, short tempered, easily annoyed, impatient .Approach: Remove patient from triggering situations when possible; respect personal space and rights Start date .Approach: When Pt is upset by hallucinations or delusions, attempt to redirect by talking one-on-one in a calm tone about something they enjoy .Start Date [DATE] . Review of the Progress Note dated [DATE] for Resident #1 revealed, .PT WAS SITTING IN DINING ROOM FOR BREAKFAST WHEN A DEMENTED PT ROLLED IN AND BUMPED HIS WHEELCHAIR. PT BECAME AGGRESSIVE CURSING AND YELLING IN DINING ROOM AS LOUD AS HE COULD. NURSE INTERVENED AND REMOVED DEMENTIA PT. PT YELLED AND SCREAMED AT NURSE AND WAS NAME CALLING. PT NOW IN ROOM EATING BREAKFAST . Review of the Behavior Analysis Report (CareAssist only) note dated [DATE] for Resident #1 revealed, .Pt was in the dining room for breakfast another pt [Resident #7] accidentally bumped the back of his [Resident #1's] chair with hers. [Resident #7's wheelchair] and [Named Resident #1] started yelling and screaming at pt.[Named Resident #7] Nurse went in to redirect pt [Resident #7] and he [Resident #1] started cursing nurse calling her a whore he was asked to leaving [leave] the dining room. pt is currently in his room . Review of the Quarterly MDS assessment dated [DATE] revealed Resident #1 had a BIMS score of 15 which indicated intact cognitive abilities. Continued review of the MDS revealed Resident #1 experienced delusions. Observation in the dining room on [DATE] at 10:20 AM, revealed Resident #1 was in the dining room in an electric wheelchair. Observation in the resident's room on [DATE] at 9:00 AM, revealed Resident #1 was in his room sitting in his wheelchair. No stop sign was present over the doorway of Resident #1's room. Observation in resident's room on [DATE] at 8:20 AM, revealed Resident #1 was in the bed and no stop sign was present over the doorway of his room. During an interview on [DATE] at 1:35 PM, Resident #1 was asked to explain what happened when Resident #2 came into his room. Resident #1 stated, .She went to my wheelchair (electric wheelchair) she turned it on .I told her to go back .I turned on the call light .she wouldn't listen, I don't want to have an accident .scared the wheelchair would have run her over .I patted her on the head .they yelled at me for doing that .I mean the jaws of life would have had to come in here and pull that wheelchair off of her .She didn't say anything to me just headed straight to the wheelchair .She backed off and staff was coming in .I don't remember the social worker coming and talking to me .She came in my room one time nude as a chicken .staff got her out of the room that night . Resident #1 was asked if the Administrator or the Director of Nursing (DON) came to talk with him related to the altercation. Resident #1 replied, No, I got a scholarship to work at [NAME] to work as a manager .They want me to take the job and sell them Hybrids that are coming out . 3. Review of the medical record revealed Resident #2 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, Aphasia, Cognitive Communication Deficit, Manic episode, Dementia, Anxiety, and Depression and expired at the facility on [DATE]. Review of the Progress Notes dated [DATE] revealed for Resident #2, .Wanders and will intrude in other Pts' [Patient's] rooms . Review of the Progress Notes dated [DATE] revealed for Resident #2 , .Pt wanders and will intrude in other pt's personal space and rooms . Review of the Progress Notes dated [DATE], for Resident #2 revealed, .Pt wanders and will intrude in other patient's personal space and rooms . Review of the Progress Notes dated [DATE] for Resident #2 revealed, .AMBULATES AD LIB [as much and as often as desired] GAIT SEMI STEADY WITH STAFF ASSISTANCE. W/C [wheelchair] MAIN MODE OF TRANSPORTAION. ABLE TO PROPEL SELF IN HALLWAYS .PT TENDS TO WANDER AT TIMES INTO OTHERS ROOMS . Review of the Nurse Practitioner Progress Note dated [DATE] for Resident #2 revealed, .Patient continues to be up daily with assistance of staff and wheelchair. Patient is able to ambulate short distances with assistance of staff . Review of the Progress Note dated [DATE] for Resident #2 revealed, .PT COMBATIVE WITH CARE AND SHOWER THIS SHIFT. PT ROAMS WHEN UP IN WHEELCHAIR AND ENTERS OTHER ROOMS . Review of the Progress Note dated [DATE] for Resident #2 revealed, .Pt frequently roams when up in W/C and will enter other patients' rooms . Review of the annual MDS assessment dated [DATE] revealed Resident #2 had a staff assessment for mental status which indicated poor short term and long-term memory. Continued review of the MDS revealed no mood or behavior symptoms were present over the last 7 days. Review of the Progress Note dated [DATE] for Resident #2 revealed, .Alert: [Named Resident #2] entered a patients room [Named Resident #1's room] and was attempting to sit in the patients wheelchair. The other patient was afraid that [Named Resident #2] was going to get hurt. The other patient [Named Resident #1] yelled for [Named Resident #2] to get out of the room and struck [Named Resident #2] with his hand on her head and back. Two nurses completed a skin assessment with no new skin issues noted . Review of the PSYCHIATRIC EVALUATION dated [DATE] for Resident #2 revealed, .Staff report cognition loss .Mood is worse with adls [activities of daily living] Patient has associated symptom of confusion .Safety concerns - Staff education regarding communication and re-direction in dementia patients . Review of the edited care plan dated [DATE] for Resident #2 revealed, .At risk for alteration in behaviors r/t [related to] disrobing, cursing at others, wandering, combativeness, and refusal of meds .Assist and encourage Pt to stay in high traffic areas when up in W/C as Pt allows Created :[DATE] .When Pt becomes annoyed with care/interactions .Provide safe environment and attempt care/interactions later when possible. Created: [DATE] .Redirect me when needed I will wander in my W/C. Offer me a snack or drink if I become agitated when redirected. I do not know my personal boundaries .Created: [DATE] .Encourage patient to be up for meals and in dining room to discourage wandering during meal times Created:[DATE] . The facility staff failed to redirect, prevent, or provide a safe environment for Resident #2 on [DATE] prior to her being struck by Resident #1 after wandering into his room. Review of the 5-day MDS assessment dated [DATE] revealed Resident #2 had a staff assessment for mental status which indicated poor short term and long-term memory. Continued review of the MDS revealed no mood or behavior symptoms were present over the last 7 days. 3. Review of the medical record revealed Resident #7 was admitted to the facility on [DATE] with diagnoses which included Vascular Dementia, unspecified severity, with mood disturbance and Depression. Review of the care plan for Resident #7 revealed, .Problem Start Date: [DATE] Behavioral Symptoms .Approach Start Date XXX[DATE] .promote safety XXX[DATE] Encourage and assist Pt with staying in high traffic areas when up in W/C as Pt allows .Offer and assist Pt to lay down in bed when wandering in W/C as Pt allows . Review of the Quarterly MDS dated [DATE] revealed Resident #7 had a BIMS score of 6 which indicated severe cognitive impairment. Continued review of the MDS revealed Resident #7 experienced delusions, physical behaviors directed toward others, and wandered 4-6 days over the last 7 day look back period. Review of the nurse Progress Notes for [DATE] for Resident #7 revealed no details related to the verbally abusive interaction that occurred on [DATE] with Resident #1. Review of the Progress Note dated [DATE] for Resident #7 revealed, .Spoke with NP .and reviewed previous verbal abusive interaction that occurred on [DATE] involving patients [Resident #1 was verbally abusive toward Resident #7] . Review of the revised care plan for Resident #7 dated [DATE] revealed, .Behavioral Symptoms .At risk for alteration in behaviors refusal of plan of care .Pt has impulsive behaviors with decreased safety awareness, false beliefs/misperceptions, physical behavior towards staff, and wandering Edited XXX[DATE] .Approach Start Date XXX[DATE] Patient may attract negative attention from other patients due to their poor understanding of personal space and spatial boundaries. Redirect as needed .When Pt is wandering, assess for unmet physical needs, psychological distress, and environmental factors. Distract Pt by introducing enjoyed activities .Educate and encourage patient to comply with plan of care . Resident #7 with a BIMS score of 6 does not have the ability to understand the need to comply with the plan of care. Review of the NP progress note dated [DATE] for Resident #7 revealed, .Per staff, patient remains at her baseline. She is pleasantly confused. She is able to propel herself in her wheel chair. She is easily redirected. No acute needs are reported by staff to this provider today .No distress. No needs identified . No mention of Resident #7's involvement in a verbal altercation with Resident #1. Observation in the resident's room on [DATE] at 2:45 PM, revealed staff assisted Resident #7 to bed. Observation in the dining room on [DATE] at 12:30 PM, revealed Resident #7 was in her wheelchair rolling to different residents introducing herself. During an interview on [DATE] at 3:50 PM, Licensed Practical Nurse (LPN) G stated, .I was here the night [Named Resident #2] went into [Named Resident #1]'s room. It was close to supper, [Named Resident #2] liked to wander, and she would get gone before you could get to her .I heard some yelling .[Named Resident #1] told me he hit her .the Administrator was still here, I told him .She was in her wheelchair but she could walk .Her room was straight across from his .they were on the same hall .Nobody seen her get up from her wheelchair that night .It wasn't the first time she had been in his room .he would yell at her and we would remove her .we tried to keep her in a wheelchair close to us .she would wheel throughout the facility .the staff knew she wandered .[Named Resident #1] said he hit her on the back, I looked at her skin I didn't see any redness .Certified Nursing Assistants (CNAs) were putting people to bed .we put a stop sign on [Named Resident #1]'s door to prevent her from going in his room . LPN G was asked if Resident #1 had ever been abusive toward any other residents. LPN G stated, .One time [Named Resident #7] was in the dining room and she bumped into his [Resident #1]wheelchair .He started cursing, I went in the dining room, he cursed me . LPN G was asked if Resident #1 was verbally abusive toward Resident #7. LPN G stated, .Yes I would say that would be verbal abuse, but I don't think I reported it .I did mention it to the NP today [[DATE]] .I was concerned about his outburst .[Named Resident #1] is delusional thinking he is married to the queen .will say he was in the military but he wasn't .He first tried to deny he hit [Named Resident #2] . During an interview on [DATE] at 4:30 PM, CNA H stated, .[Named Resident #1] has rage of fits screaming at other residents .he would scream at his previous roommate [Named Resident #5] .he will scream he would shoot them if he had a gun .[Named Resident #2] would go in everybody's room . CNA H stated, .[Named Resident #1] has been aggressive toward [Named Resident #7] .she wanders and often looking for her children .he will instantly become aggressive toward her .I feel like he could be physical or verbally aggressive toward any resident . During an interview on [DATE] at 4:45 PM, CNA I stated, .[Named Resident #1] will yell at his roommate if he gets in his way .he has a loud tone of voice .don't want anybody getting close to him .the roommate that he had before would yell some in the night .[Named Resident #1] would yell at him to be quiet . During an interview on [DATE] at 8:00 AM, CNA J stated, .[Named Resident #1] he yells and screams mostly at other residents .He got after [Named Resident #7] in the dining room one day because she tried to talk to him .He called her .[derogatory names] .[Named Resident #7] just moved and said 'why don't you want to talk to me' .we try to keep the patients away from him .he doesn't like anyone getting close to him .he did yell at his roommate [Named Resident #5] . During an interview on [DATE] at 8:20 AM, CNA L was asked why Resident #1 did not have the stop sign over his door. CNA L, stated, .After Resident #2 passed away I think they took it down . CNA L was asked if the facility still had residents that wander that could go into his room and potentially get hit like Resident #2. CNA L stated, .yea, [Named Resident #7] wanders .He [Resident #1] gets agitated with his roommate's stuff don't want nothing near him .constantly wanting his roommates stuff moved .[Named Resident #7] agitates him . During an interview on [DATE] AT 8:25 AM, the Social Service Director (SSD), stated, .I never knew [Named Resident #1] was aggressive. I wasn't aware of the interaction he [Resident #1] had with [Named Resident #7] on [DATE]. I am just now reading this in the notes. I have not done a follow up with either resident because I was not aware of the incident. The staff should have notified the Abuse Coordinator. Verbal abuse is cursing, yelling, demeaning language toward another resident. I would have observed [Named Resident #7] demeanor toward [Named Resident #1] to see if she would shy away from him or would she continue with her normal behavior. [Named Resident #7] is a very social person, so I would watch for any changes in her behavior. We have other residents that could wander in [Named Resident #1]'s room . During an interview on [DATE] at 8:55 AM, the DON stated, .I was aware that [Name Resident #7] bumped into [Named Resident #1]'s wheelchair in the dining room and [Named LPN G] intervened. I wasn't aware that he called the other resident any derogatory names. I thought he just called the nurse names. As far as I know [Named Resident #1] got along with his roommates . During an interview on [DATE] at 10:45 AM, Registered Nurse (RN) R stated, .I used these [the Quality Assurance and Performance Improvement monitoring tool] sheets for education not monitoring of the wandering resident [Resident #2]. I just mainly done teaching on what to do for a wandering resident .redirect them out of the patient's room . During an interview on [DATE] at 2:50 PM, Resident #1 stated, .I know [Named Resident #7] she is a busy body .comes around pushed me and poked me in the dining room .It upsets me I don't want to be touched .I had to leave the room .I had to get out of there, she will keep on until she provokes me to a fight .she won't back down .she just keeps on poking at me .she makes me sick .she has wandered in my room twice .they took down my stop sign off my door since the little woman passed away [Resident #2] .Named Resident #7] won't listen just keeps on trying to talk . During an interview on [DATE] at 4:31 PM, CNA W stated, .I heard a man yell, 'get out, get out' .I looked down the hall and seen [Named Resident #2]'s wheelchair sitting outside the room .[Named Resident #1] was laying in the bed .She had went to sit in his electric wheelchair .he was hitting her [Resident #2] on her back .he was raring back hitting her multiple times .I didn't know what else to do but scream stop, stop until I could get over to her .he instantly started apologizing .I got her in her wheelchair and took her to the nurse .[Named Resident #1] had his palm straight to her hitting her in the back and head 3-4 times .I mean having at it .I don't remember his call light being on . During an interview on [DATE] at 12:50 PM, the DON stated, .I would expect staff to redirect a wandering resident .try to find out the reason for wandering .does the resident need something .hungry .and stay with the resident to verify the resident's safety . The DON was asked if the facility performed any monitoring of Resident #2 after the physical altercation with Resident #1. The DON stated, .we trained our staff on how to protect the patients, going over the abuse policy .wandering patients what do you do .patient safety .the QAPI follow up training I would consider that follow up on [Named Resident #2] . 4. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses which included End Stage Renal Disease, Renal Dialysis, Muscle Wasting and Atrophy, Heart Failure, Long-Term Use of Anticoagulants, and Malignant Neoplasm of Stomach. Review of the admission MDS dated [DATE], revealed Resident #6 had a BIMS score of 13, which indicated intact cognition. Review of Registered Nurse (RN) U's Progress Note for Resident #6, dated [DATE] at 10:25 AM, revealed .Alert: I was in patient room giving him medicine and roommate [Resident #8] pushed his own bedside table that accidentally bumped this patients bedside table through the curtain. Patients bedside table bumped patients top of right knee. Patient was not bleeding at the time. Patient then came to nurses station and stated his knee was bleeding. This nurse cleaned and applied a dressing to top of right knee. MD and family notified . Review of a Physician's Order, for Resident #6, dated [DATE] revealed, .abrasion to top of right knee .Special Instructions: abrasion to top of right knee clean with normal saline and pat dry. Apply polymem [a dressing that manages drainage] oval every shift until healed .Every Shift .Day, Night . Review of the NP progress note dated [DATE] at 7:45 PM, for Resident #6, revealed, .Today staff report that the patient did sustain a small abrased area just above his right knee. Staff state that the patient reported that his knee was injured on his bedside table. Patient is found sitting on the side of his bed in his room .When asked what happened to his knee he states 'the curtain was pulled and my roommate pushed his bedside table into my bedside table and my bedside table hit my knee.' Patient did show provider how he sits on the side of his bed with his feet on the lower part of his table and pointed out the area of his table that hit his knee. Provider asked if this hurt and patient stated 'it did a little at the time but not now.' . 5. Review of the medical record revealed Resident #8 was admitted to the facility on [DATE], with diagnoses which included Type 2 Diabetes Mellitus, Hypertensive Heart Disease, Chronic Obstructive Pulmonary Disease, and Long-Term Use of Anticoagulants. During an interview on [DATE] at 11:45 AM, Resident #6 stated, .Just an hour ago my roommate cursing people throwing a fit and he shoved his tray table toward me and caused my leg to start bleeding .he shoved the nurse [RN U] that was in here too because she told him don't push me .he [Resident #8] yells and hollers and he knows I will get up . The observation revealed blood on the floor and bloody gauze laying on the overbed table. Resident #6 raised up his pants leg on his right leg to show the surveyor where the nurse just bandaged his leg due to the injury he sustained when Resident #8 became angry and pushed his tray table into Resident #6's tray table. During the interview with Resident #6, Resident #8 yelled for the nurse 3 different times. During an interview on [DATE] at 12:30 PM, RN U stated, .[Named Licensed Practical Nurse V] reported to me he [Resident #6] had an old skin tear that reopened . During an interview on [DATE] at 3:25 PM, LPN V stated, .[Named RN U] done [did] all the treatments today .[Named Resident #6]'s roommate [Resident #8] pushed the overbed table toward him and caused a skin tear .the table has now been moved to the other side of [Named Resident #8]'s bed . During an interview on [DATE] at 5:20 PM, RN U was asked about her nurse note on Resident #6. RN U stated, .I was in the room when it ha[TRUNCATED]