**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility policy review, medical record review, facility investigation review, observation and interview, the facility failed to protect the residents' right to be free from physical abuse by another resident for 2 residents (Resident #65 and Resident #6) of 13 residents reviewed for abuse. On 8/6/2024, Resident #6 grabbed Resident #65 by the shirt causing Resident #65 to turn over in his wheelchair causing scratches to the left shoulder, 3 skin tears to the left forearm, and a skin tear on the right hand to reopen. Resident #65 retaliated and struck Resident #6 in the face causing a laceration to the resident's right upper lip. The facility's failure to protect the residents' right to be free from physical abuse resulted in actual Harm for Resident #65 and Resident #6. The findings include: Review of a facility policy titled, Abuse, Neglect and Misappropriation of Property, revised 9/15/2023, revealed .It is the organization's intention to prevent the occurrence of abuse .abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish .Instances of abuse of all residents irrespective of any mental or physical condition, cause physical harm, pain or mental anguish .It includes .physical abuse . Review of the medical record revealed Resident #65 was admitted to the facility on [DATE], with diagnoses including Depression, Anxiety Disorder, Osteoarthritis Right Shoulder, and Alcohol Dependence. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed Resident #65 scored 15 on the Brief Interview for Mental Status (BIMS) assessment which indicated the resident was cognitively intact. Further review revealed Resident #65 had behaviors of rejection of care for 4 to 6 days during the assessment period with no other behaviors noted. Review of a Nurse's Note for Resident #65 dated 8/6/2024 at 7:30 AM, revealed .called to room by CNA [Certified Nursing Assistant]. Elder [Resident #65] observed laying supine in the floor by roommate's [Resident #6's] bed. Elder [Resident #65] states roommate [Resident #6] grabbed him by the shirt, would not let go, and eventually pulled him down into the floor. WC [wheelchair] was flipped over as well. T-Shirt noted to be ripped. Denies hitting his head. Scratches noted to left shoulder. Skin tears noted to right hand and left forearm. Elder also states he hit his roommate in the mouth several times with his fist when he would not let go of him. Head to toe assessment complete without further injury noted or C/O [complaint of]. Elder assisted back to WC x [times] 3 staff. Skin tears cleansed with NS [normal saline] and covered with a dry dressing per orders. Shirt changed. Denies further needs . Review of a Nurse Practitioner's (NP) Note for Resident #65 dated 8/6/2024, revealed .Chief Complaint/History of Present Illness .Patient scheduled for visit following altercation with another resident [Resident #6] this morning. The patient [Resident #65] is [AGE] year-old male who was in an altercation with another resident [Resident #6] this morning. Patient sustained skin tears to upper extremities. Skin tears are currently bandaged, and dressing is clean dry and intact. Patient denies any other injuries or complaints other than skin tears at this time. Patient denies any acute concerns or needs at this time .No acute distress noted, cooperative, alert, and oriented x 3 [to person, place, and time] .New skin tears noted to upper extremities [right hand and left forearm] with dressing in place that are clean, dry, and intact .Skin tear of upper extremity .Nursing to complete wound care. Instructed patient that if he developed any additional or worsening symptoms following altercation to notify nursing for further evaluation .Patient verbalized understanding. Plan of care ongoing . Review of a facility investigation dated 8/6/2024, revealed the staff heard a commotion in the residents' (Resident #65 and Resident #6) room. When the nurse arrived to the room, Resident #65 was in the floor beside the roommate's (Resident #6's) bed and Resident #6 was lying sideways in the bed. The residents agreed that Resident #6 had pulled Resident #65 from his wheelchair by his shirt and would not let go. Resident #65 received skin tears and Resident #6 received a laceration to his upper lip. The residents were separated immediately, and Resident #6 was placed on one on one (supervision of 1 staff to 1 resident), was sent to the hospital for a medical clearance, for possible transfer to a Geriatric (Geri) Psychiatric (Psych) facility. However, there was not facility (Geri-Psych) availability at the time. Resident #6 was moved to another room (after return from the hospital's emergency room) and the staff stayed 1 on 1 for 48 hours, he was then placed on every 15-minute rounds after the 48 hours concluded. Review of a facility document titled, Event Report Skin Integrity, for Resident #65 dated 8/6/2024, revealed .Skin Tear/Laceration left lower arm X 3 skin tears, some scratches to left shoulder. 1 inch [skin tear #1], 0.5 inch [skin tear #2], 0.5 inch [skin tear #3] .controlled bleeding .wound edges smooth .no pain .resident to resident .monitor for signs/symptoms of infection to skin tears .to left arm Q [every] shift until healed .cleaned with normal saline and cover with dry dressing . Review of a comprehensive care plan for Resident #65 dated 8/6/2024, revealed the resident was involved in a resident-to-resident altercation and the roommate (Resident #6) was moved to a different room. Review of the medical record revealed Resident #6 was admitted to the facility on [DATE], with diagnoses including Vascular Dementia with Behavioral Disturbance, Hemiplegia affecting Left Non-Dominant Side, Mood Disorder, Schizoaffective Disorder Bipolar Type, Intracranial Injury, and Compression of the Brain. Review of an annual MDS assessment dated [DATE], revealed Resident #6 scored 9 on the BIMS assessment which indicated the resident had moderate cognitive impairment. Further review revealed no behaviors were noted during the assessment period. The resident was dependent for transfers. Review of a Nurse's Notes for Resident #6 dated 8/6/2024, revealed .Called to room by CNA. Elder's roommate [Resident #65] observed laying in the floor beside elder's bed. Elder states he [elicit word] [beat] [NAME] [Resident #65] up because he was wearing his shirt and wanted it back . Elder's roommate was not named [NAME] and the roommate [Resident #65] was not wearing elder's [Resident #6's] shirt. Head to toe assessment completed. Laceration noted to right upper lip with scant amount of bleeding. Laceration cleansed . bleeding stopped. Elder assisted into his WC x 2 staff and placed 1:1 [1 on 1] with nurse. Elder states 'bye [elicit name]!' as he is assisted out of room with nurse [speaking to Resident #65]. Elder continues to exclaim, 'I [elicit word] [NAME] up like a soup sandwich and I want to do it again! I am proud of myself, and my family would be too.' Elder believes '[NAME]' [roommate, Resident #65] is 'messing around with Aunt [NAME] [Certified Nursing Assistant A, not related to Resident #6].' Elder cannot be re-directed at present. Neuro [neurological] checks completed. [baseline following traumatic brain injury (TBI)] .Elder transferred to [hospital] ER [emergency room] for medical eval [evaluation] at approximately 9:30 AM . Review of a facility document titled, Event Report Skin Tear/Laceration, for Resident #6 dated 8/6/2024, revealed .laceration .right upper lip .0.2 cm [centimeter] .controlled bleeding .no pain .behavioral outburst .first aide .monitor for signs/symptoms of infection Q shift .until healed . Review of a Physician's order for Resident #6 dated 8/6/2024, revealed .one on one . Review of a Physician's order for Resident #6 dated 8/6/2024, revealed .send to ER [Emergency Room] for medical clearance . (medical clearance by ER for possible transfer to a Geri-Psych unit for evaluation). Review of a Nurse's Note for Resident #6 dated 8/6/2024 at 12:19 PM, revealed .Elder [Resident #6] returned to facility at 11:35 AM, following being medically cleared at [hospital] .ER reports elder had negative CT [computerized tomography], baseline UDS [urine drug screen], and un-concerning labs. Also states elder calmed down initially but eventually became agitated when he 'wanted to come home.' Shortly after arrival, elder began yelling for '[NAME] to come down here so I can whoop your [elicit word]!' Other elder [Resident #65] (who has been moved temporarily) heard elder yelling down the hallway and became irritated and began cussing elder from doorway. Staff intervened again. Elder continues stating he wants to '[elicit word] [NAME] up again' and attempting to tear down his privacy curtain and bed rail .NP [Nurse Practitioner], notified with new orders for Haldol [antipsychotic medication] 5 mg (milligram) IM [intramuscular] now . Review of a comprehensive care plan for Resident #6 dated 8/6/2024, revealed the resident was involved in a resident-to-resident altercation, was placed on 1 on 1 monitoring and had a psychosocial follow-up for 72 hours. The residents (Resident #6 and Resident #65) were separated immediately. Review of a Nurse's Note for Resident #6 dated 8/8/2024 at 12:01 PM, revealed .NP seen pt [patient], no further behaviors noted, not combative at this time. new order to dc [discontinue] 1 on 1 and begin q 15 min [minute] checks at this time . Review of a Physician's order for Resident #6 dated 8/8/2024, revealed .every 15-minute checks . Review of a NP's Note for Resident #6 dated 8/21/2024, revealed .Patient is scheduled for routine follow-up and maintenance of chronic conditions .Patient [Resident #6] recently had exacerbation of schizoaffective disorder requiring additional doses of Haldol. Patient was sent to ER for medical clearance and referred to Geri psych. Patient was cleared medically. However, Geri psych referrals were declined due to patient's history of TBI. Following additional doses of Haldol patient returned to his baseline mental state. Patient is currently receiving Haldol 3 mg twice daily. Nursing denies any continued or worsening agitation since patient was placed on 15-minute checks .Positive for agitation and irritability but improved since altercation occurred . schizoaffective disorder, bipolar type .Continue haloperidol (Haldol) 3 mg twice daily. Will discontinue every 15-minute checks since patient's return to baseline mental state. Nursing to notify provider with any increased agitation . During an observation on 10/14/2024 at 10:20 AM, in the day room, Resident #6 was seated in a high back wheelchair, awake and alert, with no behaviors or concerns identified. During an interview on 10/14/2024 at 10:20 AM, Resident #6 initially stated he did not recall the incident (with Resident #65) and later stated .he [Resident #65] made me mad he was a talker he called me a [elicit name]. I tried to choke him to death, but he didn't hit me back . When asked if he recalled having a small cut to his lip he stated .I was so mad he might have hit me I just don't know . When asked if he had any further problems with Resident #65 or any other resident he stated No .he [Resident #65] isn't in my room any more . During an interview on 10/14/2024 at 10:40 AM, CNA A stated .I was both [provided care for Resident #6 and Resident #65] of their CNA that day [8/6/2024] .they were in their room, [Resident #6] was still in bed and [Resident #65] was in his wheelchair. I walked by and saw something had happened. [Resident #65] was on the floor, and his wheelchair was laying on its side .they were still exchanging words .[Resident #65] said he rolled by [Resident #6], and he grabbed him .[Resident #65] was out of the reach of [Resident #6] he can't get out of bed by himself, so I walked to the door and yelled at [Registered Nurse] (RN) B and the other nurse [Licensed Practical Nurse] (LPN) C came in too. They assessed [Resident #65] and got him out of the floor. [RN B] went to get bandages and I got [Resident #6] up and got him dressed and took him to the day room .[Resident #6] calls [Resident #65] [NAME] but that isn't his name . During an interview on 10/14/2024 at 10:55 AM, RN B stated .they were roommates [Resident #6 and Resident #65] they had been known to exchange words but nothing ever aggressive before .it was mainly because [Resident #6] would call [Resident #65] [NAME] and get mad when [Resident #65] didn't answer .that day [8/6/2024] he thought [Resident #65] had on his T-shirt, but he didn't he had on his own shirt .it was just a plain white T-shirt .he also stated he thought [Resident #65] was fooling around with his Aunt [NAME] which is [CNA A] but he calls her Aunt [NAME]. [CNA A] hollered for me and said that [Resident #65] was in the floor. [Resident #6] was still in his bed he had his hand on the side rail, and he was just looking at [Resident #65]. I asked what happened and [Resident #65] stated that [Resident #6] had just grabbed him as he rolled by his [Resident #6's] bed he had grabbed him by the shirt and would not let him go .after we got them separated he [Resident #65] told me that he had hit [Resident #6] a couple of times in the mouth to get him [Resident #6] to let him [Resident #65] go .[Resident #65] said when he was pulling away from [Resident #6] that his wheelchair tipped over .[Resident #65] had a skin tear on his right hand .he had 3 or 4 superficial scratches a couple of inches long to his left shoulder and 3 new skin tears to his left forearm. I [RN B] cleaned them with normal saline and put on a dry dressing .[Resident #65] wasn't afraid or withdrawn he did tell me that he felt bad for retaliating because of [Resident #6's] disability .[Resident #6] did have a small cut to the top right lip. I cleaned it up, it wasn't bleeding .neither one of them complained of any pain .[Resident #65] didn't want to leave the room, he prefers to stay in his room and look at his phone or watch TV. So we got [Resident #6] up and dressed and took him to the day room .he likes to be in the day room, and spends most of his time in there .we were able to move [Resident #6] .both are monitored daily for behaviors .[Resident #6] had a couple of days that he was yelling out, but nothing after that .neither one of them has shown any aggressive behaviors after the incident, and I am not aware of any aggressive behaviors before the incident . During an observation and interview on 10/14/2024 at 11:30 AM, Resident #65 was awake, alert, and lying in bed watching TV. Resident #65 stated .[Resident #6] grabbed me by the shirt, he said it was his shirt but I got it out of my closet, it was my shirt .he [Resident #6] stretched my shirt and scratched me .he grabbed my wheelchair and when I was trying to get away from him my chair turned over .he is crippled but he's got a strong grip .I [Resident #65] wanted to hit him back but something told me not to since he is crippled and his mind isn't right .he is not all upstairs .no that is the only problem I have had with anybody .[no] he didn't hurt me I was able to brace myself when I fell .no I am not afraid of him . During an interview on 10/14/2024 at 9:25 AM, the Director of Nursing (DON) stated, .both residents [Resident #6 and Resident #65] admitted the incident occurred [on 8/6/2024] .the physical altercation was not witnessed by staff .we did send [Resident #6] out for medical clearance for in-patient psychiatric treatment, but after he was cleared we were not able to place him .we kept him on one on one care for 48 hours then on 15 minute checks until 8/24/2024, when the Nurse Practitioner saw him and discontinued the 15-minute checks due to no further behaviors. [Resident #65] did receive 3 small new skin tears to his left forearm and some small superficial scratches to his left shoulder. [Resident #6] did receive a small cut to his right upper lip .yes, both residents did receive minor injuries . During the interview the DON confirmed the facility failed to prevent abuse of Resident #65 and Resident #6, resulting in physical harm to both residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of a facility policy, medical record review, review of a facility investigation, and interview the facility failed to protect the resident's right to be free from physical abuse of 1 resident (#3) of 7 residents review for abuse of 13 resident sampled residents. The Facility's failure to prevent resident to resident altercation resulted in actual harm for Resident #3 when Resident #4 threw a plastic coke bottle and hit Resident #3 in the face causing a contusion under her left eye and yelled at Resident #3 causing her to cry and be afraid. The findings include: Review of a facility policy titled, Abuse, Neglect and Misappropriation of Property, last revised on 10/17/2022, showed .It is the organization's intention to prevent the occurrence of abuse .Abuse is defined as the willful inflection of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . Resident #3 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including Alzheimer's Disease, Abnormal Posture, Dementia with Behavioral Disturbance, Hypertension, Parkinson's Disease, Bipolar Disorder, Restlessness/Agitation, Congestive Heart Failure and Generalized Anxiety Disorder. Review of Resident #3's annual Minimum Data Set (MDS) assessment, dated 5/9/2023, showed a Brief Interview for Mental Status (BIMS) assessment score of 3 indicating severe cognitive impairment. The resident had potential indicators of psychosis of delusions, behavioral symptoms of verbal behavior directed toward others 1 to 3 days during the assessment period. Review of Resident #3's Other Events-Change in Condition Report, dated 6/7/2023 at 4:58 AM, showed .Description Resident to resident .Pt [patient] was lying in bed when another pt. wandered into room, tore her TV off of wall, threw coke on her, and allegedly hit her in the face .Provider Notified: Yes .NP [Nurse Practitioner] .resident sent to ER [Emergency Room] for eval [evaluation] and treat . Review of Resident #3's Nursing Progress Note, dated 6/7/2023 at 5:06 AM, showed .Pt. heard from room yelling, other pt. had wandered into room, Pt. reports that the pt. that wandered into her room had hit her, contusion noted underneath left eye. DON [Director of Nursing] contacted as well as NP and order was given to send to ER for evaluation . Review of Resident #3's Hospital ER Progress Note dated 6/7/2023, showed .presents from nursing home for assault by another patient .The assault was not witnessed. The patient complains of pain under her left eye as well as neck pain. She denies headache. No other complaints .Follow up with PCP [primary care physician] . Review of Resident #3's Nursing Progress Note, dated 6/7/2023 at 7:12 AM, showed .Ambulance .here to return elder to facility . Review of Resident #3's Behavioral Medicine Progress Note dated 6/7/2023, showed .nsg [nursing] reports resident altercation where pt. was the non-aggressor .Today patient is calm with no acute anxiety or agitation. Currently, pt. has no recollection of recent altercation .No noted clinical evidence of any psychological harm noted per exam . Review of Resident #3's comprehensive care plan, revised 6/7/2023, showed .at risk for an alteration in my mood, behavior, cognition, and level of functioning .at risk to experience adverse psychosocial changes such as an increase in depressive and anxious signs/symptoms that have the potential to negatively affect my well-being r/t [related to] negative encounter with another resident .observe and report to physician any changes in mood, behavior, cognition and level of functioning caused by situational stressor(s) .Observe for psychosocial changes .Psych PA [Physician Assistant]/NP to follow up with resident on next scheduled visit reinforce appropriate expressions of feelings .Sent to ER for evaluation of contusion under eye .SSD [Social Service Director] to visit with resident as needed . Review of a facility investigation, dated 6/7/2023, showed all residents were in bed. Resident #4 was sitting on his bed. CNA #2 had gone to the restroom and at 2:15 AM heard screaming she rushed out and went in Resident #3's room where the TV was on the floor broke, and Resident #4 was standing over Resident #3's bed and yelling .you crackhead [explicit name] I know you took my pills . CNA #2 was rushing to bed and Resident #4 picked up a plastic bottle of diet coke and began to throw it. She (CNA #2) got in between the residents and Resident #4 grabbed CNA #2 around the throat and started choking her. CNA #2 got away and called a CNA from up front to come and help. Resident #4 backed up and set down in floor. LPN #1 came back to room and coaxed Resident #3 to his room where he was placed on one on one with CNA #2. LPN #1 immediately went to Resident #3's room and did a head-to-toe skin assessment where he found a contusion below her left eye . Resident #4 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Metabolic Encephalopathy, Delirium, Parkinson's Disease, Dementia with Behavioral Disturbance, Depression, Restlessness/Agitation, Legal Blindness and Traumatic Brain Injury. Review of Resident #4's comprehensive care plan dated 8/5/2022, showed .behavioral .at risk and/or active behavior problems including physical/verbal aggression and making threatening actions towards others as evidenced by resistant to asking for assistance for transfers/ambulation resulting in multiple falls, blocks others from entering his bedroom by sitting in his wheelchair against the door .throws food on the floor, pulls built-in furniture off the walls such as the sink and toilet, dresser, bed frame (has a mattress on the floor) and televisions, yells and curses others .At risk for causes harm to himself and or others .intervene as needed to protect the rights and safety of others; approach in calm manner, divert attention, remove from situation and take to another location as needed .investigation/monitor need for psychological/psychiatric services .no blinds or curtains due to elder pulling them down with the potential for causing harm to himself .Resident is legally blind in both eyes and is at risk for harm related to visual impairment .adapt environment to resident's needs . Review of Resident #4's quarterly MDS assessment dated [DATE], showed a BIMS assessment score of 5 indicating severe cognitive impairment. The resident had signs and symptoms of Delirium including inattention, disorganized thinking, potential indicators of Psychosis of delusions, behaviors of other behavioral symptoms not directed toward others 4 to 6 days during the assessment period. Review of Resident #4's Nursing Progress Note, dated 5/26/2023, showed .pt. yelled and cursed the entire shift .pt. attempted to assault this nurse. Pt. was only able to grab this nurse's arm once and only swung fist and kick not open air, pt. calmed with aggression . Review of Resident #4's Event-Change in Condition Report, dated 6/7/2023, showed .resident to resident altercation .resident wandered into another residents room, tore TV off of wall, threw coke on her, allegedly hit her in the eye .Provider notified: Yes .[NP] .remains 1:1 at present . Review of Resident #4's Nursing Progress Note dated 6/7/2023 at 5:10 AM, showed .Pt. was found in another pt. room, pt. threw coke on that pt. [Resident #3] and had tore TV from wall, pt. stood and transferred to wheelchair and was taken to room, placed on 1:1 monitoring d/t [due to] other resident [Resident #3] accusing him of striking her on the face since being placed back in his room he has been hitting the walls in his room and screaming. Pt. has had to be redirected multiple times . Review of Resident #4's Physician Order dated 6/7/2023 at 1:31 PM, showed .emergency discharge due to danger to self and others . Review of Resident #4's Behavioral Medicine Progress Note, dated 6/7/2023, showed .nsg [nursing] reports resident altercation where pt. was the aggressor .some increased agitation, hitting walls, verbal aggression, delusions .patient with noted increased labile mood, paranoia, agitation, aggression. Currently on 1:1 . Review of Resident #4's Nursing Progress Note dated 6/7/2023 at 3:13 PM, showed .ambulance here to transfer to ER . During an interview on 9/11/2023 at 12:45 PM, CNA #3 stated .[Resident #3] did have a bruise under her left eye . During an interview on 9/11/2023 at 4:00 PM, CNA #2 stated .heard [Resident #3] holler I ran down to the room, it looked like he [Resident #4] had hit the TV when he enter the room .he [Resident #4] had thrown the coke bottle at her [Resident #3] and she did have coke all over her .she said he threw the bottle at her .he was leaned over her yelling at her about his pills he said she had taken all of his hydrocodone and called her a dumb [explicit name] .I immediately separated them and he grabbed my throat I said [Resident #4] it's me [CNA #2] we didn't take you your medicine .he is blind, he is very loud and always fixated on pills .I think he was throwing the bottle because he was mad thinking someone taking his pills .she was upset her diet coke had been thrown at her and was spilled .she did say she was scared, and she was crying .she did have a red mark under her left eye I think it was her left .she was very concerned about her diet coke, but it was late in the night and a man had came in her room so naturally she was upset . During an interview on 9/11/2023 at 6:40 PM, LPN #1 stated .she [CNA #4] had left the unit to take a break [CNA #2] came to the unit to watch the residents and I had gone to lunch .[CNA #2] did a round and went to the bathroom .she came out and heard [Resident #4] yelling at [Resident #3] that she had taken his pills .[CNA #2] reported that [Resident #4] was standing over [Resident #3] and it appeared he had thrown coke all over her .it was like he had knocked her TV off the wall it was twisted and cracked it looked like he had head butted it but he didn't have any marks on him .Everything was thrown all over her room, with him being blind it would be hard to say if he threw the coke at her or just threw it .but he was intentionally yelling at her cursing saying you took my [explicative] pills but yes he said the word .[CNA #2] said she [Resident #3] was just lying there not defending herself or nothing .her left eye was just a little red under it and it did later bruise .it wasn't a black eye it was just a small bruise under her eye where the plastic bottle hit her .we did sent her to the ER .after she came back she seemed a little sad . During an interview on 9/20/2023 at 1:45 PM, the Administrator stated .this was a resident to resident altercation .he is blind and cannot see at all .he does scream and curse and he is accusatory of staff taking his medications . because of the situation he is in with the traumatic brain injury, he has no sense of his surroundings, he is delusional .it was just a freak accident that the resident was in the path of the bottle .the point is he screamed all the time . During an interview on 9/21/2023 at 8:40 AM, the DON stated .when I got here before 2:30 AM, and the incident occurred at approximately 2:15 AM .she was in her bed her TV was laying in the floor .I saw the place below her left eye at that time it did not look like a bruise it was just a little reddened area .he was accusatory and verbally abusive to staff but he had never been to any residents .