**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards. NA A failed to have another staff assist while providing care for Resident #1 in the bed on 12/29/2024. Resident #1 rolled out of the bed, fell to the floor face down, was transferred to the ER and was diagnosed with laceration on left forehead, a subdural hematoma (collection of blood outside the brain that can be life threatening), a subarachnoid hemorrhage(bleeding in the space below the arachnoid layer of the brain) and possible C6/T1 fractures (C6 is the 6th cervical vertebrae that is in your neck, supports the head, protect the spinal cord and allow head motion; T1 is the 1st Thoracic vertebrae, connect the neck to the upper back) . Resident #1 was hospitalized . This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/30/24 at 4:18 pm and an IJ template was given. While the IJ was removed on 12/31/24 at 1:47 pm, the facility remained out of compliance at a level of no actual harm with a potential for more than minimal harm, that was not immediate jeopardy at a scope of isolated, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for falls, injuries, hospitalization, and death. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Vascular dementia, Cognitive communication deficit, Unspecified sequelae of cerebral infarction (a condition that may occur at any time after causal condition. Cerebral infraction is process that result in an area of necrotic tissue in the brain) . Review of Resident #1's quarterly MDS assessment dated [DATE] reflected a BIMS( is a mandatory tool used to screen and identify the cognitive condition of residents) could not be conducted , and staff interview indicated Resident #1 had both short and long-term memory problems. Section GG (Functional abilities) reflected impairment on one side of both upper and lower extremities. It was also reflected in section GG Resident #1 was dependent to roll left and right - the ability to roll from lying on back to left and right side and return to lying on the back on the bed (Helper does all of the effort. Resident does none of the effort to complete the activity. Or the assistance of 2 or more helpers is required for the resident to complete the activity.). Review of Resident #1's care plan dated 10/29/2024 reflected Resident #1 had ADL Functional Status/Rehabilitation Potential and Bed Mobility amount of assist: x 2. The resident was at risk for falling related to Hemiplegia (characterized by total or complete paralysis on one side of the body), Impaired mobility, Poor sitting trunk control, and was NWB. The care plan reflected the resident was dependent transfers with a mechanical lift (often referred to as Hoyer lifts, are devices designed to help caregivers move a person from a sitting to standing position and from one place to another within a room or house). The resident was limited in the ability to dress/undress self, related to hemiplegia with contractures. Review of Resident #1's POC (carefully prepared outline of nursing care showing all of the patient's needs and the ways of meeting them) or CNAs reflected Resident #1 requires x2 assist with bed mobility. Review of Resident #1's progress note from 12/29/24 reflected written by LVN C CNA reported resident rolled off bed when she was changing brief. Supervisor RN here and advised. Resident face down on floor. Called EMS. EMS transporting resident to [city name]. Gash noted on forehead. Called (family) No answer. Unable to leave vm Left VM (DON) notified by nurse supervisor. family returned call. Advised resident will be transported to .ER. Review of Resident #1's hospital records from 12/29/24 reflected: Patient had a left forehead laceration that was repaired. She was also found to have subdural hematoma, subarachnoid hemorrhage and possible C6/T1 fractures. placed in C-collar. Will admit to Trauma Service for further care. During an interview on 12/30/2024 at 10:21 am NA B stated he knew not work alone with any Resident. NA B stated if the other CNAs were busy, he would call the nurse for assistance to provide care for a Resident. NA B stated he was in-serviced by the Weekend Supervisor on fall risk, bed safety and safe lifting. NA B stated he was trained on where and how to find the residents care plan in matrix. Later at about 1:30 pm, NA B demonstrated to the state surveyor on how to locate residents POC in matrix to provide care for resident. NA B stated is was important to know how to locate the residents POC to know how much assistance was needed. During a phone interview on 12/30/2024 at 11:17 am the Weekend supervisor stated on the morning of 12/29/2024 a little before 5:00 am, she heard the NA called out for help and she went to the room and found Resident #1 on the floor between the bed and the wall, by the window, face down with blood coming from her face. The Weekend Supervisor stated the NA was in the room by herself, and no other staff was in the room assisting the NA to provide care for Resident #1. The Weekend Supervisor stated she protected Resident #1's head because she was bleeding from the left eyebrow area, and moaning, while LVN C called EMS. She stated Resident #1 was immediately transferred to the ER due to concerns for injuries. The Weekend Supervisor said she notified the DON of the incident and initiated in-services on 12/29/2024 regarding fall preventions, safe lifting and bed safety. The Weekend Supervisor stated Resident #1 required 2-persons physical assist to roll over in bed due to her contractures from a stroke. She stated the CNAs/NAs were trained on how to check the residents POC for ADL assistance. During a phone interview on 12/29/2024 at 12:31 pm LVN C stated she was the nurse on duty when Resident #1 fell out of bed. LVN C stated she heard NA A called for help and stated Resident #1 had fallen from the bed. LVN C stated when she and the Weekend Supervisor got to the room, NA A was in the room without another staff, Resident#1 was face down on the floor between the wall and the bed with blood. LVN C stated they were not sure where the blood was coming from, so the Weekend Supervisor tried to protect Resident#1's head while went to call EMS. LVN C stated they did not want to move Resident #1 due to a possible head injury, so the Weekend Supervisor was on the floor with the Resident #1 until EMS got to the facility. LVN C stated EMS got to the facility, repositioned Resident #1 and they noted a big gash on her forehead and Resident #1 was transported to the local hospital ER. LVN C stated she completed an incident report, the Weekend Supervisor started in-services on safe transfers, bed safety and fall prevention. LVN C stated Resident #1 required 2-persons for bed mobility due to history stroke. During a phone interview on 12/30/2024 at 12:54 pm NA A stated on the morning of 12/29/2024 while she was getting Resident #1 ready for a Hoyer transfer , she rolled Resident #1 to the right side, and she fell out of bed, and landed between the bed and the window. NA A stated she notified LNV C and the Weekend Supervisor, and the resident was transferred to the ER. NA A stated she was going to call for help after prepping Resident #1 for the transfer. NA A stated she knew Resident #1 was 2-person assist with Hoyer transfers and she now found out that Resident #1 was 2-persons with bed mobility. NA A stated she was trained on how to check the matrix (the system used by the facility for electronic documentation) to access the residents POC to provide care and on how to position and transfer a resident. NA A said she was called by the Administrator and told she was suspended pending the investigation of the incident. During an interview on 12/30/2024 at 2:26 pm the Sr. VP of Clinical Operation stated NA A was not a CNA, she was an NA, and she knew not to provide care for residents unless there was a licensed nurse or another CNA present. She also stated the NA A knew Resident #1 was a 2-person assist with bed mobility and NA A knew how to check the POC for residents to know how to provide care. During an interview on 12/31/2024 at 10:51 am, the HR/BOM staff stated she was responsible to ensure all new hires knew their job descriptions. She stated NA A went over her job description. She Stated NA A was not yet certified so she could not do any direct care for a resident except if a CNA or a licensed nurse was present. Multiple telephone calls were attempted on 12/30/2024 at 11:16 am, 11:17 am,3:25 pm through 12/31/2024 at 10:16 am to reach NA A regarding her job description and not providing direct care for a r resident unless there was another CNA or a licensed nurse present but was unsuccessful. A returned call was not received prior to exit. Review of NA A's competency check-off dated 10/30/2024 reflected she was check-off on turns, repositioning residents timely/correctly, and transfers (1-person assist, 2-person assist and Hoyer lift). Review of the facility's in-services reflected the facility-initiated in-services on 12/29/2024 on safe lifting, bed safety and fall preventions for nursing staff (Nurses, CNAs and NAs). Review of NAs job description for the facility reflected: Position Title: NURSE AIDE Reports To Position: DIRECTOR OF NURSING JOB SUMMARY-- Under the supervision of the Charge Nurse, the Helping Hands Aide performs non-professional, non-direct resident care duties and assists in maintaining a positive physical and psychosocial environment for the resident. Review of facility's policy titled Accidents and incidents-Investigating and Reporting dated November 2021 reflected: Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Review of facility's policy titled Required Training, Certification and Continuing Education of Nurse Aides, undated, reflected: It is the policy of this facility to comply with State and Federal regulations and requirements as they pertain to the training, certification, and continuing education of its nurse aides. 2. This facility will employ nurse aides in the following circumstances: a. Those who have successfully completed a State approved nurse aide training or competency evaluation program (NATCEP) and are awaiting certification results. They may be employed as full-time and permanent but must provide documentation of certification within 4 months of their hire date. Facility will verify certification through the appropriate state's nurse aide registry. The Sr. VP for Clinical and ADON were notified on 12/30/24 at 4:18 pm that an IJ had been identified and an IJ template was provided. The following Plan of Removal submitted by the facility was accepted on 12/31/2024 @ 10:57 AM. Plan of Removal: F689 - The facility must ensure each resident receives adequate supervision and assistance devices to prevent accidents. NA failed to have another staff assist while providing care with Resident #1 in the bed. [Resident #1] rolled out of the bed, fell to the floor face down, was transferred to the ER and was diagnosed with laceration on left forehead and fracture of C6 and T1 vertebrae. 1. Immediate Actions Taken for Those Residents Identified: Action: [Resident #1] was assessed following fall, transferred to the ER, and subsequently admitted to the hospital for further evaluation and treatment. Person(s) Responsible: Charge Nurse/Weekend Supervisor Date: 12-29-2024, 5:30 a.m. 2. How the Facility Identified Other Possibly Affected Residents: Action: All residents' orders, care plans, resident profile and MDSs reviewed to ensure the methods of transfer match. Any discrepancies will be discussed with the IDT , to include clinical leadership, therapy, and certified nurse aides and licensed nursing staff, as needed, to verify the proper method of transfer is occurring. After any discrepancies have been identified and corrected, resident orders, care plans, resident profile and MDS will be compared no less than quarterly when MDS assessments are completed to ensure everything matches. When changes are made related to change of condition, all noted changes will be verified in the order, care plan, resident profile, and any significant change MDS assessment, if applicable. Person(s) Responsible: Director of Nursing, MDS Nurse, Regional MDS, and/or Designee Date: 12-30-2024 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Educate Director of Nursing and Assistant Director of Nursing on required new hire orientation with Certified Nurse Aides/Nurse Aides and licensed nurses to include return demonstration for where to find resident profile information in MatrixCare POC (transfer ability, bed mobility, self-care, toileting, eating, and the number of staff required to complete these activities of daily living to ensure resident safety). Person(s) Responsible: Sr. VP of Clinical Operations or designee Date: 12-30-2024 Action: Licensed Nurses and Certified Nursing Aides/Nurse Aides educated on Safe Lifting and Movement of Residents and checking resident profile to ensure appropriate number of staff used for all activities of daily living (i.e., transfers, bed mobility, toileting, eating, and self-care). Staff to be educated includes facility staff and temporary staff- agency and/or PRN staff (licensed nurses and nurse aides) that may transfer a resident or assist with activities of daily living. Unlicensed Nurse Aides will be educated that they are not authorized to transfer any resident without a Certified Nurse Aide or licensed nurse present. Licensed Nurses and Certified Nursing Aides/Nurse Aides will be educated prior to working their next shift. Person(s) Responsible: Director of Nursing and/or Designee Date: 12-30-2024 Action: Despite having documented education on Matrix POC and resident profiles as well as her own admission that she knew where to find transfer ability and mobility assistance requirements for each resident, by her own admission, the NA stated that she made the decision not to follow established policies and procedure which resulted in injury to [Resident #1]. The NA was suspended immediately pending outcome of the investigation. The NA's employment will be terminated effective immediately. Person(s) Responsible: Director of Nursing and/or Designee Date: 12-31-2024 4. How the Corrective Actions Will be Monitored, by whom and for how long: Action: Director of Nursing and/or Designee will observe 3 transfers/resident ADL activities per week x4 weeks to ensure staff (licensed nurses/CNAs/NAs) check the resident profile and perform the appropriate transfer or ADL care based on the resident plan of care which designates the number of staff required. Monitoring will continue for 4 weeks or until compliance is achieved. At no time will NAs be allowed to transfer residents without direct supervision. Person(s) Responsible: Director of Nursing and/or Designee Date: 12-30-2024 Action: Ad hoc QAPI performed with Medical Director to review the Immediate Jeopardy Template and the facility's plan to remove the immediacy. Person(s) Responsible: Administrator Date: 12-30-2024, 5:30 PM The Surveyor monitored the POR on 12/31/24 as followed: Review of facility's in-services reflected the following: 12/29/2024 the following in-services were initiated by the weekend supervisor for all direct care staff after the incident: Safe Lifting, fall prevention and bed safety. 12/30/2024 the DON and ADON were educated by the Sr. VP of Clinical Operation on new hire orientation. LVN/RN/CNA/NA must do return demonstration on how to find Resident's profile info in matrix. 12/30/2024 All direct care staff were in-serviced on POC training and abuse and neglect, initiated by the ADON. During interviews on 12/31/2024 from 11:10 am - 1:20 pm, two CNAs, one RN, and one LVN stated there were trained on abuse and neglect, safe lifting, fall prevention and bed safety, POC training prior to starting their shifts. They all stated they knew how to find the residents mobility status in the POC in matrix. They stated they had to do return demonstration on how to access a resident's POC. They all stated 2-person bed mobility meant 2-persons assist while working with a resident in the bed. Staff stated it was important to follow the resident's POC to prevent injuries. They all stated an NA was not to provide direct care for a resident independently except there is a licensed nurse or another CNA. Review of facility's POR document dated 12 /30/2024 @ 5:30 pm,reflected QAPI was held with the Medical Director, the ADON and the Administrator via phone to discuss the Immediate Jeopardy template. Review of NA A's personnel file reflected the staff was terminated as of 12/31/2024. The ADM, ADON and Sr, VP of clinical Operation were notified on 12/31/24 at 1:47 pm that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm that is not immediate jeopardy at a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #2) of three residents reviewed for accidents and hazards. The facility failed to have consistent documentation for Resident #2's transfer status and failed to ensure she was properly transferred on 10/27/24. Her left leg foot caught on the wheelchair while being transferred by one person assistance to her bed which resulted in multiple fractures to her tibia and fibula (spiral fractures). This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/29/24 at 3:56 PM and an IJ template was given. While the IJ was removed on 10/30/24 at 3:00 PM, the facility remained out of compliance at a level of no actual harm at a scope of isolated with a potential for more than minimal harm, that was not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk for falls, injuries, and hospitalization. Findings included: Review of Resident #2's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a brain disorder that causes memory loss, thinking problems, and behavior changes), repeated history of falls, lack of coordination, and muscle wasting and atrophy (wasting away). Review of Resident #2's quarterly MDS assessment, dated 10/08/24, reflected a BIMS could not be conducted due to rarely/never being understood. Section G (Functional Status) reflected she required extensive assistance with 2+ assistance for transferring and bed mobility. Review of Resident #2's quarterly care plan, revised 10/29/24, reflected she had impaired balance during transfers R/T OA and limited ROM to bilateral shoulders. She was a 1-2 person transfer but can use mechanical lift depending on her capabilities with an intervention of providing 1 person assistance for transferring. Review of a Physical Therapy order, dated 05/01/24, reflected Resident #2 may be transferred using the mechanical lift for safe transfers. Review of a progress note in Resident #2's EMR, dated 10/27/24 at 11:03 PM and documented by LVN E, reflected the following: [CNA F] informed this nurse as he was pickins [sic] [Resident #2] from wheelchair to lay her in bed when he heard [Resident #1]'s left ankle pop. [CNA F] believes her foot got caught on wheelchair. Fibula is swollen and bruised. [Resident #2] is stating it hurts . Call made for STAT x-ray . Review of a progress note in Resident #2's EMR, dated 10/28/24 at 5:41 AM and documented by LVN E, reflected the following: 911 called for pickup . [Resident #2] complaining of pain. Left lower leg has gotten more swollen and bruised. Reapplied ice . (x-ray company) has not made it here yet. Review of a progress note in Resident #2's EMR, dated 10/28/24 at 8:45 AM and documented by LVN B, reflected the following: Recvd [sic] verbal report from (hospital ER) for [Resident #2] return . Verbal Report: Multiple fractures to tibia and fibula (spiral fractures) . Left leg placed in long splint from hip to mid-thigh. To be bedbound upon return to facility. Review of Resident #2's ER discharge paperwork, dated 10/28/24, reflected the following: Visit Diagnoses: Closed fracture of proximal end of left fibula (primary), closed nondisplaced spiral fracture of shaft of left tibia. Medical Decision Making: [Resident #2] was found to have left fibula and spiral tibia fracture . I did ask the charge nurse to file an APS report given reportedly low mechanism injury and injury pattern. Observation on 10/29/24 at 10:22 AM revealed Resident #2 asleep in her room. Her bed was in a low position, fall mat in place, and call light was within reach. During an interview on 10/29/24 at 10:33 AM, the PTA stated Resident #2 had not been on therapy's caseload since 2023. She stated it was up the staff member's preference on how to transfer Resident #2. She stated there were some aides who did not have the correct stand-and-pivot technique or did not feel comfortable transferring her alone. She stated Resident #2's physical abilities could fluctuate often. She stated in her opinion, to transfer her safely, there should be two staff members assisting. During a telephone interview on 10/29/24 at 12:38 PM, LVN E stated she was working the night shift when the incident with Resident #2 happened (10/27/24). She stated CNA F informed her he believed her foot got stuck in the wheelchair when he heard a popping sound. She stated the fractures she acquired were consistent with the twisting motion of her leg getting stuck in the wheelchair. She stated Resident #2 was a 1-2 person assist and it normally depended on the aide. She stated CNA F transferred her on his own before with no issues. She stated he was a big guy and used a gait belt and did not have any problems. During an interview on 10/29/24 at 1:03 PM, the DON stated staff knew residents' transfer status by their care plans, in the POC (EMR), and it was communicated to them. She stated the POC, MDS, and care plans should typically match. She stated Resident #2 could be a 1-2 person transfer or a mechanical lift could be utilized when needed. She stated Resident #2's physical ability fluctuated during the day - sometimes she was more tired at different times of the day. She stated the mechanical lift could be used for safety but it was not very typical that it was used for her. She stated CNA F told her when he was transferring Resident #2 from her wheelchair to her bed (on 10/27/24) he heard a pop and believed her leg was caught by the wheelchair. She stated upon hire, they conducted trainings and competencies regarding transferring but no in-servicing or trainings were conducted since the incident with Resident #2. Attempted interviews with CNA F On 10/29/24 were unsuccessful. Multiple telephone calls were attempted to reach CNA F. A returned call was not received prior to exit. Review of CNA F's competency check-off, dated 08/29/24, reflected he had been observed and checked off for transfers. review of the facility's Safe Lifting and Movement of Residents Policy, revised 03/31/23, reflected the following: Policy Statement: In order to protect the safety and well-being of staff and residents, and to promote quality of care, this facility uses appropriate techniques and devices to lift and move residents. . 3. Nursing staff, in conjunction with the rehabilitation staff, shall assess individual residents' needs for transfer assistance on an ongoing basis. Staff will document resident transferring and lifting needs in the care plan. The ADM and DON were notified on 10/29/24 at 3:56 PM that an IJ had been identified and an IJ template was provided. The following Plan of Removal submitted by the facility was accepted on 10/30/24 at 12:44 PM: Plan of Removal: F689 - The facility must ensure each resident receives adequate supervision and assistance devices to prevent accidents. The facility failed to ensure Resident #2 was properly transferred. Her foot got caught in the wheelchair when being transferred to the bed. She was diagnosed with multiple fractures to her tibia and fibula (spiral fracture). The facility failed to have consistent documentation for Resident #2's transfer status. 1. Immediate Actions Taken for Those Residents Identified: Action: Resident #2 was assessed by the LVN on duty post-accident, MD notified, MD ordered x-rays, Resident was sent to the hospital. Resident returned to facility. Resident discharge orders included remain non weight bearing and follow up with the orthopedic surgeon. This appointment was scheduled for 10/31/24. The Licensed Nurses and the CNAs were educated on the these orders, Person(s) Responsible: Charge Nurse Date: 10/30/2024 continue to monitor 2. How the Facility Identified Other Possibly Affected Residents: Action: All residents' orders, care plans, resident profile and MDSs reviewed by the Regional MDS Nurse to ensure the methods of transfer match. Any discrepancies were reviewed with the IDT on 10/30/24, to include clinical leadership, therapy, and certified nurse aides and licensed nursing staff. The method of transfer determined by IDT such as gait belt, one/two person or mechanical lift will be updated in the Orders, care plan, resident profile and the MDS. Resident #2 was reviewed upon return, and it was determined by the IDT that she was now a mechanical lift 2 person transfer. The orders, care plan and resident profile were updated. Person(s) Responsible: Director of Nursing, MDS Nurse, Regional MDS, and/or Designee Date: 10/30/2024 by 9AM 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Educate Administrator, Director of Nursing, Assistant Director of Nursing, and MDS Coordinator on residents' orders (if resident requires a mechanical lift), care plans, resident profile and MDSs accurately reflect residents' transfer status. Person(s) Responsible: Clinical Resource Nurse Date: 10/30/2024 by 1PM Action: The CNA that transferred Resident #2 when they received the fracture was educated on Safe Lifting and Movement of Residents on 10/28/24 and return demonstration was completed at this time. Licensed Nurses and Certified Nursing Aides educated on Safe Lifting and Movement of Residents and checking resident profile to ensure that they are aware of the correct transfer method for that resident. Lift and Transfer competencies will be performed on licensed Nurse and Certified Nurse Aides. Licensed Nurses and Certified Nursing Aides will be educated prior to working their next shift. There will be safe transfer training and how to access resident profile to ensure proper transfer is being used. The facility is not using agency personal, but all PRN and New hires will be trained prior to working their first shift Person(s) Responsible: Director of Nursing and/or Designee Date: 10/29/2024 by 10PM 4. How the Corrective Actions Will be Monitored, by whom and for how long: Action: MDS Coordinator to complete MDSs to include the transfer status in the look back period, prior to the RN signature, Director of Nursing will review the transfer coding on the MDS and will ensure orders (if mechanical lift), care plans, and resident profile match to have consistent documentation in place for all residents for next 4 weeks . Person(s) Responsible: Director of Nursing and/or Designee Date: 10/29/2024 by 10PM Action: Director of Nursing and/or Designee will observe 3 transfer a week, including any current, PRN or newly hired staff for x4 weeks and then monthly thereafter to ensue staff check resident profile and perform the appropriate transfer per the resident profile and procedure. The facility does not currently use agency staff. Person(s) Responsible: Director of Nursing and/or Designee Date: 10/29/2024 by 10PM QAPI: Action: Ad hoc QAPI performed with Medical Director to review the Immediate Jeopardy Template and the facility's plan to remove the immediacy. Person(s) Responsible: Administrator Date: 10/29/2024 by 10PM The Surveyor monitored the POR on 10/30/24 as followed: During an observation and interview on 10/30/24 at 1:10 PM revealed CNA D finding a resident's transfer status on their profile in their POC. Before the transfer, she locked the resident's wheelchair, ensured his feet were flat on the ground in front of him, explained to him what they were about to do, and appropriately utilized the gait belt to transfer him from his wheelchair to his bed. She stated she was in-serviced before her shift on safe transfers and locating residents' transfer status. During interviews on 10/30/24 from 1:42 PM - 2:50 PM, two RNs and three CNAs from both shifts stated they were in-serviced on safe transfers before working their shift. All stated they were able to find resident transfer statuses on their face sheet in the POC or in their care plans. They all stated gate belts should always be used for safety. The staff stated if it was a transfer from the wheelchair to the bed, you would ensure the wheelchair was locked, the resident's feet were flat on the floor and facing the bed, they were stable, and at a safe distance to the bed. They all stated limited assistance meant close supervision and residents should never transfer alone unless they were independent. The staff stated safe transfers were important to avoid injuries. Review of QAPI documentation, dated 10/29/24, reflected the DON and ADM met with the MD via telephone to discuss the Immediate Jeopardy template. Review of the audit conducted by the RMDSN to ensure all residents' care plans, orders, MDS, and profiles matched for transfers, dated 10/29/24, reflected 19 residents requiring 1 person assistance, five residents requiring 2-person assistance, two residents that were independent, and seven residents who required a hoyer (mechanical) lift. Review of an in-service, dated 10/29/24 and conducted by the CRN, reflected the DON, ADON, and MDSC were educated on the following: Ensure that all care plans, each residents' profiles, and the MDS match and line up per resident and that the proper transfer status is listed adequately in each place. Please ensure that if the resident is a mechanical lift that the orders are in place aligning with the care plan and MDS. Review of three residents' EMRs, on 10/30/24, reflected their transfer status consistent throughout their charts. Review of an in-serviced, dated 10/29/24 - 10/30/24 and conducted by the Administration staff, reflected all direct care staff were educated on safe transferring and finding resident transfer status in their POC profiles. Review of a document, dated 10/29/24 and documented by the DON, reflected the following: CNA F was re-educated on safe transfers and mobility post-incident and demo/re-demo skills were verified by nurse and DON. The ADM and DON were notified on 10/30/24 at 3:00 PM that the IJ had been removed. While the IJ was removed, The facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of four residents reviewed for pain. The facility failed to provide effective pain management or investigate the reason for the increased pain for Resident #1 when he complained of pain to his lower abdomen/groin area from 09/01/24 - 09/03/24. He was sent to the ER on [DATE] and diagnosed with a UTI, sepsis, and a blood clot in his bladder. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/29/24 at 3:56 PM and an IJ template was given. While the IJ was removed on 10/30/24 at 3:00 PM, the facility remained out of compliance at a level of no actual harm at a scope of isolated that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for prolonged and unnecessary pain and suffering and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including acute kidney failure, disorder of urinary system, diabetes , and a history of UTIs and sepsis (a serious condition in which the body responds improperly to an infection). Review of Resident #1's quarterly MDS assessment, dated 08/20/24, reflected a BIMS score of 15, indicating he had no cognitive impairment. Section H (Bladder and Bowel) reflected he had an indwelling catheter. Review of Resident #1's quarterly care plan, dated 08/01/24, reflected he required a suprapubic catheter related to obstructive uropathy (a blockage in the urinary tract that makes it hard to urinate) with an intervention of frequent and as needed incontinence checks to ensure catheter was not leaking. It further reflected he was at risk for increased pain related to DM, PVD , and generalized weakness with an intervention of monitoring pain every shift. Review of Resident #1's progress note, dated 08/31/24 at 11:31 AM and documented by LVN F, reflected the following: [Resident #1] C/O lower abdominal pain. Distention noted. Has blood coming out around meatus/catheter and bloody urine. Denies any trauma. Cath appears intact . Called EMS for transport . Review of Resident #1's progress note, dated 08/31/24 at 7:41 PM and documented by LVN E, reflected the following: [Resident #1] returned by ambulance from (hospital) . [Resident #1] had suprapubic catheter reinserted 16F. Spoke with (nurse) from hospital who stated [Resident #1]'s urine is wine in color . Review of Resident #1's ER documentation, dated 08/31/24, reflected the following: . [Resident #1] is more altered than normal and pulled out his suprapubic cath and is now having blood and blood clots out of his cath. Final diagnosis: Suprapubic catheter dysfunction Review of Resident #1's progress note, dated 09/01/24 at 9:28 PM and documented by RN A, reflected the following: [Resident #1] c/o penile pain. PRN Tylenol given as ordered and [Resident #1] stated that it is not effective and requesting for a more effective pain pill . Nurse to notify PCP. Review of Resident #1's progress note, dated 09/01/24 at 10:50 PM and documented by RN A, reflected the following: (Physician) called and gave the ff T.O: Tramadol 50mg Q6hrs PRN x 10 days for pain - placed to MAR Review of Resident #1's progress note, dated 09/02/24 at 8:40 AM and documented by LVN B, reflected the following: [Resident #1] complaints of pain at penis . Tylenol given per PRN order on file . Review of Resident #1's progress note, dated 09/03/24 at 7:31 AM and documented by LVN B, reflected the following: Tramadol given for pain per PRN order on file. Review of Resident #1's progress note, dated 09/03/24 at 11:40 AM and documented by LVN B, reflected the following: [Resident #1]'s suprapubic catheter drainage tube not draining properly; repositioned tubing to gravity, currently flowing. [Resident #1] complains of pain; Tylenol given per PRN order on file. Review of Resident #1's progress note, dated 09/03/24 at 8:38 PM and documented by RN A, reflected the following: [Resident #1] complaining of penile pain. Tramadol still not due until 10:46PM. Tylenol PRN given as ordered. [Resident #1] stated that he wants to go to the ER and having a pain scale of 10 . Called 911 . Review of Resident #1's September 2024 MAR reflected the following documented for pain: 09/01/24: Day 8/10; Night 6/10 09/02/24: Day 2/10; Night 2/10 09/03/24: Day 2/10; Night 4/10 Review of Resident #1's physician order, dated 09/20/23, reflected acetaminophen capsule; 500 mg; 2 tabs ; every 6 hours - PRN. Review of Resident #1's September 2024 MAR reflected acetaminophen was administered the following times: 09/01/24: 7:33 AM (Somewhat effective) 09/01/24: 8:15 PM (Not effective) 09/02/24 8:37 AM (Somewhat effective) 09/02/24 2:39 PM (Effective) 09/02/24 8:39 PM (Effective) 09/03/24 11:37 AM (Not effective) 09/03/24 8:32 PM (Not effective) Review of Resident #1's physician order, dated 09/01/24, reflected tramadol; 50 mg; 1 tab; every 6 hours - PRN. Review of Resident #1's September 2024 MAR reflected tramadol was administered the following times: 09/01/24 11:09 PM - (Somewhat effective) 09/03/24 7:31 AM (Effective) 09/03/24 4:46 PM (Not effective) Review of Resident #1's hospital discharge paperwork, dated 09/17/24, reflected the following: admit date : [DATE] Service Date: 09/04/24 HPI: [Resident #1] . who presents with sepsis 2/2 SP tube infection . [Resident #1] presents from (facility) c/o severe pain to penis and lower abdomen. [Resident #1] has suprapubic catheter and noticed blood in catheter x4days . Brief Hospital Course: [Resident #1] transferred to our emergency room with complaining of severe lower abdominal pain and blood around the suprapubic catheter. [Resident #1] found to have hypoglycemia , acute renal failure and UTI and admitted to IMCU . underwent cystoscopy and evacuation of large clot . His urine culture grew multiple bacteria and treated with IV Zosyn more than 10-day course. [Resident #1] presented with an elevated creatinine and went up to 7.4 and subsequently down to 3.3. His acute kidney injury most likely related to large blood clot in the bladder neck obstructing the ureter. During a telephone interview on 10/21/24 at 11:15 AM, Resident #1's FM C stated before he (Resident #1) was sent to the hospital on [DATE], he had been complaining of pain to his penis for several days. She stated when she visited him before he was sent out, he was doubled over crying in pain and crying out, I just wish they would get this fixed! She stated it was heart-breaking and he should have been sent to the hospital sooner . During a telephone interview on 10/21/24 at 12:38 PM, Resident #1's NP stated when a resident was in pain, she would want to try all interventions first before sending them to the ER. She stated if the tramadol had not been effective for Resident #1 (from (09/01/24 - 09/03/24) she would have thought the staff would have reached out to her for other possible interventions such as a medication or dosage change. During a telephone interview on 10/21/24 at 12:54 PM, RN A stated the PRN medication (tramadol and Tylenol) had not helped to alleviate Resident #1's pain (from 09/01/24 - 09/03/24). She stated she could not remember how much pain he was in on 09/01/24, but believed it was a lot. She stated on 09/03/24, he was yelling/moaning/groaning in pain and the CNA told her he had been like that and he was getting worse. She stated whenever she thought he needed hospitalization in the past he would always refuse, but that day (09/03/24), he was in so much pain he kept telling her to send him. During an interview on 10/21/24 at 1:14 PM, LVN B stated she could not remember if the tramadol was effective for Resident #1 (at the beginning of September 2024). She stated he had always been very vocal about his pain levels. During an interview on 10/21/24 at 1:30 PM, CNA D stated she remembered Resident #1 being in a lot of pain, way much more than normal from 09/01/24 - 09/03/24. She stated there was something really, really wrong. She stated urine and blood was coming out of his penis. She stated he kept saying, it hurts, it hurts. She stated he believed he should have been sent to the hospital sooner but Resident #1 had a history of saying, Why? They do not do anything for me anyways. She stated on 09/03/24 he could not take the pain anymore and requested to go to the hospital. During an interview on 10/21/24 at 3:14 PM, the DON stated she remembered Resident #1 complaining of pain (at the beginning of September 2024) but could not remember if it was an increase in pain any more than normal. She stated she was not made aware that his pain medications were not effective. She stated her expectations would be for the nursing staff to notify the NP if they were not effective to ensure they could alleviate his pain in a timely manner . During a telephone interview on 10/29/24 at 11:40 AM, LVN B stated if she knew blood and urine was coming out of Resident 1's penis, it would be in her progress notes. She stated he had bouts where that would happen when there was over-flow and because of his end-stage kidney disease. She stated when it would happen, they would send him to the ER and they would send him back same day with no new orders. During a telephone interview on 10/29/24 at 12:38 PM, LVN E stated she remembered Resident #1 having pain at the beginning of September (2024) to his groin/stomach area. She stated she could not remember if the pain medications were effective. She stated she did not know about urine or blood coming out of his penis. She stated if she had, she would have notified the NP . During a telephone interview on 10/29/24 at 1:12 PM, Resident #1's NP stated if a resident was in pain and the current pain regiment was not effective and all interventions had been tried and the pain was still uncontrolled and unmanaged, she would expect for the nurses to use their nursing judgement regarding when to send a resident out to the ER. She stated she could not answer if Resident #1 had been sent out sooner (than 09/03/24) if it would have prevented the blood clot. Review of the facility's Pain Assessment and Management Policy, revised July of 2022, reflected the following: General Guidelines: 1. The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management. 2. Pain management is defined as the process of alleviating the resident's pain based on his or her clinical condition and established treatment goals. . 5. Acute pain (or significant worsening of chronic pain) should be assessed every 30 to 60 minutes after the onset and reassess as indicated until relief is obtained. . Reporting: Report the following information to the physician or practitioner: 1. Significant changes in the level of the resident's pain ; . 3. Prolonged, unrelieved pain despite care plan interventions. The ADM and DON were notified on 10/29/24 at 3:56 PM that an IJ had been identified and an IJ template was provided. The following POR was approved on 10/30/24 at 12:44 PM: Plan of Removal: F697 - The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. The facility failed to provide effective pain interventions for Resident #1 when he was complaining of pain to his lower abdomen/groin area. The facility failed to investigate the reason for Resident #1`s pain. 1. Immediate Actions Taken for Those Residents Identified: Resident #1 no longer resides at [the facility]. 2. How the Facility Identified Other Possibly Effected Residents: Action: All residents' pain monitoring on the residents' Medication Administration Record MAR was reviewed by DCO for the month of October. Director of Nursing and/or Designee will communicate with Medical Director all residents that triggered for pain and any new orders will be implemented by the Director of Nurses Person(s) Responsible: Director of Clinical Operations, Director of Nursing, and/or Designee Date: 10/30/2024 by 10AM 3. Measures Put into Place/System Changes to remove the immediacy, and what date these actions occurred: Action: Director of Nurses educated Assessing pain, treating pain (as ordered), monitoring for effectiveness, and notifying physician for any residents whose pain medication is not effective or new onset or increase/change in pain. Person(s) Responsible: Clinical Resource Nurse Date: 10/29/2024 by 10PM Action: Licensed Nurses and Certified Nursing Aides educated over pain & reporting pain. Licensed Nurses: Assessing pain, treating pain (as ordered), monitoring for effectiveness, and notifying physician for any residents whose pain medication is not effective or new onset or increase/change in pain. Licensed Nurses and Certified Nursing Aides will be educated prior to working their next shift The Facility is not currently using agency personal, but PRN and new hires will be educated before working their first shift. Person(s) Responsible: Director of Nursing and/or Designee Date: 10/29/2024 by 10PM 4. How the Corrective Actions Will be Monitored, by whom and for how long: Action: Review pain assessments for prior day(s) during clinical meeting for 4 weeks and will be ongoing for any residents that have expressed or demonstrated pain to ensure effective intervention/investigation/notification for residents complaining of pain. Person(s) Responsible: Director of Nursing and/or Designee Date: 10/29/2024 continue ongoing QAPI: Action: Ad hoc QAPI performed with Medical Director to review the Immediate Jeopardy Template and the facility's plan to remove the immediacy. Person(s) Responsible: Administrator Date: 10/29/2024 by 10PM The Surveyor monitored the POR on 10/30/24 as followed: During interviews on 10/30/24 from 1:42 PM - 2:50 PM, two RNs and three CNAs from both shifts stated they were in-serviced on pain management before working their shift. The CNAs stated any time a resident was in pain a nurse should be notified immediately. All stated some non-verbal signs of pain would be grimacing, moaning, crying, or increased blood pressure. The nurses stated after administering pain medication, the effectiveness needed to be checked within the hour, and if it was not effective, the NP needed to be notified . All staff stated the importance of pain management was to ensure residents were comfortable, vital signs were controlled, and to ensure a good quality of life. During interviews on 10/30/24 from 12:38 PM - 12:59 PM with three residents , all reported they were not currently in pain and when they were, they told their nurse and would receive pain medication. Review of QAPI documentation, dated 10/29/24, reflected the DON and ADM met with the MD via telephone to discuss the Immediate Jeopardy template. Review of an in-serviced, dated 10/29/24 - 10/30/24 and conducted by the Administration staff, reflected all direct care staff were educated on pain management and reporting pain. Review of an in-service, dated 10/29/24 and conducted by the CRN, reflected the DON was in-serviced on assessing pain, treating pain (as ordered), monitoring the effectiveness, and notifying the MD. Review of a Daily Pain Audit, dated 10/30/24 and completed by the CRN, reflected all residents were audited for pain and only one had a pain score over 4 (from 1-10). He was administered his pain medication and it was effective. The ADM and DON were notified on 10/30/24 at 3:00 PM that the IJ had been removed. While the IJ was removed, the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse and neglect for 4 of 16 residents (Residents #2, 12, 18, and 28 ) reviewed for abuse/neglect. The facility failed to take sufficient protective measures after Resident #18 physically assaulted Resident #2 on 04/27/22, verbally assaulted Resident #28 on 08/10/22, or after Resident #18 physically assaulted Resident #12 on 12/28/22. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 01/10/23 at 11:25 AM. While the IJ was removed on 01/13/23, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of pattern due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This failure placed residents at risk of bodily, emotional, and psychosocial harm and neglect, including hospitalization or death. Findings included: Review of facility's policy Abuse Prevention Program dated June 2021 reflected the following: Policy Statement 1. The administrator is responsible for the overall coordination and implementation of our centers abuse, prevention, program, policies, and procedures. 2. All residents have the right to be free from abuse, collect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary, seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the residents symptoms. 6. Our center will protect residents from harm, reprisal, discrimination, or coercion, during investigations of abuse allegations. 7. Our center will provide protections for the health, welfare, and rights of each resident residing in the center to ensure the reporting of crimes. 9. All occurrences of abuse, neglect, miss treatment, injuries of unknown source and theft or misappropriation of resident. Property will be analyzed by the quality assurance and performance improvement committee to determine if system changes need to be made. Policy Interpretation and Implementation As part of the resident abuse prevention program, the administration will: 8. Involve the resident council in monitoring and evaluating the centers abuse, prevention program, and 9. Establish and implement a QAPI review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse. Identification 4. The physician and staff will help identify risk factors for peace within the center; for example, significant numbers of residence/patience, with unmanaged, problematic behavior; significant injuries and physically dependent individuals; problematic family relationships; issues related to staff, knowledge, and skill; or performance that might affect resident care. Investigation 1. The administrator has the overall responsibility for the coordination and implementation of our centers. Abuse, prevention, program, policies, and procedures. The administrator is the abuse prevention coordinator. In the absence of the administrator, the Director of nursing will serve in this capacity. 2. Administrator has the authority to delegate coordination and implementation of various components of these policies and procedures to other individuals within the center. 7. The administrator will ensure that any further potential abuse, neglect, exploitation, or miss treatment is prevented. 8. The administrator will inform the resident and his/her representative of the status of the investigation, and measures taken to protect the safety and privacy of the resident. Response Treatment/Management 1. The staff and physician will monitor individuals who have been abused to address any issues regarding their medical condition, mood, and function. Monitoring/Follow-Up 2. The Medical Director will advise center management and staff about ways to ensure the basic medical, functional, and psychosocial needs are being met, and that potentially preventable or treatable conditions affecting function and quality of life or dressed appropriately. 3. Physician will advise the center and help review and address abuse and neglect issues as part of the quality assurance process. Protection of residents during abuse investigations 1. During abuse, investigations, residence will be protected from harm by the following measures: see. c. If the alleged abuse involves another resident, the accused resident's representative and attending physician will be informed of the alleged abuse incident, and that there may be restrictions on the accused resident's ability to visit other resident rooms on attended. If necessary, the accused resident's family members may be required to help meet this requirement. d. Within five working days of the alleged incident, the center will give the resident, the resident's representative, state survey and certification agencies, accused individuals, the ombudsman as needed, etc. a written report of the findings of the investigation, and a summary of corrective action taken to prevent such an incident from recurring. Analysis 1. The quality assurance and performance improvement committee will review all reports of abuse, neglect, mistreatment, injuries of unknown source and theft or misappropriation of resident property during their regularly scheduled meetings. 2. Reviews of each occurrence will be made to determine if policies, procedures, or center systems need to be modified to prevent further incidents of abuse or theft. 3. The quality assurance and performance improvement committee will provide the administrator with a written report of its findings and recommendations. The administrator will review such recommendations and act accordingly. 4. Copies of any changes to our abuse prevention program policies and procedures will be provided to Residents and Center stuff as established by center policy and training programs. Resident #2 Review of the undated face sheet for Resident #2 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of hemiplegia and hemiparesis (paralysis of half the body), dementia with behavioral disturbance, and cognitive communication deficit (difficulty speaking and understanding language). Review of the quarterly MDS for Resident #2 dated 11/03/22 reflected a BIMS score of 11, indicating a mild cognitive impairment. It reflected a mood severity score of 00, indicating little or no depressive mood. It reflected Resident #2 required the extensive assistance of one person for transfer and the limited assistance of one person for locomotion. Review of the care plan for Resident #2 dated 10/11/22 reflected the following: Resident is limited in range of motion to RT side R/T CVA. Resident has delusions R/T Psychotic Disorder with Delusions. Impaired memory/recall problem R/T Hx of CVA AEB short term memory problem. Maintain body in functional alignment when at rest Review of a progress note dated 04/27/22 documented by LVN B reflected: During shift change, CNA yelled down the hall for nurses to come to resident's room due to an altercation. This nurse and oncoming nurse went to resident's room and oncoming nurse separated residents who were in the middle of room. This nurse interviewed both residents to attempt to determine factors contributing to altercation and actions of both residents during the event. This nurse obtained this resident's statement which was difficult due to constant interruption from (Resident #18) even with attempted redirection. resident's statement of altercation was obtained without difficulty or interruption from resident. This resident's statement he reported he was cold in his room and drew the curtain in attempt to prevent the cold air from blowing directly on him like he always does when he feels cool. However (Resident #18) stated that he didn't care that his roommatewas cold that he felt claustrophobic and therefore drew the curtain back. (Resident #2) reported that after (Resident #18) did not care he was cold that he swung at (Resident #18) in an attempt to get him to leave the curtain alone swung at (Resident #18) but did not make contact with (Resident #18) during the swing. This nurse specifically asked (Resident #18) if this resident actually touched or made contact with him during the swing with (Resident #18) reported He tried to hit me but did not. Then resident stated that (Resident #18) hit this resident in the head with his crutch and knocked his cowboy hat off his head. CNA indicated when she came in the room before contacting nurses (Resident #18) was picking up hat from ground and throwing it back at this resident. (Resident #18) reported that, Yes he hit (Resident #2) and was aware of situation and circumstance during this event. This nurse did clarify with both residents that the only one that made contact hitting this resident was (Resident #18), both agreed that this was the case. Oncoming nurse asked (Resident #18) to calm down in the day room. While (Resident #18) was walking past this resident, he was being verbally aggressive and very hostile toward this resident. (Resident #2) did make an attempt to grab at (Resident #18) at this time but was unable to; CNA intervened and no contact made. (Resident #18) continued to yell and be very hostile toward this resident in a very loud tone. This nurse called DON to inform her of altercation and that this resident received a blow to the head with crutch by (Resident #18). No LOC. She informed this nurse to separate residents so they could calm down/cool off and then she would call back, check in and address event tomorrow being she was at home. This nurse informed oncoming nurse of conversation. (Resident #18) in day room. This resident stayed in room, sitting in his wheelchair. Resident #12 Review of the undated face sheet for Resident #12 reflected an [AGE] year-old female admitted to the facility on [DATE] with diagnoses of vascular dementia with behavioral disturbance, impulse disorder, major depressive disorder, and anxiety disorder. Review of the quarterly MDS for Resident #12 dated 12/19/22 reflected a BIMS score of 01, indicating a severe cognitive impairment. It reflected a mood severity score of 05, indicating a moderately depressive mood. It reflected Resident #12 required the extensive assistance of one person for transfer and the limited assistance of one person for locomotion. Review of the care plan for Resident #12 dated 10/11/22 reflected the following: Resident has impaired decision making R/T dementia. Was struck by another resident on 08/14/20. Resident will have positive experiences in daily routine without overly demanding tasks and without becoming overly stressed. Determine if decisions made by the resident endanger the resident or others. Intervene if necessary. Encourage to verbalize feelings, concerns and fears. Clarify misconceptions. Respect resident's rights to make decision(s). Use non-verbal communication techniques to encourage response. Review of progress notes for Resident #12 reflected the following: *12/28/2022 by LVN B: This nurse heard yelling coming from another resident's (Resident #18's) room, when approaching the room, PT was in the hallway and looking in (Resident #18's) room as this nurse was approaching room-stating Don't hit resident! PT informed this nurse that (Resident #18) just struck (Resident #12) in the face. When this nurse arrived to room it was crowded in the doorway, because it was on the opposite side of (Resident #18) who struck (Resident #12). (Resident #12) had a banana that was taken from (Resident #18) roommate's side of the room. This nurse and med aide removed (Resident #12) from room to evaluate to, (Resident #12) crying and did say I'm ok. Some redness on left cheek and neck areas. (Resident #12) offered ice pack or pain reliever-resident declined at this time. This nurse contacted ADM, DON and RP. Witness statement faxed to admin. *01/02/2023 by PsyPA: A patient visit with (Resident #12) was conducted at (facility) on 01/02/23. She appeared at ease with no emotional or physical discomfort. Her EMR was reviewed, and staff input was sought. It was reported that (Resident #12) was struck by another resident on 12/28/22, during an incident involving her presence in another resident's room and a banana. No serious injuries were reported. Cognitive function was unchanged. No adverse side effect from prescribed psychiatric medication were reported by staff. The current plan of care appears to be reasonable. Psychiatric medication, require no changes. SPC will continue to visit with the resident, review progress notes and make recommendations regularly. Resident #28 Review of the undated face sheet for Resident #28 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of heart failure, hypertension (high blood pressure), kidney failure, and asthma. Review of the quarterly MDS for Resident #28 dated 12/20/22 reflected a BIMS score of 7, indicating a moderate cognitive impairment. It reflected a mood severity score of 00, indicating little or no depressive mood. It reflected Resident #28 required supervision of one person for transfer and the limited assistance of one person for locomotion. Resident #18 Review of the undated face sheet for Resident #18 reflected a [AGE] year-old male admitted to the facility on [DATE] with diagnoses of cerebral palsy, muscle wasting and atrophy, lack of coordination, muscle weakness, psychophysiological insomnia (disorder in which sleep-preventing associations have become internalized and persist even though the initial cause of insomnia has been removed), major depressive disorder, disruptive mood dysregulation disorder (mood disorder diagnosed in children who present with recurrent irritable or angry mood and severe temper outbursts that interfere with their ability to function at home, in school, or with their friends), spinal muscular atrophy (a genetic neuromuscular disorder that affects motor neurons in the spinal cord causing progressive muscle degeneration and weakness), borderline intellectual functioning, and irritability and anger. Review of the quarterly MDS for Resident #18 dated 12/20/22 reflected a BIMS score of 15, indicating no cognitive impairment. It reflected a mood severity score of 00, indicating little or no depressive mood. It reflected Resident #18 exhibited verbal behavioral symptoms toward others 1-3 days of the lookback period. It reflected Resident #18 required the extensive assistance of two people for transfer and the limited assistance of one person for locomotion. Review of the care plan for Resident #18 dated 10/11/22 reflected no care planning for aggressive behaviors. It reflected no care planning related to Resident #18's cognition. Review of progress notes for Resident #18 reflected the following: *04 /27/22 written by LVN B During shift change, CNA yelled down the hall for nurses to come to (Resident #18)'s room due to an altercation. This nurse and oncoming nurse went to (Resident #18)'s room and oncoming nurse separated residents who were in the middle of room. This nurse interviewed both residents to attempt to determine factors contributing to altercation and actions of both residents during the event. This nurse obtained (Resident #2)'s statement which was difficult due to constant interruption from (Resident #18) even with attempted redirection. (Resident #18)'s statement of altercation was obtained without difficulty or interruption from (Resident #2). In (Resident #2)'s statement he reported he was cold in his room and drew the curtain in attempt to prevent the cold air from blowing directly on him like he always does when he feels cool. However this (Resident #18) stated that he didn't care that his (Resident #2) was cold that he felt claustrophobic and therefore drew the curtain back. (Resident #2) reported that after this (Resident #18) did not care he was cold that he swung at this (Resident #18) in an attempt to get him to leave the curtain alone but did not make contact with this (Resident #18) during the swing. This nurse specifically asked (Resident #18) if the (Resident #2) actually touched or made contact with him during the swing with this (Resident #18) reporting He tried to hit me but did not. Then (Resident #2) stated that (Resident #18) hit (Resident #2) in the head with his crutch and knocked his cowboy hat off his head. CNA indicated when she came in the room before contacting nurses the (Resident #18) was picking up hat from ground and throwing it back at (Resident #2). This (Resident #18) reported that, Yes he hit (Resident #2) and was aware of situation and circumstance during this event. This nurse did clarify with both (Resident #18)s that the only one that made contact hitting (Resident #2) was this (Resident #18), both agreed that this was the case. Oncoming nurse asked (Resident #18) to calm down in the day room. While (Resident #18) was walking past (Resident #2), he was being verbally aggressive and very hostile toward (Resident #2). (Resident #2) did make an attempt to grab at this (Resident #18) at this time but was unable to; CNA intervened, and no contact made. This (Resident #18) continued to yell and be very hostile toward (Resident #2) in a very loud tone. This nurse called DON to inform her of altercation and that (Resident #2) received a blow to the head with crutch by this (Resident #18). No LOC. She informed this nurse to separate residents so they could calm down/cool off and then she would call back, check in and address event tomorrow being she was at home. This nurse informed oncoming nurse of conversation. (Resident #18) in day room. As this nurse was leaving the facility and holding the door open for another (Resident #18) to come in, this (Resident #18) started walking out the building, this nurse tried to stop (Resident #18) from coming out by informing him he needed to sign out. This (Resident #18) ignored this nurse and pushed by to continue outside without notifying the staff/signing out as care plan. This nurse informed charge nurse that (Resident #18) was outside. *04/28/22 by former DON: (Resident #18) reports he is in a foul mood today. Seen by (PsyPA) this morning for discussion. No changes noted to orders. Patient's (family member) came in to speak with DON regarding yesterday's incident - writer not part of conversation. After discussion, resident and (family member) left the facility for the day. (family member) given labeled/individually packaged medications for the day. - no questions for RN. 04/28/22 by former DON: Talked with (Resident #18's) (family member) today in a long meeting of approx. an hour. (Resident #18's) (family member) was concerned about the altercation between (Resident #18) and the roommate. I have discussed this at length and the plan is to have the roommate moved and the Mental health PA to once again talk to (Resident #18). *05/04/22 by LVN B: This nurse heard this resident down the hall yelling SHUT UP at another resident in the hallway. This nurse redirected this resident and informed him not to speak to residents in this manner. Resident stated that the resident yelled at him first, no indication this happened. *7/20/22 by LVN B: This nurse heard this resident yell, Shut up! from the nurse's station and this nurse went to the day where this nurse confronted resident to ask what/who he was yelling at and he said that he was yelling at another resident, because she yelled at him first. This nurse spoke to resident and informed him not to yell at anyone and to respect other residents. Resident told the nurse, he will not and that he didn't not want this nurse to look at him and if he was to go anywhere it was outside. This nurse did not engage in behavior and informed DON. *07/20/22 by LVN B: This nurse went back to check on resident in day room, when resident had another female resident in a wheelchair in very close contact. This nurse removed female resident and then this resident huffed and puffed and proceeded to the outside patio. This nurse informed DON and DON notified (therapist) and now since resident is interfering with the care and health of our residents the DON stated to keep resident on an every 30 minutes monitoring at this time. This nurse informed oncoming shift and informed CNAs. *08/10/22 by LVN D: CNA witnessed pt. shoving cane into other resident's face in front on the nurses station. They were standing about 5 feet apart and cane did not touch (Resident #28). It was obvious that pt. did not want to hurt (Resident #28) but was informed that his actions were unacceptable. Pt. has been upset since he dropped his phone on the floor earlier today and the phone stopped working correctly. (Resident #28) stated that he was Okay and that he would let (Resident #18) cool down. (Resident #28) went down to his room and got ready for bed. (Resident #18) stayed at the nurse's station and talked to (former staff member), he calmed down after their conversation and then headed to his room. Pt. has history of agitation and aggressive behavior. Will continue to monitor. *10/17/22 by the SW: Completed Safe Survey with resident today. Stated he was not afraid of any abuse or neglect. In fact he said if anyone tried to hurt him he would hurt them first. He was upset and stated he felt he was being wrongfully accused of inappropriately touching someone. Resident went on to say he is misunderstood and his (family member) feels as if he is being discriminated against because he is misunderstood. He stated that the way to treat the other residents is like you would a child, slap their hands and tell them no when they misbehave. Resident stated that the pillow in his chair is the blue wedge pillow that his (family member) previously referred to be missing. He stated he keeps it in his chair at all times. *10/28/22 by unnamed agency LVN: Observed resi throwing items out of his room. This nurse was down the hall checking blood sugars and went to go see what was going on. This nurse observed resi slowly slid self down to his knees then lay his crutches out beside him. Resident did let himself slid down the last 6 inches to a foot slightly harder but did not appear to be in any pain. Resi then looked up and saw this nurse standing there and got himself up without saying anything. Shortly after this resi came screaming down the hall scaring other residents that he did not want fish. This nurse advised him that screaming down the hall was not appropriate behavior, and it was disrespectful to the other residents. Resi then stated well I am angry because I just fell. Resi again told that was not appropriate behavior. Resi was walking around ad lib with use of his crutches. No redness noted to knees and no pain or limitations to movement beyond normal deformity noted or expressed. Resi then was approached by another resident asking if he was ok and he yelled at that resident as well. *11/15/22 by MD: Staff reports more aggressive behavior lately. Chart and meds reviewed. Request psych visit with pt. and daytime staff to review and evaluate. *12/28/22 by LVN B: This nurse heard yelling coming from resident's room, when approaching the room, PT was in the hallway and looking in resident's room as this nurse was approaching room-stating Don't hit resident! PT informed this nurse that this resident just struck another resident in the face. When this nurse arrived to room it was crowded in the doorway, because it was on the opposite side of the resident's room. Resident upset that resident was taking roommate's banana. This nurse and med aide removed other resident from this resident's room. This resident kept yelling with PT about other resident She shouldn't be in my room! Resident then seen going to his side of the room and sitting in recliner and getting on his phone. This nurse then receives a phone call from DON stating that resident contacted mom and DON received an email from mom regarding incident. This nurse informed admin and DON of incident. Regional DON informed this nurse that she overheard the conversation resident was having on the phone admitting to hitting resident. *12/30/22 by the DON: This nurse addressed the altercation with resident that happened on 12/28/2022 between him and another resident. I spoke with him on how to control his anger and other ways he could have handled the situation. He agreed that he should have left the room and came to find a staff member to help. He stated that he gets angry really fast and it's hard for him to control his temper. He did ask to speak to his therapist. I emailed his therapist who replied that he would be by to see resident as soon as he could. Resident seems to be calm during this conversation but very defensive. Will continue to monitor. *01/02/23 by PsyPA: A patient visit with (Resident #18) was conducted at (facility) on 01/02/23. He demonstrated agitation and anger and repeatedly complained about the facility staff and his family. He said that he is never happy and that when death comes, he will welcome it, because he will be at peace. It was reported in the resident's progress notes that he had struck an elderly resident with dementia resident in the face on 12/28/22, because the other resident had taken a banana that belonged to his roommate. (Resident #18) says that the other resident struck in first. When questioned about the incident, he attempted to justify his actions as a manifestation of the anger which he holds inside of himself because, as he says, no one understands his personal pain, nor do they attempt to understand his needs. He has demonstrated problems with personal interaction with other residents, some of whom are elderly and suffering from dementia. He believes that the facility will try to discharge him, and he is fearful of where he will end up. Changes to his psychiatric medication will likely not resolve any of these issues, and (Resident #18) has been resistant any increases or additions to his medication. (Psychiatric clinic) will continue to visit with the resident, review progress notes and make recommendations regularly. *01/04/23 by the DON: Contract for Safety signed by resident. Witnessed by DON and BOM. Resident's (family member) informed and verbalized understanding. Resident has no threats for harming himself or others. Review of the facility investigation report (HHSC 3613) dated 01/04/23 reflected the following: Description of the allegation: PT heard Resident #18 yelling at someone, he walked to Resident #18's door and saw Resident #12 on Resident #18's roommate's side of the room holding a banana. Resident #18 was yelling at her to 'give it back.' When she didn't. Resident #18 struck Resident #12 in the face and neck. Description of Injury: Resident #12 was very shaken and upset. Description of Assessment: Head to toe assessment, resident crying. Some redness on left cheek and neck areas. Resident offered ice pack or pain reliever - resident declined at this time. Provider response: Residents separated, Resident #12 assessed. 911 call to report incident, PD report #2219528. Families/RPs notified. Medical Director notified. Resident #18 cautioned about striking other residents. Body audits on all of the residents, safe surveys conducted, no findings of abuse or neglect to other residents. Referral concerning this incident made to Resident #18 psych NP and LCSW therapist. Investigation Summary: PT witnessed Resident #18 strike Resident #12 in the face and neck. In an interview on 1/2/2023 conducted by psych NP, Resident #18 admitted striking Resident #12, because she had taken a banana belonging to his roommate, and that Resident #12 struck him first. Monitored Resident #12 for any signs of injury or dress. Nursing continues to monitor Resident #18 behaviors. Observation on 01/09/23 at 07:03 AM revealed Resident #18, a younger male with contractions in his arms and legs, walking with aluminum crutches in hall 100. Resident #12, a frail, elderly female self-ambulated in her wheelchair up and down hall 100 and did not reply when addressed. No staff was immediately visible on hall 100 until 7:10 AM. During an interview on 01/09/23 at 07:15 AM Resident #18 stated there was an incident three weeks ago in the sanctuary of his room regarding himself and Resident #12. Resident #18 stated he was not what they would call an impulsive person and then amended his statement to say that he was actually impulsive. Resident #18 stated he would be lying if he said he did not do this on impulse. Resident #18 began speaking about some family history and the psychological and anger management problems it had caused him. Resident #18, with that understood, he was not saying what he did was a good idea, and he took responsibility for everything that happened. Resident #18 stated at the time of the incident, he was already a little bit frustrated, and Resident #12 happened to be in the wrong place at the wrong time. Resident #18 stated he was sitting on his end of the room by the computer, window, and bathroom when Resident #12 came in as a wanderer. Resident #18 stated staff would often overlook these wandering residents going into rooms. Resident #18 stated Resident #12 came into their room and began going through his roommate's refrigerator and got out and began eating a banana. Resident #18 stated without yelling and screaming but making his voice heard, he told Resident #12 she could not be in there. Resident #18 stated there was staff at the time was walking up and down the halls, and no one came in and intervened. Resident #18 stated he understood they could not always stop what they were doing, and what he was told afterward was, It's not your responsibility to protect your roommate's stuff. Resident #18 stated if it was not his responsibility, it had to be somebody else's. Resident #18 stated he was not saying the staff did not act accordingly, as they may have been waiting for the right moment to intervene, but no one came in. Resident #18 stated he went toward Resident #12 and told her again to leave. Resident #18 stated he grabbed Resident #12 and pulled her back out of the refrigerator and his roommate's side of the room, took the banana out of her hand, and told her a third time he needed her to leave. Resident #18 stated Resident #12 said, go to hell and hit him with an open palm on the right side of his face. Resident #18 stated as a knee jerk reaction, he slapped Resident #12 in the face. Resident #18 stated at this point the PT and LVN B came into his room. Resident #18 stated they did not bother to react if a wandering resident was in there, but they would react if Resident #18 got loud enough and hit her. Resident #18 stated he did not injure her, she was not broken, and there were no marks. Resident #18 stated he was making the point that he may have been outraged and pissed off, but that was not an excuse for what he did. Resident #18 stated Resident #12 could not defend herself. Resident #18 stated Resident #12 had not been in his room since then. Resident #18 stated the ADM had not talked to him about this incident. Resident #18 stated he had anger management problems and unresolved anger, but he would not lash out at anyone unless it was an emotional reaction. During an interview on 01/09/23 at 11:17 AM, LVN B stated she was a witness to part of the incident of resident-to-resident abuse of Resident #12 by Resident #18.