**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, The facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand for 1 of 9 (Resident #1) reviewed for discharges. The facility did not complete the process for home health services for Resident #1 to receive continued care prior to discharge. 5/22/2023 Resident # 1 discharged from the facility to a motel in the community. Resident # 1called 911 and admitted to the hospital on [DATE] for cellulites and abscess to his left foot that required debriding a surgical procedure. An IJ was identified on 7/6/2023. The IJ began on 5/22/2023 and removed on 5/25/2032. While the IJ was removed on 5/25/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy because (e.g.) all staff had not been trained on 5/25/2023. The failure could place residents at risk of worsened health conditions and hospitalizations. Findings included: Record review of hospital records dated 5/24/2023, reflected Resident #1 admitted to the hospital on [DATE]. The records reflected Resident #1had an amputation of the third middle toe on the left foot on 4/26/2023 with a delayed closure. The medical records reflect Resident #1 was seen for cellulites and abscess to his left foot. The records reflected that the abscess was debrided through a surgical procedure. Resident #1 discharged from the hospital on 6/6/2023 to the community. Record review of a face sheet dated 4/30/2022 indicated Resident #1, was a [AGE] year-old male admitted on [DATE]. He had diagnoses of acute osteomyelitis, left ankle and foot (infection of the bone), Tachycardia unspecified ( a rapid heartbeat that may be regular or irregular but is out of proportion to age and level of exertion), acquired absence of other left toe (code classification of medical billing), type 2 diabetes mellitus with hyperglycemia ( when a person living with [NAME][e 2 diabetes has high blood sugar levels), bipolar disorder ( a disorder associated with mood swings ranging from depressive lows to manic highs), and Cutaneous abscess ( a localized collection of pus in the skin and may occur on any skin surface). Record review of the MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 15, which indicated cognitively intact. Section G Functional status of the MDS reflected Resident # 1 required one person assist Ambulation/Transfers, bathing, hygiene, dressing and grooming. Record review of a care plan dated 4/30/2023 reflected Resident #1 had a short- term goal with a discharge plan to return back to the community. The care plan reflected, ADL function status/Rehabilitation potential interventions included: Ambulation/Transfers, bathing, hygiene, dressing and grooming required one person assist, OT/PT/ST as needed Record reviewed of doctor's order dated 5/22/2023, reflected Resident # 1 was at baseline and to be discharged with all medications except controlled medications. Record review of community referral for home health care services dated 5/22/2023, reflected Resident # 1 would be picked up for services in the community once a PCP was assigned. Record review of nursing note dated 5/22/2023 written by the ADON, indicated Resident #1 was discharged per doctor's order, Resident # 1 signed for all medications given to him. Resident # 1 was instructed on all medications and how to take medications. Resident # 1 was given 20.00 cash for food. An phone interview at 9:30a.m. with Resident # 1, revealed he was discharged from the facility to a motel. Resident # 1 stated the facility paid for a few days at the motel and gave him 20.00 cash for food. Resident # 1 stated asked the facility how he was going to get the continued care and to his appointments that were scheduled. Resident # 1 stated the facility did not provide him with any follow-up information for continued care services. Resident # 1 stated he called 911 to go back into the hospital so that he could get continued medical care. Resident # 1 had been in the motel for 2 days. An interview on 5/22/2023 at 12:30p.m. with the SOWK, revealed Resident #1 was discharged from the facility on 5/22/2023. She stated she completed a referral for Home health services on 5/22/2023. The SOWK stated the application for services for Resident # 1 was accepted pending the resident had a PCP in place. The SOWK stated she was not aware of who Resident # 1 PCP would be since he had discharged from the facility. An interview at 12:45 p.m. on 5/25/2023 with the DON, revealed the facility received an order from the doctor for the discharge that indicated Resident # 1 was at his baseline and no longer required this level of treatment. The DON stated Resident # 1 was discharge with his medications and all his belongings. The DON stated the SOWK set up continued care services in the community for Resident # 1 through home health care. An interview at 1:41p.m. on 5/25/2023 with other state agency staff, revealed Resident # 1 was discharged on 5/22/2023 and he was made aware of the discharge by Resident # 1. The other state agency staff stated Resident # 1 did not have services set up in the community for continued treatment services. The other state agency staff revealed Resident # 1 was convinced to go back to the hospital to get the services he needed. An interview at 4:30p.m. on 5/25/2023 with the Regional ADM, revealed that Resident # 1 was covered by the current PCP at the facility once he discharged from the facility so that he could start his services in the community. The Regional ADM revealed this information should have been provided to the home health provider and Resident #1 so that services in the community could have continued. The Regional ADM revealed the SOWK should have provided this information and would be in-serviced on the process to set up continued services for any resident. An interview at 4:09pm on 7/5/2023 with the NP revealed, she believed that the PCP would follow the resident until another PCP has been chosen. The NP stated the SOWK worker would need to ensure that the resident was set up for continued treatment services in the community. The NP stated Resident #1 was stable to discharge from the facility. She stated they would write a prescription or see the resident at one of their community clinics, however the SOWK would set these services up when the resident discharged from the facility and make them aware when it has been set up so that Resident # 1 could have been seen at one of their community clinics until another PCP had been selected. Record review of the facility's policy titled, Transfer and Discharge Policy, dated March 2021, revealed Policy: In determining the transfer location for a resident, the decisions to transfer to a particular location is determined by the needs, choices and best interests of the resident. The Regional ADM. was notified on 7/6/2023 at 3:30pm., an IJ had been identified due to the above failures. It was determined their failures placed Resident # 1 in an IJ situation on 5/22/2023. The facility implemented the following interventions: An interview at 4:09pm on 7/5/2023 with the Regional ADM. revealed, that they implemented as part of their discharge process was to identify all discharges coming up and discuss with the IDT steps to take to ensure the process was completed timely to ensure residents have a safe discharge in place with continued services set up. The ADM was able to show the current list of residents seeking discharge to other facilities and those seeking discharge to the community. An interview at 4:30pm on 7/5/2023 with SOWK revealed, she had been in-serviced on the admission/discharge policy and procedure. The SOWK was able to discuss the process in which they take when discharging for homeless residents and setting up services in the community. She stated she was advised that the facility PCP would provide services to residents after they discharging to the community for continued services at one of their facilities in the community until a new PCP has been obtained. The SOWK stated she was familiar and has worked with some of the community facilities that accept homeless people to assist the resident to transition back into the facility. Records review of in-service and sign-in sheets regarding Admissions and Discharges policy and procedure dated 5/25/2023 conducted by the traveling ADM, reflected the SOWK and other IDT members had been in-serviced on this process. Records reviewed of QAPI meetings dated 6/28/2023, reflected the IDT members and admissions and discharges were discussed as part of this meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, The facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility. This orientation must be provided in a form and manner that the resident can understand for 1 of 9 (Resident #1) reviewed for discharges. The facility did not complete the process for home health services for Resident #1 to receive continued care prior to discharge. 5/22/2023 Resident # 1 discharged from the facility to a motel in the community. Resident # 1called 911 and admitted to the hospital on [DATE] for cellulites and abscess to his left foot that required debriding a surgical procedure. An IJ was identified on 7/6/2023. The IJ began on 5/22/2023 and removed on 5/25/2032. While the IJ was removed on 5/25/2023, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that was not Immediate Jeopardy because (e.g.) all staff had not been trained on 5/25/2023. The failure could place residents at risk of worsened health conditions and hospitalizations. Findings included: Record review of hospital records dated 5/24/2023, reflected Resident #1 admitted to the hospital on [DATE]. The records reflected Resident #1had an amputation of the third middle toe on the left foot on 4/26/2023 with a delayed closure. The medical records reflect Resident #1 was seen for cellulites and abscess to his left foot. The records reflected that the abscess was debrided through a surgical procedure. Resident #1 discharged from the hospital on 6/6/2023 to the community. Record review of a face sheet dated 4/30/2022 indicated Resident #1, was a [AGE] year-old male admitted on [DATE]. He had diagnoses of acute osteomyelitis, left ankle and foot (infection of the bone), Tachycardia unspecified ( a rapid heartbeat that may be regular or irregular but is out of proportion to age and level of exertion), acquired absence of other left toe (code classification of medical billing), type 2 diabetes mellitus with hyperglycemia ( when a person living with [NAME][e 2 diabetes has high blood sugar levels), bipolar disorder ( a disorder associated with mood swings ranging from depressive lows to manic highs), and Cutaneous abscess ( a localized collection of pus in the skin and may occur on any skin surface). Record review of the MDS assessment dated [DATE] indicated Resident #1 had a BIMS score of 15, which indicated cognitively intact. Section G Functional status of the MDS reflected Resident # 1 required one person assist Ambulation/Transfers, bathing, hygiene, dressing and grooming. Record review of a care plan dated 4/30/2023 reflected Resident #1 had a short- term goal with a discharge plan to return back to the community. The care plan reflected, ADL function status/Rehabilitation potential interventions included: Ambulation/Transfers, bathing, hygiene, dressing and grooming required one person assist, OT/PT/ST as needed Record reviewed of doctor's order dated 5/22/2023, reflected Resident # 1 was at baseline and to be discharged with all medications except controlled medications. Record review of community referral for home health care services dated 5/22/2023, reflected Resident # 1 would be picked up for services in the community once a PCP was assigned. Record review of nursing note dated 5/22/2023 written by the ADON, indicated Resident #1 was discharged per doctor's order, Resident # 1 signed for all medications given to him. Resident # 1 was instructed on all medications and how to take medications. Resident # 1 was given 20.00 cash for food. An phone interview at 9:30a.m. with Resident # 1, revealed he was discharged from the facility to a motel. Resident # 1 stated the facility paid for a few days at the motel and gave him 20.00 cash for food. Resident # 1 stated asked the facility how he was going to get the continued care and to his appointments that were scheduled. Resident # 1 stated the facility did not provide him with any follow-up information for continued care services. Resident # 1 stated he called 911 to go back into the hospital so that he could get continued medical care. Resident # 1 had been in the motel for 2 days. An interview on 5/22/2023 at 12:30p.m. with the SOWK, revealed Resident #1 was discharged from the facility on 5/22/2023. She stated she completed a referral for Home health services on 5/22/2023. The SOWK stated the application for services for Resident # 1 was accepted pending the resident had a PCP in place. The SOWK stated she was not aware of who Resident # 1 PCP would be since he had discharged from the facility. An interview at 12:45 p.m. on 5/25/2023 with the DON, revealed the facility received an order from the doctor for the discharge that indicated Resident # 1 was at his baseline and no longer required this level of treatment. The DON stated Resident # 1 was discharge with his medications and all his belongings. The DON stated the SOWK set up continued care services in the community for Resident # 1 through home health care. An interview at 1:41p.m. on 5/25/2023 with other state agency staff, revealed Resident # 1 was discharged on 5/22/2023 and he was made aware of the discharge by Resident # 1. The other state agency staff stated Resident # 1 did not have services set up in the community for continued treatment services. The other state agency staff revealed Resident # 1 was convinced to go back to the hospital to get the services he needed. An interview at 4:30p.m. on 5/25/2023 with the Regional ADM, revealed that Resident # 1 was covered by the current PCP at the facility once he discharged from the facility so that he could start his services in the community. The Regional ADM revealed this information should have been provided to the home health provider and Resident #1 so that services in the community could have continued. The Regional ADM revealed the SOWK should have provided this information and would be in-serviced on the process to set up continued services for any resident. An interview at 4:09pm on 7/5/2023 with the NP revealed, she believed that the PCP would follow the resident until another PCP has been chosen. The NP stated the SOWK worker would need to ensure that the resident was set up for continued treatment services in the community. The NP stated Resident #1 was stable to discharge from the facility. She stated they would write a prescription or see the resident at one of their community clinics, however the SOWK would set these services up when the resident discharged from the facility and make them aware when it has been set up so that Resident # 1 could have been seen at one of their community clinics until another PCP had been selected. Record review of the facility's policy titled, Transfer and Discharge Policy, dated March 2021, revealed Policy: In determining the transfer location for a resident, the decisions to transfer to a particular location is determined by the needs, choices and best interests of the resident. The Regional ADM. was notified on 7/6/2023 at 3:30pm., an IJ had been identified due to the above failures. It was determined their failures placed Resident # 1 in an IJ situation on 5/22/2023. The facility implemented the following interventions: An interview at 4:09pm on 7/5/2023 with the Regional ADM. revealed, that they implemented as part of their discharge process was to identify all discharges coming up and discuss with the IDT steps to take to ensure the process was completed timely to ensure residents have a safe discharge in place with continued services set up. The ADM was able to show the current list of residents seeking discharge to other facilities and those seeking discharge to the community. An interview at 4:30pm on 7/5/2023 with SOWK revealed, she had been in-serviced on the admission/discharge policy and procedure. The SOWK was able to discuss the process in which they take when discharging for homeless residents and setting up services in the community. She stated she was advised that the facility PCP would provide services to residents after they discharging to the community for continued services at one of their facilities in the community until a new PCP has been obtained. The SOWK stated she was familiar and has worked with some of the community facilities that accept homeless people to assist the resident to transition back into the facility. Records review of in-service and sign-in sheets regarding Admissions and Discharges policy and procedure dated 5/25/2023 conducted by the traveling ADM, reflected the SOWK and other IDT members had been in-serviced on this process. Records reviewed of QAPI meetings dated 6/28/2023, reflected the IDT members and admissions and discharges were discussed as part of this meeting.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure the resident's right to be free from abuse for 3 (Resident #1, Resident #2, and Resident #3) of 68 residents reviewed for abuse. 1. Resident #1 grabbed Resident #2 by her hair and started punching her. 2. Residents #1 and #3 were pulling on each other's shirts, scratching, and punching the other. An IJ was identified on 4/29/23 at 6:21pm. Although the IJ was removed on 05/02/23 at 5:21pm, the facility remained out of compliance at a severity level of no actual harm and scoped at a pattern due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This failure place residents at risk for serious injury, emotional distress, and death. Findings included: Resident #2 Review of Resident #2's face sheet dated 4/29/23 revealed she was originally admitted to the facility on [DATE] and returned to the facility on 7/8/22 from a Behavioral Hospital. Resident #2's primary diagnoses included hypertension, schizophrenia, dementia, hearing loss, Parkinson's disease, cognitive communication deficit, paranoid schizophrenia, recurrent depressive disorders, and insomnia. Review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 15. The MDS also indicated Resident #2 had no symptom presence and frequency during her mood interview. The MDS indicated Resident #2 had delusions (misconceptions or beliefs that are firmly held, contrary to reality), verbal behavioral symptoms directed towards others 4 to 6 days, rejected evaluations or care daily, and did not wander. The MDS also indicated Resident #2 was received antipsychotic medications for 2 days, on a routine basis, no gradual dose reductions were attempted, and gradual dose reductions were not documented by a physician as clinically contraindicated. The MDS indicated Resident #2 was independent with her bed mobility, transfers, walking between locations in her room and corridor on same floor, and eating and required supervision with walking in corridor on unit, dressing, and personal hygiene. Review of Resident #2's care plan revised on 3/22/23 revealed under one of her problems that started on 9/17/22 and was edited on 3/22/23 by RN A, she had socially inappropriate/disruptive behavioral symptoms as evidenced by having difficulty navigating in social situations and interactions, has conversations with self and others not there, voices paranoid thinking, can become verbally and physically aggressive, refuses care routinely secondary to Paranoid Schizophrenia, Anxiety, and Dementia. The goal for Resident #2's problem that was edited on 3/9/23 by RN A revealed she will not exhibit socially inappropriate/disruptive behavior. Current socially inappropriate/disruptive behavior pattern included difficulty interacting and awareness of other residents and navigating self in social settings. One of the approaches started on 9/17/22 revealed staff must Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Another approach started on 9/17/22 revealed staff must help Resident #2 Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Two other approaches started on 9/17/22 revealed staff must Remove resident from other residents' rooms and unsafe situations, When resident becomes socially inappropriate/disruptive, move resident to a quiet, calm environment. Review of Resident #2's progress note dated 9/17/22 at 6:40pm by LVN A revealed at approximately 5:00pm, she observed Resident #2 rolling in the hall in her wheelchair. LVN A heard shouts move, no you move. LVN A saw two residents in the hall side by side in their wheelchairs. The two residents were unable to pass with obstacles in the hall. LVN A got up to attend to the matter before it went too far. Before LVN A could reach Resident #2, Resident #2 was struck in the head repeatedly by Resident #1. A CNA closer to the residents than LVN A broke up the physical altercation. Resident #2 was assessed and had no apparent injuries. The progress note did not indicate whether Resident #2 was assessed by psychiatry after the incident. Review of Resident #2's progress note dated 3/21/23 at 12:09pm by the SW revealed Resident #2 mentioned pain in one area of her body and denied any other pain. Resident #2 said she was okay, but she wanted to talk to the police. The SW informed the nurse of Resident #2's pain and contacted the police to send a law enforcement office to the facility. Review of Resident #2's progress note dated 3/21/23 at 1:44pm by the ADON revealed Resident #2 had an altercation with another resident around 9:30am. Resident #2 was noted standing in the threshold of the doorway waiting for HL to finish cleaning her room. Resident #2's behavior was to yell. Resident #1 was in the hallway. Resident #1 rolled his wheelchair over to Resident #2, stood up from his wheelchair, grabbed her hair, and punched her. HL witnessed the altercation. Police came to investigate the incident. Residents #1 and #2 were separated. Resident #1 was to be moved from facility. The progress note did not indicate whether Resident #2 was assessed by psychiatry after the incident. Resident #3 Review of Resident #3's face sheet dated 4/29/23 revealed he was originally admitted on [DATE] and returned 2/26/23. Resident #3's primary diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (blood pressure that is higher than normal), cognitive communication deficit (difficulty with thinking and how someone uses language), muscle weakness, and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 11. The MDS indicated Resident #3 had no symptom presence and frequency during his mood interview. The MDS also indicated Resident #3 had no potential indicators of psychosis, did not exhibit any physical, verbal, or other behavioral symptoms toward others, did not reject evaluations or care, and did not wander. The MDS indicated Resident #3 required supervision with bed mobility, moving between locations, and eating, limited assistance with transfers and toilet use, extensive assistance with dressing and personal hygiene, and was independent with moving and returning from off-unit locations. Review of Resident #3's care plan revised on 3/9/23 revealed under one of his problems that started on 7/15/22 and edited on 2/22/23 by RN A, he had a memory/recall problem/severe cognitive deficit. The goal for Resident #3's problem that was edited on 2/22/23 revealed he will not sustain serious injury due to memory/recall deficit. Two of the approaches started on 7/15/22 included ensure resident's areas were free of hazards and redirect resident when entering unsafe areas. Review of Resident #3's progress note dated 11/7/22 at 3:09pm by LVN B revealed Resident #3 was seen in a physical altercation with another resident. Both residents were seen pulling on each other's shirts, scratching, and punching the other. Residents were quickly pulled apart from one another. No injuries were present on Resident #3 at the time and Resident #3 did not complain of any pain. The progress note did not indicate whether Resident #3 was assessed by psychiatry after the incident. Resident #1 Review of Resident #1's face sheet dated 4/28/23 revealed he was admitted to the facility on [DATE] with primary diagnoses including cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), bipolar disorder (disorder associated with episodes of mood swings), schizophrenia (mental disorder in which people interpret reality abnormally), psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), restlessness and agitation. Review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15. The MDS indicated Resident #1 did not have any symptoms present during his mood interview. The MDS also indicated Resident #1 did not have any potential indicators of psychosis, did not exhibit any physical, verbal, or other behaviors towards others, did not reject evaluations or care, and did not wander. The MDS indicated Resident #1 required supervision with his bed mobility, was independent with his transfers, walking in room and corridor, moving between locations, and eating, limited assistance with toilet use, and extensive assistance with dressing and personal hygiene. The MDS also indicated Resident #1 received antipsyhotic, antiaxiety, and antidepressant medications for 7 days, received antipsychotics on a routine basis, did not have a physician document a gradual dose reduction as clinically contraindicated, and did not have a gradual dose reduction documented by a physician and clinically contraindicated. Review of Resident #1's care plan revised on 3/22/23 revealed under one of his problems that started on 9/17/22 and was edited on 3/22/23 by the former DON, he had socially inappropriate/disruptive behavioral symptoms as evidenced by physical and verbal aggression towards other residents and staff secondary to Bipolar D/O, TBI, Schizophrenia, Psychotic D/O with Hallucinations, Anxiety, Restlessness & Agitation. The goal for Resident #1's problem that was edited on 3/9/23 by RN A revealed he not harm self or others secondary to socially inappropriate/disruptive behavior. Current behavior pattern included verbal and physical aggression in certain social situations when his needs or demands are not met immediately. One of the approaches started on 9/17/22 and edited on 9/18/22 revealed staff must Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Another approach started on 9/17/22 and edited on 9/18/22 revealed staff must help Resident #1 Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Review of Resident #1's psychiatry clinical note dated 9/21/22 stated under the behavior section: Medication has been taken regularly. He needs assists or cues to get self-care done. His relationships with staff and other residents are improving. His anger is well controlled. Impulsive behaviors are not currently being displayed . The note also stated under the staff report section: [NAME] had an altercation with another resident on 9/17 where he and another female resident got into a verbal dispute that resulted in patient grabbing female resident and punching her several times in the head. Once the incident was broken up he went to his room and no further incidents between the two were noted. When discussing these behaviors with patient he is remorseful and apologizes for his impulsive behaviors when angry. Provider discussed events with patient's mom so she could also address them with him as well. Review of Resident #1's psychiatry clinical note dated 11/11/22 stated under the behavior section: Medication has been taken regularly. He needs assists or cues to get self-care done. His relationships with staff and other residents are normal. His anger is well controlled. Impulsive behaviors are not currently being displayed . There was no staff report section included in the note regarding Residents #1 and #3's incident on 11/7/22. Review of Resident #1's psychiatry clinical note dated 3/24/23 stated under the behavior section: Medication has been taken regularly. He needs assists or cues to get self-care done. He is socializing less with staff and other residents. [NAME]'s anger is poorly controlled. Impulsive behaviors continue to be a problem. The note also stated under the staff report section: [NAME] had a major altercation on 3/21/23 (provider was not notified until today). His neighbor was out in the hallway yelling and cursing at the housekeeper who was cleaning her room and [NAME] came out to where she was in the hallway and yelled at her to be quiet. This caused her to keep yelling and then turn her anger toward him and they exchanged words until [NAME] got up from his wheelchair and began punching the other resident. [NAME] has since been moved to another hall away from her room and no incidents between the two or any other resident have occurred since then. When provider asks [NAME] about this incident he states, it wasn't my finest moment .I just snapped. He is remorseful today about events that happened. Review of Resident #1's progress note dated 9/17/22 at 5:40pm, written by LVN A revealed at approximately 5:00pm, she observed Residents #1 and #2 engage in a verbal dispute. LVN A started to walk from the nursing station toward Residents #1 and #2 to stop the matter. Before LVN A could reach Residents #1 and #2 as they sat in their wheelchairs at the beginning of D hall, she observed Resident #1 hold Resident #2 and strike her repeatedly with a closed fist on the top of her head and on the side of her head. There were other residents seated in the lobby area between LVN A and Residents #1 and #2. LVN A called for Resident #1 to stop. A CNA working on D hall reached Residents #1 and #2 before LVN A and removed Resident #1's grasp of Resident #2. LVN A rolled Resident #1 to his room. Review of Resident #1's progress note dated 11/07/22 at 2:55pm, written by LVN B revealed Resident #1 was seen in a physical altercation with another resident. Resident #1 and the other resident were pulling on each other's shirts, scratching, and punching. Resident #1 and the other resident were quickly pulled apart by a CNA and CMA. Resident #1 began yelling at the other resident that he would kill him. When Resident #1 was asked what happened, he stated, He wouldn't stop kicking my chair and told me to move, that's why I beat his ass. The progress note did not indicate whether Resident #1 was assessed by psychiatry after the incident. Review of Resident #1's progress note dated 3/21/23 at 1:33pm written by the ADON revealed at approximately 9:30am, she heard shouting on D hall. Residents #1 and #2 were physically fighting in the hall. HL witnessed the altercation that lasted a few seconds. Resident #1 grabbed Resident #2 by her hair and punched her in her head and breast area. Resident #1 stated he snapped when Resident #2 was yelling at HL. The ADON took Resident #1 to her office. Law enforcement was called and arrived at the facility because Resident #2 wanted to press charges on Resident #1. Review of Resident #1's progress note dated 3/21/23 at 2:00pm but recorded as a late entry on 03/22/23 at 10:43am written by RN A revealed it was reported to him that Resident #1 became aggressive with another resident. After review, it appeared Resident #1's triggers were loud noises and verbal outbursts from other sources. Review of Resident #1's progress note dated 3/21/23 at 3:30pm written by SW revealed she visited Resident #1 regarding the incident that took place with another resident. Resident #1 stated his actions and stated understanding of the consequences. Review of Provider Investigation Report submitted to the State Agency on 3/21/23 at 11:45am revealed there was a resident to resident incident on 3/21/23 at 9:55am in D Hall. Resident #2 was listed as an individual/resident involved. Resident #2's functional ability was listed as total assistance. Resident #2's level of supervision was listed as within hearing. Resident #2 was listed as interviewable, did not have the capacity to make informed decisions, did not wear a wander guard at the time of the incident, and had a history of physical aggression. Resident #2's other pertinent history revealed she had a history of outbursts, but mostly not towards anyone. Resident #1 was also listed as an individual/resident involved. Resident #1's functional ability was listed as total assistance. Resident #1's level of supervision was listed as within eyesight. Resident #1 was listed as interviewable, not independently ambulatory, had the capacity to make informed decisions, and did not wear a wander guard at the time of the incident, and had a history of physical aggression. Resident #1's other pertinent history revealed he had both physical and verbal aggression towards staff and other residents and had been involved in other altercations in the past. No alleged perpetrators were listed. HL was listed as a witness. No adverse injury or effect were noted. Description of injury revealed there was no injury on either Residents #1 and #2 at the time and both of them were being monitored for late reactions/injuries. Provider response revealed Resident #1 was kept on one-on-one monitoring, removed from the hall to another, medications were reviewed, and emergency care plan with residents family was initiated to discuss his behaviors and a possible discharge. Investigation findings were inconclusive. Provider action taken post-investigation revealed staff were in-serviced on resident to resident altercation, Resident #1 was relocated to another hall, there was an emergency care plan with his family about resident's aggression and the possible discharge if his behaviors continued, and his medications were reviewed. The report did not indicate whether Resident #2 was assessed by psychiatry after the incident. The ADM signed the report on 3/28/23. Review of statements included with the Provider Investigation Report submitted to the State Agency on 3/21/23 at 11:45am revealed HL witnessed the incident between Residents #1 and #2. HL wrote a statement on 3/21/23. HL said in her statement that Resident #1 was punching Resident #2's head, kicking Resident #2, and pulling Resident #2's hair. HL also said in her statement that she tried to open Resident #1's fingers to let Resident #2 go, but Resident #1 was so strong and would not let Resident #2 go. HL said in her statement that she kept telling Resident #1 to stop punching, kicking, and pulling Resident #2. HL also said in her statement that she remembers yelling for her boss, HS, to come help her. HL also said in her statement that Resident #1 eventually let Resident #2 go. HL said in her statement she hoped Resident #2 was okay. Statements also revealed SW met with Resident #2 in the front lobby on 3/21/23 and obtained a statement from her. Resident #2 said in her statement that she was in some pain in the chest area and her head. This information was reported to the charge nurse. Resident #2 also said in her statement that when she was asked what took place, she responded, I don't know. He just started hitting and punching me! I didn't do anything to him. Resident #2 added she wanted to call the police. SW confirmed resident #2 wanted to call the police and resident #2 responded, Yes, that's assault and battery, I know my rights! SW contacted the police and resident #2 waited for their arrival in the front lobby. Statements also revealed SW met with Resident #1 in her office on 3/21/23 and obtained a statement from him. Resident #1 said in his statement that he reported Resident #2 had been keeping him up all night for the past four days with constant yelling and cursing. Resident #1 also said in his statement that when he saw Resident #2 yelling at HL, he just had it. Resident #1 said in his statement when proceeding with the events, I just grabbed her by her hair and kept punching her. Resident #1 added in his statement that he knew what he did was wrong, but he had just had enough. Resident #1 said in his statement that he reported no pain and understood he might have to face some consequences to come. Review of an in-service dated 3/22/23 revealed staff were trained by RN A on monitoring Resident #1, identifying signs of overstimulation (i.e., loud noises, screaming, and arguing), and how to approach a resident who was overstimulated. Staff were trained to encourage the resident to move to a calmer area whenever he/she became overstimulated. Policy and procedure for dealing with resident behaviors undated was attached to the in-service. Review of an in-service dated 3/27/23 revealed staff were trained by the ADM and DON on resident-to-resident altercations. Staff were trained to pay attention to agitation, not to ignore residents since they can ultimately make things worse, and types of behavior are forms of communication. Policy and procedure for resident-to-resident altercation dated December 2016 was attached to the in-service. Review of an in-service dated 4/25/23 revealed staff were trained on abuse and neglect. The in-service did not indicate who trained staff. Staff were trained to protect residents and staff, the definitions for abuse and neglect, what to do if abuse and/or neglect was seen or suspected, and who was the abuse coordinator. Review of resident safety surveys dated 3/23/23 and included with the Provider Investigation Report submitted to the State Agency on 3/21/23 at 11:45am revealed eight residents said no staff or resident harmed or mistreated them, they have not witnessed anyone else being harmed or mistreated, they felt safe staying at the facility, they felt staff respectfully treated them, and they knew how and who to report if they needed to report an incident. Review of Provider Investigation report submitted to the State Agency on 11/8/22 at 8:15pm revealed there was a resident to resident altercation on 11/7/22 at 2:50pm in the living area. Resident #1 was listed as an individual/resident involved. Resident #1's functional ability was listed as total assistance. Resident #1's level of supervision was listed as within hearing. Resident #1 was listed as interviewable, did not have the capacity to make informed decisions, had no indication of wearing a wander guard at the time of the incident, and had a history of physical aggression. Resident #1's other pertinent history revealed he had a history of engaging in physical and verbal altercations with other residents and staff. Resident #3 was also listed as an individual/resident involved. Resident #3's functional ability was listed as total assistance. Resident #3's level of supervision was listed as within hearing. Resident #3 was listed as interviewable, had the capacity to make informed decisions, and did not wear a wander guard at the time of the incident. Resident #3's other pertinent history revealed he was usually quiet and sits with other residents to watch tv in the living area. No alleged perpetrators were listed. A former staff member was listed as a witness. No adverse injury or effect were noted. No description of injury was noted. Description of allegation noted a charge nurse reported and documented Residents #1 and #3 were seen in the living area holding each others' shirts and punching each other. Provider response revealed Residents #1 and #3 were put on one-on-one monitoring, observed for 72 hours for any adverse effects from incidents, and staff were in-serviced on resident-to-resident altercation. Investigation findings were confirmed. Investigation summary noted Residents #1 and #3 were involved in altercation, both residents were doing well during the investigation, and have stated they were not in pain. Provider action taken post-investigation revealed Residents #1 and #3 were monitored for behaviors, injuries, and psychological or emotional distress resulting from the incident and staff were in-serviced on resident-to-resident altercation. The report did not indicate whether Residents #1 and #3 were assessed by psychiatry after the incident. The ADM signed the report on 11/14/22. Review of statements included with the Provider Investigation Report submitted to the State Agency on 11/8/22 at 8:15pm revealed SW met with Resident #3 at bedside on 11/8/22 and obtained a statement from him. Resident #3 said in his statement that Resident #1 kept pushing his chair. Resident #3 also said in his statement that in return, he got ready to hit him. Resident #3 said in his statement that he was okay and just in minor pain from the altercation with Resident #1. Statements also revealed SW met with Resident #1 in her office on 11/8/22. Resident #1 said in his statement that Resident #3 pushed his chair and added, he always does this and I'm tired of it! Resident #1 also said in his statement that in return, he got up and punched him in the face. Resident #1 said in his statement that he was okay now and in better spirits. Review of resident safety surveys dated 11/9/22 and included with the Provider Investigation Report submitted to the State Agency on 11/8/22 at 8:15pm revealed six residents said no staff or resident harmed or mistreated them, they have not witnessed anyone else being harmed or mistreated, they felt safe staying at the facility, they felt staff respectfully treated them, and they knew how and who to report if they needed to report an incident. Review of an in-service dated 11/14/22 revealed staff were trained on resident to resident altercation. The in-service did not indicate who trained staff. Staff were trained to redirect residents when they were having an outburst that can lead to an altercation. Policies and procedures for resident-to-resident altercation dated December 2016 and dealing with resident behaviors undated were attached to the in-service. Review of a Provider Investigation Report submitted to the State Agency on 9/17/22 at 6:45pm revealed there was a resident on resident altercation on 9/17/22 at 5:00pm in the hallway. Resident #1 was listed as an individual/resident involved. Resident #1's functional ability was listed as total assistance. Resident #1's level of supervision was listed as within eyesight. Resident #1 was listed as interviewable, did not have the capacity to make informed decisions, had no indication of wearing a wander guard at the time of the incident, and had a history of physical aggression. Resident #1's other pertinent history revealed he had a history of aggressive behaviors towards other residents and staff and was unable to control his emotions prior to his cerebral infarction. Resident #2 was also listed as an individual/resident involved. Resident #2's functional ability was listed as minimal. Resident #2's level of supervision was listed as within eyesight. Resident #2 was listed as interviewable, did not have the capacity to make informed decisions, did not wear a wander guard at the time of the incident, and had a history of verbal aggression. Resident #2's other pertinent history revealed she had a diagnosis of schizophrenia, anxiety disorder due to known physiological condition, wandered to other residents' rooms sometimes as early as 2:00am and some of them were aggravated when she wandered into their room, and prior to incident wandered into Resident #1's room and he woke up from sleep. No alleged perpetrators were listed. No witnesses were listed. No adverse injury or effect was noted. Description of injury noted no injuries sustained by either of the residents. No description of allegation was noted. Provider response revealed Residents #1 and #2 were put on 72 hour evaluations by nurses and social service, social service conducted daily assessments of both residents for 3 days, Resident #1's Psych NP was notified and indicated she would review his medications, residents were placed on 15 minute checks for late injuries and to avoid re-occurrence, and staff were in-serviced on resident on resident altercations. Investigation findings were confirmed. Provider action taken post-investigation revealed Residents #1 and #2 were put on 72 hour evaluations by nurses and social service, social service conducted daily assessments for 3 days, Resident #1's Psych NP was notified and indicated she was going to review his medications, residents were placed on 15 minute checks for late injuries and to avoid re-occurrence, staff were in-serviced on resident on resident altercations and residents had since been okay. The report did not indicate whether Resident #2 was assessed by psychiatry after the incident. The ADM signed the report on 9/24/22. Review of CNA C witness statement dated 9/17/22, indicated CNA C was putting a resident in her geri-chair. CNA C said in her statement Resident #1 started yelling at her to move. CNA C stated she told Resident #1 she was almost done putting the resident in her geri-chair. CNA C stated Resident #1 proceeded through her and the resident she was helping. CNA C stated Resident #1 hit the other resident's feet with his wheelchair as she was going down with the hoyer lift and she told Resident #1 that's rude. CNA C stated Resident #1 told her to move because she was in his way and about time she did her job. CNA C told Resident #1 she always did her job and Resident #1 said Fuck you, you don't do shit. CNA C said she ended all conversation with Resident #1. CNA C indicated Resident #1 was very rude, bullied other residents, and some residents were even scared to go around him. CNA C stated Resident #1 entered another resident's room while the resident was in the hospital and took his personal items, drinks, food, and money and bragged about it. CNA C indicated she witnessed and reported Resident #1 several times running over another resident's feet, telling her to move, calling her names, pushing her chair to where he was trying to move her until she hit the wall, cussing at the nurses, calling the nurses names, and knocking things off the nurse's cart when he was mad. Review of CNA D's witness statement dated 9/17/22, indicated she heard Resident #1 and #2 arguing in the hallway. CNA D indicated Resident #2 was talking, Resident #1 punched her repeatedly in the face until she came running back down the hallway to stop him. Review of Resident #2's statements written by the SW on 9/19/22 indicated Resident #2 did not know what the SW was referring to when she spoke with her regarding the incident. Resident #2 indicated she had no concerns or complaints regarding the weekend. Further review revealed the SW followed up with Resident #2 on 9/20/22 and 9/22/22. Resident #2 asked the SW why she kept asking her about the past weekend and appeared to not recall what the SW was referring to. Review of Resident #1's statement written by the SW dated 9/19/22 revealed Resident #1 said he was not harmed or upset about the event involving Resident #2 on 9/17/22 and had no concerns or complaints regarding the weekend. The SW followed up with Resident #1 on 9/20/22 and 9/22/22. Resident #1 said \he was over it, fine, and had no concerns or complaints regarding the weekend. Resident safety surveys dated 9/19/22 revealed eight residents said no staff or resident harmed or mistreated them, they have not witnessed anyone else being harmed or mistreated, they felt safe staying at the facility, they felt staff respectfully treated them, and they knew how and who to report if they needed to report an incident. Review of an in-service dated 9/18/22 revealed staff were trained on abuse prevention. The in-service did not indicate who trained staff. Review of an in-service dated 9/18/22 revealed staff were trained on dealing with resident behaviors and resident-to-resident altercations. A former DON trained staff. Resident Monitoring 15 Minute Checks Forms dated 9/17/22, 9/18/22, and 9/19/22 revealed Residents #1 and #2 were checked on by staff every 15 minutes. Staff reported time, Resident #2's location, and signed each entry. During an interview on 4/28/23 at 10:36am, the ADM said the incident between Residents #1 and #2 happened on 3/21/23. The ADM said HL was[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for 3 (Resident #1, Resident #2, and Resident #3) of 68 residents reviewed for incidents. 1. On 9/17/23, a nurse witnessed Resident #1 repeatedly strike Resident #2 in the head. 2. On 11/7/23, staff witnessed Resident #1 and Resident #3 pulling on each other's shirts, scratching, and punching each other. 3. On 3/21/23, HL A witnessed Resident #1 grab Resident #2 by her hair and repeatedly punch her. An IJ was identified on 4/29/23 at 6:21pm. Although the IJ was removed on 05/02/23 at 5:21pm, the facility remained out of compliance at a severity level of no actual harm and scoped at a pattern due to the facility continuing to monitor the implementation and effectiveness of the corrective systems. This failure placed all residents at risk for accidents, serious injury, emotional distress, and death. Findings included: Resident #2 Review of Resident #2's face sheet dated 4/29/23 revealed she was originally admitted to the facility on [DATE] and returned to the facility on 7/8/22 from a Behavioral Hospital. Resident #2's primary diagnoses included hypertension, schizophrenia, dementia, hearing loss, Parkinson's disease, cognitive communication deficit, paranoid schizophrenia, recurrent depressive disorders, and insomnia. Review of Resident #2's quarterly MDS dated [DATE] revealed a BIMS score of 15. The MDS also indicated Resident #2 had no symptom presence and frequency during her mood interview. The MDS indicated Resident #2 had delusions (misconceptions or beliefs that are firmly held, contrary to reality), verbal behavioral symptoms directed towards others 4 to 6 days, rejected evaluations or care daily, and did not wander. The MDS also indicated Resident #2 was received antipsychotic medications for 2 days, on a routine basis, no gradual dose reductions were attempted, and gradual dose reductions were not documented by a physician as clinically contraindicated. The MDS indicated Resident #2 was independent with her bed mobility, transfers, walking between locations in her room and corridor on same floor, and eating and required supervision with walking in corridor on unit, dressing, and personal hygiene. Review of Resident #2's care plan revised on 3/22/23 revealed under one of her problems that started on 9/17/22 and was edited on 3/22/23 by RN A, she had socially inappropriate/disruptive behavioral symptoms as evidenced by having difficulty navigating in social situations and interactions, has conversations with self and others not there, voices paranoid thinking, can become verbally and physically aggressive, refuses care routinely secondary to Paranoid Schizophrenia, Anxiety, and Dementia. The goal for Resident #2's problem that was edited on 3/9/23 by RN A revealed she will not exhibit socially inappropriate/disruptive behavior. Current socially inappropriate/disruptive behavior pattern included difficulty interacting and awareness of other residents and navigating self in social settings. One of the approaches started on 9/17/22 revealed staff must Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Another approach started on 9/17/22 revealed staff must help Resident #2 Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Two other approaches started on 9/17/22 revealed staff must Remove resident from other residents' rooms and unsafe situations, When resident becomes socially inappropriate/disruptive, move resident to a quiet, calm environment. Review of Resident #2's progress note dated 9/17/22 at 6:40pm by LVN A revealed at approximately 5:00pm, she observed Resident #2 rolling in the hall in her wheelchair. LVN A heard shouts move, no you move. LVN A saw two residents in the hall side by side in their wheelchairs. The two residents were unable to pass with obstacles in the hall. LVN A got up to attend to the matter before it went too far. Before LVN A could reach Resident #2, Resident #2 was struck in the head repeatedly by Resident #1. A CNA closer to the residents than LVN A broke up the physical altercation. Resident #2 was assessed and had no apparent injuries. The progress note did not indicate whether Resident #2 was assessed by psychiatry after the incident. Review of Resident #2's progress note dated 3/21/23 at 12:09pm by the SW revealed Resident #2 mentioned pain in one area of her body and denied any other pain. Resident #2 said she was okay, but she wanted to talk to the police. The SW informed the nurse of Resident #2's pain and contacted the police to send a law enforcement office to the facility. The progress note did not indicate whether Resident #2 was assessed by psychiatry after the incident. Review of Resident #2's progress note dated 3/21/23 at 1:44pm by the ADON revealed Resident #2 had an altercation with another resident around 9:30am. Resident #2 was noted standing in the threshold of the doorway waiting for HL to finish cleaning her room. Resident #2's behavior was to yell. Resident #1 was in the hallway. Resident #1 rolled his wheelchair over to Resident #2, stood up from his wheelchair, grabbed her hair, and punched her. HL witnessed the altercation. Police came to investigate the incident. Residents #1 and #2 were separated. Resident #1 was to be moved from facility. The progress note did not indicate whether Resident #2 was assessed by psychiatry after the incident. Resident #3 Review of Resident #3's face sheet dated 4/29/23 revealed he was originally admitted on [DATE] and returned 2/26/23. Resident #3's primary diagnoses included cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), hypertension (blood pressure that is higher than normal), cognitive communication deficit (difficulty with thinking and how someone uses language), muscle weakness, and anxiety disorder (feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities). Review of Resident #3's quarterly MDS dated [DATE] revealed a BIMS score of 11. The MDS indicated Resident #3 had no symptom presence and frequency during his mood interview. The MDS also indicated Resident #3 had no potential indicators of psychosis, did not exhibit any physical, verbal, or other behavioral symptoms toward others, did not reject evaluations or care, and did not wander. The MDS indicated Resident #3 required supervision with bed mobility, moving between locations, and eating, limited assistance with transfers and toilet use, extensive assistance with dressing and personal hygiene, and was independent with moving and returning from off-unit locations. Review of Resident #3's care plan revised on 3/9/23 revealed under one of his problems that started on 7/15/22 and edited on 2/22/23 by RN A, he had a memory/recall problem/severe cognitive deficit. The goal for Resident #3's problem that was edited on 2/22/23 revealed he will not sustain serious injury due to memory/recall deficit. Two of the approaches started on 7/15/22 included ensure resident's areas were free of hazards and redirect resident when entering unsafe areas. Review of Resident #3's progress note dated 11/7/22 at 3:09pm by LVN B revealed Resident #3 was seen in a physical altercation with another resident. Both residents were seen pulling on each other's shirts, scratching, and punching the other. Residents were quickly pulled apart from one another. No injuries were present on Resident #3 at the time and Resident #3 did not complain of any pain. The progress note did not indicate whether Resident #3 was assessed by psychiatry after the incident. Resident #1 Review of Resident #1's face sheet dated 4/28/23 revealed he was admitted to the facility on [DATE] with primary diagnoses including cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), bipolar disorder (disorder associated with episodes of mood swings), schizophrenia (mental disorder in which people interpret reality abnormally), psychotic disorder (severe mental disorders that cause abnormal thinking and perceptions), anxiety disorder (mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), restlessness and agitation. Review of Resident #1's quarterly MDS dated [DATE] revealed a BIMS score of 15. The MDS indicated Resident #1 did not have any symptoms present during his mood interview. The MDS also indicated Resident #1 did not have any potential indicators of psychosis, did not exhibit any physical, verbal, or other behaviors towards others, did not reject evaluations or care, and did not wander. The MDS indicated Resident #1 required supervision with his bed mobility, was independent with his transfers, walking in room and corridor, moving between locations, and eating, limited assistance with toilet use, and extensive assistance with dressing and personal hygiene. The MDS also indicated Resident #1 received antipsyhotic, antiaxiety, and antidepressant medications for 7 days, received antipsychotics on a routine basis, did not have a physician document a gradual dose reduction as clinically contraindicated, and did not have a gradual dose reduction documented by a physician and clinically contraindicated. Review of Resident #1's care plan revised on 3/22/23 revealed under one of his problems that started on 9/17/22 and was edited on 3/22/23 by the former DON, he had socially inappropriate/disruptive behavioral symptoms as evidenced by physical and verbal aggression towards other residents and staff secondary to Bipolar D/O, TBI, Schizophrenia, Psychotic D/O with Hallucinations, Anxiety, Restlessness & Agitation. The goal for Resident #1's problem that was edited on 3/9/23 by RN A revealed he not harm self or others secondary to socially inappropriate/disruptive behavior. Current behavior pattern included verbal and physical aggression in certain social situations when his needs or demands are not met immediately. One of the approaches started on 9/17/22 and edited on 9/18/22 revealed staff must Assess whether the behavior endangers the resident and/or others. Intervene if necessary. Another approach started on 9/17/22 and edited on 9/18/22 revealed staff must help Resident #1 Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Review of Resident #1's progress note dated 9/17/22 at 5:40pm, written by LVN A revealed at approximately 5:00pm, she observed Residents #1 and #2 engage in a verbal dispute. LVN A started to walk from the nursing station toward Residents #1 and #2 to stop the matter. Before LVN A could reach Residents #1 and #2 as they sat in their wheelchairs at the beginning of D hall, she observed Resident #1 hold Resident #2 and strike her repeatedly with a closed fist on the top of her head and on the side of her head. There were other residents seated in the lobby area between LVN A and Residents #1 and #2. LVN A called for Resident #1 to stop. A CNA working on D hall reached Residents #1 and #2 before LVN A and removed Resident #1's grasp of Resident #2. LVN A rolled Resident #1 to his room. Review of Resident #1's psychiatry clinical note dated 9/21/22 stated under the behavior section: Medication has been taken regularly. He needs assists or cues to get self-care done. His relationships with staff and other residents are improving. His anger is well controlled. Impulsive behaviors are not currently being displayed . The note also stated under the staff report section: [NAME] had an altercation with another resident on 9/17 where he and another female resident got into a verbal dispute that resulted in patient grabbing female resident and punching her several times in the head. Once the incident was broken up he went to his room and no further incidents between the two were noted. When discussing these behaviors with patient he is remorseful and apologizes for his impulsive behaviors when angry. Provider discussed events with patient's mom so she could also address them with him as well. Review of Resident #1's psychiatry clinical note dated 11/11/22 stated under the behavior section: Medication has been taken regularly. He needs assists or cues to get self-care done. His relationships with staff and other residents are normal. His anger is well controlled. Impulsive behaviors are not currently being displayed . There was no staff report section included in the note regarding Residents #1 and #3's incident on 11/7/22. Review of Resident #1's psychiatry clinical note dated 3/24/23 stated under the behavior section: Medication has been taken regularly. He needs assists or cues to get self-care done. He is socializing less with staff and other residents. [NAME]'s anger is poorly controlled. Impulsive behaviors continue to be a problem. The note also stated under the staff report section: [NAME] had a major altercation on 3/21/23 (provider was not notified until today). His neighbor was out in the hallway yelling and cursing at the housekeeper who was cleaning her room and [NAME] came out to where she was in the hallway and yelled at her to be quiet. This caused her to keep yelling and then turn her anger toward him and they exchanged words until [NAME] got up from his wheelchair and began punching the other resident. [NAME] has since been moved to another hall away from her room and no incidents between the two or any other resident have occurred since then. When provider asks [NAME] about this incident he states, it wasn't my finest moment .I just snapped. He is remorseful today about events that happened. Resident #1's progress note dated 9/17/22 at 5:40pm, written by LVN A revealed at approximately 5:00pm, she observed Residents #1 and #2 engage in a verbal dispute. LVN A started to walk from the nursing station toward Residents #1 and #2 to stop the matter. Before LVN A could reach Residents #1 and #2 as they sat in their wheelchairs at the beginning of D hall, she observed Resident #1 hold Resident #2 and strike her repeatedly with a closed fist on the top of her head and on the side of her head. There were other residents seated in the lobby area between LVN A and Residents #1 and #2. LVN A called for Resident #1 to stop. A CNA working on D hall reached Residents #1 and #2 before LVN A and removed Resident #1's grasp of Resident #2. LVN A rolled Resident #1 to his room. Review of Resident #1's progress note dated 11/07/22 at 2:55pm, written by LVN B revealed Resident #1 was seen in a physical altercation with another resident. Resident #1 and the other resident were pulling on each other's shirts, scratching, and punching. Resident #1 and the other resident were quickly pulled apart by a CNA and CMA. Resident #1 began yelling at the other resident that he would kill him. When Resident #1 was asked what happened, he stated, He wouldn't stop kicking my chair and told me to move, that's why I beat his ass. The progress note did not indicate whether Resident #1 was assessed by psychiatry after the incident. Review of Resident #1's progress note dated 3/21/23 at 1:33pm written by the ADON revealed at approximately 9:30am, she heard shouting on D hall. Residents #1 and #2 were physically fighting in the hall. HL witnessed the altercation that lasted a few seconds. Resident #1 grabbed Resident #2 by her hair and punched her in her head and breast area. Resident #1 stated he snapped when Resident #2 was yelling at HL. The ADON took Resident #1 to her office. Law enforcement was called and arrived at the facility because Resident #2 wanted to press charges on Resident #1. Review of Resident #1's progress note dated 3/21/23 at 2:00pm but recorded as a late entry on 03/22/23 at 10:43am written by RN A revealed it was reported to him that Resident #1 became aggressive with another resident. After review, it appeared Resident #1's triggers were loud noises and verbal outbursts from other sources. Review of Resident #1's progress note dated 3/21/23 at 3:30pm written by SW revealed she visited Resident #1 regarding the incident that took place with another resident. Resident #1 stated his actions and stated understanding of the consequences. Review of Provider Investigation Report submitted to the State Agency on 3/21/23 at 11:45am revealed there was a resident to resident incident on 3/21/23 at 9:55am in D Hall. Resident #2 was listed as an individual/resident involved. Resident #2's functional ability was listed as total assistance. Resident #2's level of supervision was listed as within hearing. Resident #2 was listed as interviewable, did not have the capacity to make informed decisions, did not wear a wander guard at the time of the incident, and had a history of physical aggression. Resident #2's other pertinent history revealed she had a history of outbursts, but mostly not towards anyone. Resident #1 was also listed as an individual/resident involved. Resident #1's functional ability was listed as total assistance. Resident #1's level of supervision was listed as within eyesight. Resident #1 was listed as interviewable, not independently ambulatory, had the capacity to make informed decisions, and did not wear a wander guard at the time of the incident, and had a history of physical aggression. Resident #1's other pertinent history revealed he had both physical and verbal aggression towards staff and other residents and had been involved in other altercations in the past. No alleged perpetrators were listed. HL was listed as a witness. No adverse injury or effect were noted. Description of injury revealed there was no injury on either Residents #1 and #2 at the time and both of them were being monitored for late reactions/injuries. Provider response revealed Resident #1 was kept on one-on-one monitoring, removed from the hall to another, medications were reviewed, and emergency care plan with residents family was initiated to discuss his behaviors and a possible discharge. Investigation findings were inconclusive. Provider action taken post-investigation revealed staff were in-serviced on resident to resident altercation, Resident #1 was relocated to another hall, there was an emergency care plan with his family about resident's aggression and the possible discharge if his behaviors continued, and his medications were reviewed. The ADM signed the report on 3/28/23. Review of statements included with the Provider Investigation Report submitted to the State Agency on 3/21/23 at 11:45am revealed HL witnessed the incident between Residents #1 and #2. HL wrote a statement on 3/21/23. HL said in her statement that Resident #1 was punching Resident #2's head, kicking Resident #2, and pulling Resident #2's hair. HL also said in her statement that she tried to open Resident #1's fingers to let Resident #2 go, but Resident #1 was so strong and would not let Resident #2 go. HL said in her statement that she kept telling Resident #1 to stop punching, kicking, and pulling Resident #2. HL also said in her statement that she remembers yelling for her boss, HS, to come help her. HL also said in her statement that Resident #1 eventually let Resident #2 go. HL said in her statement she hoped Resident #2 was okay. Statements also revealed SW met with Resident #2 in the front lobby on 3/21/23 and obtained a statement from her. Resident #2 said in her statement that she was in some pain in the chest area and her head. This information was reported to the charge nurse. Resident #2 also said in her statement that when she was asked what took place, she responded, I don't know. He just started hitting and punching me! I didn't do anything to him. Resident #2 added she wanted to call the police. SW confirmed resident #2 wanted to call the police and resident #2 responded, Yes, that's assault and battery, I know my rights! SW contacted the police and resident #2 waited for their arrival in the front lobby. Statements also revealed SW met with Resident #1 in her office on 3/21/23 and obtained a statement from him. Resident #1 said in his statement that he reported Resident #2 had been keeping him up all night for the past four days with constant yelling and cursing. Resident #1 also said in his statement that when he saw Resident #2 yelling at HL, he just had it. Resident #1 said in his statement when proceeding with the events, I just grabbed her by her hair and kept punching her. Resident #1 added in his statement that he knew what he did was wrong, but he had just had enough. Resident #1 said in his statement that he reported no pain and understood he might have to face some consequences to come. Review of an in-service dated 3/22/23 revealed staff were trained by RN A on monitoring Resident #1, identifying signs of overstimulation (i.e., loud noises, screaming, and arguing), and how to approach a resident who was overstimulated. Staff were trained to encourage the resident to move to a calmer area whenever he/she became overstimulated. Policy and procedure for dealing with resident behaviors undated was attached to the in-service. Review of an in-service dated 3/27/23 revealed staff were trained by the ADM and DON on resident-to-resident altercations. Staff were trained to pay attention to agitation, not to ignore residents since they can ultimately make things worse, and types of behavior are forms of communication. Policy and procedure for resident-to-resident altercation dated December 2016 was attached to the in-service. Review of an in-service dated 4/25/23 revealed staff were trained on abuse and neglect. The in-service did not indicate who trained staff. Staff were trained to protect residents and staff, the definitions for abuse and neglect, what to do if abuse and/or neglect was seen or suspected, and who was the abuse coordinator. Review of resident safety surveys dated 3/23/23 and included with the Provider Investigation Report submitted to the State Agency on 3/21/23 at 11:45am revealed eight residents said no staff or resident harmed or mistreated them, they have not witnessed anyone else being harmed or mistreated, they felt safe staying at the facility, they felt staff respectfully treated them, and they knew how and who to report if they needed to report an incident. Review of Provider Investigation report submitted to the State Agency on 11/8/22 at 8:15pm revealed there was a resident to resident altercation on 11/7/22 at 2:50pm in the living area. Resident #1 was listed as an individual/resident involved. Resident #1's functional ability was listed as total assistance. Resident #1's level of supervision was listed as within hearing. Resident #1 was listed as interviewable, did not have the capacity to make informed decisions, had no indication of wearing a wander guard at the time of the incident, and had a history of physical aggression. Resident #1's other pertinent history revealed he had a history of engaging in physical and verbal altercations with other residents and staff. Resident #3 was also listed as an individual/resident involved. Resident #3's functional ability was listed as total assistance. Resident #3's level of supervision was listed as within hearing. Resident #3 was listed as interviewable, had the capacity to make informed decisions, and did not wear a wander guard at the time of the incident. Resident #3's other pertinent history revealed he was usually quiet and sits with other residents to watch tv in the living area. No alleged perpetrators were listed. A former staff member was listed as a witness. No adverse injury or effect were noted. No description of injury was noted. Description of allegation noted a charge nurse reported and documented Residents #1 and #3 were seen in the living area holding each others' shirts and punching each other. Provider response revealed Residents #1 and #3 were put on one-on-one monitoring, observed for 72 hours for any adverse effects from incidents, and staff were in-serviced on resident-to-resident altercation. Investigation findings were confirmed. Investigation summary noted Residents #1 and #3 were involved in altercation, both residents were doing well during the investigation, and have stated they were not in pain. Provider action taken post-investigation revealed Residents #1 and #3 were monitored for behaviors, injuries, and psychological or emotional distress resulting from the incident and staff were in-serviced on resident-to-resident altercation. The ADM signed the report on 11/14/22. Review of statements included with the Provider Investigation Report submitted to the State Agency on 11/8/22 at 8:15pm revealed SW met with Resident #3 at bedside on 11/8/22 and obtained a statement from him. Resident #3 said in his statement that Resident #1 kept pushing his chair. Resident #3 also said in his statement that in return, he got ready to hit him. Resident #3 said in his statement that he was okay and just in minor pain from the altercation with Resident #1. Statements also revealed SW met with Resident #1 in her office on 11/8/22. Resident #1 said in his statement that Resident #3 pushed his chair and added, he always does this and I'm tired of it! Resident #1 also said in his statement that in return, he got up and punched him in the face. Resident #1 said in his statement that he was okay now and in better spirits. Review of resident safety surveys dated 11/9/22 and included with the Provider Investigation Report submitted to the State Agency on 11/8/22 at 8:15pm revealed six residents said no staff or resident harmed or mistreated them, they have not witnessed anyone else being harmed or mistreated, they felt safe staying at the facility, they felt staff respectfully treated them, and they knew how and who to report if they needed to report an incident. Review of an in-service dated 11/14/22 revealed staff were trained on resident to resident altercation. The in-service did not indicate who trained staff. Staff were trained to redirect residents when they were having an outburst that can lead to an altercation. Policies and procedures for resident-to-resident altercation dated December 2016 and dealing with resident behaviors undated were attached to the in-service. Review of a Provider Investigation Report submitted to the State Agency on 9/17/22 at 6:45pm revealed there was a resident on resident altercation on 9/17/22 at 5:00pm in the hallway. Resident #1 was listed as an individual/resident involved. Resident #1's functional ability was listed as total assistance. Resident #1's level of supervision was listed as within eyesight. Resident #1 was listed as interviewable, did not have the capacity to make informed decisions, had no indication of wearing a wander guard at the time of the incident, and had a history of physical aggression. Resident #1's other pertinent history revealed he had a history of aggressive behaviors towards other residents and staff and was unable to control his emotions prior to his cerebral infarction. Resident #2 was also listed as an individual/resident involved. Resident #2's functional ability was listed as minimal. Resident #2's level of supervision was listed as within eyesight. Resident #2 was listed as interviewable, did not have the capacity to make informed decisions, did not wear a wander guard at the time of the incident, and had a history of verbal aggression. Resident #2's other pertinent history revealed she had a diagnosis of schizophrenia, anxiety disorder due to known physiological condition, wandered to other residents' rooms sometimes as early as 2:00am and some of them were aggravated when she wandered into their room, and prior to incident wandered into Resident #1's room and he woke up from sleep. No alleged perpetrators were listed. No witnesses were listed. No adverse injury or effect was noted. Description of injury noted no injuries sustained by either of the residents. No description of allegation was noted. Provider response revealed Residents #1 and #2 were put on 72 hour evaluations by nurses and social service, social service conducted daily assessments of both residents for 3 days, Resident #1's Psych NP was notified and indicated she would review his medications, residents were placed on 15 minute checks for late injuries and to avoid re-occurrence, and staff were in-serviced on resident on resident altercations. Investigation findings were confirmed. Provider action taken post-investigation revealed Residents #1 and #2 were put on 72 hour evaluations by nurses and social service, social service conducted daily assessments for 3 days, Resident #1's Psych NP was notified and indicated she was going to review his medications, residents were placed on 15 minute checks for late injuries and to avoid re-occurrence, staff were in-serviced on resident on resident altercations and residents had since been okay. The ADM signed the report on 9/24/22. Review of CNA C witness statement dated 9/17/22 indicated CNA C was putting a resident in her geri-chair. CNA C said in her statement Resident #1 started yelling at her to move. CNA C stated she told Resident #1 she was almost done putting the resident in her geri-chair. CNA C stated Resident #1 proceeded through her and the resident she was helping. CNA C stated Resident #1 hit the other resident's feet with his wheelchair as she was going down with the hoyer lift and she told Resident #1 that's rude. CNA C stated Resident #1 told her to move because she was in his way and about time she did her job. CNA C told Resident #1 she always did her job and Resident #1 said Fuck you, you don't do shit. CNA C said she ended all conversation with Resident #1. CNA C indicated Resident #1 was very rude, bullied other residents, and some residents were even scared to go around him. CNA C stated Resident #1 entered another resident's room while the resident was in the hospital and took his personal items, drinks, food, and money and bragged about it. CNA C indicated she witnessed and reported Resident #1 several times running over another resident's feet, telling her to move, calling her names, pushing her chair to where he was trying to move her until she hit the wall, cussing at the nurses, calling the nurses names, and knocking things off the nurse's cart when he was mad. Review of CNA D's witness statement dated 9/17/22 indicated she heard Resident #1 and #2 arguing in the hallway. CNA D indicated Resident #2 was talking, Resident #1 punched her repeatedly in the face until she came running back down the hallway to stop him. Review of Resident #2's statements written by the SW on 9/19/22 indicated Resident #2 did not know what the SW was referring to when she spoke with her regarding the incident. Resident #2 indicated she had no concerns or complaints regarding the weekend. Further review revealed the SW followed up with Resident #2 on 9/20/22 and 9/22/22. Resident #2 asked the SW why she kept asking her about the past weekend and appeared to not recall what the SW was referring to. Review of Resident #1's statement written by the SW dated 9/19/22 revealed Resident #1 said he was not harmed or upset about the event involving Resident #2 on 9/17/22 and had no concerns or complaints regarding the weekend. The SW followed up with Resident #1 on 9/20/22 and 9/22/22. Resident #1 said he was over it, fine, and had no concerns or complaints regarding the weekend. Resident safety surveys dated 9/19/22 revealed eight residents said no staff or resident harmed or mistreated them, they have not witnessed anyone else being harmed or mistreated, they felt safe staying at the facility,[TRUNCATED]