**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined, for 2 of 35 sampled residents, that the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice. Specifically, full and complete neuro checks were not performed on three separate occasions for two residents who suffered falls with head injuries, and a resident was not taken to the hospital upon being found unresponsive. Additionally, it was discovered this resident had a hip fracture three days later. Resident identifiers: 10 and 32. Findings include: 1. Resident 10 was admitted to the facility on [DATE] with diagnoses which included vascular dementia with behavioral disturbance, encephalopathy, cognitive communication deficit, and unspecified sequelae of cerebral infarction. On 2/19/20 resident 10's medical record was reviewed. Nursing progress notes revealed the following incidents: a. On 10/27/19 at 12:10 PM, Resident [10] was ambulating down hall headed east by shower room when he came up to laundry barrel in hall and he reached for hand rail on wall when he lost balance falling to floor on left side staff that seen (sic) him fall reported that he didn't see him hit his head but was noted to have approx 1 x 1 cm (centimeter) bruise with approx 1/4 cm skin tear on left temple area . b. On 11/8/19 at 4:24 PM, .Neuro checks have been within normal range.[Note: There is no progress note indicating why neuro checks were being done] c. On 11/9/19 at 3:27 AM, Re-injured left eyebrow on fall 11/08/19. [Note: There is no progress note documenting a fall, however, there is an incident report dated 11/7/19 documenting resident 10 being found on the floor] d. On 12/31/19 at 4:12 AM, Approximately 2215 (10:15 PM), [resident 10] fell in his bedroom, and hit his head on the heater in his room. When a facility resident had an unwitnessed fall or an observed fall with head injury, irregularly spaced neurological assessments (neuro checks) were performed over a period of 48 hours. Neurological assessments include, at a minimum, pulse, respiration, and blood pressure measurements; assessment of pupil size and reactivity; equality of hand grip strength; and level of consciousness. Resident 10's neuro checks sheet for the fall on 10/27/19 was missing the following; a. All assessments of level of consciousness, pupil size and reactivity, and hand grip strength. b. All assessments for the 11th, 15th, 19th, 24th, and 48th hours. The neuro check sheets for the falls on 11/9/19 and 12/31/19 were requested. However, the Director of Nursing stated they were missing from the resident's medical record and was unable to provide them. 2. Resident 32 was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's disease, obsessive compulsive disorder, and generalized muscle weakness. On 2/19/20 resident 32's medical record was reviewed. Nursing progress notes revealed the following incidents: a. On 10/10/19, 318-2 pushed [Resident 32] into the wall, hitting her head, and her shoulder on the wall. b. On 11/8/19, CNA (Certified Nursing Assistant) called RN to resident .CNA reports peer stood and pushed her to the floor after she reached for his coffee. c. On 11/16/19, [Resident 32] found on the floor in her room, laying (sic) between her part of the room and 308-2 part of the room .[Resident 32] was laying (sic) on her left side, and unresponsive. The neuro checks sheet for the fall on 10/10/19 was missing the following: a. On the 11th hour check, level of consciousness, pupil size and reactivity, and hand grip strength assessments. b. On the15th hour check, level of consciousness, pupil size and reactivity, and hand grip strength assessments. c. All assessments for the 19th, 24th, 32nd, 40th, and 48th hours. The neuro checks sheet for the fall on 11/8/19 was missing the following: a. For the 45 minute check, blood pressure, pulse, oxygen, level of consciousness, pupil size and reactivity, and hand grip strength assessments. b. For the 90 minute, 2nd and 3rd hour checks, the level of consciousness, pupil size and reactivity, and hand grip strength assessments. c. All assessments for the 1st, 4th, 5th, 6th, 10th, 14th, 30th, 38th, and 46th hours. For the fall on 11/16/19, the assessments of resident 32's level of consciousness, pupil size and reactivity, and hand grip strength were not performed until 14 hours after the fall. There were 11 required times that were missed. Further investigation regarding resident 32's fall on 11/16/19 revealed the following nursing progress notes: a. On 11/16/19 at 7:15 PM, [Resident 32] found on the floor in her room, laying between her part of the room and 308-2 part of the room .[Resident 32] was laying on her left side, and unresponsive .She slowly became responsive, assessed her hips and shoulders, then proceeded to roll her onto her back where a complete physical assessment could be done. Mo (sic) injuries noted at this time 308-2 stated that she pushed [resident 32] down .Neuro checks initiated. Pt (patient) lifted to a chair and removed form the room. b. On 11/17/19 at 5:03 AM, While staff was getting her ready for bed, [Resident 32] looked like she was in pain. Resident had a dose of schedule Tramadol. It seemed that help her with pain. c. On 11/18/19 at 1:33 AM, .[Resident 32] has been limping on her left leg while walking, and has decreased use of left arm, and was seen cradling it some .While awake [resident 32] was walking around the unit, but after sometime it was obvious that she was in pain and she was given pain medication and encouraged to sit either in a normal chair or a wheelchair. d. On 11/19/19 at 4:51 PM, Resident having pain in left hip, arm, and rib areas. Resident putting light pressure on LLE (lower left extremities). MD (medical director) and hospice nurse notified, x-ray of left hip .ordered. X-ray result impression: suspected nondisplaced left femoral neck fracture. Recommended MRI (Magnetic Resonance Imaging) of left hip for confirmation of fracture. On 2/25/2020 at 8:12 AM, RN 3 was interviewed. RN 3 stated that, I walked into the room and asked her roommate what happened. [Roommate name] said ,'I pushed her down'. A head to toe assessment was done, I checked her hips and shoulder then got her back up in her chair. We did neuro checks because obviously being pushed that hard she would have hit her head. On 2/25/2020 at 9:40 AM, a Medical Doctor (MD) 1 was interviewed. MD 1 stated that resident 32 should have been sent to the emergency room that night. MD 1 stated, It's not an automatic given, but if the resident was unresponsive and unable to give an accurate account then sending them out to the hospital would be appropriate.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, it was determined for 1 of 35 sampled residents, that the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and that each resident receives adequate supervision and assistance devices to prevent accidents. Specifically, one resident's care plan was not updated, the resident was not monitored more frequently, moved closer to the nurses' station, nor moved to the third floor for better supervision. Also, the facility failed to keep the facility in good repair and caused the resident to have a fall. Resident identifier: 18. Findings include: Resident 18 was admitted to the facility on [DATE] and readmitted on [DATE] with a diagnosis of fracture left femur, osteoporosis, and diabetes mellitus, and dementia, insomnia, left artificial hip joint, dysphagia, and cognitive communication; hearing loss, gastro-esophageal reflux, and history of falls, abscesses. On 2/20/2020, resident 18's medical record revealed that resident 18 had eight falls with over a seven month period. Nurse's notes had falls occurring on: a. On 6/6/2019 resident 18's roommate was calling for help. We found resident 18 on the floor, laying on resident 18's right side with head towards nightstand. Resident 18 had legs semi-extended. Resident was alert. Nurse and CNAs checked for injuries no injuries were noted. b. On 6/7/2019 resident 18 had another fall this am. Resident 18 was found on the floor parallel next to his bed on his back. When asked what happened, he stated that he fell out of bed, that he did not hit his head. c. On 7/8/2019 resident 18 had un-witnessed fall and has a laceration to left side of head, glued shut by hospice on 7/8. d. On 8/17/2019 resident 18 was found by a CNA in the resident's room found him in the bathroom on the floor. He was setting right in front of the toilet with his back leaning against bathroom wall. Resident 18 was patiently waiting for someone to come and help him up. e. On 10/1/2019 resident 18 had an un-witnessed fall. Resident 18 was found on his knees beside table and chair. No injuries noted. f. On 11/21/2019 it was reported to nurse that resident 18 was near the window and fell during the night. Resident was helped into bed by roommate. Resident was assessed by nurse and found no injuries. g. On 1/6/2020 resident 18 had an un-witnessed fall from toilet about 1300 (1:00 PM) due to toilet broken. Res denied head hit. Skin intact, no bruises noted this time. h. On 1/29/2020 resident 18 was founding sitting on floor in his room about 17:20 PM. Resident 18 is alert to self and complaining of pain on left buttock. Resident 18 could not move of left leg while staff was assessing him. Reported to Centric Physicians. X-ray was ordered and resident's X-ray on the Left hip was taken and the results was faxed back that stated Resident 18 had a fractured femoral neck. Resident 18 was transported to St. Mark's hospital Emergency department. Director of Nursing (DON) was notified and resident 18's sister was called, who said she would contact resident 18's daughter. On 2/25/2020 an interview with the DON was conducted. The DON stated that the following interventions were implemented: 1. Floor mats and pads. 2. Found that he could walk with a walker, so we took those away because they could have been a bigger problem due to resident 18 being unsteady. 3. Good footwear, reminders, wears shoes. 4. Resident 18 doesn't acknowledge his needs. 5. Resident 18 would be found in the bathroom. The DON continued by saying he was admitted from home on the dementia unit. Now I'm more inclined to think he has dementia than when we first got here. He could remember a lot long term but his long term wasn't the greatest. He's fastidious.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 7. Resident 59 was admitted to the facility on [DATE] with diagnoses which included generalized anxiety disorder, impulse disorder, depression, dementia behavioral disturbance, chronic pain, dysphagia, muscle weakness, cognitive communication, concussion with loss of consciousness, psychotic disorder with delusions, transient cerebral ischemic, impulsiveness, and traumatic brain injury. On 2/22/2020, resident 59's medical record was reviewed. Two entries contained information about an abuse incident: a. Nurse progress notes revealed that on 7/31/2019 at 9:36 PM, Resident [59] had an encounter with another resident this evening. She got in the other resident space and right up close to her face and started to tell her to not do something. The other resident then started yelling back and grabbed her by the chest. This occurred for a few seconds until staff separated them. No injuries noted. No redness to chest. No scratching raised areas or markings. Both parties removed from the area and assessed for emotional injuries. MD notified. Administrator notified. b. On 8/7/2019, an Incident Report was filed by the facility Administrator. On 7/31/2019, caregivers separated the residents as resident 4 grabbed residents 59 on her shirt collar and breast area. An investigated was conducted: Resident 4 and 59 and their caregivers were interviewed regarding the incident. Residents 4 and 59 agree that resident 4 grabbed resident 59's shirt collar and then resident 59's breasts in response to resident 4 feeling intimidated by resident 59's posturing and to resident 59's insistence that resident 4 follow facility rules. During the incident resident 4 asked resident 59 if resident 59 would hit her and resident 59 answered affirmatively, but did not return touch of resident 4 during the incident. When assessed and asked, resident 59 experienced no physical harm, however, she did feel emotionally harm from her interaction with resident 4. When asked, Resident 59 feels safe in the facility and is not fearful of resident 4. The incident report investigation determined that Resident 59 did express what she called emotional harm from the incident, abuse is substantiated. 3. Resident 14 was admitted on [DATE] with diagnoses which included Alzheimer's disease, major depressive disorder, anxiety disorder, personal history of self-harm, hypertension, benign prostatic hyperplasia, weakness, hyperlipidemia, and insomnia. Resident 14's medical record was reviewed on 2/19/20. A progress note for resident 14 dated 9/17/19 documented Nurse heard resident yelling 'Get out of here' coming from his room around 1613 (4:13 PM). Nurse went into his room to investigate and found him holding his arms up in the air while 317-3 was standing over him attempting to punch him. Resident stated that 317-3 came into his room and punched him twice in the face. Nurse separated the residents and escorted 317-3 out of resident's room. Nurse then assessed resident for injuries and found his left eye was bruising up and his left cheek was starting to swell. Ice pack was applied to resident's left cheek and eye, PRN pain medication was offered but resident refused it. MD (medical doctor), DON (Director of Nursing), administrator, and daughter notified. A follow-up progress note dated 9/19/19 documented .Recalls incident where peer punched him. Recognizes peer. Avoids peer's path and eye contact with peer. Bruising to left eye is purple/yellow/green. An incident report investigation conducted by the facility administrator on 9/25/19, documented On 09/17/2019, From [resident 14's] description [resident 10] went into [resident 14's] room and sat on the bed with [resident 14] prior to having a physical altercation with [resident 14]. [Resident 10] initially started to push [resident 14], which escalated to throwing punches. During the incident [resident 14] attempted to defend himself as [resident 10] punched him several times. The residents separated as [resident 14] backed off, followed by [resident 10] backing off. The residents were assessed for injuries and vital signs were taken. [Resident 14] presented with a bruise under is left eye. [Resident 10] was unable to provide information regarding the incident due to his diagnosis. vascular dementia with behavioral disturbance. When asked post immediate incident, [resident 10] is unable to offer further details. [Resident 14] was able to describe the incident as detailed above. Caregivers were unable to offer further details. The residents were separated and kept apart from each other that evening. The incident was reported to the administrator. Police official was called and met with the residents and the administrator. APS (adult protective services) was informed of the incident. The physician was notified of the incident. Facility leadership instructed caregivers to keep the residents apart from each other in dining room and other areas. Caregivers were also instructed to watch for early signs of escalating behavior and intervene as appropriate. [Resident 14] indicated that he felt 'jittery' in the facility, didn't fear the resident involved, and apart from the bruising is not currently exhibiting signs of pain, distress, or harm. As such, abuse is substantiated. 4. Resident 35 was admitted to the facility on [DATE] with diagnoses which included schizoaffective disorder, dementia, cognitive impairment, chronic obstructive pulmonary disease, pseudobulbar affect, hypertension, major depressive disorder, anxiety, gastro-esophageal reflux disease, asthma, and insomnia. Resident 35's medical record was reviewed on 2/19/20. A review of resident 35's progress notes revealed the following documentation: a. On 7/15/19 About 0006 (12:06 AM), [resident 35] was heard yelling for nurse from her bedroom. When approached by nurse [resident 35] stated that her roommate [resident 49] tried to rape her. When questioned further about the incident she stated that [resident 49] came to her and put her hand down [resident 35's] pants while she was sleeping. When I spoke to [resident 49] about the incident, resident stated that she thought [resident 35] wanted sex. A staff member has been in front of their door since the incident to monitor, and ensure a repeat incident doesn (sic) not occur. b. On 7/23/19 At approximately 1815 (6:15 PM) CNA (certified nursing assistant) and 315-3 notified nurse that [resident 49] had managed to get into room [ROOM NUMBER] while staff was cleaning up dinner. 315-3 stated that [resident 49] 'tried to get at' [resident 35]. Nurse and CNA went to talk to resident and she stated [resident 49] walked toward her and [resident 35] put her hands up and told her to stop and then 315-3 said something to [resident 49] also and then [resident 49] left the room. Resident [35] upset that [resident 49] will not leave her alone. Staff notified to keep eyes on [resident 49] and try to keep her from resident. c. On 7/24/19 At approximately 1500 (3:00 PM) nurse was informed by CNAs that [resident 49] had walked into the dinning room during an activity and that she tried to grab [resident 35's] crotch. [Resident 35] stated that she slapped [resident 49's] hand away. The activities person saw her slapping [resident 49's] hands and interveened (sic) and then took [resident 35] to the other nurse on duty. Resident stated that [resident 49] came up to her and was reaching to grab her between the legs when she slapped her hand away. [Resident 49] was taken back to her room and nurse took [resident 35] down to speak with DON who will notify the administrator. Staff keeping the two residents separated. Will continue to monitor the situation. A review of the facility incident reports pertaining to the incidents with resident 35 and resident 49 revealed the following: a. The incident report investigation for the incident on 7/15/19, conducted on 7/23/19 by the facility administrator, documented . On 07/15/2019 at approximately 12:16am, a nurse heard loud noises coming from [resident 49] and [resident 35's] shared room. Conflicting reports have that [resident 49] put her hand down the front side of [resident 35's] pants while [resident 35] was on her bed. Investigation: Caregivers and the residents were interviewed separately and have conflicting reports as to the extent of what took place. [Resident 49] states that she touched [resident 35] on the front genital area with the back side of her hand. [Resident 35] reports that she stopped touching from occurring by extending her foot letting [resident 49] know that she would kick her if she made a further move. Both residents confirmed that an advance was made that was sexual in nature and unwanted by [resident 35]. [Resident 35] appeared to the nurse to have experienced emotional harm as a result of the incident and that she was quite upset. To date post incident, no physical harm to [resident 35] has been observed. In an interview the next afternoon, the resident remembered the incident and stated that she was upset but answered ?no? (sic) when asked if she experienced emotional harm. The two residents were separated from each other and a 1 on 1 was put in place to guard against further interaction. The incident was reported to the administrator. APS and Police were notified. Police followed up with the incident, without speaking with the residents. [Resident 35] does not show any signs of psychosocial distress at this date as evaluated by the director of social services. Due to [resident 35's] observed distress at the time of the incident, abuse is substantiated. b. The incident report investigation for the incident on 7/24/19, conducted on 8/6/19 by the facility administrator, documented word for word the exact same investigation that was documented on the previous incident report from 7/23/19. [Note: There was no incident report for the incident on 7/23/19.] On 2/25/2020 at 1:43 PM, an interview was conducted with the Staff Development Coordinator (SDC). The SDC stated that per her understanding, resident 35 was woken up by resident 49 standing over resident 35 and telling resident 35 that she needed to have sex with her. The SDC stated that she did not know if there was any sexual contact. The SDC stated that resident 49 was moved to a private room down the hall after the incident. The SDC stated that prior to the incident; the facility was unaware of any past sexual assault issues with resident 49. The SDC stated that staff had to keep an eye on resident 49 because she would try to sit by resident 35 and talk to her; resident 35 then became visibly distressed. The SDC stated that resident 49 tried to get close to resident 35 a couple of times after the first incident on 7/15/19. 5. Resident 43 was admitted on [DATE] with diagnoses which included ataxia, chronic kidney disease, unspecified psychosis, major depressive disorder, seizures, heart failure, encephalopathy, hypertension, aphasia, dementia with behavioral disturbance, cognitive communication deficit, atrial fibrillation, anemia, hyperlipidemia, immune thrombocytopenic purpura, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, and myocardial infarction. Resident 43's medical record was reviewed on 2/19/2020. A review of resident 43's progress notes revealed the following documentation: a. On 4/20/19, Resident in his room yelling. This Nurse responded to find [resident 43] sitting on his bed with blood running down the side of his nose. When asked what happened, [resident 43] stated that [resident 22] hit him in the face. [Resident 22] was sitting on his bed, and when asked what happened, [resident 22] responded that [resident 43] was making too much noise, so he hit him. Small cut on right side of nose, swollen bottom lip. Dr notified. Administrator notified. b. On 7/11/2019 Res (resident) has an altercation with another resident this morning. [Resident 43] was yelling at staff and was very agitated about not being able to eat a chocolate bar. He yelled obscenities at staff in the hall way, standing up by the wall. Staff was concerned that he would fall, or agitate other residents. [Resident 43] was very loud and continued yelling despite multiple offers to get him some other forms of chocolate. Staff continued to attempt to resolve the situation and asked him to go to his room and discuss this matter in private, or asked that he yell in a place thatwas (sic) more private to not upset any others. Another resident who was sitting near by was listening and watching. This interaction. The other resident [22] came in between staff and [resident 43], grabbed [resident 43] and pushed him up against the wall then let him go. Res did stumble to the floor on his knees and had a small skin tear to the right forearm. Both residents were removed from the area. [Resident 43] was assessed for injuries, vitals taken and neurochecks (sic) initiated. He has no neuro (neurological) deficits. He continued to yell at staff. He went to his room,vitals (sic) were taken and no other injuries noted. MD notified, DON notified, administrator notified. Monitored through the day. He had no loss of conscientiousness. No changes in consciousness. A written statement about the incident on 7/11/19 by LPN 4 documented [Resident 43] standing/yelling in hallway (swearing) calling CNA [4] a bitch. [LPN 4] was directing [resident 43] toward room. [Resident 43] was agitated. [Resident 22] responded to threat to [LPN 4]. [Resident 22] grabbed [resident 43] by neck, pushed him to the wall. [Resident 43] hit his head with push, fell to the floor. Tried to grab side bar on wall. [Resident 43] has bump on head [resident 43] has small superficial skin tear on arm. Patients separated. [Resident 43] moved to his room. [Resident 22] moved to his room. Neither residents remember the incident when asked. A review of the facility incident reports pertaining to the incidents with resident 43 and resident 22 revealed the following: a. The incident report investigation for the incident on 4/20/19, conducted on 4/25/19 by the facility administrator, documented When asked, [resident 43] stated that [resident 22] hit him in the face. [Resident 22] responded that he hit [resident 43] because he was making too much noise. When asked two days after the incident, [resident 22] doesn?t (sic) remember the incident. [Resident 22] did not answer when asked regarding the incident. Action Taken: The residents were separated and kept apart from each other that evening. The incident was reported to the administrator. Police official was called and did not meet with either resident. APS was informed of the incident. The physician was notified of the incident. Facility leadership instructed caregivers to position [resident 22] and [resident 43] apart from each other in dining room and other areas. [Resident 43's] room was changed as part of a previous plan. Caregivers were also instructed to watch for early signs of escalating behavior and intervene as appropriate. [Resident 22] indicates that he feels safe in the building. [Resident 43] did not answer but is not currently exhibiting signs of pain, distress, or harm. As such, abuse is substantiated. b. The incident report investigation for the incident on 7/11/19, conducted on 7/12/19 by the DON, documented Resident has been trying to take more oral intake despite orders for NPO (nothing by mouth). He has been started on ST (speech therapy) for diet evaluation. His yelling at the staff, triggered the other resident who is protective of staff and females. This resident is hard to assess as he only speaks when he wants to, and is often only when he wants to express frustration or anger. Wound will be monitored. The facility investigation report sent to the SA (State Agency) by the facility administrator documented Action Taken: The residents were separated and kept apart from each other. The incident was reported to the administrator. Police official was called and did not meet with either resident. APS (Adult Protective Services) was informed of the incident. The physician was notified of the incident. Facility leadership instructed caregivers to position [resident 22] and [resident 43] apart from each other in dining room and other areas. Caregivers were also instructed to watch for early signs of escalating behavior and intervene as appropriate. [Resident 22] indicates that he feel safe in the building. [Resident 43] did not answer but is not currently exhibiting signs of pain, distress, or harm. As such, abuse is substantiated. Based on interview and record review it was determined, for 8 of 35 sampled residents, that the facility failed to ensure the residents were free from abuse and neglect. Specifically, the facility did not provide protection to ensure that residents were free from verbal and physical abuse from other residents. Resident identifiers: 10, 14, 17, 32, 35, 43, 47, and 59. Findings include: 1. Resident 10 was admitted to the facility on [DATE] with diagnoses which included vascular dementia with behavioral disturbance, encephalopathy, cognitive communication deficit, and unspecified sequelae of cerebral infarction. On 2/19/2020 at 8:43 AM, resident 10 was observed sitting in a wheelchair. Another resident forcefully kicked resident 10's wheelchair twice while he was sitting in it, swore at resident 10, and accused resident 10 of blocking the hall. Staff escorted the other resident away. There was no incident report completed. On 2/23/2020 at 5:07 PM, resident 10 and another resident were observed during a verbal altercation. Resident 10 was guided to the other side of the room and then staff walked away. Resident 10 then returned back to the other resident and resumed the verbal altercation. Staff again guided Resident 10 away to the other side of the room and then walked away. Resident 10 again returned to the other resident and resumed yelling at him. Staff then took Resident 10 by the hand and walked down the hall with him. There was no incident report completed. On 2/19/2020 resident 10's medical record was reviewed. Nursing progress notes revealed the following 13 abusive incidents: a. On 9/17/19, CNA (Certified Nursing Assistant) saw resident go into room [ROOM NUMBER] at approximately 1635 (4:35 PM) .When staff arrived to room this resident was laying on 306-1's bed, 306 was standing over him and the two of them were hitting each other .Nurse assessed for injuries and found a large bruise and skin tear to left arm near wrist, he has bruising to back of both hands, and swelling to left hand. b. On 9/17/19, At approximately 1500 (3:00 PM) staff witnessed resident and 306-1 coming out of room [ROOM NUMBER] fighting. They were both attempting to hit each other. c. On 9/17/19, At approximately 1613 (4:13 PM) nurse heard 314-3 yelling Get out of here from nurses station, nurse went to investigate and found 314-3 sitting on his bed with his hands up trying to stop this resident (resident 10) from punching him. d. On 10/8/19, Nurse heard loud angry growling coming from 319-1 when nurse went to investigate nurse saw this resident (resident 10) and 319-1 facing each other and they both had their arms out in front of them. When 319-1 went to hit this resident and this resident pushed 319- . e. On 10/25/19, .RN (Registered Nurse) reports resident (resident 10) was found on the floor in a supine position. Head was pointed towards the door and feet out stretched towards the window. Peer was on top of resident. f. On 10/29/19, At 1905 (7:05 PM), [resident 10] was observed laying (sic) on the ground in the hallway by room [ROOM NUMBER], and next to resident 318-2. Resident 318-2, stated that [resident 10] was trying to get into his sister's room, and so he grabbed him .lowered [resident 10] to the floor so that he would stop. g. On 10/30/19, He had a res (resident) to res where contact was made between anther (sic) resident and him .Some redness at the time that has since resolved. Res requires constant supervision and stand by from staff to maintain safety h. On 10/31/19, [Resident 10] continues to be agitated. He walked up to this nurse during shift report, grabbed nurse by the arm, and began punching nurse .staff was unable to stop him from going into others rooms, unless they were right next to him, either blocking the doorway, or calling out to him and directing him away while being right next to him. i. On 10/31/19, CNA (Certified Nursing Assistant) reports resident met peer at the end of the hall. Both were attempting to open the door that leads to the stairs. Resident pushed peers hands out of the way and they both started to slap at each others hands. j. On 11/1/19, . Resident went into room [ROOM NUMBER]. Resident in bed one got upset, got him from the arm and tried to throw him on the bed. k. On 11/1/19, Heard yelling and looked down the hall. Observed 306 bed 1 push resident [10] from the front. The resident fell to the ground striking his head against the floor. l. On 11/7/19, .RN reports resident [10] was found on the floor in peer's room. Central Supply Manager (CSM) interviewed. States observed peer dragging resident out of peers room. Resident was supine while being dragged. m. On 1/16/2020, Res had a physical encounter with another resident at dinner time this shift. Res went to take a cup from someone and the other person got upset and physical contact was made. [Incident report states resident 10 was struck in the eye and abdomen.] Resident 10's Care Plan contained the following focus areas and interventions pertaining to aggression and abuse prevention: a. Focus - [Resident 10] has behavioral issues such as wandering, responding to others with aggressive behaviors, risk of escalating behaviors. Date Initiated: 10/09/2019 Revision on: 11/08/2019 b. Focus - Not easily re-directible (sic) and can be aggressive (with staff and other residents) when attempting to re-direct. Date Initiated: 10/09/2019 Revision on: 11/29/2019 c. Interventions - Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Date Initiated: 10/09/2019 d. Interventions - If verbal cues do not work, take his hand and guide him away. If he begins hitting or kicking to residents, guide him away from behind. If he begins hitting or kicking staff, try to get to his side and maintain the safety of [resident 10] and staff. Date Initiated: 11/01/2019 On 2/20/2020 at 11:01 AM, RN 3 was interviewed. RN 3 stated that when residents had an altercation, We intervene. We pull them apart. We check for injuries and notify the providers and do an incident report. We can't do any restraints. We don't do any sort of physical restraints training. When asked specifically about resident 10, RN 3 stated, He'll kind of smack you a bit when he walks by if he's mad but that's it. Everyone just keeps an eye on him. On 2/20/2020 at 11:12 AM, CNA 4 was interviewed. CNA 4 stated that when residents were physically aggressive with each other, We intervene and separate them. We separate them by bringing one resident away and telling them to stop. We never have to hold residents, usually we just verbalize. When asked specifically about resident 10, CNA 4 stated, Almost daily when we change him he'll hit us, kick us, grab us, that sort of thing. And he squeezes hard! He did have a couple resident to resident incidents and some of the other residents complained about him going into their rooms. We all keep an eye on him to make sure he doesn't go into other resident's rooms. On 2/20/2020 at 11:22 AM, CNA 5 was interviewed. CNA 5 stated that [Resident 10] can be a bit aggressive. I haven't had any violence training, I don't think. I might have some coming up, I'm not sure. On 2/20/2020 at 11:32 AM, CNA 2 was interviewed. CNA 2 stated, There's times we've had to pull residents apart or hold them. The longest we've had to hold was for 30 seconds I think. In general I know we're not supposed to grab residents but I don't know what our policy is. When asked specifically about resident 10 she stated, This morning during cares he was swinging at us. We all just try to keep an eye on him to keep him safe when he's out in the hall. On 2/24/2020 at 1:14 PM Licensed Practical Nurse (LPN) 1 was interviewed and asked how staff keeps resident 10 safe. LPN 1 stated, [Resident 10] is more monitoring for agitation. He gets agitated when redirected. If there's a resident to resident we report it to the doctor and administrator. On 2/25/2020 at 3:30 PM the Director of Nursing (DON) was interviewed. The DON stated that when resident 10 had behaviors, the nurses are supposed to put in notes about immediate interventions. If they weren't enough interventions, we'll update the care plan in the next IDT (Interdisciplinary Team) meeting. We've asked the nurses to put their interventions on the nurses note or the incident note itself. If the resident being abused has a reaction, we teach the staff to report that as an incident. We found that the Ativan was the best thing for [resident 10]. His incidents have decreased since then. He's not a hoarder but if you tell him to leave he doesn't understand it; he can't follow directions. On 2/25/2020 at 5:00 PM, the Administrator was interviewed. The Administrator stated that the facility protects residents from other and responded to aggressive residents by staff being very aware of residents and by having staff act appropriately. The Administrator stated that there were a lot of opportunities for potential incidents. We try to do the best we can and we're not perfect with that. The Administrator stated that the facility proactively avoids resident to resident abuse by doing a lot of in-services and trainings included the journeys training for instructions on how to interact with the memory care population. That is the proactive piece of that, and I think that's probably not resident specific proactive, it's probably reactive on that. The program training especially for the Alzheimer's unit, the reactionary stuff is really proactive. There are times when there are near misses or near incidents when we say, 'hey, that happened, we say we should be smarter about that going forward'. The Administrator stated that the facility had regular abuse training, including types of abuse, who to report it to, the time frame, etc., and was completed upon hire and at least yearly. The Administrator stated that the facility had a monthly QA (Quality Assurance) meeting and we've QAPI'd (Quality Assurance and Performance Improvement) abuse and potential abuse, and staff addressed specific residents who are ramping up or who have had recent incidents. 2. Resident 32 was admitted to the facility on [DATE] with diagnoses which included dementia, Alzheimer's disease, obsessive compulsive disorder, and generalized muscle weakness. On 2/19/2020 resident 32's medical record was reviewed. Nursing progress notes revealed the following abuse incidents: a. On 7/11/19, Pt wandering into other residents (sic) rooms today. She attempted to wander into 316-3 when the resident 316-3 kicked her in the lower leg. b. On 7/13/19, [Resident 32] was walking down the hall when 316-3 grabbed her by the right wrist and pulled her in a half circle. Nurse intervened . c. On 10/10/19, 318-2 pushed [Resident 32] into the wall, hitting her head, and her shoulder on the wall. d. On 10/25/19, RN states she observed resident fall to her hands and knees after 315 bed 1 grabbed her by the arms and pushed her out of room [ROOM NUMBER] .Has purple/red marks along forearm. e. On 11/8/19, CNA called RN to resident .CNA reports peer stood and pushed her to the floor after she reached for his coffee. f. On 11/16/19, [Resident 32] found on the floor in her room, laying (sic) between her part of the room and 308-2 part of the room .[Resident 32] was laying (sic) on her left side, and unresponsive. [Note: Neurological (Neuro) checks were not done and a head to toe assessment failed to detect a femoral neck fracture]. g. On 11/17/19, [Resident 32] was found to be kneeling at the side of her bed closest to 308-2. When asked about if she saw what happened, [Resident 32] roommate 308-2 stated she was just trying to push [Resident 32] back onto her own side .From her reaction, it sounded like she pushed [Resident 32] and caused her to fall to the floor. h. On 11/18/19, Staff found [Resident 32] kneeling next to her bed .When staff asked [Resident 32] roommate who was nearby if she knew what happened, she became upset, and stated that she was just trying to push [Resident 32] away from her own bed. i. On 12/17/19, Staff entered [Resident 32] room when they heard her roommate screaming. [Resident 32] was found on the floor at the foot of her bed laying (sic) on her left side, and Her roommate was yelling at her. [Resident 32] had some bruising, and skin tears on bilateral forearms. Roommate became very defensive when asked about the incident stating that [Resident 32] was in roommate's area trying to take roommate's things. Wandering into others personal space, and taking their belongings d/t (due to) her confusion is a normal behavior for [Resident 32]. j. On 2/4/2020, nurse called to lounge area and informed that this resident and 310-1 were fighting over the baby doll that [Resident 32] was holding .[Resident 32] wouldn't let 310-1 take the doll so 310-1 hit her in the left cheek and then she hit 3[TRUNCATED]