**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to protect a resident's right to be free from physical abuse by a resident (R1.) This affected 3 (R2, R3, and R11) of 6 residents reviewed for abuse. R1 was observed hitting 3 residents (R2, R3, and R11) on 3 separate occasions; R1 struck R11 in the head 4 times with a pillow, R1 struck R3 in the back with his shoe, and R1 struck R2 across her face with the insole of his shoe. The facility failed to protect residents from physical abuse. Using the reasonable person concept a resident would be saddened and distressed after being hit in their home. Evidenced by: The facility's policy titled Abuse, Neglect, Mistreatment, Exploitation, Misappropriation of Property or Injuries of Unknown Origin, and Mandatory Reporting of a Crime dated 1/24/23, states in part, .II. Policy: Each resident has the right to be free from abuse, neglect, mistreatment, exploitation, misappropriation of resident property .Residents must not be subjected to the preceding by anyone, including but not limited to, facility staff, other residents, consultants .All alleged violations will be reported to the administrator or designee, Director of Nursing, and the nurse manager immediately, thoroughly investigated and measures implemented to prevent further incidents. Incidents that meet state and federal criteria will be reported to the Division of Quality Assurance (DQA) and the Office of Caregiver Quality (OCQ) immediately. Immediately is defined as not later than 2 hours, if the alleged violation involves abuse or results in serious bodily injury, or 24 hours, if the alleged violation does not involve abuse and does not result in seriously bodily injury. A written report filed within 5 working days of the incident . V. Procedures: A .6. Neighborhood treatment teams shall identify residents whose personal histories render them at risk for abusing other residents, and develop intervention strategies to prevent occurrences, monitoring for changes that would trigger abusive behavior, and reassessing these interventions on a regular basis .B. Identification, Investigation, Protection, and Reporting: It is the policy of [facility name] that reports of abuse as defined above are promptly and thoroughly investigated. The investigation is the process used to try to determine what happened. The investigation will begin immediately, once informed of an event .The Investigation will include: .3. What happened: a. Residents' statements .b. Peer statements .d. Involved staff and witness statements of events (written or verbal statements documented), staff or witnesses that were in the area at the time of the incident .10. Root cause analysis of the incident 11. Conclusion based on findings . Example 1: R1 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's Disease, Dementia with agitation, Major Depressive Disorder, Anxiety Disorder, and cognitive communication deficit. R1's most recent MDS (Minimum Data Set) dated 5/9/23, states that R1 is rarely/never understood. R1's MDS also indicates that he requires supervision and set up assist for locomotion on the unit. R11 was originally admitted to the facility on 12/ 28/22 with diagnoses to include dementia, non-traumatic brain dysfunction, anxiety disorder, and cirrhosis. R11's most recent MDS dated [DATE] states that R11 has a BIMS (Brief Interview of Mental Status) of 99, indicating that he was unable to complete the interview. The MDS also indicates that R11 requires extensive assist of 2 staff members for bed mobility and transfers and is completely dependent on staff for locomotion on the unit. R1 has documented behaviors of being physically aggressive with staff and wandering into peers' rooms. Documentation is as follows: April 2023 - R1 was physically aggressive with staff for 36 out of 90 shifts. R1 wandered into peers' rooms 67 out of 90 shifts. May 2023 - R1 was physically aggressive with staff for 33 out of 90 shifts. R1 wandered into peers' rooms 67 out of 90 shifts, with one shift not documented on. June 2023 - R1 was physically aggressive with staff for 40 out of 90 shifts. R1 wandered into peers' rooms 58 out of 90 shifts, with nine shifts not documented on. July 2023 - R1 was physically aggressive with staff for 30 out of 93 shifts. R1 wandered into peers' rooms 68 out of 93 shifts, with three shifts not documented on. August 2023 - R1 was physically aggressive with staff for 7 out of 23 shifts. R1 wandered into peers' rooms 15 out of 23 shifts, with one shift not documented on. It is important to note that the facility is not documenting R1's behaviors when he is physically or verbally aggressive towards other residents. On 4/24/23, R1 hit R11 with a pillow several times. R1's nurse's notes on 4/24/23 at 8:44 PM state in part, Resident was delusional, accusatory, and physically and verbally aggressive early in the shift. Resident was accusing staff of abusive towards an individual. Resident became agitated when staff attempted to reassure. Per CNA (Certified Nursing Assistant,) resident grabbed a pillow and hit another resident sitting in a Broda chair four times. Resident attempted to kick a staff while writer was trying to redirect the resident. When writer was trying to provide reassurance, the resident was verbally abusive towards the writer .Staff allowed the resident to wander on his own and resident eventually settled . R1's nurse's notes on 4/24/23 at 10:50 PM state in part, Per CNA, around 1615 (4:15 PM) resident became agitated and was wandering around the living room. Resident unexpectedly pulled a pillow from another resident (victim) who was sleeping in the Broda chair. Resident began hitting the other resident with the pillow four times . R11's nurse's notes on 4/24/23 at 11:12 PM state in part, Resident was the victim of the assault that occurred on the living room at 1615 (4:15 PM.) Another resident hit the resident with pillow four times unprovoked . R11's nurse's notes on 4/24/23 at 11:12 PM (second entry) state in part, Resident was drowsy for most of the shift, with intermittent restlessness. However, resident was under supervision t/o (throughout) the shift. Between 1635-1645 (4:35 PM - 4:45 PM), resident was restless in his Broda chair. Redirection provided, with minimal effect. Writer gave PRN (as needed) lorazepam (Ativan) PO (by mouth.) A minute later, writer was behind the Broda chair and got distracted by another resident when the resident got up quickly from his chair. Writer attempted to help the resident but when the resident took a step his feet got tangled with the blanket. Resident then fell on the carpet .Resident reported pain and was agreeable to PRN. Writer gave PRN morphine PO (by mouth), with good effect . Of note, a dependent person would likely be saddened and distressed when someone enters their living space unprovoked and hits them repeatedly. R11 became restless and subsequently had a fall after the incident. It is important to note that there is no documentation indicating that the facility implemented any interventions to R1's care plan to ensure that other residents were kept safe from R1. Example 2: R3 was originally admitted to the facility on [DATE] with diagnoses that include dementia, major depressive disorder, personality disorders, and anxiety disorder. R3's most recent MDS dated [DATE] states that R3 has a BIMS of 9 out of 15, indicating that he is moderately cognitively impaired. R3's MDS also indicates that he requires extensive assist from 2 staff members for bed mobility and transfers, and that he requires limited assistance from 2 staff members for locomotion on the unit. On 5/11/23, R1 struck R3 with his shoe. R1's nurse's notes state, in part: 5/11/23 at 1:06 PM - Resident was day 5 without BM (Bowel Movement.) Resident very restless, agitated, and aggressive to staff during cares. Writer administered PRN suppository around 09 am. Around 0930 staff found him using room D115's bathroom. Resident was sitting on his recliner did not say anything and appears to be not care Resident has a Lg (large) BM in D115's bathroom. Resident was restless and agitated around 10:30 AM. Staff must monitor closely to prevent altercation. PRN risperidone administered around 10:40 AM and was effective. Resident calm down later but kind of more relax and touched One time to female staff and one time to male resident at room D113 holding from the back and putting his head over the shoulder. Staff must intervene, educated as he is redirect able [sic] . 5/11/23 at 6:41 PM - Writer notified that R1 was finished with his meal, sitting at dining spot. CNA near him was assisting another resident and told R1 to finish his milk. R1 became reactive and struck CNA in the face. CNAs assisted R1 away form [sic] the dining area and back to a recliner in the living room. R1 appeared calm, staff turned away and went back to attending to residents in the dining area. R1 quickly removed a shoe and got up and went to another resident who was sitting eating his dinner and came up behind him and struck his left shoulder with his shoe. The other resident was very surprised, fearful, had not been talking or involved with R1 or the CNA during the previous incident .His shoes were kept off, and he has another RN (registered Nurse) providing 1:1 for the time being .RN reports increased restlessness and agitation on the PM (evening) shift . 5/11/23 at 8:55 PM - Resident aggression: Staff reported that resident was upset when asked to finish his drinks during his meal and threw his silverware on the floor. Resident then proceed toward the staff who was feeding resident (R3) at the time. Resident hit the staff in the face; staff redirected him and sat him on recliner in living room. Resident once again proceeded toward staff and this time he hit the resident (R3) with his shoe in the back/shoulder area. Staff intervened before resident hit his peer again. Resident (R3) has no apparent injury but c/o (complained of) pain on back when lifting his shirt up . R3's nurse's notes state, in part: 5/11/23 at 9:48 AM - Resident was struck by another resident in his left back shoulder when he was having dinner. Staff intervene and remove another resident from him before struck again. Writer and nurse supervisor assessed resident and found no apparent injury. Resident c/o (complained of) pain on the area that was struck. Resident was able to describe the situation and sound worried at the time . Of note, a dependent person would likely be saddened and distressed if someone enters their living space unprovoked and hits them. R3 expressed pain, fear, and was very surprised with being hit. On 8/8/23 at 8:18 AM, Surveyor interviewed R3. Surveyor asked R3 if he remembered being hit with a shoe? R3 stated yes, he whopped me alongside my head and back. Surveyor asked R3 how it made him feel? R3 stated that it made him feel helpless. Surveyor asked R3 if it hurt when the other resident hit him? R3 stated yes. Surveyor asked R3 if he was afraid the other resident was going to hit him again? R3 stated yes. On 8/8/23 at 8:37 AM, Surveyor interviewed CNA L. Surveyor asked CNA L to explain the events of the incident between R1 and R3. CNA L stated that R1 hit R3 with his shoe, and that R3 didn't do anything to R1. CNA L stated that R1 wanders around the unit and goes into other resident's rooms. Surveyor asked CNA L what interventions were implemented after the incident? CNA L reported that they took R1 to his room, called the nurse, and then he came back out into the common area. CNA L stated that they had to make sure that R1 did not go near R3. Example 3: R2 was admitted to the facility on [DATE] with diagnoses to include dementia, bipolar disorder, major depressive disorder, generalized anxiety disorder, and borderline personality disorder. R2's most recent MDS dated [DATE] states that R2 has a BIMS of 14 out of 15, indicating that she is cognitively intact. R2's MDS also states that she requires supervision and set up assistance for bed mobility, transfers, and locomotion on the unit. It is important to note that during this survey, R2 was observed to be either in a reclining chair, or in her bed. R2 was not observed to be wandering the unit. On 6/10/23, R2 was struck repeatedly in the face by R1. R1's nurse's notes state, in part: 6/10/23 at 2:48 PM - Writer was alerted by charge nurse that during writer's break, there was an incident between R1 and R2. Upon further investigation with CNA staff and staff member who witnessed the incident, writer learned that R1 hit R2 in the face 3-4 times using an insole from his shoe. Per CNA, R1 had been wandering around the unit prior to this in an agitated manner, and followed R2 in an aggressive manner after hitting her .Current plan of action is to have 1:1 staff on the PM shift for safety and for R1 to no longer have shoes (will have grippy socks or possibly lightweight slippers instead) . 6/10/23 at 10:28 PM - Resident aggressive with cares. Per intervention d/t (due to) resident altercation, resident not allowed to wear shoes. Resident somehow found the shoes. When staff attempted to take the shoes, resident became agitated and aggressive towards the staff . 6/19/23 at 2:36 PM - In the morning around 0900 (9:00 AM) resident softly touched peer (R2) on her shoulder from behind . R2's nurse's notes state, in part: 6/10/23 at 2:41 PM - .Writer then assessed R2. R2 was upset following the incident, crying, and repeatedly stating a man hit me in the face and get me away from him .Writer provided PRN trazodone to resident for agitation . 6/10/23 at 8:30 PM - Resident drowsy/sleeping majority of the shift, up only with meal and toileting. 1:1 supervision this shift. Per staff, resident confused and tearful. During COVID screening, resident reported about dying in one hour d/t her oxygen de-sating. O2 (oxygen) 95%. Resident perseverating on wanting to see the doctor or nurse for everything especially discomfort from her lips and mouth. During HS (bedtime) medication, resident was moaning and crying. Resident reports lips and mouth pain . 6/11/23 at 1:58 PM - Resident agitated and anxious this shift .PRN lorazepam was administered at 12:00 with her scheduled medications. PRN lorazepam had minimal effects . Of note, a dependent person would likely be saddened and distressed to have someone enter their living space unprovoked and hit them. The facility implemented 1:1 supervision at the time of the incident and removed R1's shoes, but it is important to note that the facility allowed R1 to keep his shoes, per his guardian's request and just removed the insoles, and did not provide extended supervision to prevent further incidents; this is R1's second attack using his shoes. On 8/7/23 at 3:34 PM, Surveyor observed R1 in the TV (television) area with his shirt off, leaning over the back of a recliner that another resident was sitting in. On 8/7/23 at 3:36 PM, Surveyor observed R1 standing at the counter, irritable, talking, and fidgety. R2 is also sitting at the counter; R1 was approximately 4 feet away from R2. On 8/7/23 at 3:37 PM, Surveyor observed R1 to move behind R2's recliner chair at the counter. R2 began calling out, staff took R2 to her room. R1's CNA [NAME] states NO SHOES WITH INSOLES ON THE HOUSEHOLD (may wear when leaving NBHD (neighborhood) with wife or for activities.) Surveyor observed R1 to be wearing his black tennis shoes throughout the survey, unable to visualize whether there were insoles inside them. On 8/8/23 at 8:37 AM, Surveyor interviewed CNA L. Surveyor asked CNA L to explain the incident between R1 and R2. CNA L stated that R1 was wandering around the unit and kept taking his shoes and socks off. CNA L reported that they tried to get R1 to put his shoes back on, and then R1 tried to go into another resident's room to urinate, CNA L stated that R1 shoved her and then went and sat down. CNA L reports that at that time, she went to get another resident out of someone's room, R1 took off his shoes off and hit R2, R2 was sitting in the recliner. CNA L stated that R1 was still trying to hit R2 after she intervened, but she was standing in the way, so he just hit her. Surveyor asked CNA L if the facility provided education to staff after the incident? CNA L stated that she was not aware of any education provided. Surveyor asked CNA L what interventions were implemented for R1 after the incident? CNA L stated that they were to provide 1:1, R1 and R2 are not to be close together, R1 is not to have shoes on, and if R1 is agitated, staff are to try to get him to his room. On 8/8/23 at 10:05 AM, Surveyor interviewed CNA M. Surveyor asked CNA M what interventions are in place for R1? CNA M reported that they are to supervise him when he's wandering, make sure he's not going into other residents' rooms, make sure other residents aren't getting too close to him, and to monitor his demeanor. Surveyor asked CNA M if R1 was allowed to wear shoes? CNA M stated yes, he just can't have insoles. On 8/8/23 at 10:45 AM, Surveyor interviewed SN I (Supervisory Nurse.) Surveyor asked SN I what the facility's process was for a resident-to-resident altercation? SN I stated that they protect and separate the residents, get help if needed, and report it immediately; CNAs are to report it to the first nurse they see or call the charge nurse and start an investigation immediately. SN I stated that depending on the severity and intent, they would call law enforcement and that they need to report it to the SA (State Agency) within 2 hours and have 5 days to complete. Surveyor asked SN I if she could explain why there wasn't a report sent to the SA regarding R1's resident to resident altercation on 4/24/23? SN I stated that she was unaware of the incident. Surveyor asked SN I if the incident should have been investigated? SN I stated yes. Surveyor asked if the incident should have been reported to the SA? SN I stated that she didn't know. Surveyor asked SN I if there was documentation of the interventions that were implemented for R1 after each incident? SN I stated that they should keep R1 away from other residents and monitor. Surveyor asked SN I if there was any documentation of the monitoring? SN I stated they do not have formal documentation of monitoring. Surveyor asked SN I what interventions were implemented after the incident between R1 and R3? SN I reported that they moved R3 to another household, they provided 1:1 supervision for R1. Surveyor asked SN I if the 1:1 supervision was long term? SN I stated that she didn't know. Surveyor asked SN I about interventions implemented after the incident with R1 and R2. SN I stated that she had told staff that R1 was to not have any shoes, due to this being his second attack with his shoes, staff removed the shoes. SN I reported that R1's wife was not pleased with the removal of the shoes and wanted him to always wear shoes, so they were given back. Surveyor talked with SN I about the incident on 6/19/23 where R1 touched R2 on the shoulder. Surveyor asked SN I how R1 was able to get close enough to touch R2? SN I stated that she did not know. On 8/8/23 at 2:38 PM, Surveyor interviewed DON B (Director of Nursing.) Surveyor asked DON B about the interventions implemented after each of R1's resident-to-resident altercations. DON B stated that she didn't have anything to add if Surveyor spoke with SN I. R1 has a history of aggressive behaviors including striking other residents. The facility failed to protect and ensure residents are free from abuse.