**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, incident review, staff interview, and policy and procedure review, the facility failed to protect the residents' right to be free from physical abuse by a resident for 3 of 12 sample residents (#29, #71, #73) and verbal abuse by a staff member for 1 of 12 sample residents (#72). This failure resulted in actual physical harm to resident #71 and mental harm, based on a reasonable person, to resident #72. The findings were: 1. Review of an incident report dated 10/25/24 showed the administrator and nurse manager were notified at approximately 9:15 AM of a verbal incident involving CNA #1 and resident #72. The incident report showed resident #72 was upset and began to follow CNA #1 while being verbally aggressive. At some point, the CNA turned around and engaged verbally with the resident causing other staff members to respond by assisting with redirection of the resident and staff member. The following concerns were identified: a. Review of the significant change MDS assessment dated [DATE] showed resident #72 had a BIMS score of 5 out 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia and depression. b. Review of the camera footage without sound from 10/25/24 on 12/12/24 09:52 AM showed CNA #1 walked down the hall toward resident #72's room with resident #72 walking behind him. CNA #1 entered resident #72's room. The resident entered the room and the CNA exited with a mechanical lift. Shortly after, the resident exited the room and walked in the same direction the CNA walked, toward the common area by the nurses' station. The CNA went to another room off camera, and the resident went to a table in the common area. The CNA returned to the common area and the resident got up from a table and walked toward MA-C #1 at the nurse's cart. At that time, the CNA began pointing at the resident followed by the resident pointing at the CNA. The CNA and resident moved toward one another, becoming very close to each other, while additional staff members arrived in the common area and attempted to get between the resident and CNA. The additional staff members assisted the resident out of the common area, toward his/her room, while the CNA continued to move toward the resident. Continued review showed the additional staff members attempted to prevent CNA #1 from moving toward resident #72. Additional staff members were able to separate the CNA and the resident; however, the CNA got free from them and headed toward the resident, who was down the hall. Staff continued to attempt to redirect the CNA and eventually, were able to get him to go toward the nurses' station. c. Interview with CNA #2 on 12/11/24 at 6:51 PM revealed CNA #2 was in the restorative room when she heard some yelling. CNA #2 went down the hall where she observed resident #72 and CNA #1 positioned chest to chest and yelling at each other. CNA #2 revealed multiple staff attempted to get CNA #1 and the resident away from each other. CNA #2 revealed after staff were able to get distance between them, the resident started making noises which upset CNA #1 again and, at one point, CNA #1 started running toward the resident with his fists up. When the resident was redirected to his/her room, s/he wanted to call the police on CNA #1. Further interview revealed she did not recall specific phrases stated by either the resident or CNA #1; however, she revealed both were using a lot of profanity. d. Interview with RN #1 on 12/11/24 at 7 PM revealed resident #72 had been agitated that day and when the RN came out of the nurse's station, the resident was by the door. The RN revealed the resident made comments about wanting to leave the facility. The RN revealed approximately an hour later, she was giving report and could hear CNA #1 speaking in a loud voice saying Get the F out of here. The RN revealed the CNA was positioned very close to resident #72 and was in [his/her] face. The RN revealed the resident was making inappropriate comments and noises toward CNA #1 and the CNA went after [him/her]. At that time, the RN attempted to stop the interaction by pulling the CNA away; however, he broke away and another staff member attempted to stop the CNA. The RN revealed she and another staff member were eventually able to get the resident to his/her room and get the resident calmed down. The RN revealed the CNA was the aggressor and charged at the resident using profanity and yelling loudly. The RN stated CNA #1 was using more physical intimidation versus verbal threats; however, the CNA did repeatedly tell the resident to get the F out here. Further interview revealed the resident did not seem afraid of the CNA and was more worried other staff would be upset with him/her; however, the resident did say s/he wanted to call the cops. e. Interview with CNA #3 on 12/11/24 at 7:09 PM revealed during the incident, she was in a resident room down the hall, by the pool table, and she heard screaming going on. CNA #3 walked out, observed CNA #1 yelling at resident #72, and observed other employees were separating them. CNA #3 revealed the resident was making inappropriate noises toward CNA #1 and calling the CNA names which caused CNA #1 to attempt to charge toward the resident with his hand in a fist. CNA #1 was telling the resident to go back to [his/her] F-ing room and CNA #3 remembered CNA #1 cursing at the resident. CNA #3 revealed the resident was angry when CNA #1 was saying things and the resident was trying to push through staff. Further interview revealed the resident was angry all day after that; however, s/he did not verbalize any fear. f. Interview with CNA #1 on 12/12/24 at 9:06 AM revealed he was assisting the roommate of resident #72 and while getting a hoyer lift, resident #72 was making very upsetting remarks about the CNA assisting the roommate. CNA #1 revealed the resident was trying to prevent him from providing care to the roommate, was using profanity toward the CNA, and was calling the CNA the N word. CNA #1 revealed resident #72 began following him and, in the past, the resident had been violent. When the resident was following him, CNA #1 got upset. CNA #1 revealed the resident was very alert, very knowledgeable, and very competent. CNA #1 stated he tried going to the nurses' station to get assistance; however, the doors were locked because the nurses were afraid of the residents. CNA #1 stated he went into the bathroom and when he came out of the bathroom, he realized it was himself and the resident, alone. CNA #1 revealed he had to shout at the resident because he felt the resident was going to do something. CNA #1 revealed he eventually told the resident Do not call me the f-ing N word. CNA #1 revealed the other staff held him back, which he felt was very disturbing. CNA #1 stated he felt embarrassed staff were holding him. CNA #1 revealed he told the resident to stop calling him the N word and the resident continued calling the CNA names. CNA #1 revealed the other staff were all hiding and he felt it was a hostile environment. CNA #1 revealed the resident had attacked other employees and CNA #1 made a report with the police following the incident. After being separated by other staff, CNA #1 was startled and the resident was still calling him names. CNA #1 revealed he walked away from the situation at that time and was escorted to the office. CNA #1 confirmed he was terminated from the facility; however, he stated he did not threaten the resident. CNA #1 revealed the resident wanted to do him harm and the CNA did not want to be intimidated by the resident. CNA #1 revealed he did not request to move to the other unit due to male staff were not allowed to go the other unit. g. Interview with the administrator and infection preventionist/education specialist on 12/12/24 at 10 AM revealed CNA #1 went after resident #72 and was saying the resident knew better. They revealed the CNA could have walked away at any time and when the resident was still upset, the CNA should have left the area. They revealed the CNA felt the resident was cognitively intact and was purposely antagonizing staff. They revealed on the day of the incident, resident #72 had met with the doctor and did not like his/her doctor's answer, which caused him/her to be upset prior to the altercation with CNA #1. Additionally, the resident had eaten breakfast, and when staff cleared his/her plate, the resident returned, and which also upset the resident because s/he believed s/he did not get any food. 2. Review of an incident report dated 8/10/24 showed resident #73 was resting in his/her bed when resident #71 entered the room and attempted to get in the bed. CNA #1 did not witness the incident; however, she heard a slap sound, heard resident #71 say ouch, and heard resident #73 say get [him/her] out. A mark was observed on the left side of resident #71's face. The following concerns were identified: a. Review of the quarterly MDS assessment dated [DATE] showed resident #71 had short-term and long-term memory impairment and diagnoses which included Alzheimer's disease, anxiety disorder, and depression. b. Review of the quarterly MDS assessment dated [DATE] showed resident #73 had a brief interview for mental status score of 1 out 15, which indicated severe cognitive impairment, and diagnoses which included non-traumatic brain dysfunction, non-Alzheimer's dementia, and anxiety disorder. c. Review of a progress note for resident #71 dated 8/10/24 and timed 10:13 AM showed Called to locked unit per CNA. CNA stated [resident #71] was noted walking into another resident's room. While she directed herself to redirect resident, she heard slap-like sounds x 2. [Resident #71] was redirected from the room and was noted with erythema to left side of face. Assessed resident. Erythema noted to left side of face. No edema noted. No other skin abnormalities noted. No visible or vocal s/s of pain noted . d. Review of a progress note for resident #71 dated 8/11/24 and timed 12:18 AM showed [Resident #71] is on alert charting related to being post resident on resident altercation with [resident #71] being the receiver from 8/10/24. Light redness noted to Left side of face this evening. [Resident #71] showed no signs or symptoms of fear from other community members. No signs or symptoms of distress related to altercation noted/reported at this time. No new injuries noted/reported at this time. Staff will continue to monitor . e. Review of a progress note for resident #71 dated 8/11/24 and timed 8:45 AM showed .Minimal erythema noted to left side of face. Denies any pain or discomfort at this time . f. Review of a progress note for resident #71 dated 8/12/2024 and timed 12:40 AM showed [Resident #71] is on alert charting related to being post resident on resident altercation with ____(resident's name) being the receiver from 8/10/24. Redness to face is resolved at time of assessment . g. Interview with CNA #4 on 12/11/24 at 6:22 PM revealed the CNA heard resident # 71 say ow and heard a slap. The CNA couldn't remember if resident #71 had injuries. 3. Review of an incident report dated 11/3/24 showed resident #72 was upset because his/her meal was not to his/her liking. The resident became verbal aggressive towards staff then walked away. At that time, resident #29 was moving up the hallway in his/her power wheelchair and both residents declined to step around or give room for the other to get by. Resident #72 stepped in front of resident #29 then accused resident #29 of running into him/her. Resident #72 then struck resident #29 with an open hand on the right side of his/her face. The following concerns were identified: a. Review of the significant change MDS assessment dated [DATE] showed resident #72 had a BIMS score of 5 out 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia and depression. b. Review of the quarterly MDS assessment dated [DATE] showed resident #29 had a BIMS score of 15 out of 15, which indicated the resident was cognitively intact, and diagnoses which included anxiety disorder and depression. c. Review of a progress note for resident #29 dated 11/3/24 and timed 6:24 PM showed [Resident #29] was coming back from dinner in [his/her] power wheelchair. A previously agitated resident walked in path of [resident #29]. [Resident #29] stated get out of my way. The agitated resident then hit [his/her] ankle on the foot rest of the w/c. The agitated resident then said ow!' and spun around and smacked [resident #29] on R [right] side of face. [Resident #29] and the other resident were separated. [Resident #29] went to room and was instructed to stay away from aggressive resident. [Resident #29] complied and not sought out [sic] other resident. The other resident has not sought [sic] further interactions with [resident #29]. [Resident #29] was assessed for injury but none noted at this time . d. Review of a progress noted for resident #29 dated 11/3/24 and timed 6:39 PM showed . [resident #29] was involved in incident where [s/he] received physical aggression in form of a slap to the R side of face. [Resident #29] was initially upset but has no noted injuries at this time . e. Review of a progress note for resident #29 dated 11/3/24 at 11:54 PM showed Victim in resident to resident altercation earlier this evening. Resident initially upset and wanting to know what was being done in regard to incident and asking to press charges. Resident was reassured that staff would do their best to keep [him/her] and aggressor away from each other for safety. Resident agreeable and eventually made no further mention of incident. Appears to be anxious but denies being fearful . f. Review of a progress note for resident #29 dated 11/4/24 and timed 5:19 PM showed Resident is on alert charting for having received physical aggression. [S/He] has been out of [his/her] room and has been in a pleasant mood. [S/He] did become anxious when the aggressor came near the nurse station for a soda. [S/He] said, get [him/her] out of here. The other resident was redirected and no other issues noted. Resident did not raise any concerns about [him/her] other wise [sic] and did not complain of any issues from the incident. [S/He] has been calm and relaxed . g. Interview with resident #29 on 12/12/24 at 9:01 AM confirmed s/he was hit by another resident; however, s/he did not want to discuss the incident further. h. Interview with LPN #1 on 12/11/24 at 8:14 PM revealed resident #72 was very upset that day. The resident began to walk off and walked in front of resident #29. Resident #72 turned around to yell at the LPN and when s/he turned, s/he walked into resident #29's wheelchair. Resident #72 then turned and hit resident #29. The LPN revealed resident #29 was pretty upset and wanted to press charges. The LPN revealed resident #29's face was pink immediately after; however, it did not last. Further interview revealed resident #29 was not afraid of resident #72, just mad at him/her. 4. Review of a facility incident report dated 7/16/24 showed resident #131 came out of his/her room with a garbage can and hit resident #73 in the head, right shoulder, and arm. Staff immediately contained resident #131 and took him/her to his/her room. Residents were kept separated and RN #2 was called into the unit by the aides. The RN assessed resident #73 for injuries and none were noted. Resident #73 was noted to be shocked and didn't understand what had happened. The following concerns were identified: a. Review of the quarterly MDS assessment dated [DATE] showed resident #73 had a BIMS score of 1 out 15, which indicated severe cognitive impairment, and diagnoses which included non-traumatic brain dysfunction, non-Alzheimer's dementia, and anxiety disorder. b. Review of the significant change MDS assessment dated [DATE] showed resident #131 had short-term and long-term memory impairment and diagnoses which included non-Alzheimer's dementia and depression. c. Review of a progress note for resident #132 dated 7/16/24 and timed 7:05 PM showed .At approximately 1846 [6:46 PM] this nurse was called into the unit related to an altercation between [resident #131] and another community member. When this nurse arrived in unit other community member was sitting in a stationary chair with back against wall outside of room [ROOM NUMBER] rubbing [his/her] right upper arm and shoulder. A metal trash can was noted on the other side of the doorway of room [ROOM NUMBER] and trash was noted on the floor. Staff reported that [resident #131] suddenly came out of room [ROOM NUMBER] with trash can and began hitting other community member with it. [Resident #131] was in [his/her] room pacing back and forth with CNA .When asked what happened [resident #131] stated I don't know. When this nurse asked why [s/he] hit the other community member [resident #131] stated I didn't, maybe you should call 911 . d. Interview with MA-C #1 on 12/11/24 at 6:39 PM revealed resident #131 had been having a lot of behaviors on the day of the incident. Resident #131 was in his/her room and resident #73 was sitting in chair in the common area. MA-C #1 revealed out of nowhere, resident #131 walked out of his/her room and hit resident #73 with a metal trash can. MA-C #1 intervened right away and notified the nurse. The MA-C revealed resident #73 was shocked and didn't really know what happened. MA-C #1 revealed resident #73 was rubbing his/her arm and face following the incident. e. Interview with CNA #5 on 12/12/24 at 8:31 AM confirmed resident #131 was in his/her room then came out and hit resident #73 with a trash can. The CNA revealed resident #73 was upset; however, s/he did not react to the incident. 5. Review of a facility incident report dated 10/7/24 showed a resident-to-resident altercation occurred when resident #67 began to shadow box and pace around the unit following a denied sexual proposition to a staff member. As resident #67 passed resident #71, s/he struck resident #71 in the head. The following concerns were identified: a. Review of the quarterly MDS assessment dated [DATE] showed resident #71 had short-term and long-term memory impairment and diagnoses which included Alzheimer's disease, anxiety disorder, and depression. b. Review of the significant change MDS assessment dated [DATE] showed resident #67 had short-term and long-term memory impairment and diagnoses which included non-Alzheimer's dementia, manic depression, and psychotic disorder. c. Review of a progress note for resident #71 dated 10/8/24 and timed 1:11 AM showed Aides alerted nurse(s)that resident had been in an altercation with another resident. Just prior to the incident, resident was sitting in a recliner in the community lounge area. Aggressor was observed by staff hitting at the air in front resident's face and made [sic]. It is unknown exactly which side of resident's face where contact was made. Resident did not react or say anything following the incident. Staff immediately separated resident from aggressor. Head to toe assessment completed. No injuries noted. Resident did not respond when asked if [s/he] is afraid. Resident remained standing near exit of unit following incident. Does not appear to be fearful at this time. Staff continued to observe resident for any behavior changes or signs of fear . d. Interview with CNA #6 on 12/11/24 at 6:06 PM revealed resident #67 had an idea the CNA was his/her significant other and at times s/he would get inappropriate. S/he was walking around the unit saying they should do inappropriate things. The CNA told the resident no and asked another CNA to step in. CNA #6 went to provide one on one care with another resident and had to close the door because resident #67 was upset. After that, CNA #6 heard resident #67 had hit resident #71; however, she did not observe it. Further interview revealed she did not recall resident #71 having any injuries. e. Interview with CNA #7 on 12/11/24 at 6:26 PM revealed resident #67 was very upset and had been inappropriate with another aide. The CNAs switched assignments as a result. The CNA revealed resident #67 was going up and down the unit and hit resident #71. Following the strike, CNA #7 revealed resident #71 was confused; however, s/he can't really verbalize things. The CNA revealed resident #71 seemed confused about why s/he got hit, there were no physical injuries, and the resident was hit on the side of his/her face. CNA #7 was unsure if resident #67 meant to hit resident #71 because resident #67 was upset and was swinging his/her arms. f. Interview with RN #3 on 12/12/24 at 9:30 AM revealed when she went back to assess resident #71, s/he had no response and there was no evidence of an injury. Following the incident, a staff member was placed with each resident to keep them apart. The RN revealed she thought resident #67 was just triggered. Further interview revealed resident #71 did not say much verbally. g. Interview with RN #4 on 12/11/24 at 7:40 PM revealed resident #71 was very demented and s/he did not attempt to protect him/herself from others. She revealed following the incident the resident did not have injuries and did not display fear; however, if resident #71 were in the right state of mind, s/he would probably be fearful of resident #67. 6. Review of the policy titled Resident Abuse/Neglect Including Misappropriation of Resident Property and Resident-to-Resident Altercations last revised 11/7/19 showed .The resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation .It is the policy and practice of WRC that all residents will be protected from abuse and neglect .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on incident review, medical record review, staff interview, and policy review, the facility failed to ensure residents were free of accidents for 2 of 9 sample residents (#48, #78) reviewed for accident hazards. This failure resulted in actual harm to residents #48 and #78. The findings were: 1. Review of the significant change MDS assessment dated [DATE] showed resident #48 had short-term and long-term memory problems and diagnoses which included fracture of the right femur, atrial fibrillation, and dementia. The resident had a BIMS score of 3 out of 15, which indicated severe cognitive impairment. Review of the care plan last revised on 9/12/24 showed resident #48 is dependent on staff for all transfers, using a gait belt. The following concerns were identified: a. Review of a progress note dated 10/20/24 and timed 5:30 AM showed CNA states that resident was being transferred X [times] 1 assist from wheelchair to bed. At this time staff member states that resident was trying to pull [his/her] brief down, and CNA attempted to help resident pull it back up mid-transfer. At this time, resident lost his/her balance and sat down hard on the armrest of the wheelchair. Resident unable to re-state what had happened, stating s/he just fell, and hit that thing hard, (pointing to the arm of the wheelchair). Resident was assessed for acute injuries. Resident has facial grimacing, and is observed to be in severe pain when attempting to assist resident back to bed. Resident continued to be in extreme pain when staff attempted to roll resident to either side to put a clean brief on resident. b. Review of a history and physical dated 10/20/24 and timed 11:05 AM showed the resident was brought in by ambulance and was unable to ambulate. The x-ray showed a right hip intertrochanteric fracture. c. Interview with LPN #2 on 12/12/24 at 9:42 AM revealed that around 5:30 AM to 6 AM the CNA transfered resident #48 from the bed to the wheelchair when the resident's knees buckled and s/he hit [his/her] crotch on the armrest of the wheelchair. The nurse reported the resident was in the wheelchair when the CNA let her know about the fall. The resident complained of pain in his/her pelvis and was assessed by the nurse. The nurse noted no bruising or internal rotation at that time. The nurse administered the resident's scheduled pain medication and when it did not decrease the resident's pain, the nurse called the resident's daughter who asked the nurse to send the resident to the emergency department. The nurse revealed it was the policy for a gait belt to be used for all transfers however there was not a gait belt used for the transfer. d. Interview with the education specialist on 12/12/24 at 10:34 AM revealed gait belts were to be used for every transfer and staff were educated at orientation, annually, and when they were caught not using gait belts during transfers. 2. Review of the admissions MDS dated [DATE] showed resident #78 had diagnoses of a urinary tract infection (UTI) and non-Alzheimer's dementia. Further review showed the resident experienced repeated falls and wandering, and had a BIMS score of 6 out of 15, which indicated severe cognitive impairment. The following concerns were identified: a. Review of a facility incident report dated 10/19/24 showed sometime between 9 PM and 10 PM on 10/18/24 the North patio back door alarm went off. Several aides walked outside but did not find anyone. On 10/19/24 at 12:30 AM the back door alarm went off again, and CNA #8 found resident #8 outside in the fenced patio area. S/he was immediately brought in and taken to his/her room and assessed and warmed up. The resident told staff s/he was going to find his/her spouse in the truck. Further review showed staff reviewed video footage of resident #78 which showed the resident exited the North patio west gate at 10:24 PM camera time. At 10:47 PM camera time two staff members were seen investigating the patio. On 10/19/24 at 1:02 AM camera time the resident entered the North patio [NAME] gate and entered back on the patio. b. Review of a progress note dated 10/19/24 at 7:36 AM showed the resident was assessed by nursing and found to have had wet clothing, deep red knees with a top layer of skin rubbed off, and a bruised second toe on his/her left foot. A wanderguard was placed on the resident's right wrist. c. Review of the care plan dated 10/19/24 showed the resident was an elopement risk/wanderer, disoriented to place, had a history of attempts to leave the facility unattended, impaired safety awareness and wandered aimlessly. d. Interview with the facility administrator on 12/11/24 at 5:57 PM revealed there was not clear video footage of the resident leaving or returning to the building, and there was no longer any video footage to review. e. Interview with the facility administrator on 12/12/24 at 11:24 AM revealed the policy for door alarms was to go and visually check the area. The administrator revealed the staff had not been aware of the resident's elopement, a headcount was not performed, and she could not explain how the resident was gone that long. Further, the administrator revealed the facility policy addressed how to search for a resident that is known to be missing but did not address steps to be taken when doors were alarmed. 4. Review of the Elopement and Missing Resident policy revised on 4/2019 showed the policy did not address steps to take when the doors are alarmed. 5. Review of the Safe Lifting and Movement of Resident Policy revised on July 2017 showed .4. Staff responsible for direct resident care will be trained in the use of manual (gait/transfer belts .).

Based on review of incident reports and facility documentation, staff and resident interviews, medical record review, and review of facility policies, the facility failed to ensure the resident was free from verbal abuse by another resident for 2 of 4 allegations reviewed (residents #5 and #7), which resulted in psychosocial harm to resident to resident #5. The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 6/20/24. 1. Review of the 3/30/24 quarterly Minimum Data Set (MDS) assessment showed resident #6 (perpetrator) had a Brief Interview for Mental Status (BIMS) score of 15 out of 15, indicating no cognitive impairment and had a diagnosis of Schizophrenia. Review of the 5/18/24 annual MDS assessment showed resident #5 (victim) had a BIMS score of 8 out of 15, indicating moderate cognitive impairment. The following concerns were identified: a. Review of an incident report showed on 6/12/24 resident #5 was walking into the dining room. Resident #6 yelled at the resident Trash! You're nothing but trash! Why don't you get some shorter shorts, you're just trashy! Resident #5 also told staff that resident #6 told him/her if you come near me, I'll hit you. Certified nurse aide (CNA) #1 walked with resident #5 back to the north unit, and the resident was in tears. Review of the facility's investigation findings showed As is often the case on a daily basis, [resident #6] made rude and unnecessary remarks to [resident #5] causing [him/her] to feel emotional distress and fear. b. During an interview on 7/2/24 at 5:04 PM CNA #1 stated resident #6 called resident #5 trashy and stated don't come near me. She stated she walked with resident #5 who was crying. c. Review of the medical record for resident #5 showed the following progress notes: 6/13/24- resident expressed fear of the other resident; 6/14/24- the resident continued to feel anxious and fearful of resident #6; 6/16/24- resident reports s/he feels anxious and fearful of resident #6; 6/17/24- the resident reported s/he continues to feel anxious and fearful of resident #6; and 6/18/24- resident continues to feel anxious when in common areas when resident #6 was around. d. On 7/3/24 at 9:14 AM resident #5 was interviewed. When asked if s/he ever had any issues with another resident, the resident replied just with [resident #6]. The resident stated resident #6 called him/her names and was mean to him/her. The resident stated I was scared of [him/her]. The resident stated s/he felt better today because resident #6 was just discharged . e. Resident #6 was unable to be interviewed because the resident was transferred to another facility on 7/2/24. f. During an interview on 7/3/24 at 9:17 AM the administrator confirmed resident #5 was upset after the incident with resident #6. She stated the resident was checked in on weekly by staff and continued to say s/he was fearful of resident #6. 2. Review of the 4/6/24 quarterly MDS assessment showed resident #7 (victim) had a BIMS score of 9 out of 15, indicating moderate cognitive impairment. A BIMS dated 7/2/24 showed resident #7 scored 11 out of 15, indicating moderate cognitive impairment. Review of the 4/20/24 quarterly MDS assessment showed resident #8 (perpetrator) had a BIMS score of 15 out of 15, indicating intact cognition. The following concerns were identified: a. Review of an incident report showed on 6/8/24 resident #7 came out of his/her room visibly upset and stated I cannot do it anymore with my roommate .[S/he] just said that [s/he] is going to get a double aught six and blow my head off because I'm a pedophile rapist. The nurse spoke to the resident's roommate, resident #8, who stated s/he told the resident that I ought to get someone to get me a thirty aught six so I can shoot [him/her] in the head . Resident #7 was offered another room and was moved to another room away from resident #8. The facility's investigation findings showed Verbal aggression and abuse was verified in this investigation. [Resident #8] did threaten [his/her] roommate [Resident #7] on the evening of 6/8/24 causing [him/her] to feel scared, unsafe and uncomfortable in [his/her] room. b. On 7/3/24 at 9 AM resident #7 stated s/he moved to the current room about a month ago because resident #8 threatened him/her. The resident stated s/he couldn't take it anymore and s/he was afraid if s/he stayed, it would get physical. The resident stated s/he was happy with the room change. c. An interview with resident #8 was attempted, but the resident was asleep. d. During an interview on 7/3/24 at 11:23 AM licensed practical nurse (LPN) #1 stated resident #7 told her that his/her roommate had threatened to shoot him/her. The resident stated s/he couldn't stay with the other resident anymore. She stated she ensured the resident didn't actually have a weapon. She further stated they moved resident #7 to another room that night and the resident has been doing good since the room change. 3. Review of the facility's policy Resident Abuse/Neglect Including Misappropriation of Resident Property and Resident-to-Resident Altercations, revised 11/7/19, showed The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation was defined in this subpart . 4. The following plan of correction was implemented by the facility by 6/20/24: a. Resident #6 was offered counseling, but refused to see them. The resident was placed on a title 25 hold for transfer to the psychiatric hospital. Resident #7 was moved away from resident #8. b. Facility developed a weekly check-in with all residents to enhance monitoring for abuse. c. Staff completed training on de-escalation and abuse. d. The facility reached out to an outside source for resources on abuse training. The facility developed a library for staff education. e. The facility has an active performance improvement project (PIP) in quality assurance for abuse.

Based on medical record review, staff and resident interviews, and review of incident documentation, the facility failed to ensure residents were free from abuse by other residents for 1 of 3 allegations of abuse reviewed (#1). Resident #1 experienced physical and psychosocial harm as a result of an interaction with another resident. The findings were: 1. Review of the 4/6/24 admission Minimum Date Set (MDS) assessment showed resident #1 (victim) had a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition, and had the ability to understand others and makes self understood. 2. Review of the 3/30/24 admission MDS assessment showed resident #2 (perpetrator) had a BIMS score of 1, indicating severe cognitive impairment, and a diagnosis of dementia. 3. Review of an incident report showed on 4/28/24 resident #1 came out of his/her room and told licensed practical nurse (LPN) #1 that resident #2 had thrown a water cup at him/her. The cup struck the resident in the face causing a small scratch near the mouth and soaked him/her in water. The facility's conclusion of their investigation was .conclude that a physical resident on resident altercation did occur. Residents were immediately separated and a temporary room move was conducted that day .[resident #2] was then moved to a private room on 4/30/24 on the men's secure unit .[Resident #1] was noted by some staff to be more somber after the incident but had no major behavioral changes. 4. Review of a progress note dated 4/28/24 showed resident #1 stated his/her roommate threw a water pitcher at him/her. There were two marks on the resident's face; a small scratch on the upper lip and one on the right upper cheek. The resident's clothes were covered with water. The note further showed Client is afraid to go back to [his/her] room. Another note dated 4/29/24 showed Resident did not enter into his original room this shift, stating [s/he] did not want to be around [his/her] roommate. Resident is currently staying in a temporary room at this time. 5. On 5/23/24 at 8:38 AM resident #1 stated s/he did not have any issues with their current roommate, but had issues with the previous one. When asked what happened, the resident stated [name of resident #2] tried to kill me. When asked for details, the resident stated resident #2 took a water mug and .scratched my face all to hell. When asked how that made him/her feel, the resident stated I'm scared of [him/her]. The resident stated s/he doesn't see the other resident as much now, except in the dining room .but there are security cameras there. 6. An interview with resident #2 was attempted on 5/23/24 at 9:43 AM, but the resident didn't recall an incident with a roommate. 7. During an interview on 5/23/24 at 9:50 AM LPN #1 stated resident #1 told her that resident #2 had thrown a water mug at him/her. She stated the resident had two marks on his/her face; one on the forehead and one on the cheek. She stated water was all over. She further stated resident #1 was alert and oriented and after the incident told her that s/he was afraid of resident #2. She stated after the incident resident #1 stayed in the common area with staff the rest of the day, which was unusual for him/her. 8. On 5/23/24 at 10:08 AM the administrator confirmed the incident involving residents #1 and #2. She stated resident #1 refused to go back to his/her room as long as that [guy/gal] is there. When asked what had been done since the incident, the administrator stated around the time of the incident staff were assigned chapters 1-3 in the MANDT book, which covered triggers, communication, de-escalation, etc. However, she stated not all staff had completed the training. When asked if the incident had been reviewed in quality assurance, she stated they review abuse incidents but they had not had a QA meeting since the incident. The next meeting was in June.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident representative and staff interview, state survey agency incident database review, and policy and procedure review, the facility failed to protect the resident's right to be free from physical abuse by another resident for 2 of 4 sample residents (#2, #4) reviewed for abuse allegations. This failure resulted in actual harm to resident #2 and resident #4 who sustained injuries during a resident-to-resident altercation. The findings were: 1. Review of the facility incident reported to the state survey agency incident database dated 12/5/23 and timed 6 PM showed resident #2 and resident #4 were involved in a resident-to-resident physical altercation in the room of resident #4. The residents were observed on the floor with resident #2's arm wrapped around the head of resident #4. Resident #4 was observed hitting resident #2, with a closed fist, in the face. Immediate interventions included removing resident #2 from the room and assisting him/her to his/her room at the opposite end of the unit. The residents were placed on increased monitoring to prevent interactions. Both residents were placed on neurological evaluations and a stop sign was placed on the doorway of resident #4 to prevent others from entering his/her room. Further review showed both residents sustained injuries as a result of the altercation. 2. Observation on 12/26/23 at 4 PM showed resident #4's room was no longer located on the secure unit near resident #2. 3. Review of the significant change MDS assessment dated [DATE] showed resident #4 had a BIMS score of 4 out of 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia, delusions, and an anxiety disorder. Further review showed the resident walked without assistance, had no skin problems, no fractures, and received antianxiety and antidepressant medications during the 7-day look-back period. The following concerns were identified: a. Review of a progress note dated 12/5/23 and timed 8:27 PM showed .This nurse was called into another [resident #4's] room by [CNA #5] in the [locked unit] at approximately 1800 [6 PM]. When this nurse arrived in room [resident #4] was on the floor next to the empty bed in room with other community members [other resident's] arm around [his/her] neck [NAME] [sic] head lock, both community member's legs were intertwined, and [resident #4] hit other community member in the face, under the left eye and left side of nose, with a closed hand. As staff were pulling community members apart [resident #4] hit other community member in the face again in the same spot with a closed fist. Prior to incident [resident #4] was noted pacing in [his/her] room. [CNA #5] stated that she had been in another community members room with the door shut providing cares when she heard a commotion. Whensheexited [sic] room she heard other community member say get off me, get off me. She noticed other community member wasn't in [his/her] chair and entered room to find community members on the floor intertwined. [CNA #5] stated she then immediately came and got help. Community members were pulled apart from one another. Other community member was immediately taken out of [resident #4's] room and to [his/her] own. Head to toe physical assessment performed. [Resident #4] had no red areas noted to bilateral lower extremities or bilateral upperextremities [sic]. Laceration approximately 1 cm long noted to lobe of right ear. Hematoma noted to top right side of head. No other red or areas of discoloration noted/reported atthis [sic] time. No other injuries noted at this time. Neurological checks initiated related to altercation and unwitnessed fall. Stop sign placed on [resident #4's] door to dissuade other community members from entering [his/her] room. When asked what happened [resident #4] stated What are you going to do about that asshole? If [s/he] comes back in here again I will kick [his/her] ass again. [S/He's] tough, but so am I . b. Review of a progress note dated 12/8/23 and timed 11:01 AM showed .Resident was in Res [resident] on Res altercation, has bruising to hand, and face. Resident stated [his/her] lower back was hurting today. PRN [as needed] APAP [analgesic] administered. Resident reports it is effective . c. Review of a hospital discharge note dated 12/9/23 showed the resident had rib fractures and a lumbar transverse process fracture. d. Review of a physician note dated 12/17/23 showed .[S/He] is being seen today for follow up rib fractures, decreased appetite, debility. Rib Fractures: Patient with recent hospitalization for rib fractures after an altercation with another resident and fall. Patient reports right upper, outer chest pain to which Tylenol [analgesic] is effective . e. Interview with the resident representative for resident #4 on 12/27/23 at 11:53 AM confirmed the resident's room was moved outside the secure unit, away from resident #2. Further interview, confirmed the resident sustained 3 broken ribs and a broken vertebra, had a hematoma to his/her head, had a bruise to his/her eyes, and had a dark bruise to his/her hand following the altercation. 3. Review of the quarterly MDS assessment dated [DATE] showed resident #2 had a BIMS score of 6 out of 15, which indicated severe cognitive impairment, and diagnoses which included non-Alzheimer's dementia. Further review showed the resident received antipsychotic medication and had behavioral symptoms not directed toward others on 1 to 3 days during the look-back period. The following concerns were identified: a. Review of a progress note dated 12/5/23 and timed 8:59 PM showed .This nurse was called into another community member's room by [CNA #5] in the [locked unit] at approximately 1800 [6 PM]. When this nurse arrived in room [resident #2] was on the floor next to the empty bed in room with [his/her] arm around other community member'sneck [sic] in a head lock, both community member's legs were intertwined, and other community member hit [resident #2] in the face, under the left eye and left side of nose, with a closed hand. As staff were pulling community members apart other community member hit [resident #2] in the face again in the same spot with a closed fist. Prior to incident [resident #2] was sitting in chair out in common area. [CNA #5] stated that she had been in another community members [sic] room with the door shut providing cares when she heard a commotion. Whenshe [sic] exited room she heard other community member say get off me, get off me. She noticed [resident #2] wasn't in [his/her] chair and entered room to find community members on the floor intertwined. [CNA #5] stated she then immediately came and got help. Community members were pulled apart from one another. [Resident #2] was immediately taken out of other community members [sic] room and to [his/her] own. Once in [resident #2's] room [resident #2] began settling down and sat in [his/her] recliner. This nurse performed a head to toe physical assessment. No red or discolored areas noted to torso bilateral lower extremities, upper left extremity or head at this time. A skin tear approximately 2 cm x 1 cm was noted to right lateral wrist. [Resident #2] had blood noted to the left corner of [resident #2's] mouth and lower lip. Thorough oral assessment was completed and no injury to mouth or face was noted. No hematomas noted to head. [Resident #2] did complain of right wrist pain and a headache at this time. Neurological checks initiated related to unwitnessed fall and being hit in the head. Staff hung a stop don't enter banner over other community members door to dissuade [resident #2] from entering room again. b. Review of a progress note dated 12/6/23 and timed 8:10 PM showed the resident .remains on alert charting post unwitnessed fall and resident to resident altercation, with injury to left wrist, dressing on left wrist clean dry and intact. resident [sic] denies pain and discomfort at this time. will [sic] continue to monitor through out [sic] shift . 4. Interview with RN #1 on 12/27/23 at 12:40 PM revealed she heard resident #4 yelling for resident #2 to get out of his/her room and upon entering witnessed the residents punching each other and fall to the floor while fighting. The nurse revealed both residents received injuries from the fight. Further interview revealed the residents were immediately separated, both residents remained in their own rooms the remainder of the night, and a stop sign was placed across the doorway of resident #4. 5. Interview with RN #2 on 12/27/23 at 9:50 AM revealed resident #4 was sent to the hospital 3 days after the altercation due to chest pain and the family refused to allow the resident to return unless the facility could ensure the resident's safety. 6. Interview with the DON on 12/28/23 at 12:05 PM revealed resident #4 did not complain of pain right after the altercation but when s/he did, it was of chest pain so s/he was sent to the hospital on [DATE]. At that time, the facility was notified of the fractures to resident #4 by the hospital. The DON revealed the facility was not sure if the fractures were from the resident-to-resident altercation because the resident was mostly independent and did not have pain immediately after the altercation. The DON did confirm resident #2 received a skin tear to the right wrist and resident #4 received a laceration to the right ear lobe, a hematoma to top of his/her head, bruising to the left hand, face, and right upper chest, and required more staff assistance for a few days. 7. Review of the facility policy dated September 1999 titled Resident Abuse/Neglect Including Misappropriation of Resident Property and Resident-to-Resident Altercations showed .all residents will be protected from abuse and neglect .1. Abuse, is .the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of facility incident reports, review of medical records, staff interview, and review of policy and procedures, the facility failed to protect the resident's right to be free from physical abuse by a staff member for 1 of 7 sample residents (#1) reviewed for abuse. This failure resulted in harm to resident #1, who had injuries including a bloody nose, a goose egg to the forehead, and complaints of pain that required transport to the emergency department (ED) for evaluation. The findings were: Review of the admission MDS assessment dated [DATE] showed resident #1 had diagnoses which included renal insufficiency, non-Alzheimer's dementia, malnutrition, and asthma. Further review of the MDS showed the resident wore a wander/elopement alarm, required daily antipsychotic medications and frequent antianxiety medications. Review of the BIMS score showed the resident had a score of 6 out of 15, signifying severe cognitive impairment. Review of the care plan for the resident dated 1/19/23 showed the resident is an elopement risk/wanderer related to disoriented to place. Resident wanders aimless, significantly intrudes on the privacy or activities. Further review of the care plan showed Upon admission [resident name] was easily agitated and could become verbally and physically aggressive (especially in late afternoon/evenings). Interventions included COMMUNICATION: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff member when agitated. Review of the nursing progress note dated 1/24/23 at 7:30 PM and authored by LPN #1 showed the resident was going in and out of other resident's rooms and throwing things. S/he was trying to hit other residents. Further review of this nursing progress note entry showed .directed this patient to [his/her] room and got there and patient went down to the floor. This nurse was trying to get under this pt's arms to assist [him/her] and around [his/her] chest and got [him/her] up off the floor while CNA was taking care of the resident's roommate. The resident was over [his/her] bed and grabbed this nurse by the left wrist and swung [his/her] fist punching this nurse in the right temple causing this nurse to fall and unable to control fall landing with right shoulder to this resident's nose and face. The resident's nose began to bleed and this nurse tried to stop it and get some tissues to do so and this pt stated to this nurse to get away from [him/her] or [s/he] would kill this nurse before [s/he] got killed. On 1/24/23 an incident report was initiated related to this incident showing LPN #1 was suspended from duty, and law enforcement was called the night of the incident. The following concerns were identified: 1. Review of the facility's incident report initiated on 1/24/23 showed the resident was assessed by the facility on 1/24/23 at approximately 9:45 PM and noted to have a bloody nose, a goose egg on [his/her] forehead, and is complaining of rib pain. It was determined the resident's injuries required evaluation at the ED. 2. Review of the nursing progress note dated 1/24/23 at 11:40 PM showed Resident left facility at this time via stretcher/EMS to emergency department . 3. Further review of the facility's incident report showed CNA #1 was identified as the CNA who was in the resident's room at the time of the incident. CNA #1 told the facility he was initially afraid to tell the truth about the incident, but he did see LPN #1 cock back his arm and hit resident #1. Additionally, the incident report showed CNA #2 told the facility she saw LPN #1 in the nurse's station after the incident. The LPN was visibly upset and when CNA #2 asked him what happened he told her, I f*cking hit him. CNA #2 reported LPN #1 later told her he had fallen on the resident and his shoulder hit the resident. 4. Review of a statement written by CNA #1 dated 1/27/23 at 3:29 PM showed .after the new resident fell down like 5 times [LPN #1] dragged the new resident in [his/her] room and the new resident got up and tried to attack [LPN #1] again [LPN #1] took the resident down another time in [his/her] room and had the new resident in a head lock and was choking [him/her] and after the new resident tried to bite him [LPN #1] picked [the resident] up and slammed [him/her] on the bed I after that the new resident hit [LPN #1] in the face broke his glasses and [LPN #1] hit the new resident back with a closed fist how I know it was a closed fist is because he cocked back his arm and hit him. CNA #1 was on leave at the time of the investigation and unavailable for interview. 5. Observation of resident #1 on 2/14/23 from 1:45 PM to 3:15 PM showed the resident in the common area of the secure unit and regularly stood over and yelled at residents who were seated. Staff frequently redirected the resident by attempting to divert his/her attention to other things, such a magazines, or by attempting to convince the resident to go to his/her room. This redirection would only be effective for a short time before the resident was once again yelling at staff or other residents. An attempt to interview the resident during the observation was unsuccessful. 6. Interview with the DON on 2/14/23 at 10:30 AM confirmed interviews with staff members in the course of the facility's investigation of the incident resulted in the facility calling law enforcement with new information. Review of the facility's incident report showed LPN #1 was arrested. 7. Interview with the DON on 2/15/23 at 11 AM revealed it was the desire and intent of the facility to prevent all abuse for all residents, and confirmed the facility's investigation had shown that abuse occurred. 8. Review of the policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated 2001 showed Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation .The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the objectives.