Based on medical record review, staff and resident interviews, and review of incident reports and facility documentation, the facility failed to protect the resident's right to be free from physical abuse by a client from another facility for 1 of 1 sample residents (#1) reviewed for abuse allegations, which resulted in physical and psychosocial harm. Corrective measures were implemented by the facility prior to the survey and compliance was determined to be met on 10/6/23. The findings were: 1. Review of the 9/12/23 significant change Minimum Data Set (MDS) assessment showed resident #1 scored 15 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident was cognitively intact. 2. Review of a progress note dated 9/19/23 showed the resident attended work for a little while, but then came home due to an altercation. 3. Review of an incident report submitted to Healthcare Licensing and Surveys (HLS) showed on 9/19/23 a client (#C1) from another facility (located on the same campus) attacked resident #1 at the resident's work station. It was documented the resident received a scratch near his/her armpit and a torn shirt. 4. On 10/9/23 at 3:19 PM security officer #1 stated on 9/19/23 while on foot patrol he encountered client #Cl, who was upset at resident #1 for something s/he had said. The security guard went to the training center where resident #1 was working and asked him/her to apologize to client #C1. He stated he was observing from around the corner when client #C1 entered the training center and went over to resident #1. He stated resident #1 started to apologize to client #C1 when client #C1 grabbed the resident by the shirt, and tore his/her shirt. The security guard separated the residents and other staff arrived to help. 5. During an interview on 10/9/23 at 3:30 PM security guard #2 stated when her arrived to the training center on 9/19/23 he saw security guard #1 had ahold of client #C1, who was trying to get to resident #1. He stated resident #1 was in his/her wheelchair and was not fighting back. 6. On 10/9/23 at 3:45 PM shift supervisor #1 stated he was attending a training at the training center on 9/19/23 and during a break he came around the corner and heard resident #1 stating s/he wouldn't apologize to client #C1, and client #C1 was ripping the shirt off of resident #1. He stated security was present. 7. During an interview on 10/9/23 at 4:27 PM resident #1 stated on 9/19/23 s/he encountered client #C1 outside who yelled at him/her. Resident #1 stated s/he ignored it and went to work at the training center. S/he stated security guard #1 came to him/her and asked if s/he could apologize to client #C1 and s/he said OK. Resident #1 stated client #C1 came in and started yelling. Resident #1 stated s/he said sorry and then client #C1 grabbed his/her hand and slammed it on the desk. S/he stated the client then grabbed him/her and ripped their shirt. The resident stated s/he received a scratch near his/her shoulder and forearm. The resident stated as a result of the altercation, s/he was afraid of client #C1. The resident stated I hate to be scared, but I am. 8. On 10/10/23 at 8:30 AM Professional Development Center (PDC) instructor #1 stated on 9/19/23 she didn't observed the actual incident between client #C1 and resident #1 because security had already intervened when she came upon it. She stated that she did talk to resident #1 after the incident. She stated resident #1 was visibly shaken with a trembling voice. She stated resident #1 had a ripped shirt. 9. During an interview on 10/10/23 at 9 AM resident rights advocate #1 stated client #C1 attacked resident #1 on 9/19/23. She stated the resident had a ripped shirt and a small scratch. She stated she would consider the incident substantiated for abuse because the client did get ahold of the resident and ripped his/her shirt. 10. During an interview on 10/10/23 at 11:06 AM registered nurse (RN) #1 stated she assessed resident #1 after the incident. She stated the resident had a little scratch that s/he claimed was from client #C1. She stated it could have been because the resident did have a ripped shirt. She stated since the incident the resident has said s/he is afraid of client #C1. 11. Review of a progress note dated 9/19/23 by RN #1 showed Upon assessment, [resident] had no redness or bruising noted to shoulders although [s/he] was claiming [his/her] pain was a 9 and now was a 12. Did have a small scratch to right inner shoulder. Left forearm where [resident] had a scab was also opened now but unknown if that was from other resident or [resident] picked at it as [s/he] is known to pick at [his/her] skin .although [resident] reports that other resident did that as well . 12. Review of facility documentation and interview with the nursing home administrator on 10/10/23 at 1:24 PM revealed the facility already had a plan of correction for F600 in place prior to this incident, and it continued after the incident. Compliance was determined to be met on 10/6/23. The actions taken by the facility included: a. The client from the other facility (#C1) had his/her work route changed so s/he would not be in the same building as resident #1. b. All residents have had their care plans updated to reflect risk of abuse. c. Staff education related to abuse, with focus on resident to resident abuse, was completed on 9/19/23, 9/26/23, and 10/3/23. Additional trainings are scheduled. Trainings were scheduled weekly for one month then monthly for two months. d. Audits were completed related to abuse and monitored in quality assessment and performance improvement (QAPI) meetings. Audits are continuing. There have been no other allegations of abuse since this incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, staff interview, review of facility investigations and incident reports, and review of policy and procedures, the facility failed to protect the resident's right to be free from physical and mental abuse by a resident for 1 of 4 residents (#3) reviewed for abuse. This failure resulted in harm to resident #3, who sustained bruising and expressed continued fear of resident #4. The findings were: Review of the quarterly MDS assessment dated [DATE] for resident #4 showed the resident had diagnoses which included CVA, non-Alzheimer's dementia, seizure disorder, TBI, and psychotic disorder. Further review showed the resident had a BIMS score of 13/15, indicating intact cognition. Review of the resident's reported behavior showed behavioral symptoms of hitting, kicking, pushing, scratching, grabbing, threatening others and screaming and cursing at others occurred 1 to 3 days every week. Review of the annual MDS assessment dated [DATE] for resident #3 showed the resident had diagnoses which included renal insufficiency, osteoporosis, a history of fractures, and non-Alzheimer's dementia. Further review showed the resident had a BIMS score of 7/15 indicating severe cognitive impairment. Review of the resident's behavior documentation included delusions along with weekly physical and verbal behaviors directed at others. The following concerns were identified: 1. Review of the facility investigation of a 7/23/23 at 10:20 PM incident between resident #4 and resident #3 showed resident #4 was in the bath and resident #3 was in the kitchen eating. Resident #4 came out of the bath and instead of going around the kitchen to get back to [her/his] room, [s/he] went through the kitchen, demanding resident #3 move [her/his] fat ass out of the way. When resident #3 did not move out of the way fast enough resident #4 made a fist and hit resident #3 on the shoulder and forearm. CNA #1 intervened and resident #4 attacked her making several contact punches to her chest. Resident #4 continued to chase and threaten staff members. As the incident progressed resident #4 yelled, regarding resident #3, that if [s/he] caught resident #3 [s/he] would f**king kill [him/her] and hoped [s/he] would die and rot in hell. 2. Review of photographs taken at the time of the incident showed the left arm of resident #3 had several red marks. During the assessment resident #3 stated to the nurse s/he was scared and shooken [sic] up. 3. Review of the facility's 7/24/23 incident report related to this incident showed the facility identified reddish-purple bruises on [resident #3's] forearm which appeared to be the markings from knuckles where [resident #4] hit [him/her.] 4. Interview with resident #3 on 8/15/23 at 10:15 AM revealed I avoid [resident #4]. [S/He] scares me. 5. Interview conducted with CNA #2 and CNA #3 on 8/15/23 at 10:30 AM revealed care provided for resident #4 was in flux from day to day, and [his/her] response to the methods used to intervene with aggressive behavior varied. 6. Interview with the facility human rights advocate/investigator on 8/15/23 at 11 AM revealed she had received statements from all of the staff who witnessed the occurrence and determined the incident did constitute abuse as defined. 7. Review of the policy and procedure titled Prevention of Resident Abuse, Neglect, and Exploitation dated 6/20/22 showed The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined .It is the policy and practice of the Wyoming Life, Resource Center (WLRC) that all residents will be protected from abuse and neglect. WLRC will not tolerate any form of resident abuse and will continually monitor WLRC policies, procedures, training programs, etc., to assist in preventing resident abuse.

Based on medical record review, staff and resident interviews, and review of facility documentation, the facility failed to protect the resident's right to be free from physical abuse by staff for 1 of 2 sample residents (#1) reviewed for abuse allegations. This failure resulted in physical and psychosocial harm to resident #6. The findings were: 1. Review of the 3/13/23 quarterly minimum data set (MDS) assessment showed resident #1 had diagnoses including traumatic brain injury, seizure disorder, and psychotic disorder, and scored a 15 out of 15 on the brief interview for mental status (BIMS) indicating intact cognition. Review of a progress note dated 3/6/23 showed the resident was displaying aggressive behavior towards staff. The note read .A third staff member came in, and took [resident name] to the ground. 2. Review of the facility's Client Right Investigation Report showed an allegation of physical abuse which occurred on 3/6/23 at approximately 4:15 PM involving resident #1 and certified nurse aide (CNA) #1. The allegation was reported by staff #2. CNA #3 and CNA #4 were witnesses to the incident. Staff #2 stated he saw CNA #1 pull the resident out of the wheelchair and the resident hit his/her back and head on the floor. He stated he then saw the CNA hit the resident as the CNA sat on top of the resident. Further review of the report showed the facility's investigation conclusion was Allegation of abuse is verified. There is enough evidence presented through written statements that [CNA #1] did in fact pull [resident] from [his/her] wheelchair by [his/her] leg/ankle, resulting in [resident] landing on the floor. It cannot be determined if that force caused any injuries. There is not enough evidence presented witness statements or pictures proving that [CNA #1] punched [resident.] 3. Review of facility investigation documentation showed the following written statements: a. On 3/6/23 Staff #2 wrote .witness a staff pull a client out of [his/her] wheelchair Cient hit [his/her] back and [his/her] head on the floor then the staff hit the client as he sat on top of [him/her]. b. On 3/7/23 CNA #3 wrote .[resident] continued to hit and kick .[CNA #1] then grabbed [resident's] leg and started to pull [resident] out of [his/her] chair. When I realized what he was doing I tried to let [resident] down as easy as I could, so that [s/he] wouldn't be injured. c. On 3/7/23 CNA #4 wrote .[CNA #1] came in and grabbed [resident] by ankle and pulled [resident] out of wheelchair to floor and then held [resident] down . 4. Further review of the facility's Client Right Investigation Report showed the resident was interviewed by the facility investigator and a Department of Family Services (DFS) caseworker on 3/9/23. The resident stated that staff beat him/her up but s/he could not remember their names. The resident was asked if s/he was punched and s/he said yes, but could not remember where. S/he said maybe it was my side but could not remember which side. 5. Review of a progress note by RN #5 dated and timed 3/6/23 at 5:20 PM showed at 5:10 PM she assessed the resident following the incident which showed .2 purple bruises under the left upper arm. Bruise #1 is maroon in color, linear and approx 2 cm x 1 cm. Bruise #2 is round, light purple 2 cm x 2 cm. The note also showed the resident had superficial scratches to both arms which the resident stated was from self harm. There was also a superficial wound to the resident's forehead that appears to be an old wound that may have been opened up . 6. Further review of the Client Right Investigation Report showed registered nurse (RN) #5 met the facility investigator on 3/7/23 at 10:30 AM to assess resident #1. There was a large blue, red and purple bruise and scrapes near the bruise on the mid to lower part of the ribcage area on the left side. When [RN] saw the bruise on [resident's] back she said I didn't see that yesterday. [RN] asked [him/her] where [s/he] got the bruises and [resident] said from the staff- couldn't remember his name, beat him/herself up .We asked [resident] if [s/he] could show me [his/her] left arm near the inner bicep and tricep area. There were several bruises, different sizes, all appeared to be recent as they were red, blue and purple with several scratches on inner arm area and on armpit and one on chest area, close to the armpit. I photographed all bruising and scratches/scrapes .[RN] said that the bruising on [his/her] back was from when [s/he] was throwing [himself/herself] around in the wheelchair, as it would match up that part of [his/her] chair and that [s/he] throws [himself/herself] really hard. 7. On 3/30/23 at 3:17 PM CNA #3 was interviewed. He stated resident #1 was trying to hit and kick him/herself and CNA #4 while the resident was in the wheelchair. He stated CNA #1 grabbed the resident's leg and pulled and the resident landed on the floor. He stated he was surprised. He stated he had a hold of the top part of the resident and tried to lower the resident when that happened. He further stated CNA #1 did not say anything to them prior. He stated he did not see CNA #1 punch the resident. 8. On 3/30/23 at 3:23 PM staff #2 was interviewed. He stated he worked in supply and was in the house [facility] that day. He stated CNAs #3 and #4 were trying to keep resident #1, who had tried to leave in his/her wheelchair, in the house. He stated CNA #1 then walked over and grabbed the resident's leg and pulled. He stated the resident came out of the wheelchair and hit the floor. He stated the other CNAs had a hold of the upper part of resident at first, but the resident still hit the floor. He stated CNA #1 then hit the resident in the side with his fist while the resident was on the ground. He stated what he observed looked very intentional and was straight up abuse to me. 9. During an interview on 3/30/23 at 3:35 PM CNA #4 stated during the incident resident #1 was swinging at them. He stated CNA #1 came in and got ahold of the resident by the ankle and pulled the resident onto the floor from the wheelchair. He described it as a firm pulling motion and stated the resident landed on his/her back. He stated he was shocked that happened. He stated there was no communication from CNA #1 prior to that. He did not observe the CNA hit the resident. He stated after the incident CNA #1 told him he thought the resident would be safer to deal with on the floor. 10. On 3/30/23 at 4:47 PM CNA #1 was interviewed. He stated that the resident did hit the floor when s/he came out of the wheelchair and I was the unlucky one holding [her/him]. He stated he tried to communicate with the other CNAs by using his eyes (looked down to the floor) to show his intention that they should get the resident onto the floor from the wheelchair. He stated he didn't verbally say anything. He stated when the resident was kicking at him, the resident slid a little down in the wheelchair. He grabbed the resident's ankle and the resident slid out and landed on his/her back. He stated the other CNAs looked dumb founded. He stated when the resident was on the floor s/he was trying to hit him, so he laid across the resident. He stated he did not hit the resident. 11. On 3/31/23 at 9:13 AM resident #1 was interviewed. When asked how staff treated him/her, the resident replied good except for the staff on the house, [name of CNA #1]. The resident stated that staff person was suspended or fired, and I'm glad. During the interview, s/he described two incidents involving CNA #1. The resident mentioned being grabbed out of the wheelchair and stated he punched me. The resident also mentioned being slammed into a wall. The resident did not know the dates. The resident stated after the second incident, s/he was taken to his/her room by security. The resident stated after the second incident s/he had bruising to the back which the facility took pictures of. The resident stated s/he has PTSD and that added to it .nothing but nightmares since. 12. On 3/31/23 at 11:50 AM the nursing home administrator (NHA) stated since the incident staff received education. However, she stated the facility had not implemented any audits or monitoring and had not had a quality assurance (QA) meeting since the incident.

Based on medical record review, staff and resident interviews, and policy and facility documentation review, the facility failed to ensure a restraint was the least restrictive alternative and used for the least amount of time for 1 of 1 sample residents (#1) with restraints, which resulted in psychosocial harm. The findings were: 1. Review of the 3/13/23 quarterly minimum data set (MDS) assessment showed resident #1 had diagnoses including traumatic brain injury, seizure disorder, and psychotic disorder, and scored a 15 out of 15 on the brief interview for mental status (BIMS) indicating intact cognition. The assessment showed the resident did not use restraints. Review of the facility's Client Right Investigation Report for an incident on 3/6/23 showed All security involved [security officers #1, #2, #3] assisted with putting [resident] in the suicide vest and stated that they have had no training on how to get it on and that they hold [resident] while staff put on the vest. The following concerns were identified: a. Review of a written statement dated 3/7/23 by security guard #1 showed .[security guard #2], [security guard #3)] and I assisted staff in getting [resident] into the smock. [Security guard #2] and I did a modified side body hug for [his/her] arms and [security guard #3] took care of [resident's] good leg. b. Review of a written statement dated 3/7/23 by security guard #2 showed .Received a call from [social worker] who said that [resident] needed to be placed in a suicide smock . c. Review of a written statement dated 3/7/23 by security guard #3 showed .[resident's] behavior escalated. Me and the other security guards assisted with the smock and side body support . d. Review of a written statement by certified nurse aide (CNA) #4 dated 3/7/23 showed .Suicide vest was called for and the four of us applied the vest to [resident]. [Resident] resisted and fought against vest being applied. e. Review of a progress note by RN #5 dated and timed 3/6/23 at 5:20 PM showed at 5:10 PM she assessed the resident following an incident. The resident was in a suicide smock at the time of the assessment. The nurse documented .2 purple bruises under the left upper arm. Bruise #1 is maroon in color, linear and approx 2 cm x 1 cm. Bruise #2 is round, light purple 2 cm x 2 cm. The note also showed the resident had superficial scratches to both arms which the resident stated were from self harm. There was also a superficial wound to the resident's forehead that appears to be an old wound that may have been opened up . f. Further review of the Client Right Investigation Report showed registered nurse (RN) #5 met the facility investigator on 3/7/23 at 10:30 AM to assess the resident #1. There was a large blue, red and purple bruise and scrapes near the bruise on the mid to lower part of the ribcage area on the left side. When [RN] saw the bruise on [resident's] back she said I didn't see that yesterday. [RN] asked [him/her] where he got the bruises and [resident] said from the staff-couldn't remember his name, beat [him/her] up .We asked [resident] if [s/he] could show me [his/her] left arm near the inner bicep and tricep area. There were several bruises, different sizes, all appeared to be recent as they were red, blue and purple with several scratches on inner arm area and on armpit and one on chest area, close to the armpit. I photographed all bruising and scratches/scrapes .[RN] said that the bruising on [his/her] back was from when [s/he] was throwing [himself/herself] around in the wheelchair, as it would match up that part of [his/her] chair and that [s/he] throws [himself/herself] really hard. g. Interview on 3/31/23 at 8:48 AM with social worker #1 revealed he told security to use the suicide vest on the resident on 3/6/23 but he stated there was miscommunication. He stated he did not mean for security to physically hold the resident in order to put it on. He stated the suicide vest should be a choice for the resident, and if the resident doesn't want to wear it, 1:1 staff can be utilized for safety. h. During an interview on 3/31/23 at 9:58 AM security guard #2 stated they were told to put the suicide vest on the resident. He stated the resident was hitting them, and so they used a 2 person body hug while the resident was in bed in order to get the vest on him/her. He stated the 2 person body hug was a MANDT [behavioral crisis intervention program] procedure in order to control the resident's arms so s/he couldn't hit. He stated it restricted the movement of the arms. i. Interview on 3/31/23 at 9:13 AM with the resident #1 revealed s/he was put in bed and security staff and a CNA grabbed the restraint vest and put it on him/her. The resident stated s/he didn't want to wear it and staff held him/her down to put it on. The resident stated s/he has PTSD and that added to it .nothing but nightmares since. j. During interviews on 3/30/23 at 3 PM and on 3/31/23 at 10:56 AM the nursing home administrator (NHA) stated the suicide vest/smock was not a restraint because it was a velcro sleeveless smock that allowed freedom of movement and access to the body. However, the NHA acknowledged that security staff used MANDT procedures to hold the resident in order to put the vest on. She stated the facility did not consider MANDT procedures restraints and therefore the MDS assessment was not coded for restraints and the facility did not get orders for emergency use of MANDT holds. She further stated that she agreed that documentation related to MANDT holds needed to be better, and did not show how long the MANDT procedure was used or that the MANDT hold was released as soon as possible. k. Review of The Mandt System. Student Workbook, curriculum 2.0 (undated) provided by the facility showed the techniques/holds, including the side body hold, were identified as restraints. The Glossary of Terms included .Physical restraint- The application of sanctioned physical techniques by one of more certified individuals that reduces or restricts the ability of an individual to move their arms, legs, or head freely. l. On 3/31/23 at 11:50 AM the facility administrator stated MANDT holds were considered restraints. m. Review of the medical record for resident #1 showed no documentation related to the MANDT hold on 3/6/23, such as alternatives tried or how long the resident was restrained. Review of physician orders showed no order for the emergency use of a restraint on 3/6/23. n. Review of the facility's policy Use of Physical Restraints (dated 4/1/22) showed .Emergency use of restraints is permitted if their use is immediately necessary to prevent the resident from injuring himself/herself or others and/or to prevent the resident from interfering with life-sustaining treatment, and no other less-restrictive interventions are feasible. a. The Director of Nursing Services has the authority to order the use of emergency restraints. The Medical Provider must be notified of such use and the reason for the order. b. Orders for emergency restraints may be received by telephone and shall be signed by the physician within forty-eight (48)hours .Documentation regarding the use of restraints shall include: .c. How the restraint use benefits the resident by addressing the medical symptom; d. The type of physical restraint used; e. The length of effectiveness of the restraint time; and f. Observation, range of motion and repositioning flow sheets.