Every finding on record at Tamarack Ridge Health and Rehabilitation

Based on record review, observation, interview and facility policy review, the facility failed to ensure Resident #23's skin care was completed as ordered by the physician. This affected one resident (Resident #23) of three residents reviewed for care and services. The facility census was 95.Findings include: Review of the medical record for Resident #23 revealed an admission date of 07/20/23. Diagnoses included paralysis affecting the left non-dominant side, bipolar disorder, depression, muscle weakness, insomnia and respiratory failure.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #23 was cognitively intact. He required supervision for eating, partial assistance for oral hygiene, substantial assistance for personal hygiene and was dependent on staff for toileting and showering. He had no noted skin issues.Review of the care plan dated 10/10/25 revealed Resident #23 had an alteration in skin integrity as evidenced by a rash to his left inner thigh/groin area. Interventions included assessing the area for size, color and drainage as needed, providing treatment per physician's orders and assessing for pain.Review of the physician's orders for December 2025 revealed in order to cleanse Resident #23's left inner thigh/groin area with soap and water, pat dry and apply house stock powder (miconazole), an antifungal powder, to the area every shift for a rash. The order began on 06/29/25.Review of the treatment administration record (TAR) for December 2025 revealed the ordered treatment of miconazole powder to Resident #23's left inner thigh/groin area was not signed off as completed per physician's orders on day shift on 12/09/25, 12/11/25, 12/13/25, 12/14/25, 12/18/25, and 12/20/25. Interview and observation on 12/22/25 at 8:08 A.M. with Resident #23 revealed he received a powder to his upper left thigh because it was itchy at times. He revealed some staff were better than others at making sure he received it every day. Observation at the time of the interview revealed a large, red area approximately three inches long by two inches wide on Resident #23's left thigh.Interview on 12/22/25 at 10:09 A.M. with Registered Nurse (RN) #202 revealed she was aware Resident #23 had some issues with skin integrity related to his groin and legs. She revealed the facility was responsible for applying treatments as ordered, since Resident #23 was unable to do so himself.Interview on 12/23/25 at 9:58 A.M. with the Director of Nursing (DON) confirmed she could provide no other evidence the skin treatment ordered for Resident #23 had been completed as ordered.Review of the facility policy titled Skin Assessment, dated 03/15/24, revealed the facility would ensure necessary treatment and services were provided for the completion and documentation of skin integrity. Areas of altered skin integrity would be treated according to medical direction and would be followed conscientiously.This deficiency represents noncompliance investigated under Complaint Number 2649255.

Based on record review, observation, interview, and review of the facility policy, the facility failed to ensure Resident #96's physician orders were followed and care planned interventions were implemented to administer Resident #96's pain medication timely. This affected one resident (Resident #96) out of three residents reviewed for pain management. The facility census was 95.Findings include:Review of Resident #96's medical record revealed an admission date of 12/22/25 with diagnoses including type two diabetes mellitus with diabetic neuropathy, chronic pain syndrome and restless leg syndrome.Review of Resident #96's admission Assessment and Baseline Care Plan dated 12/22/25 included Resident #96 was a new admission and was alert and oriented. Resident #96 used an electric wheelchair and was non-ambulatory. Resident #96 required assistance with physical function, and set-up, supervision with bathing, grooming, and toileting.Review of Resident #96's Pain assessment dated [DATE] included in the last five days Resident #96 was on a scheduled pain medication regimen. Resident #96 received as needed pain medication. Non-medication interventions for pain used were rest and repositioning. Resident #96 had chronic, dull, throbbing bilateral lower extremity pain. Over the last five days Resident #96 frequently experienced pain, pain frequently made it hard for him to sleep at night, and he frequently limited his participation in rehabilitation therapy sessions due to pain. Resident #96 frequently limited his day-to-day activities because of pain. Resident #96 stated rest, mood and emotions were affected by pain. Resident #96's worst pain over the past five days was rated at an eight out of a 10, zero being no pain and 10 being the worst pain. Review of Resident #96's physician orders dated 12/22/25 at 1:11 P.M. revealed pregabalin oral capsule 100 milligrams (mg) (medication to treat nerve pain), give 100 mg by mouth two times a day for pain.Review of Resident #96's physician orders dated 12/22/25 at 1:11 P.M. revealed hydrocodone-acetaminophen (Norco) oral tablet 5-325 mg (opioid pain medication), give one tablet by mouth every six hours as needed for moderate to severe pain. Attempt and document non-pharmacological interventions prior to medication administration.Review of Resident #96's progress notes dated 12/22/25 at 4:39 P.M. included Resident #96 denied pain at this time and stated he had pain in his back and neck at times and required pain medication for relief. Review of Resident #96's progress notes dated 12/22/25 at 6:57 P.M. revealed a message was sent to the Nurse Practitioner (NP) #210 requesting a prescription for Norco be sent to the pharmacy.Review of Resident #96's progress notes dated 12/22/25 at 9:14 P.M. revealed an authorization to pull request for Norco was sent to the pharmacy.Review of Resident #96's Pain Level Summary dated 12/23/25 at 2:23 A.M. revealed Resident #96 had a pain level rated a three out of 10.Review of Resident #96's progress notes dated 12/23/25 at 2:24 A.M. included acetaminophen tablet (Tylenol) 325 mg (analgesic), give two tablets by mouth every four hours as needed for pain was given.Review of Resident #96's progress notes dated 12/23/25 at 2:24 A.M. revealed pregabalin oral capsule 100 mg, give 100 mg by mouth two times a day for pain was not available.Review of Resident #96's progress notes dated 12/23/25 at 3:18 A.M. included Biofreeze cool external gel four percent (topical pain relief), apply to bilateral legs topically every eight hours as needed for pain.Review of Resident #96's progress notes dated 12/23/25 at 4:57 A.M. included acetaminophen 325 mg , two tablets follow up pain scale was one and the Tylenol was effective.Review of Resident #96's progress notes dated 12/23/25 at 4:58 A.M. revealed Biofreeze was effective.Observation on 12/23/25 at 8:10 A.M. revealed Registered Nurse (RN) #211 was preparing Resident #96's medications for administration. RN #211 stated Resident #96 was admitted yesterday. Resident #96 was sitting in a wheelchair and stated, what can I do to get my Norco (hydrocodone-acetaminophen oral tablet 5-325 mg), I am in pain. RN #211 stated Resident #96 did not come with a script for Norco, and the night nurse asked the pharmacy to reach out to NP #210 for a prescription. RN #211 stated Resident #96 should have an order to administer Norco every six hours as needed, but they did not have a prescription for it. RN #211 stated Resident #96 had Biofreeze at 3:18 A.M. and she was preparing acetaminophen 325 mg tablets and was going to administer two tablets now. RN #211 indicated after 5:00 P.M. the on-call NP or Physician had to be called if anything was needed for the residents. Review of Resident #96's Pain Level Summary dated 12/23/25 at 8:17 A.M. revealed Resident #96's pain level was rated a six out of 10.Review of Resident #96's progress notes dated 12/23/25 at 8:17 A.M. included acetaminophen tablet 325 mg, give two tablets by mouth every four hours as needed for mild pain was given.Observation on 12/23/25 at 9:35 A.M. of RN #211 revealed she was preparing Resident #96's pain medication, Norco 5-325 mg, for administration. Resident #96 was lying on his left side and when he rolled onto his back, then to a sitting position he had facial grimacing. Resident #96 appeared to be in pain and when RN #211 asked what his pain level was Resident #96 rated his pain level at a seven out of 10. Resident #96 stated had been asking for his pain medication since he was admitted on [DATE] and he did not sleep well because he had back pain and restless leg syndrome. Resident #96 stated this his first Norco pill since he was admitted .Review of Resident #96's Pain Level Summary dated 12/23/25 at 9:35 A.M. revealed Resident #96's pain level was rated at a seven out of 10.Review of Resident #96's progress notes dated 12/23/25 at 9:35 A.M. included hydrocodone acetaminophen oral tablet 5-325 mg, give one tablet by mouth every six hours as needed for moderate to severe pain.Review of Resident #96's progress notes dated 12/23/25 at 11:12 A.M. revealed pregabalin oral capsule, give 100 mg by mouth two times a day for pain. NP #210 would order the pregabalin when she was at the facility today.Resident #96's care plan dated 12/23/25 included Resident #96 was at risk for alteration in comfort related to back pain, stenosis, arthritis, peripheral vascular disease, neuropathy, and restless leg syndrome. Resident #96's complaints and signs and symptoms of discomfort would be reduced or resolved following intervention. Interventions included administering medications as ordered; medications as ordered to manage pain; monitor for increased levels of pain and notify the physician.Interview on 12/23/25 at 11:42 A.M. of RN #212 revealed she worked on 12/22/25 from 6:00 P.M. until 6:00 A.M. on 12/23/25 and was assigned to care for Resident #96. RN #212 stated she tried to get a prescription for Resident #96's Norco pain medication and sent a message to NP #210 to have her send a prescription to the pharmacy but did not get a response. RN #212 indicated she called the pharmacy in the morning before her shift ended on 12/23/25 and the pharmacy staff told her they were trying to reach out for a script. RN #212 stated she did not call the on-call Physician or NP for Resident #96's prescription because my honest answer is I was doing a million things, and I was going 100 miles an hour from start to finish. RN #212 stated she was frustrated because I was not getting the Norco. RN #212 indicated she explained to Resident #96 why he did not have his Norco, she talked to him at length, and he did not appear to be upset. RN #212 stated she did not try to get a prescription for Resident #96's pregabalin because she did not realize the pregabalin was due, and she was so focused on his Norco. RN #212 confirmed Resident #96 needed a prescription for pregabalin. RN #212 stated she administered acetaminophen and Biofreeze to Resident #96 and it seemed to help his pain.Interview on 12/23/25 at 12:39 P.M. of the Director of Nursing (DON) revealed the nurses were responsible to make sure Resident #96 had a prescription for Norco and pregabalin, and when Resident #96's orders were verified with NP #210 they might not have realized they needed a prescription. The DON stated RN #212 sent a fax to the pharmacy on 12/22/25 at 9:14 P.M. asking for authorization to pull Norco and RN #211 followed up this morning.Interview on 12/23/25 at 1:25 P.M. of NP #210 revealed Resident #96 was admitted on [DATE], and she had not seen him yet. NP #210 stated she was contacted early this morning about Resident #96's Norco and pregabalin, and she sent prescriptions for both to the pharmacy. NP #210 stated she was not contacted on 12/22/25 about Resident #96's Norco or pregabalin and maybe the on-call NP or Physician was contacted. NP #210 confirmed she verified Resident #96's medications with a nurse from the facility, but the nurse did not tell her prescriptions were needed for pregabalin and Norco, and if the nurse did not tell her a prescription was needed then I don't know'.Review of the facility policy titled Pain Assessment and Management, dated 03/31/16, included assessment and adequate treatment of pain was central to the management of the physical and psychological well-being of residents.

Based on record review and interview, the facility failed to ensure there were accurate advance directive orders and information in place throughout the medical records for Residents #13 and #68. This affected two (#13 and #68) of 31 residents reviewed for advance directives. The facility census was 83. Findings include: 1. Review of Resident #13's medical record revealed the resident was admitted to the facility on [DATE]. Diagnoses included chronic obstructive pulmonary disease, diabetes mellitus, and depression. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #13 was cognitively intact. Review of the physician's orders for Resident #13 revealed an order dated 12/13/24 for a Do Not Resuscitate Comfort Care Arrest (DNRCC-A) (meaning invasive or extreme life-supporting measures were allowed under any circumstance except for cardiac or respiratory arrest) code status. Review of the electronic chart for Resident #13 revealed a DNRCC-A code status. Review of the hard medical chart for Resident #13 revealed there was no code status in the hard chart. An interview on 03/31/25 at 1:58 P.M. with Registered Nurse (RN) #352 stated she would go to the hard chart to see a signed copy of the advance directive if applicable. RN #352 verified Resident #13's hard chart did not have a code status sheet and the electronic chart stated DNRCC-A for Resident #13. 2. Review of Resident #68's medical record revealed the resident was admitted to the facility on [DATE] with diagnoses including dementia, psychosis, and anxiety disorder. Review of the Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #68 was rarely understood. Review of the physician's orders for Resident #68 revealed an order dated 12/13/24 for a Do Not Resuscitate Comfort Care (DNRCC) code status (meaning only comfort measures would be initiated in the event of a medical emergency). Review of the electronic chart for Resident #68 revealed a DNRCC code status signed by the physician. Review of the hard medical chart for Resident #68 revealed there was a DNR paper signed by the physician, but it did not identify if Resident #68's wishes were DNRCC or DNRCC-A. An interview on 03/31/25 at 1:58 P.M. with Registered Nurse (RN) #352 stated she would go to the hard chart to see a signed copy of the advance directive if applicable. RN #352 verified Resident #68's hard chart had a signed DNR in her chart, but it wasn't marked DNRCC-A or DNRCC. RN #352 verified Resident #68's electronic chart stated DNRCC. An interview on 03/31/25 at 02:05 P.M. with Director of Nursing (DON) verified Resident #68's hard chart had a signed DNR in her chart, but it wasn't marked DNRCC-A or DNRCC and the electronic chart stated DNRCC. On 04/01/25 at 8:30 A.M., the DON brought a DNRCC which the resident's power of attorney (POA) signed on 02/13/24. The DON stated it was in Resident 68's hard chart, that was thinned out by medical records. Review of the facility policy titled Residents' Rights: Treatment and Advanced Directives, updated 11/22/16, revealed upon each resident admission, each resident would be provided with written information to formulate an advanced directive. The policy identified documentation must be recorded in the medical record of such a directive and a copy of the directive must be included in the resident's medical record.

Based on observations, record review, and resident and staff interviews, the facility failed to ensure a resident had her ace wraps according to physicians' orders. This affected one (#56) of two residents reviewed for edema. The facility census was 83. Findings include: Review of the medical record for Resident #56 revealed an admitted [DATE]. Diagnoses included heart failure, dementia, hypertension, and edema. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #56 had intact cognition. Resident #56 required supervision from staff for dressing/personal hygiene. Review of the Medication Administration Record (MAR) for March 2025 revealed Resident #56's ace wraps were to be put on daily in the morning and removed at night. Review of the plan of care dated 02/15/23 revealed the resident was at risk for cardiac symptoms related to diagnosis of hypertension, congestive heart failure and atrial fibrillation. Interventions included taking medications as ordered, monitoring the effectiveness of interventions and ace wrap to bilateral lower extremities on in the morning and off at bedtime. Observation and interview on 03/31/25 at 10:04 A.M. revealed Resident #56 was dressed and sitting in her recliner with her feet on the floor. Resident #56's feet and ankles were swollen, and she had her slippers on. Resident #56 stated she was to have wraps on her feet and ankles and staff will put them on when they have time. Observation on 03/31/25 at 3:00 P.M. revealed Resident #56 did not have ace wraps on her bilateral ankles and feet. Resident #56 was sitting in her recliner with feet on the floor. Subsequent observations on 04/01/25 at 8:58 A.M. and 1:53 P.M. of Resident #56 revealed she was not wearing ace wraps on her bilateral lower extremities. Interview on 04/01/25 at 1:55 P.M. with Licensed Practical Nurse (LPN) #354 stated Resident #56 was to have her ace wraps on in the morning and off at night. LPN #56 verified Resident #56 was not wearing her ace wraps.

Based on observations, record review, interview and policy review, the facility failed to ensure Resident #39's oxygen concentrator was administered as physician ordered. This affected one (#39) of one resident reviewed for oxygen administration. The facility identified 13 residents in the facility who were on oxygen therapy. The facility census was 83. Findings include: Review of the medical record for Resident #39 revealed and admitted [DATE]. Diagnoses included heart failure, atrial fibrillation, and hypertension. Review of the physician orders for April 2025 revealed an order for oxygen per nasal cannula continuous every shift at four liters/minute (LPM). Review of the plan of care dated 12/30/24 revealed Resident #39 has respirator deficiencies and abnormalities of pulmonary function related to heart failure, atrial fibrillation and pulmonary nodule. Interventions included to administer oxygen as ordered. Observation on 03/31/25 at 11:06 A.M. revealed Resident #39 was receiving oxygen via nasal cannula with a flow rate of two LPM. Subsequent observations on 03/31/25 at 3:30 P.M., 04/01/25 at 8:45 A.M., and at 10:50 A.M. revealed Resident #39's oxygen rate was still at two LPM via nasal cannula. Interview and observation on 04/01/25 at 10:52 A.M. with Licensed Practical Nurse (LPN) #354 stated Resident #39 was to be wearing oxygen via nasal cannula at four LPM. Observation with LPN #354 verified Resident #39's oxygen concentrator was set at two LPM not four LPM. LPN #354 verified Resident #39's oxygen was not at the correct flow rate. Review of the facility policy titled Oxygen Administration dated 07/30/24 revealed oxygen is administered to residents who need it. Consistent with professional standards of practice.

Based on record review, observation, staff interview, review of manufacturer instructions, review of Medscape guidance, and policy review, the facility failed to prime an insulin pen per manufacturer instructions prior to administration, resulting in a significant medication error. This affected one (Resident #60) of five residents reviewed for medication administration. The facility identified 14 residents who received insulin via a pen-injector. The facility census was 83. Findings include: Review of the medical record for Resident #60 revealed an admitted [DATE]. Diagnosis included type two diabetes mellitus with diabetic chronic kidney disease. Review of the plan of care dated 11/20/24 revealed Resident #60 was at risk for hyper/hypoglycemia related to insulin-dependent diabetes mellitus. Intervention included to administer medications as ordered. Review of the physician orders revealed Resident #60 was ordered Humalog 15 units subcutaneously via pen injector, three times a day and Humalog sliding scale via a pen-injector before meals. Observation on 04/01/25 at 7:21 A.M. revealed Licensed Practical Nurse (LPN) #354 administered seven medications including Humalog to Resident #60. Resident #60's blood sugar was 185, indicating Resident #60 required two additional units in addition to the scheduled 15 units. LPN #354 grabbed the pen-injector and dialed up 17 units of Humalog. LPN #354 failed to prime the pen-injector removing any air before administering insulin to Resident #60. Interview on 04/01/25 at 7:25 A.M. with LPN #354 verified she did not prime the Humalog pen as she should have. LPN #354 stated she was unaware of the need to prime the pen and she had learned something new. Review of the manufacturer instructions for Humalog KwikPen revealed the person should prime before each injection. Priming ensures the Pen is ready to dose and removes air that may collect in the cartridge during normal use. If you do not prime before each injection, you may get too much or too little insulin. Review of the facility policy titled Insulin Administration dated 2017 noted insulin pens require priming or an air-shot prior to administration. Review of Medscape guidance titled Intermittent Insulin Injections Insulin Overview dated 11/05/20 and located at https://emedicine.medscape.com/article/2049311-overview#a1 revealed to avoid air and to ensure proper dose, you will need to prime the syringe each time; to do this, dial two units; hold the pen with the needle pointing up and tap the cartridge gently a few times to get rid of any air bubble; press the push button all the way in until the dose selector returns to zero; a drop of insulin must appear at the needle tip; if not, change the needle and repeat the procedure.

Based on observation, medical record review, Self-Reported Incident review, witness statement review, police incident report, police report witness statement review, policy review, behavior toolbox review, and interview, the facility failed to ensure staff implemented the abuse policy and procedure and training regarding management of a resident having a catastrophic reaction. This affected one resident (Resident #41) of three residents reviewed for abuse. The census was 94. Findings include: Review of the medical record for Resident #41 revealed an admitted [DATE] with diagnoses of bipolar disorder, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, depression, seizures, psychoactive substance use with induced persisting dementia, anxiety disorder and chronic pain. Review of the plan of care plan dated 08/04/23 revealed Resident #41 was at risk for alteration in comfort, impaired mobility, hemiplegia, excoriation disorder and diagnoses of chronic pain. An intervention was to acknowledge the presence of pain and discomfort. Listen to the resident's concerns. Rest periods as needed. Use pain scale as reported by resident. Review of the Minimum Data Set (MDS) 3.0 quarterly assessment dated [DATE] revealed Resident #41 was cognitively intact, did not have behaviors, required partial/moderate assistance with rolling left and right and required substantial/maximal assistance with toileting. Review of the physician orders from January 2024 revealed Resident #41 was ordered acetaminophen (a medication to treat mild to moderate pain) oral tablet 500 milligrams (mg) give 1000 mg by mouth three times a day for pain, Pregabalin Lyrica (a medication to treat pain from nerve damage) oral capsule 200 mg by mouth three times a day for chronic pain, Baclofen (treats muscle spasms) oral tablet 20 mg give 20 mg by mouth three times a day for muscle spasms, levetiracetam (an anticonvulsant medication) oral tablet 750 mg give 1500 mg by mouth two times a day for bipolar disorder, and alprazolam (a psychotropic medication used to manage anxiety disorders) oral tablet 0.5 mg give 0.5 mg by mouth three times a day for anxiety. Review of the Activity of Daily Living (ADL) note dated 01/24/24 revealed Resident #41 had slightly impaired cognition and was dependent on staff for mobility . Review of the health status note dated 01/24/24 timed 11:30 A.M. revealed State tested Nurse Aides (STNAs) reported to the Director of Nursing (DON) that Resident #41 scratched, hit and pulled the STNA's hair during care. Two nurses completed a head-to-toe assessment and Resident #41 had complaint of pain to left arm. The nurse practitioner was aware. New order was obtained for Stat x-ray of left arm. Police were notified. Review of the ADL care plan updated 01/24/24 revealed Resident #41 could require assistance with ADLs, had a history of showing inappropriate sexual behaviors toward staff while being showered, Resident #41 would scratch, hit and pull hair of staff members and would make allegations of abuse. There were not any care planned inventions on how staff should respond when Resident #41 displayed sexual and/or physical behaviors. Review of the Self-Reported Incident dated 01/24/24 revealed Resident #41 alleged physical abuse involving STNA #1. At approximately 11:30 A.M. on 01/24/24, two nurse aides were giving personal care in room of Resident #41. At approximately 11:40 A.M., the Administrator was notified Resident #41 became aggressive with the staff members as they were providing personal care. Resident #41 grabbed the arm of one of the aides (STNA #1) then grabbed her by the neck and back of her head pulling out some of her hair. The other aide (STNA #2) came to assist, and Resident #41 then smacked at her face, causing a red mark before all parties could be separated. At approximately 12:15 P.M., the resident alleged that aides were rough during care. The administrator was informed by police that Resident #41 had made an allegation of abuse. When the police spoke with Resident #41 he shared that staff was allegedly rough with him. Resident #41 alleged aides pulled on his right arm, then began hitting him in the center of his back. Review of the witness statement dated 01/24/24 authored by STNA #1 revealed, at 11:30 A.M., [STNA #2] and I went into [Resident #41's room] to provide morning/perineal care. We got bed partially stripped and were in the process of rolling him to the left towards me. I grabbed his right hand and wrist as [STNA #2] was pushing his shoulder and hip. [Resident #41] started yelling, don't grab my arm, [expletive]. I explained I was just trying to roll him. He grabbed my neck and hair pulling me towards him. [STNA #2] yelled at him to stop and let me go. She then pulled his hand out of my hair. He hit her [STNA #2] in the face. We got bed together and got him redressed and [STNA #2] said she was okay with him and for me to leave and get assessed by nursing and management. He left welts on my neck and pulled my hair out. Review of the Police Incident Report dated 01/24/24 revealed on Wednesday, 01/24/24 at 11:46 A.M., Police Officer (PO) #7 was dispatched to [the facility] for a report of an assault; dispatch said that a patient assaulted two nurse assistants. Review of the police report witness statement date 01/24/24 timed 11:45 A.M. authored by STNA #1 revealed, [Resident #41] scratched my neck and grabbed my hair pulling some out during morning/perineal care. [STNA #2] tried to get him to let go, getting hit in the face/neck in the process. Review of the police report witness statement dated 01/24/24 timed 11:45 A.M. authored by STNA #2 revealed, I witnessed [Resident #41] grab the other aide by the back of the head pulling her hair out and proceeded to scratch her. We were assisting him with morning/perineal care when incident happened. I assisted in getting the resident off the other aide then finished with care. We then proceeded to notify the nurse and the higher ups. Review of the witness statement dated 01/24/24 authored by STNA #2 revealed, I, [STNA #2] and other aide went in to change [Resident #41]. We did perineal care and changed resident's sheets. Resident proceeded to attack other aide by pulling her hair and scratching/grabbing her. I proceeded to get resident off the other aide. I then finished making resident's bed. Afterwards the other aide and I went to the nurse to let her know. We then proceeded to go to the higher ups. After talking to the higher ups, I went with another worker to clean up the room. Resident then proceeded to say that his left arm is broke. I witnessed the nurse examine the arm with no pain/redness/bruising/swelling to the affected area. Review of the health status note dated 01/25/24 revealed two view x-ray completed of left arm/wrist, results were negative. Review of the health status note dated 02/05/24 timed 4:02 P.M. revealed Resident #41 was alert and oriented to person. Observation on 02/05/24 at 7:45 A.M. revealed Resident was lying in bed watching television. Interview at the time of the observation revealed Resident #41 was agreeable to talk later about the incident that occurred with the two STNAs. Resident #41 did not know what month or year he was admitted ; he said he had been at the facility for eight months. Interview on 02/05/24 at 8:15 A.M. and 12:00 P.M. with STNA #2 revealed STNA #2 had only worked with Resident #41 a few times prior to 01/24/24 and didn't think STNA #1 had worked with Resident #41 previously. Resident #41's call light was on, so STNA #1 and STNA #2 entered the room together to change his bed linens and give him a bed bath. STNA #1 rolled the resident toward STNA #1 on his right side, toward the door (STNA #2 was aware the resident's left arm was affected from his stroke) and STNA #1 grabbed his left arm (did not pull or yank) to assist him with rolling while STNA #2 applied new linens to the bed. Resident #41 then stated, you stupid [expletive] to STNA #1. As the resident was rolling onto his back, Resident #41 grabbed STNA #1 by the back of head and her hair with his right hand. STNA #2 got his hand free from the STNA's hair and Resident #41 scratched STNA #2's face by accident. STNA #2 called SOS over the Walkie Talkie. STNA #2 finished making his bed, covered him with a sheet and left the room. Interview on 02/05/24 at 9:02 A.M. with Resident #41's family member revealed on 01/24/24, two aides entered his room to change his linens. Resident #41's arm was hurt by the STNA during the incident because the aide was hurrying him and rough with him while changing the linens. The aide ignored him when he told her to stop so he hit the aide since Resident #41 was unable to get away from the STNA because he was paralyzed. Observation on 02/05/24 at 9:38 A.M. revealed Resident #4 was lying in bed holding a remote, watching television. A follow-up interview, during the observation, with Resident #41 revealed when asked if it was a good time to discuss the incident with the STNAs, Resident #41 responded, I can't talk about that. Interview on 02/05/24 at 9:53 A.M. with Registered Nurse (RN) #5 revealed she was familiar with Resident #41 and stated that Resident #41 got frustrated quickly. Resident #41 had a stroke and RN #5 believed his behaviors were a result of the stroke and history of drug use. Resident #41's left arm was affected from his stroke, and he had complained of achy pain in the left arm before. Resident #41 was ordered Tylenol 1000 milligrams three times a day for pain and Lyrica three times a day. Interview on 02/05/24 at 10:17 A.M., 11:01 A.M. and 11:37 A.M. with STNA #1 via telephone revealed STNA #1 and STNA #2 went into Resident #41's room to do ADL care prior to lunch. The STNAs explained to Resident #41 what they were going to do. The STNAs were in the process of rolling him and the resident's left arm was flopping around so STNA #1 placed his left hand in her palm to keep his arm stable. Resident #41 yelled, you're breaking my arm, [expletive] so she told the resident to rest his hand on handrail. As he was rolling onto his back, Resident #41 reached up, grabbed the back of her head/hair, and pulled her head down towards his groin. STNA #2 was able to untangle STNA #1's hair and the resident hit STNA #2 in the face while she was trying to untangle the hair. STNA #1 asked the resident, can we just get finished so you can eat lunch? STNA #1 proceeded to wash his armpits, put a gown on him then exited the room. During the care, Resident #1 kept asking for STNA's #1's name, grabbed her name badge string and pulled it and was trying to throw his legs over the edge of the bed. STNA #1 did not leave the room after Resident #41 grabbed her by the back of the head and pulled her hair because STNA #1 and STNA #2 were in the room together, STNA #1 did not want to leave STNA #2 alone with the resident, and STNA #1 was focused on getting care taken care of then they would leave the room together. STNA #1 did not use her Walkie Talkie to call for assistance because her hands were full with Resident #41. STNA #1 also reported that Resident #41 had a history of cussing at STNA #1 and calling STNA #1 derogatory names and when this happened STNA #1 would notify the nurse. Interview on 02/05/24 at 10:30 A.M. with PO #7 revealed the case involving Resident #41, STNA #1 and STNA #2 had been turned over the County prosecuting attorney to review to determine if any charges would be brought forth to any of the parties. PO #7 revealed none of the three people involved (Resident #41, STNA #1, and STNA #2) had any evidence of assault on their body when he arrived on the scene. Resident #41 was unable to give a written statement, so a verbal statement was recorded by the body camera worn by PO #7. Resident #41 reported that one aide pulled his left arm and the other aide was pushing on his back and it felt like he was being punched. Observation on 02/05/24 at 2:15 P.M. revealed Resident #41 was lying in bed watching television. Interview, during the observation, with Resident #41 revealed he spoke to his mother and his mother told him that he was allowed to speak to the surveyor. Resident #41 stated that STNA #1 seemed mad at him and he had never met her before so he wasn't sure she was actually an STNA. STNA #1 grabbed his left forearm (the resident pointed to the arm between his wrist and elbow) and reached across him and put her whole-body weight on his arm; his arm was in pain. STNA #1 told him he wasn't moving fast enough and started punching him in the back, telling him to move faster. Resident #41 stated the other aide didn't do anything to help him. The resident stated his arm was in pain for three days after the incident. He stated the pain in his arm was usually a four out of 10 on the pain scale and after the incident with the STNAs, he rated his arm pain as a five out of 10. Interview on 02/05/24 at 2:30 P.M. with the Administrator and Director of Nursing verified STNA #1 should not have continued to provide care to Resident #41 after being grabbed and hair pulled and should have immediately exited Resident #41's room. Review of the facility's Abuse, Neglect, Exploitation and Misappropriation of Resident Property dated 11/21/16 revealed the facility would educate it's staff and volunteers upon hire and annually thereafter regarding the facility's policy concerning Abuse, Neglect, Exploitation of residents, and Misappropriation of Resident Property, and how to handle resident-to-resident Abuse and Injuries of Unknown Source. These training sessions were to include, but not necessarily be limited to appropriate interventions to deal with aggressive behaviors and/or extraordinary reactions to residents to ordinary stimuli, such as the attempt to provide care (i.e. Catastrophic Reactions). Review of the undated facility's Behavioral Reference Toolbox for Behavior Reference Strategies for Some Common Behavioral Symptoms in Nursing Home Residents revealed fighting was a severe behavioral symptom because of the potential harm to others. Residents with cognitive loss did not have the skills to end conflict better ways. Separation was the first concern. When personal space was a concern of the resident, stay back a few feet from the person. Give the resident time and space to calm themselves. Verbal aggression: if the verbal aggression is directed to you and the resident is safe, you can leave. Explain your actions and that you will return later. When you return, take something in to use as a distraction. This deficiency represents non-compliance investigated under Complaint Number OH00150725.