Handmaker Home For The Aging

MDS assessment dated [DATE] revealed a BIMS score of 2 which indicated severe cognitive impairment.A comprehensive care plan initiated on October 1, 2025 revealed that this resident had a history of behavioral problems which included verbal and physical aggression towards staff and other residents, and self-inflicted injury due to dementia. A Behavior Note dated November 8, 2025 at 6:49 p.m., revealed that Resident #5 grabbed Resident #4's arm with both hands and tried to pull her down over her while yelling, you are trying to kill me.

Staff were able to get Resident #5's hands off of Resident #4 leaving small scratches on Resident #4. A Skin assessment dated [DATE], revealed that Resident # 5 had no open skin or redness.

However, the assessment documented bruising on the back of her left and right hands.An incident note dated November 8, 2025 at 8:50 p.m. revealed that Resident #5 was moved to the nurses' station for one-on-one monitoring was provided until family was able to sit with her.

The incident note also revealed that a skin check was performed on Resident # 5 which determined that the bruises on the back of her hands were old.

The 5-day Facility Investigation report dated November 12, 2025 revealed that based on the incident being witnessed by staff and documentation the facility substantiated the abuse allegation.

The Facility investigation report documented that the facility implemented and intervention and placed Resident #5 with a 1:1 sitter at all times.

Additionally, a psychological consult with medication review was also put in place.

An interview with a Licensed Practical Nurse (LPN/Staff #133) on November 12, 2025 at 2:04 p.m. revealed that they heard commotion and saw Resident #4 standing over Resident #5. Resident #5 was witnessed holding onto Resident #4's arms tightly resulting in a slight skin tear.

Staff #133 revealed that the CNA was able to get the grip of Resident #5 off of Resident #4.

However, Resident #5 gripped onto the CNA and grabbed Staff #133.

The LPN revealed that she allowed Resident #5 to hold onto her to lead her away from Resident #4 to the nurses' station.

Staff #133 noted that Resident #4 likes helping other residents and was trying to help Resident #5. Resident #5 thought Resident #4 was going to kill her so Resident #5 started fighting back. An interview with the DON (Staff #19) on November 12, 2025 at 3:45 p.m. revealed that the resident-to-resident altercation between Resident #4 and Resident #5 was substantiated.

The DON stated that Resident #5 was placed on 1 to 1 sitter and a new social worker has been put into place.

The DON noted that Resident #5's Preadmission and Screening Resident Review (PASRR) was under review.A Policy and Procedure titled, Abuse, Neglect and Exploitation updated on July, 2025 revealed that it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property.

The policy goes on to define abuse as willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.

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