Pioneer House

During an interview on 9/5/25 at 11:18 a.m. with Certified Nursing Assistant (CNA 1), CNA 1 indicated Resident 1 was known to have wandered and had aggressive behavior, and she was on special monitoring by staff, but she was not monitored at all times. CNA 1 further stated she had to get Resident 1 out of other residents' rooms on a daily basis.

During an interview on 9/5/25 at 11:56 a.m. with LN 3, LN 3 confirmed that Resident 1 was known to wander around and had instances of aggression towards other residents. LN 3 stated that direct care staff were busy providing care to other residents, and the facility did not provide sufficient staff to monitor Resident 1 at all times.

During an interview on 9/5/25 at 1:59 p.m. with the Director of Nursing (DON), DON confirmed that Resident 1 was known to be moving around and entering different residents' rooms, and she had prior incidents of aggressive behavior.

The DON confirmed that Resident 1 was seen physically touching Resident 3 in the dining room yesterday.

The DON further stated that she expected residents to be free from physical and verbal abuse.

During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, the P&P indicated, Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1.

Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to:. b. other residents.

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