Heartwood Avenue Healthcare

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to protect Resident 1's right to be free from physical abuse when Resident 2 hit Resident 1, a deficient practice identified for one of four sampled residents.This failure resulted in an injury to Resident 1's lip.Findings:Resident 1 was admitted to the facility in late 2025 with diagnosis which included difficulty in walking, a fall with head injury, and muscle weakness.During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 9/8/25, the MDS showed a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 8/15 which indicated moderately impaired cognition.Resident 2 was admitted to the facility in early 2025 with diagnosis which included dementia and an anxiety disorder.During a review of Resident 2's MDS dated [DATE], the MDS showed a BIMS score of 13/15 which indicated intact cognition.During a review of Resident 1's IDT Notes [Interdisciplinary Team] dated 10/23/25, the IDT notes indicated, On 10/23/25 at 0730 [7:30 a.m.] CNA [certified nursing assistant] staff reported that upon entering [Resident 1 and Resident 2's room], [Resident 2] was observed standing beside [Resident 1]. who (sic) was laying in bed, making a closed fist contact with [Resident 1's] chest.Licensed nurse did note a minor laceration to the resident's upper lip.During an interview on 10/29/25 at 11:51 a.m. with CNA 1, CNA 1 stated when he opened the door to check on the residents during his morning rounds, he observed Resident 1 lying in his bed and Resident 2 hitting Resident 1 in the chest with a closed fist. CNA 1 stated Resident 1 told him Resident 2 had busted his lip.

CNA 1 stated Resident 1 had a small amount of bleeding from his lip.

During an interview on 10/29/25 at 12:32 p.m. with Resident 1, Resident 1 stated while he was in bed, Resident 2 came over to his bed and smacked him in the forehead. He stated he did not remember where else he was hit.

During an interview on 10/29/25 at 12:45 p.m. with Resident 2, Resident 2 stated Resident 1 had been talking all day and had said something to me and I got ticked off.

During an interview on 10/29/25 at 12:49 p.m. with Licensed Nurse (LN1) stated she was notified by CNA 1 that Resident 2 had struck Resident 1 around change of shift (approximately 7:30 a.m. on 10/23/25), LN1 assessed Resident 1 and noted a small cut to his upper lip.

During an interview on 10/29/25 at 2:03 p.m. with the administrator (ADM), the ADM stated residents have the right to be safe in their environment.During a review of the facility's policy and procedures (P&P) titled, Abuse Prevention Program, dated 12/24, the P&P indicated, Our residents have the right to be free from abuse.This includes but is not limited to.physical abuse.As part of the resident abuse prevention, the administration will: 1.

Protect our residents from abuse by anyone including, but not necessarily limited to.other residents.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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