LOUISVILLE, KY- LYNDON CROSSING

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** 47711
Based on observation, interview, record review, and facility policy review it was determined the facility failed to ensure residents were protected from physical abuse, including resident to resident abuse, for thirty (30) of ninety-four (94) sampled residents (Residents #17, #19, #35, #36, #47, #48, #49, #56, #57, #59, #67, #69, #74, #76, #80, #81, #86, #88, #89, #91, #92, #93, #102, #110, #112, #131, #132, #138, #140, and #144) Resident #80 suffered significant injury as a result of abuse.

The facility failed to provide adequate supervision to ensure Resident #80 was protected from abuse by Resident #48 on [DATE]. Resident #48, who had a history of physical and verbal abuse towards other residents’ Resident #48 punched Resident #80, in the face, on [DATE] at 6:43 PM, causing Resident #80 to fall. Resident #80 was tearful upon assessment stating his/her hip was hurting. There was no documented evidence the facility performed a thorough assessment of Resident #80. Even though the Nurse Practitioner gave an order for an x-ray on [DATE] at 7:42 PM, the facility failed to obtain an x-ray until over twelve (12) hours later. Resident #80 was admitted to the hospital on [DATE] for a fracture to the right femoral neck with lateral displacement requiring surgery.
(a). On [DATE], at 6:43 PM, Resident #48 hit Resident #80 in the face causing him/her to fall to the floor. However, an x-ray was not obtained until [DATE] at 8:06 AM. The x-ray results revealed Resident #80 had sustained a fractured right hip, which required surgical intervention to repair the fractured hip.
(b). On [DATE], Resident #81 made contact with Resident #80’s area, resulting in Resident #80 reaching out and making contact with Resident #81’s facial area.
(c). On [DATE], Resident #47 and Resident #80 were found on a bed together. Resident #80 was lying on his/her back with his/her knees bent and did not have clothes on from the waist down. Resident #47 was observed fully clothed, on his/her knees at the foot of the bed, with his/her face in Resident #80’s crotch area.
(d). On [DATE], Resident #81 struck Resident #35 and Resident #47.
(e). On [DATE], Resident #138 hit Resident #102 on the arm three (3) times.
(f). On [DATE], Resident #131 pushed Resident #86 onto the bed and placed one hand on Resident #86’s blouse and the other hand around Resident #86’s throat.
(g). On [DATE], Resident #80 slapped Resident #76 and Resident #132 in the face.
(h). On [DATE], Resident #91 got up and brushed the back of Resident #92. Resident #92 grabbed Resident #91 by the shoulder and punched him/her in the chest.
(i). On [DATE], Resident #144 slapped Resident #67 and Resident # 74 on the left side of the face.(j). On [DATE], Resident #92 hit Resident #88 in the mouth.
(k). On [DATE], Resident #74 hit Resident #57 on the right forearm.
(l). On [DATE], Resident #132 struck Resident #101 with a right open hand on the left side of the face.
(m). On [DATE], Resident #89 made contact to the left side of Resident #59’s cheek with an open hand.
(n). On [DATE], Resident #89 made contact to Resident #59’s face three (3) times with a closed fist
(o). On [DATE], Resident #59 slapped Resident #140 with an open hand to prevent her/him from taking the water cup which resulted in an approximately two (2) inch scratch.
(p). On [DATE], Resident #110 became upset because Resident #140 had his/her belongings and hit Resident #140 on the forehead.
(q). On [DATE], Resident #35 attempted to take Resident #101’s bag. Resident #35 hit Resident #101 with an open hand on the right side of his/her check. Resident #101 returned the hit making Resident #35 stumble and fall. Resident #35 suffered a small contusion to the bridge of the nose and was sent to the emergency room for evaluation and treatment.
(r). On [DATE], Resident #144 walked up to Resident # 67 and made physical contact with the left side of Resident #67’s face, and while staff were attending to and separating Resident #67 from Resident #144, Resident #144 then turned and made physical contact with Resident #74’s left side of the face causing a mark.
(s). On [DATE], Resident #74 bit Resident # 57 on the right forearm causing a discolored area (bruise).
(t). On [DATE], Resident #36 started to yell at Resident #69 and the two (2) started a verbal altercation. Resident #69 left the room, with his/her fist clinched and approached Resident #36, at which time Resident #69 kicked Resident #36.
(u). On [DATE], Resident #56 got in Resident #69’s face and talked, pointed, and stepped on the resident’s toes. Resident #69 pushed Resident #56 back, hard enough the resident fell to the ground and landed on his/her bottom.
(v). On [DATE], Resident #112 ambulated through the common area with his/her walker and used the walker to hit Resident #17. Resident #112 then proceeded to hit Resident #17 in the shoulder. Resident #17 then hit #112 back.
(w). On [DATE], Resident #17 and Resident #93 had a physical altercation. First Resident #17 attempted to enter #93’s room and was stopped by the previous DON. Then Resident #17 walked up to Resident #93, who was standing in front of the common area television. Resident #17 was upset about that, so he/she grabbed Resident #93 by the back of the jacket and moved the resident out of the way. (x). On [DATE], Resident #19 leaned forward in the wheelchair and struck Resident #49 on the left side of his/her face with an open palm.
Immediate Jeopardy (IJ) was identified on [DATE] at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation at the highest S/S of a J, and 42 CFR 483.25 Quality of Care (F684) at the highest S/S of a J and was determined to exist on [DATE] and is ongoing. SQC was identified at 42 CFR 483.12 Freedom from Abuse, Neglect, and Exploitation (F600). The facility was notified of the Immediate Jeopardy on [DATE]. 

Review of the facility’s Investigation Report, dated [DATE], revealed Resident #80 and Resident #47 were found on a bed together. Resident #80 was lying on his/her back with his/her knees bent and he/she did not have clothes on from the waist down. Continued review revealed Resident #47 was observed fully clothed, on his/her knees, at the foot of the bed, with his/her face in Resident #80’s crotch area. Further review revealed Certified Nurse Assistant (CNA) #37 reported Resident #80 was lying in bed with no pants on, with his/her knees bent, and Resident #47 was at the foot of the bed leaning up with his/her head between Resident #80’s legs. CNA #37 separated Resident #80 and Resident #47 and notified the nurse. Additional review revealed CNA #37 stated she did not see any specific sexual activities.