Every finding on record at Desert Peak Care Center

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of two residents (#63 and #69) to be free from abuse from each other. The deficient practice could result in further abuse of residents.Findings include--Regarding Resident #63Resident #63 was admitted to the facility on [DATE], with diagnoses of bipolar disorder, major depressive disorder, hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, dementia with other behavioral disturbances, mood disorder, and other comorbid conditions. At the time of the investigation, Resident #63 remained at the facility.The Minimum Data Set (MDS) dated [DATE], indicated that Resident #63 had a Brief Interview for Mental Status (BIMS) score of 9, indicating moderate cognitive impairment, impairments in both upper and lower extremities, and was dependent on staff for activities of daily living, including wheelchair mobility and transfers from chair to bed. A behavioral treatment plan dated May 6, 2026, indicated that Resident #63 used racial slurs, cursed, and exhibited verbally aggressive behavior during periods of frustration, anger, confusion, overstimulation, or difficulty communicating his needs appropriately. The behavioral treatment plan directed staff to respond in a calm, natural, and professional manner while maintaining clear boundaries regarding respectful communication. The plan further indicated that the resident required periods of isolation and instructed staff to provide regular supportive check-ins while encouraging participation in activities, meals, and social interactions in a calm, non-pressuring manner that respected Resident #63's need for personal space.-Regarding Resident #69Resident #69 was admitted to the facility on [DATE], with pertinent diagnoses of dementia with agitation, depression, epilepsy, chronic pain, and other comorbid conditions. At the time of the investigation, Resident #69 remained at the facility.A review of Resident #69's MDS assessment dated [DATE], indicated that Resident #69 had a BIMS score of 12 indicating moderate cognitive impairment. The MDS also exhibited physical behavioral symptoms directed toward others for three days and other behavioral symptoms not directed toward others for four to six days. The assessment further indicated that these behaviors placed others at significant risk of physical injury. A behavioral care plan revised on June 18, 2026, identified behavioral problems related to dementia with agitation, with goals that included timely staff intervention to protect others and monitoring for episodes of physical aggression. A review of Resident #69's cognition care plan indicated that he had impaired cognitive function and impaired thought processes related to dementia with agitation. Interventions included monitoring for changes in cognitive function, decision-making ability, recall, general awareness, level of consciousness, and mental status.A review of a nursing note dated June 28, 2026, at 11:00 a.m., documented by Staff Nurse #29, indicated that while she was in Resident #69's room, she heard Resident #63 yelling and using profanity and racial slurs from his room. According to the nursing note, Resident #69 stated to Staff #29 that Resident #63 should not be yelling and using that kind of language in the house. Staff #29 redirected Resident #69; however, Resident #69 exited his room and attempted to confront Resident #63 in the hallway. Staff #29 intervened and separated the two residents, redirecting Resident #69 to the dining hall. The nursing note further documented that a few minutes later, Resident #69 approached Staff #29 at the nursing station requesting juice. While Staff #29 went behind the nursing station to retrieve the juice, Resident #69 ran down the hallway toward Resident #63's room. Staff #29 and Staff #5 ran after Resident #69. The nursing note stated that Staff #5 reached Resident #63's room first and removed Resident #69 from the room. Staff #29 subsequently escorted Resident #69 to the day room.A subsequent nursing note documented by Staff Nurse #5 on June 28, 2026, at 3:09 p.m., indicated that Staff #5 accompanied Staff #29 when Resident #69 headed toward Resident #63's room. Staff #5 documented that he was unable to intercept Resident #69 before he entered the room. Staff #5 stated that upon arriving at the doorway, he observed Resident #63 seated in his wheelchair near his bed while Resident #69 stood next to him. He observed both residents slapping each other and immediately separated them while both residents were swearing and threatening one another. The nursing note further documented that Resident #69 repeatedly attempted to return to Resident #63's room. Staff redirected Resident #69 to another location and initiated 15-minute safety checks.An interview with Staff #29 was conducted on July 14, 2026, at 11:30 a.m. Staff #29 stated that she was in Resident #69's room preparing him for the day at approximately 11:00 a.m. on June 28, 2026. She stated that she heard Resident #63 yelling from the hallway outside his room. According to Staff #29, Resident #63 continued yelling profanity, including the words bitch, whore, and racial slurs while wheeling himself through the hallway. Staff #29 stated that Resident #69 got up, stepped out of his room, and told Resident #63, Hey, you can't call out names like that. Staff #29 stated that Resident #63 responded, I can say whatever the fuck I want to. Staff #29 reported that she attempted to distract and redirect Resident #69 to the dining room while a certified nursing assistant (CNA) took Resident #63 to his room and reassured him that he would be assisted back to bed after lunch. Staff #29 stated that Resident #63 had recently returned from dialysis and wanted assistance transferring from his wheelchair to his bed.Staff #29 further stated that after the situation had initially settled, Resident #69 approached the nursing station a few minutes later requesting a drink. Staff #29 provided the drink, and while she returned to the nursing desk, Resident #63 again began yelling, cursing, and screaming from his room. According to Staff #29, Resident #69 placed his drink down and ran into Resident #63's room. Staff #05 also attempted to stop Resident #69 but was unable to prevent him from entering the room. Staff #29 stated that she heard sounds of hitting but could not see the interaction. At this time, Staff #5 was inside the room separating the residents. Staff #29 then escorted Resident #69 to the dining hall for lunch, and Resident #69 complied with her directions. Staff #29 stated that she later returned to check on Resident #63; however, Resident #63 continued yelling and directing racial slurs toward her, so Staff #29 left the room while a CNA remained with Resident #63. Staff #29 further stated that Resident #69 was new to the facility and reacted very quickly to the yelling and profanity, making the incident occur rapidly despite her attempts to intervene.A subsequent interview with Staff #5 was conducted on July 14, 2026, at 12:00 p.m. Staff #5 recalled that during the incident, Resident #63 was yelling continuously and swearing from his room. He stated that Resident #63 had recently returned from dialysis and wanted to go to bed. According to Staff #5, Resident #63 was waiting for staff assistance with a transfer from his wheelchair to his bed because the CNAs had not yet responded. Staff #5 could not recall the reason for the delay in CNA response. Staff #5 stated that while he was in the hallway with Staff #29, he observed Resident #69 ran toward Resident #63's room. Staff #5 stated that he attempted to catch up to Resident #69 but was unable to reach him before he entered the room. Upon entering the room, Staff #5 observed Resident #69 standing next to Resident #63 while both residents were pushing, slapping, yelling, and threatening each other. Staff #5 stated that he separated the residents and reiterated that Resident #69 continued attempting to return to Resident #63 later that day.An interview with the Assistant Director of Nursing Services (ADON), Staff #11, was conducted on July 14, 2026, at 12:40 p.m. Staff #11 stated that she became aware of the resident-to-resident altercation through a report from the nursing staff on the unit. She stated that she immediately reported the incident to the Administrator, relocated Resident #69 to another area of the facility, and later moved Resident #63 to a different hallway away from Resident #69. Staff #11 further stated that the facility reported the incident to the appropriate authorities within the required timeframe and conducted a self-reported investigation. During interviews, staff consistently stated that hitting another resident, striking the head, slapping, using profanity, and making threats constituted examples of physical and verbal abuse.A review of the facility policy titled Abuse Policy, revised July 2017, revealed that the facility was committed to preventing and prohibiting all forms of abuse and neglect. The policy stated that the facility was responsible for establishing a safe environment by identifying, correcting, and intervening in situations in which abuse was more likely to occur. The policy further required ongoing staff education and orientation addressing abuse prevention, identification and reporting of abuse, stress management, and management of verbally or physically aggressive resident behavior. In addition, the policy emphasized maintaining sufficient staffing levels to meet residents' needs and ensuring that assigned staff were knowledgeable regarding each resident's care needs and behavioral symptoms.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that 2 of 34 sampled residents (#84 and #75) were free from physical or verbal abuse from other residents (#39 and #37). The deficient practice could result in residents being physically and emotionally harmed. Findings Include: -Regarding Resident #84: Resident #84 (alleged victim) was admitted to the facility on [DATE], with diagnoses of borderline personality disorder, other schizophrenia, major depressive disorder, generalized anxiety disorder, personal history of traumatic brain injury, and chronic pain syndrome. The clinical record revealed documentations that decisions and consent were made by the resident's legal guardian/Brother. A quarterly minimum data set (MDS) dated [DATE] revealed that Resident #84 had a BIMS (brief interview of mental status) score of 15, indicating intact cognition. A behavior assessment was completed on April 15, 2026, which revealed that Resident #84 displayed behaviors that included agitation/aggression, yelling/screaming/cursing/ abrasive tone, and threatening others. A care plan dated April 15, 2026 revealed Resident #84 received physical aggression from another resident. Interventions included residents were separated immediately, Resident #84 was sent to acute care hospital for evaluation, 15-minute checks upon return from acute care setting, monitor for emotional upset and encouragement to continue with normal routine, a referral was to be sent for counseling services with a tentative start date the week of April 20, 2026 and skin checks immediately and for 3 days with a report of abnormal findings to the MD (medical doctor). An incident note dated April 15, 2026 revealed that an incident occurred in the dining room while the residents were eating dinner. The incident note indicated that Resident #84 was verbally insulting another resident, Resident #39, who then told Resident #84 not to talk to him. Resident #84 asked Resident #39 what he was going to do about it, approaching him, and then Resident #39 hit Resident #84 in his left eye. It was documented that Resident #84 stated that Resident #39 told him not to talk to him, then stood up and pushed the table and hit him. The incident note stated that Resident #84 went to his room, vitals were initiated, skin assessment completed and PERRL (Pupils are Equal, Round, and Reactive to Light). It was documented that the resident complained of pain at the site where he was struck. An incident note dated April 15, 2026 revealed that Phoenix PD (Police Department) was notified at 5:40PM. An officer responded to the complaint. The medical provider and psychiatric provider were notified at approximately 6:00PM. An online APS report was completed at 7:03PM. The case manager was notified via email at 7:27PM. The Ombudsman notified via email at 7:29PM. Review of Resident #84's order summary revealed that an order was placed on April 15, 2026 for transfer to Banner University for a 1-day follow-up care from incident. A nurse's note dated April 15, 2026 revealed that Resident #84 was picked up via AMR (American Medical Response) non-emergent transport and transferred to Banner University Medical Center on a stretcher. Transfer was initiated due to a physical altercation in which the resident sustained an assault to the left eye. It was documented that the resident complained of nausea with no episodes of vomiting observed. PRN (pro re nata – as needed) Zofran was administered, along with all scheduled medications, prior to departure to the hospital. Resident #84 was documented as stable at time of transfer. POA (Power of Attorney) and facility management were notified of transfer. A behavior note dated April 15, 2026 revealed that Resident #84 exhibited argumentative and verbally aggressive behavior toward CNA (Certified Nursing Assistant) staff during care. It was documented that Resident #84 was heard yelling at staff and making insulting remarks, stating they are the worst CNAs he has ever had. The resident was also noted to be condescending, frequently instructing CNAs on how to perform their assigned tasks. Additionally, it was noted that the resident was observed yelling out loudly instead of utilizing the call light appropriately. The note further revealed that when the call light was used, the resident repeatedly pressed it despite needs already being addressed. It was documented that staff attempted redirection and provided reassurance; however, the behavior was noted to have persisted throughout the shift until resident was picked up by AMR for transport to the hospital. A nurse's note dated April 16, 2026 revealed that the facility was informed that a scan showed a hemorrhage and fracture to the left socket and that Resident #84 was still awaiting labs and would be admitted . A nurse's note dated April 16, 2026 revealed that the facility was informed that the resident was clear to return. No new medications were ordered. Findings were a fracture in the orbital wall with a bulbar hemorrhage. A nurse's note dated April 16, 2026 revealed that Resident #84 had returned from the ER (Emergency Room) visit at 05:57AM with findings of retrobulbar hemorrhage and fracture of the inferior orbital wall. The note revealed that the provider, facility management, and Resident #84's brother were notified and that vital signs were obtained upon return. The note further documented that no new orders were received at this time and that Resident #84 was to follow up with the specialist as recommended. The note revealed that the Plan of care was ongoing. A review of the hospital discharge instructions from the emergency department dated April 15, 2026, revealed that Resident #84 received a CT (Computed Tomography) Orbits without Intravenous contrast exam. It was documented that the impression of the exam revealed that Resident #84 had an acute left inferior orbital wall mildly displaced fracture and trace left retrobulbar hemorrhage A nurse's note dated April 16, 2026 revealed that Resident #84 did not want to eat in the unit dining room due to the incident on the previous day. Facility staff offered alternative dining options and Resident #84 was in agreement, but stated I am fasting, that's the only cure for sickness. A nurse's note dated April 16, 2026 revealed that Resident #84 remained in bed throughout the day and was offered the option to dine in an alternative dining area for both breakfast and lunch. The resident declined to get out of bed for both meals. He did consume his breakfast in his room. The resident reported having no appetite for lunch and requested that Ensure supplements be provided as a meal replacement until his appetite improves. Additionally, the resident requested that psychiatry be consulted regarding the possibility of initiating antidepressant therapy . A referral has also been placed with Behavioral Health Services (BHS) for counseling support. A care plan dated April 17, 2026 revealed Resident #84 has potential for impaired vision, pain, infection r/t left orbital fracture. Interventions included to encourage Resident #84 to avoid nose blowing and sneezing with mouth closed to prevent straining, monitor for edema, bleeding, pain, S/S infection, signs of vision loss and report abnormal findings to MD/NP, monitor for pain and administer analgesics as ordered, monitor for sudden pain or increase in vision loss which may indicate orbital compartment syndrome and notify MD/NP (Nurse Practitioner) of findings, schedule optometry visits per orders, and treat anxiety r/t orbital fracture as needed. Review of Resident #84's order summary revealed that an order was placed on April 17, 2026 for Hydrocodone-Acetaminophen Oral Tablet 10-325 MG (Hydrocodone-Acetaminophen). Give 1 tablet by mouth every 4 hours as needed for pain 6-10. A skin assessment dated [DATE] revealed that the resident has bruising to his left eye. -Regarding Resident #39 Resident #39 (alleged perpetrator) was initially admitted to the facility on [DATE], and re-admitted on [DATE] with diagnoses that include intermittent explosive disorder, schizoaffective disorder bipolar type, and personality change due to known physiological condition. The clinical record revealed documentations that decisions and consent were made by the resident's responsible party/Father. A care plan entry dated September 30, 2022 with a revision of March 18, 2024 revealed a Focus area indicating that Resident #39 uses psychotropic medications r/t (related to) Behavior management, Disease process schizoaffective disorder; bipolar type with interventions including Administer psychotropic medications as ordered by physician and to monitor for side effects and effectiveness every shift . A care plan entry dated March 17, 2023 with a revision on March 18, 2024 revealed a Focus area indicating that Resident #39 has behavior problems with interventions including administration of medications as ordered and to monitor/document for side effects and effectiveness, anticipate and meet the resident's needs, and assist the resident to develop more appropriate methods of coping and interacting and to encourage the resident to express feelings appropriately. A care plan entry dated March 18, 2024 with a revision on November 26, 2024 revealed a Focus area indicating that Resident #39 uses a non-psychotropic medication for Intermittent explosive disorder with interventions including monitor for behaviors per MD/NP orders. A review of Resident #39's Order Summary Report revealed that the resident was prescribed Loxapine Succinate Oral Capsule (Loxapine Succinate) on December 17, 2024 and to be given 30 mg by mouth three times a day for AEB (As evidenced by) mood swings, aggression, disorganized thinking related to schizoaffective disorder, bipolar type. A further review of Resident #39's Order Summary Report revealed that the resident was prescribed Seroquel Oral Tablet 400 MG (Quetiapine Fumarate) on October 6, 2025 and to be given 2 tablets by mouth at bedtime for disorganized thinking, mood swings, physical aggression related to schizoaffective disorder, bipolar type. The Order Summary Report also revealed that resident #39 was prescribed Seroquel Oral Tablet 200 MG (Quetiapine Fumarate) on January 26, 2026 an to be given 1 tablet by mouth in the morning for paranoia, disorganized thinking related to schizoaffective disorder, bipolar type. A review of Resident #39's Order Summary Report revealed that the resident was prescribed Depakote Oral Tablet Delayed Release 250 MG (Divalproex Sodium) on February 10, 2026 with instructions to be given 1 tablet by mouth two times a day for mood swings related to schizoaffective disorder, bipolar type and to be given with 500mg tab to equal 750mg. A quarterly minimum data set (MDS) dated [DATE] revealed that Resident #39 had a BIMS score of 14, indicating intact cognition. An incident note dated April 15, 2026 revealed that an incident occurred in the dining room while the residents were eating dinner. The incident note revealed that Resident #39 was observed standing in a fighting stance and was asked resident to sit. Resident #39 hesitated and was asked to look at Staff # 76 and to focus on Staff #76 and then asked Resident #39 to sit and Resident #39 did sit. It was documented that resident #39 told Resident #84 to not talk to him and Resident #84 would not stop. The note revealed that resident #39 got up pushed table and hit Resident #84. Resident #39 was easily redirected, Resident #39 went to his room, and vitals were initiated with a 1:1 in place. An incident note dated April 15, 2026 revealed the police, medical provider, psychiatric provider, APS, case manager and Ombudsman were notified. A care plan entry dated April 15, 2026 revealed a Focus area indicating that Resident #39 was the aggressor in an altercation. Interventions included being placed on 1:1 supervision, reported to abuse officer/DON (Director of Nursing) immediately, and residents were immediately separated. An incident note dated April 16, 2026 revealed that the facility completed and submitted an emergent petition for evaluation at UPC (Urgent Psychiatric Center) related to the April 15, 2026 incident and is awaiting decision. A social services note dated April 16, 2026 revealed that an application for involuntary evaluation for Resident #39 and was sent to UPC (Urgent Psychiatric Center). A social services note dated April 16, 2026 revealed that the petition was accepted and that the facility was awaiting transport for Resident #39, while the resident remained on 1:1 supervision. A nurse's note dated April 16, 2026 revealed that Resident #39 was observed being picked up by two law enforcement officers at 6:42PM. Resident remained calm, cooperative, and compliant with all instructions given by officers, with no noted behavioral issues or resistance. Prior to departure, Resident #39 took all scheduled medications as prescribed without difficulty. No acute distress observed at time of transfer. An investigative interview provided by the facility on April 17, 2026 revealed that Staff #76 was sitting at the nurse's station when she heard a scream coming from the dining area. It was documented that when Staff #76 arrived in the dining area, she witnessed Resident #84 leaving the dining area and was on the phone, saying that he was calling the police. Staff #76 further stated, as documented, that Resident #39 was standing in a fighting stance, was easily redirected, and sat down to finish his dinner. Staff #76 notified the Assistant Director of Nursing (ADON), a skin assessment was performed, PERRL Staff #76 reported that Resident #84 only complained of pain on his left eye at the time and later complained of nausea/vomiting (N/V). It was documented that Staff #76 later notified family, psych, NP, and set up a non-emergent transfer to Banner University. An investigative interview provided by the facility on April 17, 2026 revealed that Staff #3/CNA (Certified Nursing Assistant) was a witness to the altercation on April, 15, 2026. It was documented that staff #3 reported that to his knowledge, Resident #84 was talking about his nightly routine before he goes to bed, when Resident #39 told him to shut up and he doesn't want to hear him speak. It was documented that staff #3 then reported that all of a sudden, Resident #39 jumped up, shoved the table out of the way, and 'socks' Resident #84 in the eye. It was further noted that staff #3 then reported that he wheeled Resident #84 from the dining room to Resident #84's room. An investigative interview provided by the facility on April 17, 2026 revealed that Staff #242/CNA had witnessed the event. It was documented that Staff #242 reported that Resident #39 asked Resident #84 not to talk to him. It was further documented that staff #242 further reported that Resident #84 continued to talk to Resident #39, and that's when Resident #39 got up from his table and went over to Resident #84's dinner table, shoved the table at him, then Resident #39 punched Resident #84 in the left eye. It was documented that Staff #242 then was reported to have gotten up to try and get Resident #39 to focus on her while the other staff member (Staff #3) took Resident #84 out of the dining room. An investigative interview of Resident #39 was provided by the facility on April 17, 2026, where it was revealed that Resident #39 told Resident #84 not to talk to him, Resident #39 said that Resident #84 would not stop talking, Resident #39 then said that he stood up and pushed the table and hit Resident #84. An investigative interview of Resident #84 was provided by the facility on April 17, 2026, where it was revealed that Resident #39 told Resident #84 don't talk to me, Resident #84 states that he was not talking, and Resident #39 stood up, pushed the table, and hit Resident #84. A phone interview was conducted with Staff #76 on April 17, 2026 at approximately 11:00AM . During the interview, Staff #76 reported that she was not in the dining area when the incident occurred and that she entered the area after the incident. She stated that she had been at the nurse's station. She stated that she heard a loud yell coming from the dining room. She stated that she observed Resident #84 wheeling himself out and that she saw Resident #39 facing another resident. Staff #76 further stated that after Resident #39 sat down, she found out Resident # 39 had struck Resident #84. She stated that she did a full assessment. Staff #76 stated that resident #39 declined to go to the hospital initially, but changed his mind. Staff #76 was able to redirect Resident #39. Staff #76 further stated that there had been no issues between the two residents prior to the event, and was not aware of any inappropriate behaviors from Resident #39 prior to the event. Additionally, Staff #76 stated that she reported the event and that the police were notified. Staff #76 was asked if anyone had witnessed the event happen and she reported that two staff members, Staff #3 and Staff #242 had witnessed the event . A phone interview was conducted with Staff #242 on April 17, 2026 at approximately 1:48 PM. During the interview, Staff #242 reported that during dinner time, Resident #39 had asked Resident #84 not to speak to him. She stated that Resident #84 asked what did he do, and Resident #39 shoved the table. Staff #242 reported that Resident #39 told Resident #84 not to talk to him again. Staff #242 then stated that Resident #84 responded with something and that was when Resident #39 hit Resident #84. Staff #242 stated that she was helping feed a resident and got up and told Resident #39 to focus on the staff. Staff #242 reported that it happened so quick and the other staff member (Staff #3) removed Resident #84 from the dining room. Staff #242 then revealed that she had witnessed Resident #39 strike Resident #84 once on the left side of his face with a closed, right fist. Staff #242 additionally revealed that there was a red mark and that you could obviously tell he had been hit. Staff #242 stated that Resident #39 was eating his dinner and was calm and that two other residents were talking about something sexual. She stated that she told the two other residents to stop because it could offend other people. She stated that after some time went by, she was helping a resident and that she witnessed resident #39 telling resident #84 not to talk to him again. She stated that that Resident #84 said something and then Resident #39 shoved the table. Resident #84 answered back something else and that's when Resident #39 struck him. Staff #242 then stated that Resident #39 did not exhibit any inappropriate behaviors toward resident #84 or other residents prior to the event, she reported the event to the nurse on shift, and had stayed with Resident #39 while he ate. A phone interview was conducted with the Responsible Party/Father (RP) of Resident #39 on April 17, 2026 at 8:53AM. RP reported that he understands that Resident #39 had an altercation with another resident and that the facility had informed him of the altercation. RP had reported that the facility said that Resident #39 punched another guy. RP reported that Resident #39 said that there was another guy tickling him and other people . RP then stated that he started in on Resident #39 and Resident #39 told him to quit and he wouldn't, so Resident #39 punched him. RP went on to say that the guy (Resident #84) wouldn't let up from what he understood. RP then continued to say that he's not saying he deserved it, and that he was pretty sure this is the first time Resident #39 hit someone. RP went on to say that Resident #39 is no longer at the facility and he was taken somewhere to get a closer observation called UPC, and when he talked to Resident #39, he was not upset at all and stated that he was obedient. An interview was conducted with Resident #84 on April 17, 2026 at 9:17 AM in the resident's room. Resident #84 reported that he was telling Resident #39 about a video game and that if he has $15, then he can play it. Resident #84 stated that Resident #39 said don't talk to me, then pushed the table and punched him right in the eyeball. Resident #84 further stated that he got punched like a truck and that Staff #242 witnessed the whole thing. He stated that it happened in the dining room. Resident #84 stated that Resident #39 was eating his food and he snapped and then hit him. Resident #84 then reported that staff brought him to his room, he felt nauseous, and went to the hospital. Resident #84 then identified Resident #39's first name as the resident who struck him. Resident #84 then reported that he called 911 and that he got skeletal damage and blood in the back of his eye from the attack. Resident #84 continued to state that he never had a problem with Resident #39. An interview was conducted with the Director of Nursing (DON/Staff #151) on April 17, 2026 at 11:17 AM. Staff #151 defined resident to resident abuse as directed verbal altercation or directed physical altercation and any altercation directed towards another resident. Staff #151 then stated that there had been a resident to resident abuse in the facility about two days prior. Staff #151 stated that she was notified that Resident #39 and Resident #84 were in the dining room, Resident #39 got up and struck Resident #84, that the event was witnessed, and that contact was confirmed by both residents. Staff #151 continued that the residents were separated, Resident #84 went to his room. Resident #39 went to his room. She stated that a 1:1 was placed with Resident #39 and the residents were kept separated. She stated that Resident #84 was placed on 15-minute checks and Resident #39 was placed on 1 to 1 supervision. Staff #151 further stated that Resident #84 agreed transfer to the hospital and returned back to the facility. She stated after the resident was back from the hospital the resident didn't want to go back to the dining room. Staff #151 further stated that he was offered to go to another dining room. She stated that an emergent petition was filed on Resident #39, it was accepted and resident #39 was transferred to get him evaluated. Staff #151 stated that there was bruising on the left eye, and an orbital fracture for resident #84. Staff #151 stated regarding their internal investigation, that there is no denying this one. She stated that she had a staff member in the dining room helping another resident eat, but it happened so fast . An interview was conducted with the Administrator (Staff #241) on April 17, 2026 at 11:42 AM. Staff #241 defined abuse, as physical contact between two residents or potentially a staff member and a resident. Staff #241 stated that resident to resident abuse, would be if one of the facility's residents abused another one of the residents. Staff #241 stated that the most recent abuse that had occurred was on Wednesday, April 15, 2026. Staff #241 stated that as a result of what he learned from the investigation Resident #39 hit Resident #84 while they were on the unit, more specifically the dining room. Staff #241 stated that there was a resulting injury to the left side of Resident #84's face. Staff #241 stated that the result of his investigation was, sending Resident #84 out, to get him checked out. He further stated that there was an injury to the orbital, but they said he could be treated at the facility. He stated that he had been told that it was a fracture. He further stated that he talked to Resident #39 a couple of times. He stated that there is no doubt that Resident #39 hit Resident #84. Staff #241 stated, there were witnesses. He further stated that iIt will be verified by the facility when the 5-day investigation is submitted. -Regarding Resident #75 Resident #75 was admitted to the facility on [DATE], with diagnoses that included schizophrenia, fracture of the lower leg, bipolar disorder, chronic obstructive pulmonary disease, anxiety disorder, type 2 diabetes, asthma, hypertension, intellectual disabilities, nicotine dependence, and obesity. A behavioral care plan dated March 23, 2026, revealed that the resident had verbal aggression towards others, and that she exhibited demanding behaviors with interventions to not provide requests when made in a demanding, rude, threatening, or aggressive manner. The behavioral care plan interventions further revealed that if the resident remained rude, threatening, or demanding, staff were to ensure safety and explain that they would return once she had calmed down. A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09, which indicated moderately impaired cognition. A physician's order dated April 3, 2026, revealed safety checks every 15 minutes from April 4, 2026, until April 10, 2026. A skin evaluation dated April 3, 2026, at 9:11 p.m. revealed that the resident's skin was intact with no scratches or open areas, with notification details to the provider of physical aggression. A health status progress note dated April 3, 2026, at 9:43 p.m. revealed that the resident was speaking loudly and verbally to another resident, when she called the other resident fat b****es and told her to give her a soda. The note revealed that the other resident told Resident #75 no, it was not her soda, and to stop it before she slapped her. The note further revealed that the resident continued to berate her verbally, and that the other resident got up and slapped Resident #75 in the face in front of the medication cart in the hallway, with unknown physical contact, because the nurse did not see the actual hit from the other resident. An incident progress note dated April 4, 2026, at 7:18 a.m. revealed that a police officer arrived at the unit at 6:46 a.m. A behavioral care plan dated April 6, 2026, revealed that the resident had a behavior of inciting peers, with interventions to approach her in a non-confrontational manner, and that at the first sign of upset, staff should immediately separate the resident from her peers who were causing upset. The behavioral care plan interventions further revealed that when the resident was noted to incite peers, staff should give her a warning to stop, and if she continued, they should provide her with a calm space to separate her from the situation and do their best to keep her a significant distance from peers who cause her upset. A care plan focus revised on April 6, 2026, revealed that the resident had behavior problems related to schizophrenia, bipolar disorder, and anxiety, with a goal to not exhibit physical aggression behaviors by the review date. The care plan focus had interventions to intervene as necessary to protect the rights and safety of others. -Regarding Resident #37 Resident #37 was readmitted to the facility on [DATE], with diagnoses that included borderline personality disorder, bipolar disorder, pseudobulbar affect, hypertensive chronic kidney disease, anxiety disorder, insomnia, type 1 diabetes, post-traumatic stress disorder, obstructive sleep apnea, and polyneuropathy. A behavioral treatment plan dated February 16, 2026, revealed that the resident had behaviors to bully or show physical aggression towards peers, with interventions for staff to intervene promptly to maintain safety and a respectful environment. The behavioral care plan interventions further revealed that staff should remind the resident of expectations for respectful behavior, with examples being we treat others with respect. Hitting or intimidating others is not okay. The behavioral care plan interventions also revealed that if needed, the resident should be separated from the peer and redirected to another activity or area to allow time to settle, and to avoid arguing during escalation and focus on de-escalation and safety. A Quarterly MDS dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. A care plan focus revised on February 24, 2026, revealed that the resident was at risk for behaviors related to bipolar, anxiety, and pseudobulbar affect, with interventions to intervene as necessary to protect the rights and safety of others. A physician's order dated April 3, 2026, revealed safety checks every 15 minutes from April 4, 2025, until April 10, 2026. A behavior progress note dated April 3, 2026, at 10:22 p.m. revealed that the resident was at the nurses' station asking for a shower when another resident came and gave staff sodas. The note further revealed that another resident asked for a soda, and Resident #37 told her no. The note also revealed that the other resident called Resident #37 a fat b**** and to mind her own business. The note revealed that Resident #37 told the other resident to stop before she slapped her, and the other resident kept name-calling until Resident #37 jumped up and swung at the other resident. An incident progress note dated April 4, 2026, at 7:20 a.m. revealed that a police officer arrived at the unit at 6:46 a.m. Review of a facility investigation dated April 8, 2026, revealed that on April 3, 2026, at approximately 5:35 p.m., it was reported that Resident #37 and Resident #75 were at the nurses' station engaged in a verbal argument over a soda when both residents stood up from their wheelchairs and approached each other. The Facility investigation further revealed that Resident #37 swung her arm at Resident #75, and staff intervened and separated the residents. The facility investigation also revealed that a skin assessment was completed for Resident #75 at the time of the incident, and there was no injury, redness, trauma, or swelling noted. The facility investigation revealed that a female peer, Resident #38, was in the area during the time of the incident and stated that she saw Resident #37 swing her arm, but did not witness any physical contact between the two residents. The facility investigation further revealed that statements were taken from staff who were present at the time of the incident, and that they reported they did not witness any physical contact, however, there was a verbal argument between the residents. The facility investigation also revealed that Resident #37 was interviewed after the incident and stated that there was a verbal interaction between the two residents over a soda, and that she stood up from her chair, but that was it. The facility investigation revealed that Resident #75 was interviewed after the incident and stated that there was a verbal interaction between the two of them, and that Resident #37 swung at her. The facility investigation revealed that the facility was unable to determine if physical contact was made between the residents. The self-report further revealed that Resident #75 complained of pain to her chin after the incident occurred, with a skin assessment noting no injuries, trauma, or swelling. The facility investigation revealed a typed statement from Resident #75, dated April 7th, 2026, that revealed she asked for a soda, and Resident #37 told her no. The typed statement from Resident #75 further revealed that they continued to argue, Resident #37 stood up from her chair, and swung her arm at Resident #75 before staff separated them from each other. The facility investigation revealed a typed statement from Resident #37, dated April 7th, 2026, that revealed that they got into a verbal argument because Resident #75 wanted Resident #37's soda, and that Resident #37 told her that she was not going to spend her money on a soda for Resident #75. The typed statement further revealed that Resident #75 said some things that were not very nice before Resident #37 stood up out of her

Based on observations, clinical record review, and staff interviews, the facility failed to ensure one Resident (#88) out of one sampled residents were assessed and care planned for the ability to self-administer medications to include tube-feedings. The universe was 157. The deficient practice could result in incorrect administration of tube feedings, leading to aspiration, choking, severe infections, nutritional mismanagement, and tube clogging.Findings include:Resident #88 was re-admitted on [DATE] with diagnoses of intracranial injury with loss of consciousness of unspecified duration, traumatic brain injury, persistent mood disorder, dysphagia, hypertension, anxiety, gastrostomy, hyperglyceridemia, hyperglycemia, suicidal ideations, depression, and other mood disorder due to known physiological condition. A review of the Self-administration of Medication assessment for Resident #88, completed on March 10, 2026, revealed that resident was fully capable of self-administrating eye drops, ear drops, topical creams and ointments. However, the assessment did not include assessment of self administering tube feeding.The clinical record revealed a physician order dated, March 30, 2026, for nothing by mouth (NPO), enteral feed every shift and to record residuals every shift, to check tube placement before initiation of formula, medication administration, and flushing of tube. An additional order revealed that the resident may self-administer tube feeding dated April 8, 2026. The Care plan revised on February 19, 2026 included that the resident is at nutritional risk r/t inadequate oral intake, NPO status, need for EN (Enteral Nutrition) to meet nutritional needs. Goal included that the resident will maintain adequate nutrition and hydration via tube feed and the resident will have no unplanned significant weight changes through next review. The Care plan did not reveal the resident ability to self administer tube feeding.An interview was conducted with Resident #88 on April 14, 2026 at 9:32 AM; the Resident stated that he has tube feeding and that he self-administers his own tube feeding. The Resident stated that he informs staff of any discomfort with his tube feeding site, and that he recently was hospitalized for the dislodging of his tube. The Resident stated that he always administers his own tube feeding. On April 17, 2026 at 8:11 AM, an interview was conducted with Staff #47, a certified nursing assistant (CNA) for Resident #88, who stated that the Resident is NPO and minimal care. She stated that the Resident informs staff of any needed assistance and informs them of his emotions and needs. Staff #47 stated that she had observed the Resident herself administrating his own tube- feeding and that she knew the Resident had a physician order to self administer his tube feedings. An interview was conducted with Staff #232, Licensed Practical Nurse (LPN), on April 17, 2026 8:13 AM. Staff #232 stated that Resident #88 administers his own tube feeding, and that there is an order for his self-administration. Staff #232 stated that she does not personally supervise the Resident administering his tube feeding, and that the Assistant Director of Nursing (ADON) reviews resident's orders. Staff #232 does not have any concerns regarding the Resident's tube feeding. An interview was conducted with Staff #156, Assistant Director of Nursing (ADON), on April 17, 2026 8:16 AM, who stated that she reviews and follows-up on assessments for residents, pertaining to self-administrating medications. She stated that she only knows of Resident #88 being able to self-administer medication and that there is a physician order for it. Staff #156 stated that she completed the self-administration assessment on Resident #88 herself, and this was done by showing the Resident how to administer the tube feeding and to educate him on site cleaning, tube position, and how to administer tube feeding. The ADON had the Resident teach and show the process back to her. She stated that the order should be in the electronic medical records. The ADON stated that the process to assess a resident for self-administration is to have a physician's order for the particular medication, then conduct an assessment and document it. The ADON then provided documentation on the electronic health records to show a completed self-administration of medication assessment, although the document revealed no documentation for tube-feeding specifically for Resident #88. The ADON stated that the assessment did not include tube feeding specifically, but that it should have included tube-feeding specifically. She stated that without the documentation on an assessment for tube-feeding, this can put the Resident at risk for incorrectly self-administrating the medication, risk for infection, malnutrition, and improperly flushing of the tube.An interview was conducted with Staff #151, Director of Nursing (DON), on April 17, 2026 at 8:33 AM. The DON stated an assessment is conducted by the facility for self-administering medication by asking the resident if they know what the medication is for, how often they are to be taking the medication, and if the resident is able to open any containers or packaging the medication arrives in. Staff #151 further stated that the assessment determines if a resident can appropriately self-administer, this is then sent to the provider for review and an order is created. She stated that this is documented in the electronic health record of the resident. The DON stated that the process to determine if a resident is able to appropriately administer medication is by observing the resident with training and education. She stated that this would then be reflected in the physician's orders and documented on the resident's care plan. The DON stated that tube feeding formula is considered a medication, and that Resident #88 does have a physician order but no assessment documented. The DON stated that the current assessment for self-administrating medication for Resident #88 does not include tube-feeding on the assessment. The DON stated that the risks for not conducting an assessment for the self-administrating includes the risk for infection, adverse reactions, taking too much or little medication, and that staff could make errors on the Resident's limitations for self-administrating medication.The facility's policy on self-administrating medications states that residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident; by assessing residents on their cognitive and physical abilities to administer medications, and if it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and the care plan.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that advance directives were accurate, consistent, and clearly defined in the medical record for 1 of 30 sampled residents (#8). The deficient practice could result in residents not receiving proper care according to their preferences or potential harm to the resident's life. Findings include: Resident #8 was readmitted to the facility on [DATE], with diagnoses that included dementia, schizoaffective disorder (bipolar type), atherosclerotic heart disease, type 2 diabetes, hypertension, hypothyroidism, gastro-esophageal reflux disease, cataracts, nicotine dependence, insomnia, muscle weakness, chronic obstructive pulmonary disease, edema, extrapyramidal and movement disorder, and hyperlipidemia.A signed advance directive statement form in Resident #8's Electronic Health Record (EHR) dated [DATE], revealed that the resident had a full code status, meaning that the resident, legal guardian, health care proxy, or representative (sponsor) has directed that cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used.A physician's order for 'full code' was initiated on [DATE].A care plan focus revised on [DATE], revealed that the resident was a full code, and her wishes would be communicated and followed. A Quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. A signed advance directive statement form and orange sheet in Resident #8's Electronic Health Record (EHR) dated [DATE], revealed that the resident had a Do not Resuscitate (DNR) code status, meaning that the resident, legal guardian, health care proxy, or representative (sponsor) has directed that no cardiopulmonary resuscitation (CPR) or other life-sustaining treatments or methods are to be used.A physician's progress note dated [DATE], at 2:44 p.m. revealed that the resident was a 'full code' status. A physician's order for 'DNR' was initiated on [DATE], however, the advance directive statement was initiated and signed on [DATE].A care plan focus revised on [DATE], revealed that the resident was a DNR, and her wishes would be communicated and followed, with interventions to not resuscitate her.An interview was conducted on [DATE], at 1:26 p.m. with a Certified Nursing Assistant (CNA/Staff#54) who stated that she would know a resident's code status, either full code or DNR, by looking at the Point of Care (POC) EHR that CNAs have access to. The CNA logged into the POC application and stated that Resident #8's code status was DNR. The CNA also opened the hard copy of Resident #8's advance directive and stated that the resident was a DNR with a signed form dated [DATE]. An interview was conducted on [DATE], at 1:28 p.m. with a Licensed Practical Nurse (LPN/Staff#164) who stated that he would know a resident's code status by looking in the advance directives binder at the nurses' station, and it would also appear in the EHR banner when the physician puts an order in for their code status. The LPN stated that if there was a change in a resident's code status during their stay at the facility, they would need to get an updated physician's order at the time of the form being signed and the directive being changed. The LPN stated that the importance of having the correct order from the physician is for documentation and confirmation from the provider. The LPN further stated that the risk of inconsistency regarding advance directives would be a potential delay in care or not honoring a resident's wishes. The LPN stated that Resident #8 had a DNR code status initiated on [DATE], and that the DNR form was signed on [DATE]. The LPN stated that prior to [DATE], there was an order for full code status that was initiated on [DATE], and that the DNR order was not entered timely into the medical record. An interview was conducted on [DATE], at 1:43 p.m. with a Director of Nursing (DON/Staff#151) who stated that a resident's code status is known because there is a physician's order put into the medical record, and that the order will show in the EHR banner for each resident. The DON stated that CNAs would see code status through the POC application and that advance directives should be documented in the care plan and uploaded into the EHR. The DON also stated that if there was a change in a resident's code status, the forms would need to be redone, and the nurse would be notified of the change so that the physician's order could be updated, and the new forms would be uploaded. The DON stated that Resident #8 now has a DNR code status that was signed and completed on [DATE], and that the physician's order for DNR was initiated on [DATE]. The DON further stated that prior to [DATE], the order was for a full code status initiated on [DATE], with the previous full code form initiated on [DATE]. The DON stated that Resident #8's code status change was not communicated by medical records to the nurse manager, so the order was never changed in the record. The DON further stated that it did not meet her expectation, and that she would expect that whoever got the form signed would take the form to the nurse to update the order promptly. The DON stated that the risk of not having the correct advance directives order would be that they could inadvertently perform, or not perform, CPR in an emergency, which could potentially cause harm, and they would not be following the resident's wishes. Review of policy titled, Advance Directives, was revised in [DATE] and revealed that the resident has the right to formulate an advance directive, including the right to accept or refuse medical or surgical treatment. The policy also revealed that advance directives were honored in accordance with state law and facility policy. The policy revealed that if a resident has an advance directive, the director of nursing services (DNS) or designee notifies the attending physician of advance directives, or changes in advance directives, so that the appropriate orders can be documented in the resident's medical record and plan of care. The policy also revealed that changes or revocations of a directive must be submitted in writing to the administrator, and that residents would not be treated against their own wishes.

Based on observations, interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure medications were not left at the bedside for two residents (Resident #94 and Resident #73) out of 30 sampled residents. The universe was 149. The deficient practice could increase the likelihood of medication overdose and residents having unrestricted access to medications. Findings include: Regarding Resident 73: Resident #73 was admitted on [DATE] with diagnoses that included hyperlipidemia, bipolar disorder, stage-2 chronic kidney disease, essential (primary) hypertension, obsessive-compulsive personality disorder, bilateral primary osteoarthritis of hip, dementia in other diseases classified elsewhere, muscle wasting and atrophy, unsteadiness on feet, myalgia, patient's other noncompliance with medication regimen for other reason, dysphagia, unknown psychosis, and senile degeneration of the brain. A review of the MDS (minimum data set) dated March 3, 2026, revealed a BIMS (brief interview for mental status) score of 12, which indicated resident #73 had moderate cognitive impairment. A review of the physician orders revealed no evidence of an order for medication self-administration. Physician orders revealed an order dated March 4, 2026 for medicated menthol-zinc oxide cream for resident #73. A review of the care plan revealed no evidence that the resident was authorized to self-administer medications. A review of IDT (interdisciplinary team) notes revealed no evidence that the resident was authorized to self-administer medications. A review of assessments within the electronic health record revealed no evidence that resident #73 was assessed to self-administer medications. During an initial observation of the resident's room on April 14, 2026 around 10:10 am, a tube of zinc oxide cream with approximately 50% of its content remaining was observed to be present on the resident's bedside table. The resident was not present at the time. Following the observation, an interview was conducted with a Licensed Practical Nurse (LPN/staff #236). Staff #236 identified the tube of cream as being medicated zinc oxide cream. Staff #236 stated that the cream should have been discarded, and not left at the resident's bedside. Staff #236 stated that the potential harm associated with leaving medication at a resident's beside is that a resident could ingest the cream or put it on themselves and that poison control would have to be contacted if a resident consumed the zinc oxide cream. Following the interview, staff #236 was observed removing the cream from the resident's bedside and room. An interview was conducted on April 14, 2026 at 10:17 a.m. with certified nursing assistant (CNA/staff #186) who stated that the facility policy does not permit for medications to be left at a resident's bedside. Staff #186 advised that if she were to find a medication left at a resident's bedside, she would let a nurse know. Staff #186 stated that potential outcomes of leaving medications at the bedside is that another resident could get to the medication, or a resident would not take the medication and they were not observed taking the medication. An interview was conducted at the facility with the Director of Nursing (DON/staff #151) on April 16, 2026. Staff #151 stated that leaving a medication at a resident's bedside should not happen, that it is not compliant with the facility policy, and could result in the resident not taking the medication as needed or another resident accidentally taking the medication. Staff #151 stated that her expectation for how facility staff should handle medications found at a resident's bedside is that they should remove the medications from the resident's room and hand them over to a member of the nursing team. Staff #151 stated that in order for a resident to self-administer medications, a self-medication administration assessment must occur. If the assessment concluded the resident is safe to self-administer medications, the physician would be contacted for orders to self-administer. If the resident was assessed to not be safe to self-administer, the resident would be educated as to why they are unable to do so. Staff #151 then pulled up the orders for resident #73 and verified that the resident did not have orders to self-administer medications and that no progress notes or documentation was present that would indicate the resident was able to have medications left at the bedside. Staff #151 advised that if resident #73 was able to self-administer medications, documentation would be present in their care plan. Staff #151 stated that medications being left at a resident's bedside without orders to self-administer does not meet facility expectations. -Regarding Resident #94: Resident was re-admitted to the facility on [DATE] with diagnoses that included paraplegia, unspecified, unspecified open wound of abdominal quadrant without penetration into peritoneal cavity, sequela, and unspecified open wound, left lower leg, sequela. Review of a patient discharge instructions dated February 11, 2026 regarding a previous hospital stay revealed a new medication order for Silver Sulfadiazine topical (Silvadene 1 percent topical cream) to apply topically once a day for fourteen days. Review of the baseline care plan initiated on March 26, 2026 revealed a focus indicating Resident #94 was at risk for skin issues and pressure ulcers with interventions that included to administer treatments as ordered. There was no evidence within the care plan that indicated Resident #94 was authorized to self-administer medications. Review of the admission minimum data set (MDS) dated [DATE] revealed Resident #94 had a brief interview for mental status (BIMS) score of 15, indicating the resident was cognitively intact. Review of the MDS revealed Resident #94 had impairments on both lower extremities and was dependent on staff for showers. Further review of the MDS revealed the resident had wound infections and multi-drug resistant organisms (MDROs) and was receiving antibiotics. There was no evidence in the order summary of an active order for Silver Sulfadiazine 1 percent (%) external cream. An observation was conducted of Resident #94's bedside table on April 14, 2026 at 9:35 a.m. which revealed a 400 milligram (mg) blue container with a white lid labeled Silver Sulfadiazine 1% external cream with the resident's name, date of birth , and room number visible. At the time of the observation, Resident #94 was in bed sleeping with the covers drawn and lights off. A second observation was conducted of Resident #94's bedside table on April 14, 2026 at 10:21 a.m. which again revealed the 400 mg container of Silver Sulfadiazine 1% external cream with the resident's name, date of birth , and room number visible. An interview was conducted on April 14, 2026 at 10:43 a.m. with Resident #94. Resident #94 stated he was not sure what the container of Silver Sulfadiazine 1% external cream was and could not state how long the medication had been there. An interview was conducted on April 14, 2026 at 10:47 a.m. with a certified nursing assistant (CNA/Staff #206). Staff #206 stated CNAs are expected to round on the residents at least every two hours. Staff #206 stated when she rounds she will determine if any residents need incontinence care, urinals emptied, ice water, trash and linens taken out, and ensure residents are safe. Staff #206 further stated she would look for any medications, creams, or sharp objects in the resident's possession and/or room. Staff #206 stated if she noticed any potentially hazardous items she would remove them immediately and alert the nurse. Staff #206 stated there was a risk of patient safety if proper supervision was not conducted. An observation was conducted of Resident #94's bedside table on April 14, 2026 at 10:54 a.m. with a licensed practical nurse (LPN/Staff #190). Staff #190 stated the cream at the bedside was Silver Sulfadiazine 1% and it is used for wound care treatments. An interview was conducted on April 14, 2026 at 10:54 a.m. with Staff #190. Staff #190 stated medications require a prescription and can include oral, topicals, intravenous, subcutaneous, and over-the-counter delivery routes. Staff #190 stated staff should be rounding on their residents every two hours and ensuring there are no medications or hazardous objects in the resident's possession. Staff #190 stated if a resident wanted to self-administer medications, a physician's order is needed. Staff #190 stated the risks of not storing medications properly could lead to residents overdosing or experiencing adverse reactions to unattended medications. Staff #190 stated Resident #94 recently came back from hospital recently which is where the medication may have come from, however, does not have any orders for medications to be left on the bedside and the Silver Sulfadiazine should not have been there. Staff #190 further stated the medication on the bedside does not meet facility expectations. An interview was conducted on April 16, 2026 at 12:00 p.m. with the Director of Nursing (DON/Staff #151). Staff #151 stated a medication could include eye drops, inhalers, oxygen, nasal, pills, vitamins, and prescription lotions. Staff #151 stated provider orders are required for all medications. Staff #151 stated an assessment for self-administration must be completed to determine if the resident is safe to self-administer a specific medication. Staff #151 further stated a physician's order to self-administer medication is also required. Staff #151 stated the expectation for clinical staff would be to round on their residents every two hours to ensure the residents do not have any potentially hazardous materials or medications in their possession. A review of Resident #151's clinical record was conducted on April 16, 2026 at 12:16 p.m. with Staff #151. Staff #151 stated there were no active orders for Silver Sulfadiazine. Staff #151 stated there was no physician order or assessment completed for self-administration of medications within the clinical record. Staff #151 stated the potential risks could include adverse reactions to medications or potential overdoses. The facility's policy titled, Administering Medications-revised April 2019, stated only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The policy stated medications are administered in accordance with prescriber orders, including any required time frame. Furthermore, the policy stated that medications ordered for a particular resident may not be administered to another resident, unless permitted by state law and facility policy, and approved by the director of nursing services. The facility's policy also stated that residents may self-administer their own medication only if the attending physician, in conjunctions with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. The facility's policy titled, Self-Administration of Medications-revised February 2021, stated self-administered medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in a resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. The facility's Self-Administration of Medications Policy further states that any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. The facility's policy titled, Medication Labeling and Storage-revised February 2023, stated medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems. Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medications to several residents. The facility's policy states compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing medications and biologicals are locked when not in use, and trays or carts used to transport such items are not left unattended if open or otherwise potentially available to others. The facility's Medication Labeling and Storage Policy further states that medications for external use, as well as hazardous drugs and biologicals, are clearly marked as such, and are stored separately from regular medications.

Based on observations, clinical record review, staff interviews, and facility policy review, the facility failed to ensure that the care plan was reviewed and updated for one out of three sample Residents (#1). The deficient practice could lead residents to not receive proper care.Findings Include: Resident #1 was initially admitted on [DATE], and re-admitted on [DATE], with a diagnosis that included vascular dementia, mood disorder, constipation, venous thrombosis and embolism, hypotension, dysphagia, anxiety disorder, and post-traumatic stress disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed no Brief Interview for Mental Status (BIMS) assessment. It also revealed that cognitive skills for daily decision-making are severely impaired. The care plan dated June 09, 2025, had a focused care area for Resident #1 being at risk for elopement related to a history of elopement before admission and during stay. Interventions included assessing for fall risk, monitoring for fatigue and weight loss, and residing on a secure unit. The Behavioral treatment care plan dated November 24, 2025, revealed that Resident #1 behaviors being Sundowners. Interventions included that when Resident #1 starts showing signs of sundowning, like increased confusion, agitation, restlessness, repetitive motions, emotional distress, anxiety and restlessness, or pacing in late afternoon or evening, staff should calmly reassure the resident and provide a structured, soothing environment. Also, staff should reduce the stimulation before sundown by dimming lights gradually, minimizing noise, and avoiding large group activities. Use a consistent evening routine to help Resident #1 feel secure, and provide familiar, calming activities such as music, folding laundry, or looking through photos. Speak in a soft, clear tone and avoid correcting or arguing if he becomesconfused or disoriented. If he appears anxious, redirect him gently and offer reassurance that he is safe. Monitor for possible physical needs such as hunger, toileting, or pain that may be contributing to the behavior An incident report dated December 04, 2025, revealed that the resident #1 was pacing in the hallway and appeared to be restless, then the resident ambulated towards the north exit door and exited the facility into the smoking area, where staff followed him immediately, resident was observed climbing the wall; verbal redirection was attempted by staff, but it was not effective and facility code was initiated. One nurse is positioned outside the wall; additional staff remain inside with the resident. The Resident #1 jumped over the wall to the outside of the wall to the outside area and began running off the facility grounds. Staff continued to redirect the Resident back to safety, but were unsuccessful. The resident's sister and provider were notified. Provider gave orders for Resident #1 to be sent to the hospital. With the help of 911, Resident #1 was taken to the facility and assessed, and no injuries were noted. Immediate action was taken, which included verbal redirection; the resident refused, the provider notified, and sent to the hospital for further evaluation, resident's sister was notified regarding the current status, 911 was called for assistance, and staff followed the resident while maintaining visual contact and redirection, and non-emergent medical transport to the hospital. Review of care plan revealed no updated care plan or any new interventions for the focused area for the risk of elopement related to a history of elopement before admission and during stay after the incident occurred on December 04, 2025, with Resident #1. Review of the Behavioral Care Plan revealed no evidence of an updated care plan after the incident occurred December 04, 2025. An Incident report dated December 07, 2025, revealed that the Resident #1 was observed to be restless and agitated, with continuing pacing in the hallway. The resident refused all medication, treatments, and vitals. The resident was entering the resident's rooms, entering the nurses' station, and going through the drawers. Resident #1 called 911 multiple times at the nurses' station. Redirection and distraction was unsuccessful, the guardian was notified, and the police arrived. At 08:22 am, resident exited the unit and exited the facility. The staff called 911, and Assistant Director of Nursing (ADON), Resident #1 had a large rock posturing and attempting to throw at the staff. The guardian was on the call during the event. Resident #1 is climbing the brick wall with a rock in his hand. The nurse and another staff present at all times when he proceeded to walk to the street. ADON and the police arrived, and police helped him to get back to the facility. The Resident was noted to have a scrape on the left wrist after climbing the brick wall. Per the Psych provider, an order was placed to receive psychiatric evaluation and stabilization at the medical center. The guardian agreed to this and was transferred. The immediate action taken section of the incident report was the same as the nursing descriptions. Review of care plan revealed no updated care plan or any new interventions for the focused area for the risk of elopement related to a history of elopement before admission and during stay after the incident occurred on December 07, 2025, with Resident #1. Review of the Behavioral Care Plan revealed no evidence of an updated care plan after the incident occurred December 04, 2025. Review of the elopement care plan revealed no new interventions to prevent resident elopement after the incident happened on December 07, 2025, for Resident #1. A Discharge summary dated [DATE], at 12:58 AM revealed that at Resident #1 made his way outside by holding the exit door onto the patio. Resident #1 was able to climb over the fence and jump. It was unknown if the patient hit his head. Staff went outside and called 911 for assistance. The resident did return back inside the facility, and then later he exited the patio. American Medical Response (AMR) was called as directed by the Director of Nursing (DON) to send the resident out for assessment. Resident #1 was made aware of the issue. An interview was conducted on February 23, 2026, at 2:05 PM with a Certified Nursing Assistant (CNA/staff #6), who stated that they know if the resident wanders or is at risk of elopement by their attitude and behaviors, such as wandering up and down the halls. Staff #6 stated that they ensure residents' safety when they are an elopement risk by keeping an eye on them at all times. The CNA stated that some of the interventions that are used to ensure safety would include redirecting the resident, keeping a close eye on them, monitoring their movements, and staff will document. The CNA further stated that most of the residents are strong, and they push the exit door. She stated she does not handle care plans and would not know new interventions would be placed after the resident leaves the facility. She stated that if current interventions are not effective, the care plan should be changed and updated. Staff #6 stated that Resident #1 tried to elope, but the staff member was present with Resident #1 when she tried to leave. The staff member #6 stated she does not remember a date for when he tried to leave. She stated they do not hold residents because they can not restrain them; they just redirect the resident to return to the facility if they see them leaving. An interview was conducted on February 23, 2025, at 2:21 PM with a Licensed Practical Nurse (LPN/staff #9), who stated that as nurses do not create the care plans; the ADON and DON are the ones who update the care plans and put interventions. She stated that other departments participate in care plans and they review the care plan with behaviors, and ensure the care plan is followed at all times. Further stated that she can suggest interventions for the resident if one intervention is not effective to the DON or ADON. The LPN stated she knows if the resident is an elopement by looking over the care plan. She stated that residents with behavior are already at elopement risk, and are treated as an elopement risk. Staff #9 stated that she always checks on the residents, each employee is parked around the building in case the resident tries to leave, so they can easily notify, and do continuous rounding. An interview was conducted on February 23, 2025, at 2:40 PM with the DON (Staff #5), who stated that elopement is when the facility does not know where a resident is, or we lose sight of the resident. She stated that when elopement happens in the facility, staff start to search for the resident inside and on the grounds of the facility, and expand as they need to, notify the police department, provider, and Power of Attorney (POA), or their emergency contact. She stated that when a resident is found and returned to the facility, they assess the resident for the injuries. She stated that all the Residents get screened for elopement upon admission, quarterly, or as needed. She stated Resident #1 has climbed the fence three times. To ensure the safety of Resident #1, they sent him to the hospital after the first incident on December 04, 2025, and stated that it is not reflected on the care plan as one of the interventions. She also stated that when resident #1 came back, there were no other interventions placed and no change in medication. Staff #5 stated that the same event occurred on December 07, 2024, where Resident #1 was sent to the hospital and was seen by a psych provider. She stated that these interventions were not reflected in the care plan either. On December 26, 2025 the resident climbed the fence with the supervision of staff and was sent to the hospital, but did not return to the facility. She stated the interventions should have been implemented in the care plan, and she stated someone should have looked into and put them in there, but it was not there. She stated that care plan not being updated can risk a resident not getting proper care. The facility policy titled Care Plans, Comprehensive Person-Centered, last revised March 2022, revealed a comprehensive, person-centered care plan should include measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs, is developed and implemented for each resident. Care plan interventions are chosen only after data gathering, proper sequencing of the events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision-making. The interdisciplinary team reviews and updates the care plan when there has been a significant change in the resident's conditions and the desired outcome is not met.

Based on the clinical record review, resident interview, resident representative interview, facility documentation, and policy review, the facility failed to ensure the resident received adequate assistance devices to prevent falls for one of the three sampled Residents (#1). The deficient practice could lead to further accidents.Findings Include: Resident #1 was admitted on [DATE], with a diagnosis of bipolar disorder, chronic obstructive pulmonary disease, hypo-osmolality, anxiety disorder, extrapyramidal and movement disorder, hyponatremia, and age-related osteoporosis. The care plan dated October 15, 2025, had a focused care area for Resident #1, who is at risk for falls related to high-risk medication use, incontinence, poor mobility, hand contractures, and involuntary movements. Interventions included anticipating and meeting the resident's needs, ensuring the resident's call light is within reach, and encouraging the resident to use it for assistance as needed. Interventions further noted the resident needs a prompt response to all requests for assistance, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs, encourage the resident to participate in activities that promote exercise, physical activity for strengthening and improving mobility, ensure that the resident is wearing appropriate footwear when ambulating or mobilizing in a wheelchair, follow facility fall protocol, and evaluate and treat as ordered or as needed, and the resident needs a safe environment with even floors free from spills and/or clutter; adequate, glare-free light; a working and reachable call light, the bed in low position at night if applicable; handrails on walls and personal items within reach. The care plan dated October 15, 2025, had an additional focused care area for Activity Daily Living (ADL) self-care performance deficit related to the need for staff assistance with ADL's due to pain, contractures. Interventions included functional abilities may fluctuate related to behaviors/stamina and mood, see tasks for current levels, hoyer lift transfers and monitor for safety, bathing/showering: Avoid scrubbing & pat dry sensitive skin, bathing/showering: Check nail length and trim and clean on bath day and as necessary. Interventions further included to report any changes to the nurse, encourage the resident to discuss feelings about self-care deficit, encourage the resident to participate to the fullest extent possible with each interaction, encourage the resident to use bell to call for assistance., monitor/document/report as needed any changes, any potential for improvement, reasons or self-care deficit, expected course, declines in function and physical therapy (PT) and occupational therapy (OT) evaluation and treatment as per Medical Doctors (MD) orders. An alert notes dated November 22, 2025, at 11:18 AM revealed that Resident #1 reported to the Certified Nursing Assistant (CNA) that he fell at 5:30 am. It was noted that the nurse assessed the resident post-fall with another staff member. Resident #1 stated that he was being helped with a hoyer lift by a CNA, and that the CNA forgot to take the sling off. It was documented that the resident reported that he slid down to the floor. The registered nurse (RN) assessed the resident #1's range of motion which was within normal limits (WNL) and at baseline. Resident #1 had contractures to his legs where he is unable to extend them out; his hands were also contracted and unable to open. The Skin of resident was intact, no bruising, redness, abrasions, swelling, or skin tears noted. The resident reported that he has pain in his knees and left hip mild-moderate. He was medicated with as-needed Tylenol. The note stated that a call was placed to the resident's power of attorney (POA), Nurse practitioner (NP), and Assistant Director of Nursing (DON). The orders were received for an X-ray of the resident #1 left hip and left knee. Also, the Neuro-check were WNL, the resident#1 was alert and able to make needs known. The note stated the resident denied hitting his head. The care plan dated November 22, 2025, had a focused care area for an actual fall with: (no injury, minor injury, serious injury). Interventions included x-rays to left hip and knee. A fall risk evaluation was completed on November 22, 2026, where the resident scored 14.0 and is at risk for falls. The evaluation indicated that the resident had 1 to 2 falls in the last three months and is chair-bound. The resident was alert and oriented times three with adequate vision, gait/balance, and muscular coordination required to use assistive devices. It was documented that the resident had 3 predisposing diagnosis. Review of the X-ray results dated November 20, 2025, at 12:59 pm revealed no acute fracture or dislocation. The osseous structure appeared intact. A modest joint space narrowing. Review of the employee file of the CNA (Staff #1) who transferred Resident #1 by himself from his bed to the wheelchair, had a disciplinary action dated November 25, 2025, of termination because the staff member failed to report the resident incident and failure to use the equipment per policies and guidelines. It has also stated that the employee assisted a resident #1 into his wheelchair using Hoyer lift. When the employee #1 were transferring employee #1 did not have a second employee to assist him during the use of the hoyer lift, which caused the resident #1 to slip out of his wheelchair onto the floor. The employee #1 did not report the Resident #1 sliding off his chair onto the floor to the nurse, and got the resident up before he was able to be assessed for injuries. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 11, indicating that the resident was moderately cognitively impaired. An interview was conducted on January 22, 2026, at 08:49 AM, with Resident #1's Representative, who stated that her brother had a fall, which was caused by a staff #1 member who tried to get him up with a mechanical lift in the dark. She stated that her brother told him to turn on the light, but he still proceeded to transfer him with the mechanical lift and caused the fall. She stated that after this incident, he was terminated. An interview was conducted on January 22, 2026, at 12:14 PM with Resident #1, who stated that the staff #1 was not listening to him, and came to assist him with a mechanical lift (hoyer) at 5:30 am by himself and hooked the sling strap on the hoyer, he stated felt the tugging and that the strap was stuck, but he kept pulling it, in spite of being told that the strap was stuck. He stated that all of a sudden he fell on his bottom. He stated that after the incident, he couldn't use the leg; it got worse and worse every day. He stated he already had trouble with his left knee, and that due to staff member #1 it got worse. An interview was conducted on January 22, 2026, at 11:46 AM with CNA(Staff #4), who stated that the facility's process for Hoyer lift is to two have two people present when transferring the residents. She stated all four loops are hooked into the machine correctly, and double checked to ensure they are all connected to ensure resident safety. She stated that you should not proceed with the transfer until it is ensured that the hooked up to the machine, as it would be wrong. The CNA also stated that this is why the second person is there with you to ensure the 4 hooks are attached and advice if the hoyer lift transfer is safe to proceed. She stated that she has not witnessed any residents sliding off the sling. An interview was conducted on January 22, 2026, at 12:26 PM with a Licensed Practical Nurse (LPN/Staff #2), who stated that the facility's process for using the Hoyer lift is to have two employees use it. She stated that you would need to put the sling underneath the resident, and then on the top, you will hook the sling to the four points on the hoyer and then one of the staff members usually lifts the resident in the sling by using the remote control. Also, stated that one of the staff members will guide the resident's body to have support. She stated that the hoyer sling should be hooked up and secured; if it is not properly hooked up, the risk would be that the resident can slip off the sling. She stated that she was not there when Resident #1 had the fall, and she was not aware of the incident. An interview was conducted on January 22, 2026, at 12:42 AM with a CNA (Staff #3), who stated that the facility process for hoyer lift transfers is to have two have staff members assist, always ensure that you have correct collars attached to hook and hoyer at all times and ensure they are all secured. When the transfer is completed, they should be unhook. An interview was conducted on January 22, 2026, at 3:35 PM with a Registered Nurse (RN/ Staff #5), who stated that the facility's process for Hoyer lift is to have two staff members, who can be any combination of nursing staff members. She stated that first, the staff members will bring supplies such as the Hoyer lift, and ensure the Hoyer battery discharged , enter the patient room, and inform the resident that you will be getting them out of bed, raise the bed in the appropriate height, slide the sling underneath the resident, once it is placed, then use the ring connect sling to the Hoyer, they are color-coded and match those colors hoyer and sling, . She stated that once everything is secured, instruct the resident to cross their arms over their chest. This helps prevent grabbing onto the lift bar and reduces the risk of injury during movement. If the resident is able, have them keep their arms crossed throughout the transfer. Before lifting, ensure the wheelchair, shower chair, or geri chair (whichever is being used for the transfer) is locked and stable. Once the resident is safely lifted into the air, carefully rotate the Hoyer lift toward the receiving chair. When positioning the resident into the chair, open and position the lift legs as needed for stability. Guide the resident gently into place, cupping and supporting them as needed to ensure proper alignment. Lower the resident slowly and make sure they are properly seated with hips positioned toward the back of the chair. If the resident appears uncomfortable after lowering, pause and readjust as necessary to ensure safe and proper positioning. She stated that the risk of having one person do the Hoyer lift, can pose a risk for falls, serious injury, or even death. An interview was conducted on January 22, 2026, at 3:57 PM with the Director of Nursing (DON/Staff #6), who stated that the facility's process for hoyer lift is to have two staff members perform a Hoyer transfer. She stated that you would first put the sling under the resident and attach the color-coded loops to the Hoyer, and lift up to transfer surface and be as close to it as possible. The transfer can be a chair or a bed. The DON stated you would lift them up, place them on the surface, and remove the sling. She stated she expects to have two staff members to do the transfer; if not, this can pose a risk of injury to the resident. She stated that for Resident #1, the staff member #1 did not use the second person to conduct the hoyer lift transfer for Resident #1. She stated staff member #1 forgot to unhook the sling, which made Resident #1 slide off the chair and lower him to the ground. She stated that they performed an xray for Resident #1. She stated that having one staff member to do the Hoyer transfer does not meet her expectations, nor the facility's expectations, and that's why Staff #1 is no longer here in the facility and has been terminated. A Policy titled Lifting Machine, Using A Mechanical was revised in October 2017, revealing that at least two nursing assistants are needed to safely move a resident with a mechanical lift.

Based on clinical record review, staff interviews, WebMD, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#1) to be free from abuse by another resident (#2). The deficient practice could result in further abuse of residents when appropriate actions are not taken.Findings Include:-Resident #1(alleged victim) was admitted to the facility on [DATE] with diagnoses of dementia, COPD (Chronic Obstructive Pulmonary Disease), and essential hypertension.The census report revealed that Resident #1 shared the same unit with Resident #2 since May 21, 2025.A comprehensive care plan dated June 5, 2025, revealed that the resident had a potential for a psychosocial well-being problem related to disease process, and the resident was at risk for impaired cognitive function. The interventions included anticipate and meet resident's needs; provide necessary cue, reorient and supervise as needed; ensure/provide a safe environment; and monitor/document/report any changes in skin status such as appearance, color, and wound healing.A review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14.0, indicating that the resident was cognitively intact. The assessment also included that the resident had not exhibited behavioral symptoms.The nursing progress note dated December 3, 2025, revealed a late entry, per document, at 3:10 PM Resident #1 reported to a certified nursing assistant (CNA) that Resident #2 came into her room and hit her, and a bruise was noted to her right arm. The abuse coordinator, director of nursing (DON), resident family, and the police were notified.Another nursing progress note dated December 3, 2025, revealed per documentation, that Resident #1 approached the nursing station stating that Resident #2 went into her room and hit her. The administrator, DON, resident family, provider, and the police were notified. A skin assessment was completed and Resident #1 had redness to her face and a bruise to her right arm. Resident #2 was moved to the opposite hall. Resident #1 and Resident #2 were both placed on a 15-minute checks.On December 4, 2025, revealed another nursing progress note, per documentation, Resident #1 was on a 72-hour monitoring for a bruise on her right arm. Per documentation, the bruise was described as having a purple in the center and discoloration around the bruise.Another nursing progress note dated December 5, 2025, revealed per documentation that the resident's family informed staff that Resident #1 had bruises to her left and right upper arm. Further, per documentation, Resident #1's primary nurse assessed Resident #1 and the bruises where from the previous altercation.A Long-Term Care Evaluation progress note dated December 6, 2025, revealed per documentation, a look back detailing resident's skin change/wound acquired on December 3, 2025. Per the documentation, Resident #1 had a right outer forearm bruise, lateral right elbow bruise, and anterior neck under the chin bruise.-Resident #2 (alleged perpetrator) was admitted to the facility on [DATE], with diagnoses that included dementia, anxiety disorder, and unspecified mood disorder.The Quarterly MDS dated [DATE] revealed a BIMS score of 3.0, indicating that the resident cognition was severely impaired. The assessment also included that the resident had not exhibited behavioral symptoms.Review of care plan dated April 25, 2024, revealed an elopement risk/Resident wanders related to disorientation to place, impaired cognitive function/dementia or impaired thought processes related to dementia, and potential for behaviors related to mood disorder, dementia, and anxiety. The interventions included resident was on a secured unit; distract resident from wandering; cue, reorient and supervise as needed; intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; and remove from situation and take to alternate location as needed.A review of resident's behavioral treatment plan dated October 7, 2025, revealed that the resident's current behaviors included anxious/restless/pacing, anger/frustration, impulsive behavior/not acknowledging peer's space, and physical aggression.On December 3, 2025, the behavioral treatment plan included a resident-to-resident allegation of striking another resident.The nursing progress note dated December 3, 2025 revealed per documentation, Resident #1 informed the staff that Resident #2 entered her room and she was hit by Resident #2. The administrator, DON, Resident 's family member, provider, and police were notified. Resident #2 was assessed with no redness or bruising. Resident #2 was placed on the opposite side of the unit and was on 15-minute checks.The census report revealed that Resident #2 was moved to another room in the same unit on December 3, 2025.An Order-Administration progress note dated December 4, 2025, revealed that Resident #2 was administered an antianxiety medication for impulsive behavior. Per documentation, Resident #2 was agitated and became verbally aggressive when staff was redirecting him from entering other resident room.A review of facility's investigation report dated December 8, 2025 revealed that on December 3, 2025, Resident #1 stated to a CNA that she had been hit by Resident #2 the night before. The investigation revealed a skin assessment was performed and that Resident #1 was noted to have a bruise on the top of her right forearm and right lower jaw. The report investigation included the police was called, the medical and psych providers, responsible party, case managers were notified, and several staff members were interviewed. The investigation report included that on December 2, 2025, at 7:00 PM, Resident #1 went to the nurse's station to inform staff about Resident #2 was lying in her bed, and the incident was reported to the nurse on shift. The report included an interview with a CNA (Staff #7). Staff #7 stated that on December 3, 2025, at 3:00 PM, Resident #1 informed her that Resident #2 came in her room last night and hit me on my arm and kick me in my face. Per report, Staff #7 stated that she saw Resident #1's bruises on her arm and face. Further, per investigation report, from the assistant director of nursing (ADON), the report revealed that on December 3, 2025, Resident #1 informed a staff member that Resident #2 wheeled into her room and hit her. Resident #1 left her room to alert the staff to get Resident #2 out of her room. Per investigation report, another CNA (Staff #12) was interviewed. According to the investigation report, the Witness Statement Form dated December 2, 2025, at 7:00 PM revealed that Staff #12 was doing his rounds when Resident #1 came out of her room to inform him that Resident #2 was lying in Resident #1's bed covered in water. Per report, Resident #2 was aggressive, and Resident #2 said that it was his room. Resident #2 was escorted out of Resident #1's room, and was returned to back to his own room.An interview was conducted on December 23, 2025, at 11:16 AM with a CNA (Staff #7). Staff #7 stated that she worked in the secured unit. Her abuse training included the importance of how to handle abuse between staff and residents or between resident-to-resident. She stated that abuse can be physical, mental, verbal, sexual and financial, and that it was important to report abuse immediately to the abuse coordinator to ensure her residents' safety. She said that recently there was a resident-to -resident incident between Resident #1 and Resident #2. Staff #7 stated that Resident #1 informed her that Resident #2 came to her room and would not get out of her room; Resident #1 and Resident #2 started fighting; Resident #1 was beaten up last night; and Resident #1 was hit on her arm and was kicked on her chin by Resident #2. Staff #7 said that Resident #1 had purple blueish bruises to the left arm. After being informed by Resident #1 about the incident that happened the night before, Staff #7 stated that she reported the incident to the ADON (Staff #17) and the administrator (Staff #5). Further, Staff #7 stated that after the incident between Resident #1 and Resident #2, Resident #2 was moved to the other side of the unit.Attempted to interview Resident #1 on December 23, 2025, at 11:37 AM. Resident #1 was in her room lying in her bed, and she did not want to speak. She stated that she had already spoken to so many people.On December 23, 2025, at 11:39 AM, attempted to interview Resident #2 in his room, unsuccessful.Another staff interview was conducted on December 23, 2025, at 11:44 AM with a Licensed Practical Nurse (LPN/Staff #9). Staff #9 stated that she had been working in the secured unit. She stated that abuse was mistreating residents, can be verbal, physical or emotional. She said that if she was made aware of or witnessed any abuse, she will report it immediately to the abuse coordinator/administrator, and the director of nursing (DON). She said that the impact if an abuse was not reported could lead to her employment termination, and the resident would be in more jeopardy because the abuse will keep on happening. Further, Staff #9 stated that she was made aware of the incident between Resident #1 and Resident #2 after being notified by a CNA (Staff #7) on December 3, 2025, and she immediately reported the incident to her ADON, and the abuse coordinator. She said that she also notified the Resident #1's family and also called the police. She said that after notifying the ADON about the incident, she and the ADON met with Resident #1 in the ADON's office. She said that Resident #1 had a purple bruising on her right arm, which looks fresh and new, and Resident #1 informed them of what had happened on December 2, 2025 with Resident #2. She stated that Resident #2 was trying to take something from Resident #1, and Resident #2 grabbed Resident #1's arm. She also stated that Resident #1 informed them that it was Resident #2 that grabbed her arm. Staff #9 stated that Resident #2 goes up and down the hallway due to his dementia and was frequently redirected. Furthermore, Staff #9 stated that she considered the incident between Resident #1 and Resident #2 as abuse because Resident #2 invaded Resident #1's privacy, and the bruising on Resident #1's arm was from a physical abuse.On December 23, 2025, at 1:02 PM, an interview was conducted with the ADON (Staff #17). The ADON stated that abuse could be sexual, physical, verbal, and financial. She stated that physical abuse is when someone hit someone, and sexual abuse is when someone physically touch someone without their consent. The ADON stated that if she was made aware of any abuse, she will report the allegation of abuse to the abuse coordinator because it is the right thing to do and to make sure that the resident will feel safe. The ADON said that she was made aware of the resident-to-resident altercation between Resident #1 and Resident #2 that happened on December 2, 2025. The ADON stated that a nurse informed her that Resident #2 went inside Resident #1's room; Resident #1 asked Resident #2 to get out; Resident #2 refused to leave; and Resident #2 hit Resident #1. The ADON stated that she informed the DON and the administrator about the incident between Resident #1 and Resident #2. The ADON stated that the administrator and the DON watched the video camera and identified Resident #2 entering Resident #1's room.The DON (Staff #10) was interviewed on December 23, 2025, at 1:18 PM. The DON stated that the process and expectation regarding abuse was if hear and see or suspect abuse, to report immediately to their supervisor, the administrator, and to her. The DON said that the impact of reporting an abuse allegation was so she can start the investigation and prevent any further incident of abuse. The DON said that if the abuse was not reported in a timely manner, the resident could be at risk for further abuse. Moreover, the DON stated that abuse can be verbal, sexual, physical, neglect, and misappropriation. She said that sexual abuse could be unwanted touching, and an example of physical abuse included hitting, punching, kicking, and physical touching. Regarding an incident involving Resident #1, the DON said that Resident #1 notified a nurse after Resident #2 entered her room and Resident #2 hit Resident #1. During her investigation, the DON stated that one CNA (Staff #12) took Resident #2 out of Resident #1's room, and then Resident #2 was moved to the other side of the unit. The DON stated that she considered the incident between Resident #1 and Resident #2 a physical abuse because Resident #1 said that Resident #2 hit her and she had a bruise on her arm.Attempted to interview Staff #12 on December 23, 2025, at 1:34 PM, unsuccessful.On December 23, 2025, at 1:36 PM, an interview was conducted with the Administrator (Staff #5) in the conference room. The administrator stated that the video camera was unable to be viewed since it has been deleted or written over. The administrator stated that abuse reporting was important to protect residents and staff, and to have a safe environment. Regarding Resident #1 and Resident #2 incident, the administrator stated that the incident was an alleged physical abuse. The administrator said that Resident #1 was alleging that Resident #2 entered Resident #1's room, and Resident #1 was alleging that Resident #2 kicked and hit her. The administrator stated that he investigated and interviewed the staff. The administrator stated that Resident #2 was unable to talk due to his having a hard time communicating; none of staff witnessed the abuse; Resident #2 was inside Resident #1's room because Resident #2 was a wanderer; a nurse completed a skin assessment on December 3, 2025, the day of the incident report, and Resident #1 had a bruised on her right arm without complaint of pain; and the administrator stated that he does not know where Resident #1's bruise came from , and when her bruise happened.The interview with the administrator (Staff #5) and the DON (Staff #10) continued on December 23, 2025 at 1:57 PM in the conference room. The DON stated that the progress note dated December 3, 2025 revealed that Resident #1 had a bruise on her right arm. The DON stated that a skin assessment was performed on December 5, 2025, and it revealed that Resident #1 had a bruise on her arm and Resident #1's provider was notified. Further, the DON stated that Resident #1 could not tell her where the bruise came from, but Resident #1 said that she was hit by Resident #2 the night of December 2, 2025. The DON stated that a purple colored bruise could be a new bruise; a blue colored bruise could mean an older bruise; a yellow and greenish colored bruise could mean a much older bruise than a blue colored bruise; and a bruise depends on the resident and whether the resident was taking a blood thinner. The DON said that the bruise on Resident #1's arm was noted in the abuse allegation. The administrator stated that he cannot prove if the bruise was related to or not related to the abuse allegation, and therefore it was inconclusive. Further, the DON stated that Resident #2 did not have a history of physical aggression since he had been admitted to their facility, and Resident #2 liked to wander. However, a review of Resident #2's behavioral treatment plan dated October 7, 2025, revealed that resident's current behaviors included anxious/restless/pacing, anger/frustration, impulsive behavior/not acknowledging peer's space, and physical aggression.According to WebMd.com with a referenced date of February 27, 2025, a bruise shows up when an injury makes small blood vessels under your skin bleed. As you heal, an iron-rich substance in your blood called hemoglobin breaks down into other compounds. This process makes your bruise change colors:It's usually red right after the injury.Within a day or two, it turns purplish or black and blue.In 5 to 10 days, it may be green or yellow.In 10 to 14 days, it's yellowy-brown or light brown.It should fade away totally in about 2 weeks.Review of facility policy titled Abuse Policy, revised on December 2016, revealed the facility's residents have the right to be free from abuse. Another policy statement relating to abuse, revised in July 2017, revealed that all reports of resident abuse and or injuries of unknown source ( abuse) shall be promptly reported to local, state, and federal agencies and thoroughly investigated by the facility management.Another facility policy reviewed titled Resident's Rights, revised on February 2021, revealed that the federal and state laws guarantee certain basic rights to all resident of the facility. The rights include the resident's right to be free from abuse.

Based on interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of one resident (#5) to be free from abuse by another resident (#10). The deficient practice could lead to ongoing abuse, leading to harm of other residents.-Findings Include:Regarding Resident #5Resident #5 (Alleged Victim) was admitted to the facility on [DATE], with diagnoses including: Essential hypertension, hypo-osmolality and hyponatremia, constipation, schizoaffective disorder, unspecified convulsions, other psychoactive substance abuse, uncomplicated, catatonic disorder due to known physiological condition, acute respiratory failure with hypoxia, adult failure to thrive, anoxic brain damage, anxiety disorder, dysphagia, weakness, personal history of sudden cardiac arrest.Review of Resident #5's care plan, which was initiated on October 13, 2025, revealed a risk for behaviors related to Schizophrenia. Interventions included that the resident resided in a secured unit.A review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 08,indicating moderate cognitive impairment. The MDS further revealed that Resident #5 had unclear speech and exhibited other behavioral symptoms not directed towards others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS included that the behavior of those type occurred daily.Regarding Resident #10Resident #10 (Alleged Perpetrator) was re-admitted to the facility on [DATE], with diagnoses including: Epilepsy, not intractable, without status epilepticus, aphasia, hemiplegia unspecified affecting right dominant side, adult failure to thrive, personal history of traumatic brain injury, puncture wound without foreign body of unspecified part of head, sequela, mood disorder due to known physiological condition, undifferentiated schizophrenia, anxiety disorder, hypotension, disorder of urea cycle metabolism, history of falling, elevated white blood cell count, other thrombocytosis, gastrointestinal hemorrhage, epileptic seizures related to external causes, not intractable, without status epilepticus, muscle wasting and atrophy, not elsewhere classified, multiple sites, dysphagia, oropharyngeal phase, gastro-esophageal reflux disease with esophagitis, without bleeding.Review of Resident #10's care plan, which was revised on March 6, 2024, revealed that Resident #10 had behaviors and could be physically aggressive and refusing medications related to Schizophrenia. Interventions included providing physical and verbal cues to alleviate anxiety, assist verbalization of the source of agitation, and assist in setting goals for more pleasant behavior.A review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 07, indicating moderate cognitive impairment. The MDS further revealed that Resident #10 had exhibited no verbal or physical behavioral symptoms directed towards others during the assessment period.Review of the behavioral treatment plan that was initiated/revised on November 12, 2025, revealed that Resident #10 had refusal of care and meds, verbal aggression, physical aggression/posturing/threatening. The interventions included approaching the resident with patience and respect, reminding him to speak appropriately, and avoiding engaging in interactions when he was threatening/posturing. Remove other residents for safety if needed.Review of the orders dated November 17, 2025, for Resident #10 revealed that the resident had orders for Paliperidone palmitate ER intramuscular suspension 156 mg/ml for physical aggression and agitation related to undifferentiated schizophrenia.-Regarding November 8, 2025 IncidentOn November 8, 2025, at 7:40 p.m., a behavior note was entered into the progress notes for Resident #10. It stated that the writer witnessed Resident #10 grab onto Resident #5's shirt after the other resident took a seat in a chair near his room in the hallway. There were no injuries noted, This resident was unable to appropriately verbalize or give a statement regarding this situation. Both residents were redirected and separated for the remainder of the evening. Provider, ADON, and guardian were notified of the situation and approved a one-time order by Provider [NAME] for Ativan, an injection.On November 8, 2025, at 8:59 p.m., a nurse's note was entered into the progress notes for Resident #5. It stated that at approximately 7:40 p.m., it was observed that another resident grabbed onto his shirt after Resident #5 took a seat in a chair near that resident's room. Review of Resident #5's skin assessment dated [DATE], and November 11, 2025, revealed that Resident #5's skin was clean, dry, and intact. Also there were no skin issues or injuries noted.Review of the facility's undated 5-day investigation report regarding the altercation that occurred on November 8, 2025, revealed that at approximately 7:10 p.m., Resident #10 touched Resident #5 twice on the shoulder and tugged on his shirt sleeves.Further review of the 5-day investigation report revealed a written staff witness statement by a Certified Nursing Assistant (CNA/Staff #92). The statement indicated that Staff #92 witnessed Resident #10 tug on Resident #5's shirt.-Regarding November 16, 2025 IncidentOn November 16, 2025, at 6:29 p.m., a nurse's note was entered into the progress notes for Resident #5. It stated that the nurse was notified by staff of a physical altercation between two residents. Upon arrival, residents were separated immediately and redirected. Redness was noted on the face. The resident (self) was the responsible part; emergency contact was not listed. Notified medical NP, psych NP, DON, ADON, case manager, and police. Officer [NAME], badge #11853, incident #25-165-9943.Review of Resident #5's skin assessment dated [DATE], revealed that Resident #5's skin was pink and warm to touch with a small linear abrasion on the left facial area, intact, clean, and dry surrounding skin.Review of Resident #5's skin assessment dated [DATE], revealed that Resident #5's skin was pink and warm to touch, and skin intact and dry.On November 16, 2025, at 6:29 p.m., a nurse's note was entered into the progress notes for Resident #10. It stated that the nurse was notified by staff of a physical altercation between two residents. Upon arrival, residents were separated immediately and redirected. No injuries were noted at that time. Notified medical NP, psych NP, DON, ADON, case managers, guardian, and police. Officer [NAME], badge #11853, incident #25-165-9943.Review of the facility's undated 5-day investigation report regarding the altercation that occurred on November 16, 2025, revealed that at approximately 4 p.m., Resident #10 struck Resident #5 with an open hand in his face. A staff witness stated that she was completing documentation on the computer and did not see any physical interaction, but she heard a loud noise. Both residents were separated and escorted to their rooms. Nurse completed a skin assessment for Resident #5 and noted some redness to the face. Resident #10 was placed on 1:1 supervision and had been on 15-minute checks.Attempts were made to interview Certified Nursing Assistant (CNA/Staff #31) on November 19, 2025, at 11:58 a.m., 3:03 p.m., and on November 20, 2025, at 10:16 a.m. No return call was received.An interview was conducted by telephone on November 19, 2025, at 10:23 a.m. with Certified Nursing Assistant (CNA/Staff #92). Staff #92 stated that she was on the floor on November 8, 2025. She saw Resident #5 walking in the corridor. Resident #5 came and sat next to Resident #10, who appeared to be in an unpleasant mood. Shortly afterward, Staff #92 heard Resident #5 yelling. The incident happened very quickly, and when Staff #92 turned around, she saw Resident #10 pulling on Resident #5's shirt. Staff #92 and the floor nurse (LPN/Staff #110) intervened immediately, separated the residents, and escorted them to their rooms. Staff #92 later learned that Resident #10 was on 15-minute checks at the time. Staff #92 couldn't recall observing any skin issues.An interview was conducted by telephone on November 19, 2025, at 11:31 a.m. with Licensed Practical Nurse (LPN/Staff #110). Staff #110 stated that she heard yelling and she saw Resident #10 grabbing Resident #5's shirt. She separated and redirected both residents, and Resident #10 went to his room. No skin issues were observed, and Resident #5's post-incident skin check showed intact skin with no scratches, though it was generally dry. Staff #110 sustained a scratch on her right hand while intervening, which she believed came from Resident #10. This was the first incident in which Resident #10 displayed this kind of aggression.An interview was conducted by telephone on November 19, 2025, at 11:44 a.m. with Licensed Practical Nurse (LPN/Staff #130). Staff #130 stated that she knew both residents. She was not aware of the incident that occurred on November 8, 2025. However, she was aware of the incident on November 16, 2025. She mentioned that the incident took place while she was on her lunch break, and a CNA (Staff #31) informed her about what happened. Staff #130 conducted a skin check on Resident #5 and observed redness on the resident's face. She then notified the family and the case manager.An interview was conducted on November 19, 2025, at 1:15 p.m. with Resident #5. Resident #5 was preparing to leave the room, and a staff member redirected Resident #5 back inside for the interview. Resident #5 was unable to respond or answer questions. The surveyor observed a healing scar on Resident #5's left cheekbone.An interview was conducted on November 19, 2025, at 1:32 p.m. with Resident #10. During the interview, the resident asked the surveyor to leave the room.An interview was conducted on November 19, 2025, at 2:31 p.m. with the Administrator (Staff #140). Staff #140 stated that he remembered Residents #5 and #10. He reported that he did not know exactly what happened on November 8, 2025. He also stated that he did not have all the details regarding the incident on November 16, 2025, but he heard from staff that Resident #10 slapped Resident #5, leaving redness on Resident #5's cheekbone. Staff #140 mentioned that they were working on a plan of correction to address the issue and stated that the situation did not meet his expectations.An interview was conducted on November 19, 2025, at 3:06 p.m. with the Director of Nursing (DON/Staff #150). Staff #150 stated that she remembered Residents #5 and #10. Regarding the incident on November 8, 2025, she reported hearing that Resident #5 sat next to Resident #10, and the staff then heard yelling. By the time staff turned around, Resident #10 was holding Resident #5's sleeve. Skin checks were performed, and no concerns were noted. The residents were separated and redirected to their rooms, room changes were initiated, and families were notified. Resident #10 was placed on 15-minute checks.Regarding the incident on November 16, 2025, Staff #150 stated that she was informed that Resident #10 slapped Resident #5 on the face, resulting in redness on Resident #5's cheek. The residents were separated, the physician was notified of Resident #10's behaviors, new orders were received, and the family was informed of both the incident and the new orders. A CNA was assigned to Resident #10 for one-to-one supervision, a skin check was completed for Resident #5, and Resident #10's care plan was revised. A behavioral treatment plan was also implemented for Resident #10. Staff #150 stated that the situation did not meet her expectations and that the residents should have been monitored more closely.A further interview was conducted by telephone with Staff #150 on November 20, 2025, at 11:16 a.m. When asked about whether Staff #150 considered the incidents between Residents #5 and #10 to be abuse, Staff #150 responded, Yes, for the incident that happened on 11/16/25.Review of a policy revised in December 2016 titled Abuse Policy revealed a definition of abuse being the willful infliction of injury with resulting physical harm, pain, or mental anguish. The policy further revealed that as part of the residents' abuse prevention, administration would protect their residents from abuse by anyone including, but not necessarily limited to, facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individual.

Based on staff interviews, the facility failed to ensure that internal investigation documents were made available to the State Agency, as required, during the survey process. This failure impeded the State's ability to confirm the findings of the investigations and QAPI processes for an abuse allegation between residents (#1,#5,#10,#15 & #20).Findings Include:A formal written request for the incident reports involving residents #1,#5, #10, #15, and #20 were submitted to the facility on November 19, 2025.During an interview conducted on November 20, 2025, at 1:18 PM, with the Administrator (Staff # 140) and Director of Nursing (DON / Staff #150), the Administrator stated that the facility's incident reports were internal PCC documents and for internal use only. The Administrator explained that these reports were not shared with surveyors or any outsiders, noting that their sister facilities also didn't show the incident reports and that this practice was standard in the industry.Staff #140 further elaborated that incident reports were used internally to keep track of stuff, to fix stuff, to be aware of stuff, but it was not something that they shared with outsiders. The Administrator adamantly stated, We cannot share those documents even for the Department of Health. The staff # 140 reported that the facility provided progress notes, care plans, and other clinical information, but not incident reports.During the same interview, the staff #150 corroborated staff #140's statement , stating she had to side with the Administrator on that one because it was an internal document, and confirmed that the facility did not provide incident reports to surveyors.A signed memorandum by Staff #140 dated November 19, 2025 stated that the facility considered incident reports to be internal documents and, as such, do not share those documents with anyone who was not an employee of their company.The policy titled Designated Record Set Policy and Procedure, revised in 2025, indicated that the facility would provide personal health records that excluded incident reports. Review of the State Operations Manual revised July 9, 2025 indicated that incident and accident reports, wound logs, infection control logs, and other reports or records used to track adverse events were not protected from disclosure and could be requested by surveyors.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to ensure that residents are free from abuse from another resident (Residents #3 and #5). The universe was 144, and the sample size was 3. The deficient practice could lead to further instances of resident-to-resident altercations, thereby promoting an unsafe environment.Findings include:-Regarding Resident #3:Resident #3 was admitted on [DATE], with diagnosis that included bipolar disorder, current episode mixed, moderate; depression, unspecified; post-traumatic stress disorder, unspecified; unspecified convulsions; borderline personality disorder; and antiphospholipid syndrome.An MDS (Minimum Data Set) assessment dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating intact cognition at the time of the assessment.A skin assessment conducted on September 18, 2025, revealed no evidence of skin issues or injuries.A review of a progress note dated September 19, 2025, revealed that at 9:49 AM, an Assistant Director of Nursing (ADON/Staff #23) was notified of a resident-to-resident altercation. The progress note revealed that there were no alterations to Resident #3's skin, and the resident remained alert and oriented times 4, indicating they are alert and can accurately state their person (name), place (current location), time (date and time), and situation (reason for being there). The progress note also indicated that Resident #3 felt safe with no further concerns at that time. The progress note revealed that Resident #3 had followed up with the psychiatric provider, and the Nurse Practitioner (NP) was notified. A subsequent progress note dated September 19, 2025, revealed that at 10:15 AM, Resident #3 met with their psychiatric provider. Resident #3 denied any psychological or psychosocial disturbances from the alleged altercation, and the provider determined that there were no recommendations to change Resident #3's care.A review of another progress note, dated September 22, 2025, revealed that at 3:02 PM, an ADON (Staff #34) documented an incident investigation was conducted between Residents #3 and #5 on September 18, 2025. The progress note revealed that Resident #3 returned to the unit from the business office with a Certified Nursing Assistant (CNA) escort. The CNA escort returned with three pieces of candy for Resident #5 and then proceeded to chat with them. Resident #3 interrupted the conversation, and Resident #5 threw the three pieces of candy at Resident #3. Resident #3 had positioned herself in front of Resident #5, which led Resident #5 to slap Resident #3; Resident #3 then returned the slap to Resident #5. The progress note also revealed that Residents #3 and #5 were separated immediately. Resident #3 had been provided education regarding confrontations when met with aggression from other residents, and a skin assessment had been completed following the incident, with no evidence of injuries. -Regarding Resident #5:Resident #5 was admitted on [DATE], with the diagnosis that included type 2 diabetes with mellitus with unspecific complications; personality disorder, unspecific; cerebrovascular disease, unspecific; anxiety disorder due to known physiological condition; and chronic kidney disease.An MDS (Minimum Data Set) assessment on August 5, 2025, revealed a BIMS score of 6, indicating that the resident had severe cognitive impairment, further noting that Resident #5 had significant problems with thinking and memory.A review of a progress note dated September 18, 2025, revealed that Resident #5 transferred to a new unit. A review of a room change form dated September 18, 2025, revealed that Resident #5 had signed it.A progress note dated September 19, 2025, revealed that at 9:54 AM, an ADON (Staff #23) was notified of a resident-to-resident altercation. The progress note revealed that there were no alterations to Resident #5's skin, and the resident remained alert and oriented. The progress note revealed that Resident #5 had followed up with the psychiatric provider.A review of another progress note dated September 19, 2025, revealed that at 10:30 AM, Resident #5 met with their psychiatric provider. Resident #5 reported the incident involving Resident #3 to the psychiatric provider and stated that she had thrown her candy at Resident #3 because Resident #3 was not respecting her personal space. Resident #5 denied any psychological or psychosocial disturbances from the alleged altercation.An interview was conducted on October 7, 2025, at 1:01 PM, with Resident #3. The resident stated that they could recall the incident. Resident #3 stated that Resident #5 made racial slurs to the CNA escort and did not like what Resident #5 was saying. Resident #3 stated that she responded to Resident #5, and Resident #5 responded by throwing candy pieces at her. Resident #3 stated that she postured herself to Resident #5, Resident #5 slapped her first, and that she hit Resident #5 back. Resident #3 also stated that the CNA immediately separated the two of them and ensured that both she and Resident #5 were safe. Resident #3 also stated that the facility ensured both she and Resident #5 were placed in separate units, and that they felt safe at the facility following the incident. An interview was conducted on October 7, 2025, at 1:39 PM, with a CNA (Staff #21). The CNA stated that the facility provides training and education regarding what abuse is, how to identify abuse, and what to do if abuse or neglect is identified. The CNA also stated that allegations of abuse and neglect are to be reported to the Administrator and the DON immediately but no longer than 2 hours. Regarding the resident-to-resident altercation between Residents #3 and #5, the CNA stated that he was a witness to the altercation. The CNA stated that he recalled assisting Resident #3 to the business office to get candy to bring back for the other residents. He further stated that Resident #5 started stating racial slurs, and Resident #3 proceeded to posture herself in front of Resident #5; however, Staff #21 further stated that Resident #5 was the individual who made contact first with a slap to the arm of Resident #3. Resident #3 immediately slapped Resident #5 on her arm, and the CNA stated that he separated the two residents. The CNA further stated that due to the nature of the resident-to-resident altercation involving physical contact, the incident needed to be reported immediately for alleged abuse. An interview was conducted on October 7, 2025, at 1:42 PM, with Resident #5. Resident #5 exhibited a disorganized thought process and required prompts and cues to return to the topic of discussion. However, Resident #5 stated that she recalled an incident in which they threw candy at another resident because the resident was not respecting their personal space. Resident #5 also stated that she was moved to a new unit and was able to make new friends in the new unit. Resident #5 was unable to recall any other details.An interview was conducted on October 7, 2025, at 3:12 PM, with an ADON (Staff #34). Staff #34 stated that the facility provides training and education regarding what abuse is, how to identify abuse, and what to do if abuse or neglect is identified. Staff #34 also stated that allegations of abuse and neglect are to be reported to the Administrator and the DON immediately, but no longer than 2 hours for an adequate report and investigation. Regarding the incident between Residents #3 and #5, Staff #34 reviewed the investigation report. Staff #34 stated that Resident #3 returned to the unit with a CNA, who then proceeded to have a conversation with Resident #5. Resident #3 interrupted the conversation, and Resident #5 responded by throwing pieces of candy at Resident #3 and ultimately swatted at Resident #3 with an open hand. Resident #3 swatted back at Resident #5 with an open hand; however, a CNA separated Residents #3 and #5 before the altercation could escalate. Staff #34 stated that they assisted another ADON (Staff #23) with the investigation, during which both residents were assessed for injuries, and complete skin checks were conducted, revealing no evidence of injuries or skin concerns. Staff #34 stated that following the incident, Resident #5 was moved to another unit. Interviews with both Resident #3 and #5 had been conducted, as well as interviews with other residents and the staff in the unit. Staff #34 stated that their conclusion of the investigation is that a resident-to-resident altercation did occur, which began when Resident #5 threw candy at Resident #3.An interview was conducted on October 7, 2025, at 3:59 PM, with the Administrator (Staff #30), the Director of Nursing (Staff #20), and an Administrator in Training (Staff #28). The Administrator stated that the facility provides training and education regarding what abuse is, how to identify abuse, and what to do if abuse or neglect is identified. The Administrator also stated that abuse and neglect training also included an overview of the Elder Justice Act and the facility process as a witness to alleged abuse or neglect. Regarding the incident between Residents #3 and #5, Staff #34 stated that the allegation of resident-to-resident abuse was substantiated following a review of the collected evidence, which was compiled by Staff #23 (ADON) and Staff #34 (ADON).A review of a facility policy titled Abuse Policy revealed that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy also defined abuse as the willful infliction of injury, unreasonable confinement, or punishment that can have the result of physical harm, pain, or mental anguish or deprivation. The policy also revealed that incidents of abuse or allegations of abuse, including but not limited to resident-to-resident altercations, are to be reported within two hours from the time the facility is made aware of the incident.

Based on clinical record review, interviews, and policy and procedures, the facility failed to ensure that an allegation of verbal abuse, for one resident (#5), was reported to the State Survey Agency within the required timeframe.Findings include:Regarding resident #5Resident #5 was admitted to the facility on [DATE], with diagnoses of bipolar disorder, current episode mixed, moderate, depression, unspecified, post-traumatic stress disorder, unspecified, borderline personality disorder, anxiety disorder, unspecified, nicotine dependence, cigarettes, uncomplicated, panic disorder [episodic paroxysmal anxiety].Review of the care plan, date-initiated August 20, 2024, revealed a focus for PTSD and behavior problems related to bipolar disorder, depression, PTSD and borderline personality disorder. Interventions included administration of medication as ordered, care in pairs, and intervene as necessary to protect the rights and safety of others. Review of Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident's cognition is intact. Further review of the MDS revealed no indicators for mood or behaviors. Review of the behavior charting dated October 13, 2025, for detailed behaviors revealed the following documentation: Patient is getting increasingly annoyed with another patient's vulgar language. The patient states she is nearing the point of 'doing something.'Review of the progress note documentation dated October 24, 2025, states, Patient switched rooms and unit. Patient was on Sunset, but moved to [NAME]. Patient was comfortable with the switch and is looking forward to making new friends and having a fresh start on the new unit. Patient is alert and oriented x4, received her 1400 medications, and medications were sent over to the nurse on [NAME]. Narcotic sheets were given to [NAME] nurse.Regarding resident #10Resident #10 was admitted to the facility on [DATE], with a diagnosis including bipolar disorder, unspecified, anxiety disorder, unspecified, other chronic osteomyelitis, unspecified site.A review of the MDS dated [DATE], revealed a BIMS score of 13, indicating that the resident's cognition is intact. Further review of the MDS revealed no indicators for mood, verbal behavioral symptoms directed towards others, e.g., threatening others, screaming at others, cursing at others, and rejection of care. Review of the care plan, date-initiated September 27, 2025, revealed a focus on behavior problems related to bipolar disorder with aggressive behaviors. Interventions include care in pairs, intervening as necessary to protect the rights and safety of others. Review of the behavior care plan dated September 30, 2025, revealed past behaviors for physical aggression, threatening, leaving facilities against medical advice (AMA), mood swings, and false accusations. Current behaviors include anxiety, agitation, intrusiveness, cursing, and abrasive tone.An interview was conducted on October 28, 2025, at 9:34 am with resident #5. The resident was interviewed alone and in private in her room. Resident #5 stated she has resided at the facility for over a year. Resident #5 stated she had previously resided in another unit for approximately 5-6 months and that they have a smoking patio on the unit. Resident #5 stated she had been harassed by resident #10 numerous times. Resident #5 stated on October 15, 2025, he got into it with me during smoke break; he called me a w**** and that I have two p****** one in my mouth and one in my private parts and I should have pe***** put in them to shut me up. Resident #5 stated Licensed Practical Nurse (LPN/staff #16) and a certified nursing assistant (CNA/staff # 20) were both on the patio. Resident #5 stated that staff #16 called the assistant director of nursing Assistant Director of Nursing (ADON/staff #34) to the unit to get the situation under control and then spoke to resident #10 about it. Resident #10 stated that Resident #5 sexually harasses the female staff. Resident #5 stated that was the only time he called me those nasty names, but that he does call her a psych patient and makes fun of her blindness. Resident #5 stated, They did not take me seriously until I filed a report with the police for sexual harassment for them to move me. I spoke to the police, and they said it did not meet the criteria for an injunction for harassment, but I was granted an order for protection. Resident #5 stated she asked the staff to move her out of the unit multiple times, and the facility would not until she called the police. Resident #5 stated she could not recall who she asked to be moved. Resident #5 stated she was moved because the order of protection states that she and resident #10 are unable to be in the same residence, so they moved her to a different unit. Resident #5 stated that she does feel safe in the new unit, but is concerned that she may run into resident#10 within the facility.An interview was conducted on October 28, 2025, at 9:48 am with Licensed Practical Nurse (LPN/Staff #14). Staff # stated she has worked for the [NAME] behavior unit for approximately one month, but before that had worked for the Sunset behavior unit and was familiar with residents #5 and #10. Staff # 14 stated that resident #5 will have pseudo seizures when attention-seeking and can be verbally aggressive towards both staff and residents. Staff #14 stated that while she only provided care for resident #10 for two days, she stated that he can be a little mean towards other residents, but had not observed any vulgarity from resident #10, nor did she receive a report from the other unit as to what happened between resident #10 and resident #5. Staff #14 stated resident #5 had wanted to move off the unit for approximately one month before her move due to it being a step-up to being able to move to a group home.An interview was conducted on October 28, 2025, at 10:00 a.m. with (LPN/Staff#16). Staff #16 stated she has worked on the unit since July 2025- works every Wednesday 6a-6p. Staff #16 stated the behavior unit is a high-level behavior unit. Staff #16 stated the residents who reside on the unit are residents who are easily agitated, attention and exit seeking, and are both very physically and verbally aggressive towards staff and other residents. Staff #16 stated that when we see a resident who has become physically aggressive, we will back up and try to redirect, offer a distraction. We do contact the physician, managers, and additional staff, and have recently started a Crisis Response Protocol. Staff #16 stated that when there is a resident-to-resident incident, we will take away their privileges for activities and/or smoking, which will sometimes stop the behaviors. Staff #16 stated that resident #10 is always complaining, is very disrespectful, refuses care, and then will call the state and complain that he did not receive care. Staff #16 stated resident #10 is verbally aggressive and will make vulgar statements with no boundaries, but the aggressions are always directed towards staff. Staff # stated the incident involving residents #5 and #10 started when resident #10 became upset when the unit manager went to resident #10's room and informed him that he could not order food outside of the facility, except on designated days. Staff #16 stated resident #5 was wheeling herself towards the smoking patio when resident #10 commented, She can order at any time. Staff #16 stated that resident #5 did not reply. Staff #16 stated resident #10, then went out to the patio and was talking about it nonstop and how certain people can order from Amazon. Staff #16 stated that CNA/Staff #20 was also on the patio supervising the smoker and had reported that resident #10 did not make any inappropriate statements directed at resident #5; she stated, His mind was set on his inability to order food. Staff # 16 stated there was never any inappropriate language from resident #10 because I would need to report it to my manager. Staff #16 further stated that any inappropriate language between males and females would be considered harassment. Staff stated she was unaware if police had spoken to resident #5, and that she had not received any report that they had. An interview was conducted on October 28, 2025, at 10:27 a.m. with (CNA/Staff # 18). Staff #18 stated that they have worked on the behavior unit for eight months and is familiar with residents #5 and #10. Staff #18 stated resident 10 can be rude to some people, mostly staff, as far as not getting his way, you become the villain in his world. Staff #18 stated resident #10 is cares-in-pairs due to refusing care and will complain that it was not provided. Staff #18 stated that resident #10's interaction with other residents is never good. Staff #18 stated, he is very short with them and not very nice. Staff #18 stated that resident #10 will call other residents' names, is rude in his response towards other residents. Staff #18 reported that resident #5 is easy going. In regards to the alleged incident involving residents #5 and #10, Staff #18 stated they had heard about some type of confrontation between them, but that it was not on their shift. Staff #18 stated that when there is any type of incident with the resident's it is their responsibility to de-escalate the situation.An observation was made on October 28, 2025, at 10:40 a.m. of resident #10 on the behavior unit- observed resident agitated due to wanting his cigarette break. The resident was cursing while other residents seated near the nursing station could hear him. The staff tried informing him that he would be allowed to go out once social services provided his cigarettes. This information appeared to agitate him even further, and he proceeded to curse at the staff. The resident was eventually escorted to the smoking patio with staff. Resident #10 returned much calmer, waiting for the next cigarette break. A telephonic interview was conducted on October 28, 2025, at 11:01 a.m. with (CNA/Staff#20). Staff #20 stated that they have worked for the facility for over a year and have been working in the behavior unit since March 2025. They provided details regarding their job responsibilities, which include: responding to call lights, watching for all types of behaviors, making sure there are no resident-on-resident altercations, and looking out for resident safety. Staff #20 stated they were working on the evening shift on the date of the alleged altercation between residents #5 and #10. Staff #20 stated resident #20 has good moods and moods that can be off- and easily agitated with noises and screaming, she can get bothered, but has never had any issues with her. Staff #20 stated that resident #10 has been on the behavior unit for approximately one month. Staff #20 stated resident #10 can be boisterous, very demanding, strong with his words, and a little scary with his words that have me a little afraid. he [resident #10] likes to put fear into the CNAs with threats of calling the state on them; he speaks very aggressively. Regarding the alleged incident, Staff #20 stated residents #5 and #10 were passing words back and forth. Staff #20 stated resident #10 was using curse words directed at resident #5about the other receiving deliveries of food and from Amazon. Staff #20 stated they kept arguing about packages. Staff #20 stated she asked them to stop, but they kept accusing each other about resident #10 having food delivered and resident #10 accusing resident #5 of having Amazon deliveries. Staff #20 stated that resident #10 was using the curse words m^^^^^f*****, a**h***, and words used regarding resident #5 vagina, but did not hear any threats of sexual abuse or insertion of male genitalia. Staff #20 stated once they came back in from the patio, both residents #5 and #10 were sent to their rooms, but they continued to argue with each other, refusing to go into their rooms and separate from out in the hallway. Staff #2 stated that resident #5 finally agreed to go into her room. Staff #20 stated later that evening, there were no further disagreements. Resident #5 stayed in her room until the smoke break at 7:00p. Nothing was reported during that smoke break between them.An interview was conducted on October 28, 2025, at 11:30 a.m. with a social services assistant (Staff #22). Staff #22 stated they have worked for the facility since December 2023 and are responsible for two behavior units. Staff #22 stated their job responsibilities include: shopping for the residents, applying for ALTCS, attending care conferences, and assisting with any resources that the residents may need. Staff #22 stated that resident #10 is young, likes to order a lot of things, has made accusations about other residents, has pseudo seizures, and exhibits attention-seeking behaviors. Staff #22 stated that resident #10 has been with the facility for approximately 2 months. Staff #22 stated his behaviors include accusing staff of not caring for him, and will pick and choose who he wants to pick on, will call the state agency and make accusations, and requires a lot of redirection. Staff #22 stated his behavior towards other residents can be aggressive, by yelling at them in a high tone, speaking to them very aggressively. Staff #22 stated his use of inappropriate language is directed towards staff, but has not been observed, nor has it been reported that he has used any inappropriate language towards other residents. Staff #22 stated she was informed that there was an incident between residents #5 and #10 during the smoke break, and the inability to place orders. Staff #22 further stated that resident #5 made an accusation regarding resident #10 and was moved to another unit after she had filed a protective order for resident #10. Staff #22 stated there were no prior concerns and that they appeared to be friendly with one another. An interview was conducted on October 28, 2025, at 11:53 a.m. with the Social Services Director (Staff #24). Staff #24 stated he has been with the facility for one year and that his job responsibilities include advocating for the resident, handling grievances, speaking to the residents daily, and investigating reports if needed. Staff #24 stated resident #5 was moved to another unit due to another resident saying something to her, because it happened on another shift, and to protect the resident. Staff #24 stated, We became aware of the incident on Friday the October 24, 2025. I was informed by the Assistant Director of Nursing (AND/Staff #34) that resident #5 had made accusations that resident #10 had made verbal threats towards her and had used inappropriate language. Staff #24 stated they were unaware of what the language consisted of. Staff #24 stated that resident #10 can be verbally aggressive towards staff regularly. Staff #24 stated they have not received any reports of verbal aggression towards residents, only directed towards staff. Staff #24 stated that resident #10's behaviors are addressed by talking to him off the unit and getting to the root of the problem. Staff #24 stated that resident #10 can be verbally abusive towards staff with the use of F words. Staff #24 stated that any allegations of abuse are immediately reported to the abuse coordinator. Review of the facility's internal investigation dated October 27, 2025, revealed that on October 23, 2025, resident #5 reported to staff that she had placed a call to APS regarding resident #10 and not feeling safe with him on the same unit. Resident #5 reported to staff that resident #10 had told her that she had two p******, one in her mouth and one down below and that she should get raped. The report further documents that resident #5 contacted the police on October 24, 2025, and filed a report against resident #10. While the facility conducted an internal investigation, the facility failed to report allegations of abuse to the state agency.An interview was conducted on October 28, 2025, at 12:18 p.m. with Administrator/ Staff #30. The administrator stated he is also the abuse coordinator for the facility. Staff #30 stated staff are trained to report allegations of abuse, and part of that process is notifying the DON, separating the resident to ensure their safety, and implementing an internal investigation. Staff #30 stated he became aware of the alleged incident involving residents #5 and #10 on October 24, 2025. Staff #30 stated he was informed by (DON/Staff #32), who was informed by the Assistant Director of Nursing (ADON/Staff #34). Staff #30 stated the state agency encourages facilities to report all allegations of abuse, even when the facility determines from its internal investigation that it is unfounded. Staff #30 stated he would consider allegations of rape to be reported to the state agency. Staff #30 stated, I messed up; it should have been reported. An interview was conducted on October 28, 2025, at 12:18 p.m. with the Director of Nursing/Staff #32. Staff #32 stated that, due to the Order of Protection, residents #5 and #10 will not be able to interact with one another. The concern for joint activities will be addressed by offering activities in the units, and will work closely with the activity department to ensure the residents' safety. Staff #32 stated that all allegations of abuse should be reported to the state agency within two hours. Staff #32 stated that allegations of rape would be considered a verbal threat and should be reported, and the risk of not reporting can cause more harm to the resident.Review of the facility policy titled Abuse Policy states, Our 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, neglect, deprivation of goods or services, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.6. Identify and assess all possible incidents of abuse or allegations of abuse, including but not limited to are to be reported within 2 hours from the time the facility is made aware.

Based on staff interviews, facility documentation, and a policy review, the facility failed to implement its abuse policy by not reporting an allegation of abuse involving two residents (#5 and #10) to the State Agency. The deficient practice could result in further incidents of abuse.Findings include:Regarding resident #5Resident #5 was admitted to the facility on [DATE], with diagnoses of bipolar disorder, current episode mixed, moderate, depression, unspecified, post-traumatic stress disorder, unspecified, borderline personality disorder, anxiety disorder, unspecified, nicotine dependence, cigarettes, uncomplicated, panic disorder [episodic paroxysmal anxiety].Review of the care plan, date-initiated August 20, 2024, revealed a focus for PTSD and behavior problems related to bipolar disorder, depression, PTSD and borderline personality disorder. Interventions included administration of medication as ordered, care in pairs, and intervene as necessary to protect the rights and safety of others. Review of Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating the resident's cognition is intact. Further review of the MDS revealed no indicators for mood or behaviors. Review of the behavior charting dated October 13, 2025, for detailed behaviors revealed the following documentation: Patient is getting increasingly annoyed with another patient's vulgar language. The patient states she is nearing the point of 'doing something.'Review of the progress note documentation dated October 24, 2025, states, Patient switched rooms and unit. Patient was on Sunset, but moved to [NAME]. Patient was comfortable with the switch and is looking forward to making new friends and having a fresh start on the new unit. Patient is alert and oriented x4, received her 1400 medications, and medications were sent over to the nurse on [NAME]. Narcotic sheets were given to [NAME] nurse.Regarding resident #10Resident #10 was admitted to the facility on [DATE], with a diagnosis including bipolar disorder, unspecified, anxiety disorder, unspecified, other chronic osteomyelitis, unspecified site.A review of the MDS dated [DATE], revealed a BIMS score of 13, indicating that the resident's cognition is intact. Further review of the MDS revealed no indicators for mood, verbal behavioral symptoms directed towards others, e.g., threatening others, screaming at others, cursing at others, and rejection of care. Review of the care plan, date-initiated September 27, 2025, revealed a focus on behavior problems related to bipolar disorder with aggressive behaviors. Interventions include care in pairs, intervening as necessary to protect the rights and safety of others. Review of the behavior care plan dated September 30, 2025, revealed past behaviors for physical aggression, threatening, leaving facilities against medical advice (AMA), mood swings, and false accusations. Current behaviors include anxiety, agitation, intrusiveness, cursing, and abrasive tone.An interview was conducted on October 28, 2025, at 9:34 am with resident #5. The resident was interviewed alone and in private in her room. Resident #5 stated she has resided at the facility for over a year. Resident #5 stated she had previously resided in another unit for approximately 5-6 months and that they have a smoking patio on the unit. Resident #5 stated she had been harassed by resident #10 numerous times. Resident #5 stated on October 15, 2025, he got into it with me during smoke break; he called me a w**** and that I have two p****** one in my mouth and one in my private parts and I should have pe***** put in them to shut me up. Resident #5 stated Licensed Practical Nurse (LPN/staff #16) and a certified nursing assistant (CNA/staff # 20) were both on the patio. Resident #5 stated that staff #16 called the assistant director of nursing Assistant Director of Nursing (ADON/staff #34) to the unit to get the situation under control and then spoke to resident #10 about it. Resident #10 stated that Resident #5 sexually harasses the female staff. Resident #5 stated that was the only time he called me those nasty names, but that he does call her a psych patient and makes fun of her blindness. Resident #5 stated, They did not take me seriously until I filed a report with the police for sexual harassment for them to move me. I spoke to the police, and they said it did not meet the criteria for an injunction for harassment, but I was granted an order for protection. Resident #5 stated she asked the staff to move her out of the unit multiple times, and the facility would not until she called the police. Resident #5 stated she could not recall who she asked to be moved. Resident #5 stated she was moved because the order of protection states that she and resident #10 are unable to be in the same residence, so they moved her to a different unit. Resident #5 stated that she does feel safe in the new unit, but is concerned that she may run into resident#10 within the facility.An interview was conducted on October 28, 2025, at 9:48 am with Licensed Practical Nurse (LPN/Staff #14). Staff # stated she has worked for the [NAME] behavior unit for approximately one month, but before that had worked for the Sunset behavior unit and was familiar with residents #5 and #10. Staff # 14 stated that resident #5 will have pseudo seizures when attention-seeking and can be verbally aggressive towards both staff and residents. Staff #14 stated that while she only provided care for resident #10 for two days, she stated that he can be a little mean towards other residents, but had not observed any vulgarity from resident #10, nor did she receive a report from the other unit as to what happened between resident #10 and resident #5. Staff #14 stated resident #5 had wanted to move off the unit for approximately one month before her move due to it being a step-up to being able to move to a group home.An interview was conducted on October 28, 2025, at 10:00 a.m. with (LPN/Staff#16). Staff #16 stated she has worked on the unit since July 2025- works every Wednesday 6a-6p. Staff #16 stated the behavior unit is a high-level behavior unit. Staff #16 stated the residents who reside on the unit are residents who are easily agitated, attention and exit seeking, and are both very physically and verbally aggressive towards staff and other residents. Staff #16 stated that when we see a resident who has become physically aggressive, we will back up and try to redirect, offer a distraction. We do contact the physician, managers, and additional staff, and have recently started a Crisis Response Protocol. Staff #16 stated that when there is a resident-to-resident incident, we will take away their privileges for activities and/or smoking, which will sometimes stop the behaviors. Staff #16 stated that resident #10 is always complaining, is very disrespectful, refuses care, and then will call the state and complain that he did not receive care. Staff # stated resident #10 is verbally aggressive and will make vulgar statements with no boundaries, but the aggressions are always directed towards staff. Staff #16 stated the incident involving residents #5 and #10 started when resident #10 became upset when the unit manager went to resident #10's room and informed him that he could not order food outside of the facility, except on designated days. Staff #16 stated resident #5 was wheeling herself towards the smoking patio when resident #10 commented, She can order at any time. Staff #16 stated that resident #5 did not reply. Staff #16 stated resident #10, then went out to the patio and was talking about it nonstop and how certain people can order from Amazon. Staff #16 stated that CNA/Staff #20 was also on the patio supervising the smoking patients and had reported that resident #10 did not make any inappropriate statements directed at resident #5; she stated, His mind was set on his inability to order food. Staff # 16 stated there was never any inappropriate language from resident #10 because I would need to report it to my manager. Staff #16 further stated that any inappropriate language between males and females would be considered harassment. Staff stated she was unaware if police had spoken to resident #5, and that she had not received any report that they had. An interview was conducted on October 28, 2025, at 10:27 a.m. with (CNA/Staff # 18). Staff #18 stated that they have worked on the behavior unit for eight months and is familiar with residents #5 and #10. Staff #18 stated resident 10 can be rude to some people, mostly staff, as far as not getting his way, you become the villain in his world. Staff #18 stated resident #10 is cares-in-pairs due to refusing care and will complain that it was not provided. Staff #18 stated that resident #10's interaction with other residents is never good. Staff #18 stated, he is very short with them and not very nice. Staff #18 stated that resident #10 will call other residents' names, is rude in his response towards other residents. Staff #18 reported that resident #5 is easy going. In regards to the alleged incident involving residents #5 and #10, Staff #18 stated they had heard about some type of confrontation between them, but that it was not on their shift. Staff #18 stated that when there is any type of incident with the resident's it is their responsibility to de-escalate the situation.An observation was made on October 28, 2025, at 10:40 a.m. of resident #10 on the behavior unit- observed resident agitated due to wanting his cigarette break. The resident was cursing while other residents seated near the nursing station could hear him. The staff tried informing him that he would be allowed to go out once social services provided his cigarettes. This information appeared to agitate him even further, and he proceeded to curse at the staff. The resident was eventually escorted to the smoking patio with staff. Resident #10 returned much calmer, waiting for the next cigarette break. A telephonic interview was conducted on October 28, 2025, at 11:01 a.m. with (CNA/Staff#20). Staff #20 stated that they have worked for the facility for over a year and have been working in the behavior unit since March 2025. They provided details regarding their job responsibilities, which include: responding to call lights, watching for all types of behaviors, making sure there are no resident-on-resident altercations, and looking out for resident safety. Staff #20 stated they were working on the evening shift on the date of the alleged altercation between residents #5 and #10. Staff #20 stated resident #20 has good moods and moods that can be off- and easily agitated with noises and screaming, she can get bothered, but has never had any issues with her. Staff #20 stated that resident #10 has been on the behavior unit for approximately one month. Staff #20 stated resident #10 can be boisterous, very demanding, strong with his words, and a little scary with his words that have me a little afraid. he [resident #10] likes to put fear into the CNAs with threats of calling the state on them; he speaks very aggressively. Regarding the alleged incident, Staff #20 stated residents #5 and #10 were passing words back and forth. Staff #20 stated resident #10 was using curse words directed at resident #5about the other receiving deliveries of food and from Amazon. Staff #20 stated they kept arguing about packages. Staff #20 stated she asked them to stop, but they kept accusing each other about resident #10 having food delivered and resident #10 accusing resident #5 of having Amazon deliveries. Staff #20 stated that resident #10 was using the curse words m^^^^^f*****, a**h***, and words used regarding resident #5 vagina, but did not hear any threats of sexual abuse or insertion of male genitalia. Staff #20 stated once they came back in from the patio, both residents #5 and #10 were sent to their rooms, but they continued to argue with each other, refusing to go into their rooms and separate from out in the hallway. Staff #2 stated that resident #5 finally agreed to go into her room. Staff #20 stated later that evening, there were no further disagreements. Resident #5 stayed in her room until the smoke break at 7:00p. Nothing was reported during that smoke break between them.An interview was conducted on October 28, 2025, at 11:30 a.m. with a social services assistant (Staff #22). Staff #22 stated they have worked for the facility since December 2023 and are responsible for two behavior units. Staff #22 stated their job responsibilities include: shopping for the residents, applying for ALTCS, attending care conferences, and assisting with any resources that the residents may need. Staff #22 stated that resident #10 is young, likes to order a lot of things, has made accusations about other residents, has pseudo seizures, and exhibits attention-seeking behaviors. Staff #22 stated that resident #10 has been with the facility for approximately 2 months. Staff #22 stated his behaviors include accusing staff of not caring for him, and will pick and choose who he wants to pick on, will call the state agency and make accusations, and requires a lot of redirection. Staff #22 stated his behavior towards other residents can be aggressive, by yelling at them in a high tone, speaking to them very aggressively. Staff #22 stated his use of inappropriate language is directed towards staff, but has not been observed, nor has it been reported that he has used any inappropriate language towards other residents. Staff #22 stated she was informed that there was an incident between residents #5 and #10 during the smoke break, and the inability to place orders. Staff #22 further stated that resident #5 made an accusation regarding resident #10 and was moved to another unit after she had filed a protective order for resident #10. Staff #22 stated there were no prior concerns and that they appeared to be friendly with one another. An interview was conducted on October 28, 2025, at 11:53 a.m. with the Social Services Director (Staff #24). Staff #24 stated he has been with the facility for one year and that his job responsibilities include advocating for the resident, handling grievances, speaking to the residents daily, and investigating reports if needed. Staff #24 stated resident #5 was moved to another unit due to another resident saying something to her, because it happened on another shift, and to protect the resident. Staff #24 stated, We became aware of the incident on Friday the October 24, 2025. I was informed by the Assistant Director of Nursing (AND/Staff #34) that resident #5 had made accusations that resident #10 had made verbal threats towards her and had used inappropriate language. Staff #24 stated they were unaware of what the language consisted of. Staff #24 stated that resident #10 can be verbally aggressive towards staff regularly. Staff #24 stated they have not received any reports of verbal aggression towards residents, only directed towards staff. Staff #24 stated that resident #10's behaviors are addressed by talking to him off the unit and getting to the root of the problem. Staff #24 stated that resident #10 can be verbally abusive towards staff with the use of F words. Staff #24 stated that any allegations of abuse are immediately reported to the abuse coordinator. Review of the facility's internal investigation dated October 27, 2025, revealed that on October 23, 2025, resident #5 reported to staff that she had placed a call to APS regarding resident #10 and not feeling safe with him on the same unit. Resident #5 reported to staff that resident #10 had told her that she had two p******, one in her mouth and one down below and that she should get raped. The report further documents that resident #5 contacted the police on October 24, 2025, and filed a report against resident #10. While the facility conducted an internal investigation, the facility failed to report allegations of abuse to the state agency.An interview was conducted on October 28, 2025, at 12:18 p.m. with Administrator/ Staff #30. The administrator stated he is also the abuse coordinator for the facility. Staff #30 stated staff are trained to report allegations of abuse, and part of that process is notifying the DON, separating the resident to ensure their safety, and implementing an internal investigation. Staff #30 stated he became aware of the alleged incident involving residents #5 and #10 on October 24, 2025. Staff #30 stated he was informed by (DON/Staff #32), who was informed by the Assistant Director of Nursing (ADON/Staff #34). Staff #30 stated the state agency encourages facilities to report all allegations of abuse, even when the facility determines from its internal investigation that it is unfounded. Staff #30 stated he would consider allegations of rape to be reported to the state agency. Staff #30 stated, I messed up; it should have been reported. An interview was conducted on October 28, 2025, at 12:18 p.m. with the Director of Nursing/Staff #32. Staff #32 stated that, due to the Order of Protection, residents #5 and #10 will not be able to interact with one another. The concern for joint activities will be addressed by offering activities in the units, and will work closely with the activity department to ensure the residents' safety. Staff #32 stated that all allegations of abuse should be reported to the state agency within two hours. Staff #32 stated that allegations of rape would be considered a verbal threat and should be reported, and the risk of not reporting can cause more harm to the resident.Review of the facility policy titled Abuse Policy states, Our 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, neglect, deprivation of goods or services, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.3. Develop and implement policies and procedures to aid our facility in preventing abuse, neglect, or mistreatment of our residents.

Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#5) was not abused by another resident (#10). The deficient practice could lead to psychosocial or physical harm of a resident. -Regarding Resident #5 (alleged victim):Resident #5 was admitted to the facility November 30, 2023, with diagnoses that included schizoaffective disorder, bipolar type, post-traumatic stress disorder, unspecified, schizoaffective disorder, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, borderline personality disorder.Review of the quarterly minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating cognition is intact. Further review revealed no indicators for mood or behaviors.Review of the Care Plan revealed a focus for behavior problem which includes cares in pairs. Interventions included praise any indication of the resident's progress/improvement in behavior.Review of the Behavioral Care Plan effective June 5, 2025 revealed current behavior for verbal aggression towards staff and peers. Interventions included redirection to a quiet area or preferred activity to de-escalate, space if needed, while ensuring the safety of others. A Nurses Note dated June 19, 2025, revealed writer notified by staff of alleged altercation with res. roommate. Res. stated roommate walked behind him and hit him with an open hand in the back of the head. Writer observed res. no open areas, redness, swelling noted to area of alleged hit. Writer notified administrator, DON, APS, DHS and phoenix police department (Police report number: 2025-901621). -Regarding Resident #10 (alleged perpetrator):Resident #10 was admitted to the facility June 19, 2025 and discharged [DATE], with diagnoses that included unspecified dementia, moderate, with other behavioral disturbance, anxiety disorder, unspecified.An admission MDS assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment.A baseline care plan dated June 19, 2025, revealed Resident #10 revealed no behavioral concerns.Review of behavior charting nurse assessment dated [DATE] revealed agitation/aggression (verbal/physical towards others - Hitting, Kicking, grabbing, throwing objects, etc.) displayed. Detailed observed behaviors documented as resident expressed his frustrations by hitting another resident. Outcome documented as resident Sent out to hospital for a psych evaluation.A Daily Skilled assessment dated [DATE], revealed Resident #15 was alert with confusion to place, time, and situation. The assessment indicated No behavior issues noted. No change of condition was noted today, and there was no evidence of additional notes or follow-up regarding the interaction with Resident #10.An interview was conducted on June 25, 2025, at 2:07 PM, with Resident #5, who stated I was sitting in my wheelchair in my room and he (my new roommate) came up behind me and hit me in the back of my head, he was calling me names. The nurse tried to stop him, but he hit her or pushed her too. I had a headache for about five days. He hit me with his fist, I asked for Tylenol afterwards and they moved him out of my room. Resident stated he no longer had any contact with the resident asked to file charges and spoke to the police following the incident. Resident reported feeling safe in the facility and would report any further incidents to his family and to his nurseAn interview was conducted with Registered Nurse (RN / Staff #15) on June 25, 2025, at 2:27 PM. Staff #15 stated that he observed certified nursing assistant (CNA/Staff #20) standing next to resident #10 who was standing behind resident #5 who was sitting in his wheelchair and asked resident #10 to go back to his side of the room and finish his meal. Staff #15 stated Staff #20 reported to him that resident #10 got up and hit resident #5 in the back of the head. RN / Staff #15 stated neuro checks, skin assessment and vital signs were completed with no noted redness to the back of the head and no injuries noted for resident #10. RN / Staff #15 stated he administered Tylenol for resident #5 following the incident, who had no complaints of pain, but did state when resident #10 hit him, it hurt. RN / Staff #15. RN / Staff #15 stated residents #5 and #10 were new roommates, therefore no prior incidents. Stating resident #10 came to the unit five hours prior, as a new admit. RN / Staff #15 stated some of the behaviors received in report were sexual, physical and verbal and staff monitored the behaviors by keeping an eye on the resident who was wandering the unit, so it made it difficult. RN / Staff #15 stated resident #10 became aggressive after an hour and was placed on 1:1 for trying to exit.An interview was conducted with (CNA/Staff #20) on June 25, 2025, at 2:27 PM who observed the alleged altercation. Staff #20 stated the incident happened at dinner time, in their room and they were roommates. Staff #20 stated she was doing one on one with resident #10 due to elopement concerns. Staff #20 state she had served resident #10 his meal when resident #5 started yelling for a CNA complaining that he did not get his fish for dinner. Staff #20 stated resident #5 was not listening and kept yelling for his fish after being told they would go get it for him. - Staff #20 stated resident #10 started cussing and told resident #5 if did not stop yelling he was going to beat his a** and if you don't like the food I cooked don't eat it. Staff #20 stated both residents #5 and #10 started yelling at each other when resident #10 became upset, pushed aside the bedside table and went to bed B where resident #5 was sitting in a wheelchair by his bed and told him if he did not stop and shut the F***up he would F*** him up. Staff #20 she could not get between them, stating resident #10 was too strong, I was afraid for my own safety because he was very strong when resident #10 hit resident #5 with an open hand hit him on the back of the head with a hard a hit that made a sound. Staff #20 stated resident #5 yelled ouch. Staff #20 stated she called for help as soon as resident #5 got up and pushed her and kept calling for help when RN / Staff #15 and Licensed Practical Nurse (LPN/Staff #40) came in to help. Staff #20 stated when the nurses came in resident #5 was very upset and said that he was in pain and was observed holding his head where he got hit. Staff #20 both residents were separated and Valleywise was called and resident #10 was taken from the facility. Staff #20 stated that resident #10 K kept saying he got what he deserved. Staff #20 stated she stayed with resident #10 until he was picked up with no further interaction with resident #5.An interview was conducted with (RN/Staff #25) on June 25, 2025, at 3:30 PM. Staff #25 stated took the admitting report and was provided with information regarding resident #10 behaviors that included aggression with triggers. Staff #25 stated at admission resident #10 was nice, but resident #5 started with him and that he did not want a roommate Staff #25 stated resident #5 was not nice to resident #10. Staff #25 stated resident #5 was an exit seeker and was placed on 1:1 because of it. An interview was conducted with the Director of Nursing (DON / Staff #50) on June 25, 2025, at 3:46 PM AM. The DON stated that resident #10 was admitted and discharged on June 19, 2025. The DON stated resident #10 was receiving 1:1 supervision due to wanting to exit the unit. The DON stated she was informed by staff that resident #10 thought his child needed taken care of when he pushed the CAN out of the way and slapped resident #5 in the back of the head. The DON stated the facility was unaware of the resident's prior behaviors. The DON stated it is her expectation and the facility process to separate residents for any alleged altercations, provided 1:1 if needed and to notify all parties. Review of the facility policy titled Abuse Policy, revised December 2016 revealed 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, neglect, deprivation of goods or services, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.

Based on observation, interviews, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one resident (#6) was prevented from an accident during a hoyer transfer with major injury, and from sustaining an avoidable fall from a wheelchair with major injury. The deficient practice could lead to residents being physically harmed, with major injuries or death. Findings Include: -Regarding Resident #6's accident during a hoyer transfer: Resident #6 was initially admitted to the facility June 21, 2024, with diagnoses that included unspecified dementia with other behavioral disturbance, depression, type 2 diabetes mellitus, hypotension, chronic obstructive pulmonary disease, and chronic kidney disease. Review of a care plan dated July 6, 2024, revealed the resident has an activity of daily living (ADL) deficit and requires a hoyer lift for transfers. An additional care plan dated July 5, 2024, revealed Resident #6 is at risk for behaviors due to dementia, with interventions to anticipate and meet the resident's needs, caregivers to provide opportunity for positive interaction and attention, stop and talk to the resident as passing by, explain all procedures to the resident before starting and allow the resident time to adjust, and intervene as necessary to protect the rights and safety of others. There was no evidence of a care plan to specifically address behaviors demonstrated during hoyer transfers. A physician Encounter Note dated January 3, 2025, revealed the physician was called to see the resident for a fall from hoyer. The resident was reportedly moving around in the hoyer, when a loop came unhooked from the hoyer, causing the resident to slip out and land face down. The resident sustained a head strike with two lacerations on the forehead, and a contusion/abrasion to the right elbow and right knee. The resident has right knee pain and possible right distal femur deformity, with concerns for femur/knee fracture. EMS arrived. A Nurses Note dated January 3, 2025, revealed the resident had fallen while being transferred using a hoyer lift. The resident was laying on the floor on her back, and was bleeding from two lacerations to her head, and on her right knee. The provider was called and entered the facility shortly, and 911 was called and came for the resident at 11:02 AM. Before the fall, the resident was wiggling and yelling out to everyone that passed by her room to get her up and the resident was told she would be up by lunch time, but continued yelling. The resident was readmitted to the facility from the hospital on January 7, 2025, with additional diagnoses of nondisplaced transverse fracture of right patella, and displaced articular fracture of head of right femur. A Nurses Note dated January 7, 2025, revealed the resident has an immobilizer brace to the right lower extremity, and to continue non-weightbearing. A physician Encounter Note dated January 8, 2025, revealed Resident #6 had a fall out of a hoyer lift on January 2, 2025, and sent out to the hospital for evaluation. Imaging found a right distal femur fracture and a right patellar fracture, to be treated conservatively with a leg immobilizer brace. On April 14, 2025, at 11:53 AM, a formal request was made to the facility for the incident report and risk management report for Resident #6 for the fall from hoyer incident in January 2025. The administrator signed a statement that incident reports are internal use only and would not be available to be reviewed. An observation was conducted of the hoyer lift on the resident's unit on April 14, 2025, at approximately 1:15 PM. The hoyer lift had hooks that pointed upward by approximately 3-4 inches so that the loop of a hoyer sling could not come off the hook unless it was unweighted and lifted off, or if the loop was not fully hooked or seated correctly on the hook. An interview was conducted with a Certified Nursing Assistant (CNA / Staff #36) on April 14, 2025, at 12:26 PM. Staff #36 stated that the facility requires two staff to operate a hoyer lift for safety during transfers. Staff #36 stated that she was not present at the time of Resident #6's fall from the hoyer, however Staff #36 stated she heard that there were two staff present and questioned, how did that happen?, however was never informed how the incident happened. Staff #36 stated that the resident returned from the hospital with a bruise on her head and a fracture from the fall. An interview was conducted with a Registered Nurse (RN / Staff #80) on April 14, 2025, at 12:49 PM. Staff #80 stated that in January 2025, Resident #6 had a fall from a hoyer lift transfer, and that she was not sure how it happened, whether the sling strap tore or that the hoyer strap loop came off the hook. Staff #80 stated that the resident moves in the hoyer sometimes. Staff #80 stated that the two CNAs who were assisting the resident during the hoyer lift incident were Staff #45 and Staff #62. An interview was conducted with the Director of Rehab and Occupational Therapy Assistant (DOR / Staff #16) on April 14, 2025, at 1:07 PM. The DOR stated that she was familiar with Resident #6 and that she was aware the resident had a fall from the hoyer lift in January 2025. The DOR stated it was discussed in an IDT meeting the following day that Resident #6 was being transferred in a hoyer lift and was displaying behaviors and somehow wiggled herself out of the hoyer sling. The DOR stated that she could see how if someone was flailing in a hoyer sling, then they could possibly work themselves out of the hoyer sling. The DOR also stated that Resident #6 has moderately to severely contracted knees, which significantly limits her movement, and the resident cannot stand or walk. A telephonic interview was conducted with a CNA (Staff #62) on April 14, 2025, at 1:38 PM. Staff #62 stated that she was assisting with the hoyer transfer at the time of the incident. Staff #62 stated that Staff #45 had the resident on the hoyer lift and that Resident #6 was shaking and jiggling the straps of the hoyer sling with her hands. Staff #62 stated that the resident was up in the lift, and Staff #62 then turned around to get the wheelchair and position it. Staff #62 stated by the time she turned around again, one of the sling loops came off the hoyer lift hooks and the resident fell to the ground and hit her leg on the ground, and her head was injured. She stated that the position of the other CNA, Staff #45, at the time of the fall, was standing behind the main upright beam of the hoyer lift, so that the beam was between Staff #45 and the resident in the sling. After the resident's fall, the staff got the nurse right away. A phone call was placed to a CNA (Staff #45), for an interview on April 14, 2025, at 1:39 PM, and a voicemail was left for a return call. The staff did not return the call. An interview was conducted with an Assistant Director of Nursing (ADON / Staff #71) on April 14, 2025, at 2:31 PM. Staff #71 stated that she was aware that Resident #6 had a fall from a hoyer lift in January 2025. Staff #71 stated that she heard of the incident the following morning in the clinical meeting. Staff #71 stated that she did not know what happened during the incident, or how the fall occurred. An additional interview was conducted with an Assistant Director of Nursing (ADON / Staff #29) on April 14, 2025, at 2:41 PM. Staff #29 stated that Resident #6's fall from the hoyer in January 2025, happened before she started her employment with the facility. Staff #29 stated that the resident tends to move around and reach for things during hoyer transfers. Staff #29 stated she was not aware of how Resident #6's fall from the hoyer occurred. A telephonic interview was conducted with Resident #6's responsible party and power of attorney (POA) on April 14, 2025, at 2:57 PM. The POA stated that the facility called him in January, 2025, to inform him of the resident's fall. He stated that he was told by facility staff that the resident fell while reaching and that the staff did not witness it. He stated as an outcome, the resident had lacerations on her forehead and a fracture. An interview was conducted with the Director of Maintenance (Staff #8) on April 14, 2025, at 3:12 PM. Staff #8 stated that if there is an issue with a hoyer lift, that staff will report it, and he will look at the hoyer. He stated that no staff reported an issue with the hoyer lift on Resident #6's unit. An interview was conducted with the Director of Nursing (DON / Staff #86) on April 14, 2025, at 3:37 PM. The DON stated that she has been employed by the facility since February 17, 2025, and prior to that date, the DON position was held by Staff #90, who was no longer employed by the facility. The DON stated that residents and/or staff could be injured if staff does not follow established procedure when using equipment. She stated that she was aware that Resident #6 had a fall from a hoyer lift in January that resulted in a fracture, however she stated that she did not know any further details, and that it was not discussed by the facility. The DON stated that she was not aware of any corrective action that took place. A call was placed on April 14, 2025, at 3:51 PM, to the former DON (Staff #90) for an interview. A voicemail was left for a return call. The staff member did not return the phone call. -Regarding Resident #6's fall from a wheelchair: A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #6 had a brief interview for mental status (BIMS) score of 00, indicating the resident had severe cognitive impairment. Additionally, the assessment revealed the resident had a fall within the recent 2-6 months. A care plan dated July 6, 2024, revealed the resident is at risk for falls due to dementia, with interventions to be sure the residents call light is within reach, ensure appropriate footwear when mobilizing in wheelchair, anticipate and meet the resident's needs, and that the resident needs a safe environment on a secured dementia unit. An additional intervention to the fall risk care plan, initiated April 9, 2025, indicated to adjust Roho cushion to wheelchair to minimize falls. An additional care plan, dated July 2, 2024, revealed the resident is an elopement risk / wanderer due to dementia, with interventions to assess for fall risk, identify pattern of wandering, and to provide structured activities: toileting, walking inside and outside, and reorientation strategies. There was no evidence of a care plan specifying the quantity or times that the resident required supervision from staff. A Behavior Note dated March 2, 2025, revealed the resident was going into other resident's rooms and taking their belongings. A Psychotherapy Note dated March 3, 2025, revealed the resident tends to take items from around the unit and store them in her drawers. A Nurses Note dated April 8, 2025, revealed staff heard shouting coming from a room and observed Resident #6 lying on the floor in the fetal position in another resident's room. The extra wheelchair cushion provided had slid off of the wheelchair with the resident at the time of the fall. The resident sustained a skin tear and bruising to left hand, bruising to left elbow, and a bump to left forehead. Notifications were made to the POA and physician. A Radiology Report dated April 9, 2025, revealed an x-ray of the left ankle with findings: comminuted, displaced and angulated distal fractures of the tibia and fibula. A physician Encounter Note dated April 9, 2025, revealed the resident was being seen to follow up on a fall from wheelchair. The resident had acute tibia and fibula fractures with a recommendation to send out to the emergency department to evaluate and treat the fractures. A Therapy Screen Note dated April 9, 2025, revealed the screen was being completed status post fall. No changes noted at this time as the resident continues to require supervision for wheelchair mobility via manual wheelchair. Dycem (non-slip sheet material) is noted under the Roho cushion to reduce movement, as the Roho is needed to maintain skin integrity. Therapy not warranted at this time. A physician order dated April 9, 2025, indicated to send the resident out to the hospital for evaluation of acute pain and swelling post fall. On April 14, 2025, at 11:53 AM, a formal request was made to the facility for the incident report and risk management report for Resident #6 for the fall from wheelchair in April 2025. The facility administrator signed a statement that incident reports are internal use only and would not be available to be reviewed. An interview was conducted with a Certified Nursing Assistant (CNA / Staff #36) on April 14, 2025, at 12:26 PM. Staff #36 stated that staff supervise residents who require it, and that it is relayed in report between shifts which residents need supervision. Staff #36 stated that if they see a resident somewhere they should not be, then staff remove them from the location. Staff #36 stated that all the residents on Resident #6's unit require supervision because it is a dementia unit. Staff #36 stated that Resident #6 wanders around the unit and takes things from other residents' rooms. Additionally, Staff #36 stated she was aware that Resident #6 had fallen from her wheelchair on April 8, 2025, and that the resident was sent to the hospital. Staff #36 stated she did not know any further details. An interview was conducted with a Registered Nurse (RN / Staff #80) on April 14, 2025, at 12:49 PM. Staff #80 stated that Resident #6 normally wanders into other resident' rooms, she steals things, and starts giggling. Staff #80 stated that Resident #6 was alone in another resident's room, when Staff #80 heard a yell, and three staff members ran to the room. Staff #80 stated that the resident had a new wheelchair cushion from therapy, and recently just before this fall incident, the resident had a near fall from the cushion. Staff #80 stated that she observed the resident on the floor on her side and the cushion was on the floor with the resident, as if the resident had slid out. Further, Staff #80 stated that there was only one piece of dycem under the first wheelchair cushion, and that there were two wheelchair cushions present. Additionally, Staff #80 stated that there should have been a second piece of dycem between the first and second wheelchair cushions prevent it from sliding out. An interview was conducted with the Director of Rehab and Occupational Therapy Assistant (DOR / Staff #16) on April 14, 2025, at 1:07 PM. The DOR stated that she had issued Resident #6 a Roho cushion, and there was concern that the cushion was sliding, and then after the resident fell , staff removed the cushion. The DOR stated that she looked at the wheelchair the following morning after the fall, and there was only one wheelchair cushion at that time. The DOR stated that no staff had reported to her that there had been two wheelchair cushions in the wheelchair, and if there were, then it would be a safety concern. The DOR further stated that when there are two cushions in the wheelchair, it brings the resident up higher in the chair in relation to the armrests, and increases the likelihood for a fall. An interview was conducted with an Assistant Director of Nursing (ADON / Staff #71) on April 14, 2025, at 2:31 PM. Staff #71 stated that Resident #6 is very busy, in and out of other resident's rooms, getting into other residents' belongings. Staff #71 stated Resident #6 requires lots of supervision and redirection, as well as frequent checks. Additionally, Staff #71 stated that last week, the resident fell from her wheelchair, and that staff said that there was a cushion in her wheelchair that contributed to her fall, so the wheelchair cushion was removed from the chair. An interview was conducted with an Assistant Director of Nursing (ADON / Staff #29) on April 14, 2025, at 2:41 PM. Staff #29 stated that Resident #6 does wander into other residents' rooms and takes their belongings. In regard to the resident's fall on April 8, 2025, Staff #29 stated that the nurse was in another room when the resident fell in another resident's room. The ADON stated that the clinical team discussed the fall, and it was determined that the Roho cushion may have been the reason why the resident fell . Staff #29 stated that Roho cushions are much thicker and position the resident higher than other wheelchair cushions, and the Roho cushion had just been put in Resident #6's wheelchair recently. Staff #29 stated that once the clinical team reviewed the fall, it was decided to not have the resident use the Roho cushion, and it was removed. After the fall, the resident went to the hospital, and Staff #29 stated that the nurse called the hospital and received report that Resident #6 did have tibia and fibula fractures. Also, Staff #29 stated that there were no staff in-services done after the resident's fall. An interview was conducted with the Director of Nursing (DON / Staff #86) on April 14, 2025, at 3:37 PM. The DON stated that the facility protects residents from accidents by trying to keep them out of rooms as much as possible, and to check on residents as frequently as staff can. The DON also stated that staff supervise residents with known behaviors, and that it should be specified in the resident's care plan how much supervision that the resident requires. The DON stated that Resident #6 has dementia and wanders in her wheelchair. Regarding the resident's fall on April 8, 2025, the DON stated that the resident fell due to her cushion in her wheelchair and that the resident slid out. The DON stated that we added dycem so the resident would not slip. As an outcome, the DON stated that the resident went out to the hospital and was treated for tibia and fibula fractures. The DON stated that there were not any staff trainings or in-services after the fall incident. Review of the facility's manufacturer's instructions for the hoyer lift on Resident #6's unit, titled EZ Way Smart Lift, 500, 600, and 1,000 lb Capacities, Operator's Instructions, revised August 10, 2018, revealed that all washable EZ Way Slings are capable of bearing a 1,000 lb. weight load. EZ Way slings are made specifically for EZ Way Smart Lifts, for the safety of patients, only EZ Way slings should be used with EZ Way lifts. A pre-operation check should be completed before operating the unit. Ensure the sling is not ripped, frayed, or showing signs of wear. When attaching the sling to the lift, make a final check of all four loop attachment points to ensure each loop is sufficiently attached to the respective hook of the hanger bars. When lifting the patient, push the UP button, continue the upward motion until there is tension on the sling legs, making sure all the loops on the sling are securely hooked on the hanger bars. Review of the facility's policy titled Behavioral Assessment, Intervention and Monitoring, revised March 2019, revealed the IDT will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Review of the facility policy titled Accidents and Incidents - Investigating and Reporting, revised July 2017, revealed all accidents and incidents involving residents shall be investigated and reported to the administrator. The Incident/Accident Report shall include, as applicable: the date and time the incident took place, the nature of injury, the circumstances surrounding the accident or incident, any corrective action taken, follow-up information, and other pertinent data as necessary. Review of the facility policy titled Fall Risk Assessment, revised March 2018, revealed the nursing staff, physician, and therapy staff will establish a resident-centered falls prevention plan based on relevant assessment information. The staff will evaluate functional, psychological, and environmental factors that may increase fall risk. The staff and physician will collaborate to identify and address modifiable risk factors, and interventions to try to minimize the consequences of risk factors that are not modifiable.

Based on resident and staff interviews, clinical record reviews, and review of facility documentation, the facility failed to protect the rights of four residents (#2, #4, #6, #8, and #10) to be free from physical abuse by another resident (#2 and #10). The deficient practice could result in residents subjected to continued abuse. Findings include: Regarding residents #2 and #4: -Resident #2 was admitted to the facility on [DATE] with diagnosis including major depressive disorder, recurrent severe without psychotic features, generalized anxiety disorder, Alzheimer's disease, unspecified, unspecified dementia, unspecified severity, with other behavioral disturbance. A behavioral treatment care plan dated January 30, 2025 revealed current behaviors for resistance to care, self-isolation and physical aggression. Past behaviors included Refusal of care, withdrawn, self-isolation, worry, restless, somatic delusions, and moody. Interventions included staff should approach resident #2 with a calm, reassuring demeanor to minimize physical aggression. Use a gentle tone, slow movements, and clear, simple communication to reduce confusion and agitation. Identify potential triggers, such as discomfort, frustration, or overstimulation, and adjust the environment accordingly. If aggression occurs, avoid confrontation, provide space, and allow her time to regulate A care plan revised on May 6, 2024 revealed a focus for behavior problems. Interventions included administering medications as ordered, intervening as necessary to protect the rights and safety of others, approach and speak to the resident in a calm manner, divert their attention, remove from situation and take to alternate location as needed. The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 15, indicating resident had intact cognition. Further review of the MDS revealed the resident had no indicators for mood or behaviors. A behavior progress note dated March 22, 2025 revealed resident #2 upset with roommate, resident #4 for not closing the bathroom door. Resident #2 was yelling at resident #4 in Spanish to shut the bathroom door. Demanding and verbally aggressive with resident #4. Staff Would continue with frequent rounding. A behavior progress note dated March 25, 2025 revealed that a staff nurse witnessed resident #2 had altercation with roommate, resident #4 at 5:45am inside residents' room. A psych follow-up note dated March 25, 2025 revealed nurse practitioner presented for an urgent psychiatric follow-up with resident #2. She recently experienced a conflict with her roommate that escalated over prolonged use of the bathroom and resulted in a physical altercation. Following the incident, Resident #2 refused hospitalization and displayed verbal and physical aggression towards the staff. Consequently, she is now under 1:1 supervision. Despite her agitation, resident #2 refused her morning medications but was willing to take her afternoon dose, although her compliance remains intermittent. -Resident #4 was admitted to the facility September 23, 2029 with diagnosis including paranoid schizophrenia, post-traumatic stress disorder, unspecified, age-related osteoporosis without current pathological fracture. A behavioral treatment care plan dated October 20, 2024 revealed current behaviors for delusional beliefs, medication refusal, verbal aggression/inappropriate gestures, ADL care refusal and hoarding of cups. Known triggers are patients or staff entering her personal space. Past behaviors included hitting and biting staff, throwing items at staff, pulling the fire alarm, and throwing self on the floor. Interventions included redirecting inappropriate behaviors, attempt to focus on activity or reality-based subject, keep distanced from other residents when irritable or attempting to instigate and ask to calm down in her room. A care plan-initiated September 7, 2022 and revised on April 23, 2024 revealed a focus for behavior problems related to paranoid schizophrenia. Interventions include administer medications as ordered, monitor behavior episodes and attempt to determine underlying cause, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention, remove from situation and take to alternate location as needed. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 suggesting moderate cognitive impairment, further review of the MDS revealed the resident had no indicators for mood or behaviors. A behavior progress note dated March 25, 2025 revealed that a staff nurse witnessed resident #2 had altercation with roommate, resident #4 at 5:45am inside residents' room. A progress note dated March 28, 2025 revealed after altercation a head to toe assessment was completed, no abnormalities or injuries noted/reported. Resident refused vital [NAME], denied pain/discomfort, no needs at this time. Review of the facility investigation with discover date of March 25, 2025 included that resident #4 was interviewed. Per the documentation, resident #4 reported had taken longer than usual in the bathroom and resident #4 was tempted by the devil to strike me so she did and the nurse witnessed it. Continued review of the facility investigation included that the facility identified the incident as one resident hitting the other. The facility substantiated the resident to resident abuse. An interview was conducted April 1, 2025 with Licensed Practical Nurse (LPN/Staff #22) on April 1, 2025 at 3:05 pm. Staff #22 stated the incident between resident's #2 and #4 happened near the bathroom. Staff #22 stated resident #2 was upset, using hand gestures indicating the bathroom door-Staff #22 stated she opened up the bathroom door as resident #4 was coming out the bathroom in her wheelchair, Staff #22 stated resident #2 was standing near the door and as resident #4 came out, resident #2 started to aggressively hit resident #4 in the back of the head. Staff #22 stated resident #2 struck resident #4 about three times and as she tried to grab resident #2 hand she pulled and was very strong and hit resident #4 in the back of the head two more times. Staff #22 stated additional staff came to assist- two certified nursing assistants and a nurse- they helped get resident #2 away from resident #4 by placing resident #4 in the hallway. Staff #22 stated a skin check was done immediately on resident #4 revealing there were no noted injuries. Staff #22 stated the appropriate staff were notified of the altercation. An attempt to interview was conducted on April 1, 2025 at 3:24 pm with resident #4. Resident #4 was asleep and not easily roused. An attempt to interview was conducted on April 1, 2025 at 3:26 pm with resident #2. Resident #2 was not cooperative and not interviewable. Resident stated it's a sin to talk to you. An interview was conducted April 1, 2025 at 3:37pm with Certified Nursing Assistant (CNA/Staff #36). Staff #36 stated she was made aware of the altercation between residents #2 and #4. Staff #36 stated she was informed resident #2 had hit resident #4 on the head because she was taking too long in the bathroom. Staff #36 stated the residents were separated and resident #2 was placed on 1:1 and moved to a different room, with no further altercations. Regarding Resident #6 and #8: -Resident #6 was admitted to the facility January 7, 2025 with diagnosis including epilepsy, unspecified, not intractable, with status epilepticus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, restless legs syndrome, unspecified mood [affective] disorder, other specified depressive episodes, other personality and behavioral disorders due to known physiological condition. The care plan date-initiated January 14, 2025 with a revision on January 29, 2025 revealed the resident was at risk for behaviors related to mood disorder, cognition. Interventions included administer medications as ordered and intervening as necessary to protect the rights and safety of others. The admission MDS assessment dated [DATE] revealed a BIMS score of 15 indicating the resident cognition was intact; and that, the resident had no indicators for mood or behaviors. A progress note dated March 20, 2025 for psych follow-up revealed that the staff reported that the patient is doing well, taking her medications as prescribed without any reported verbal or physical aggression. Resident #6 is eating and sleeping well. Behavioral documentation was reviewed and is found to be at baseline. Further review revealed documentation that there was an incident involving another resident; however, the patient was not the antagonist, and the issue has been resolved and does not continue to be a concern. Further review of the progress notes revealed an alert note dated March 20, 2025. The note text reported resident is on alert charting for changing shifts. Resident has adjusted well, no complaint of being in her new room. -Resident #8 was admitted to the facility June 30, 2022 with diagnosis including polyneuropathy, unspecified, bipolar disorder, unspecified, major depressive disorder, single episode, severe with psychotic features, mild cognitive impairment of uncertain or unknown etiology, nicotine dependence, cigarettes, uncomplicated. A behavioral treatment care plan dated March 25, 2025 revealed current behaviors for verbal were disruptive behaviors. aggression, cursing and threats. Known triggers were identified as experiencing symptoms of depression. Past behaviors were identified a disruptive sound. Interventions included when exhibiting signs of anxiety, agitation, or restlessness, approach with a calm and soothing demeanor. If resident should become aggressive, provide space and do not confront directly- allow time for de-escalation. The care plan date-initiated September 7, 2022 with a revision on April 3, 2024 revealed the resident has a behavior problem as exhibited by yelling out, using profanities, opens urine bag and drains onto the floor, impaired cognitive function and impaired thought processes related to Bipolar disorder. Interventions include administer medications as ordered. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 06 indicating severe cognitive impairment; and that the resident had no indicators for mood or behaviors. A progress note dated March 21, 2025 revealed a physician encounter reporting resident having some change in behavior- mainly increased irritability and mild increased confusion. Review of the facility investigation with discover date of March 20, 2025 included that both resident #6and #8 were interviewed. Per the documentation, resident #6 reported that resident #8 was jealous of another resident, identified as resident # 12, Resident #6 reported all three residents were outside waiting for smoke break talking, when resident #8 became upset and slapped resident #6 across the left side of her face and then balled up his fists. Resident #8 reported not being able to remember hitting anyone during smoke break. Continued review of the facility investigation included that the facility identified this incident was a verbal argument between residents #6 and #8, but there was no indication of physical contact being made and that the facility was unable to substantiate abuse. An attempt to interview was conducted on April 1, 2025 at 3:03 pm with Registered Nurse (RN/Staff#46). A message was left for a return phone call. An interview was conducted on April 1, 2025 at 3:40 pm with resident #6. Resident #6 stated resident #8 slapped her on the left side of her face and doubled up his fists like he was going to hit me again when resident #12 stood up and stopped him. Resident #6 stated that her face was red for a while where her hit her. The resident stated he called her some names that she chooses not to repeat, but feels that he was jealous of resident #12. An interview was conducted on April 1, 2025 at 3:51 pm with resident #12. Resident #12 stated he was sitting on the patio next to resident #8 who was seated next to resident #6. Resident #12 stated resident #8 called resident #6 some names and four-letter words. Resident #12 stated resident #8 said f*** y** and that resident #6 replied with not in your wildest dreams when resident #8 reached over and slugged her in the face-with a partially closed hand, he hit her twice on her face. Resident #12 stated there was one staff one staff there present. Resident #12 stated resident #6 was very upset and shocked from him smacking her like that. An interview was conducted on April 1, 2025 at 4:03 pm with resident #8. Resident #8 stated I don't remember anything with resident #6. An interview was conducted on April 1, 2025 at 4:24 pm with (CNA/Staff #60) CAN stated she has worked for the facility for [AGE] years and is familiar with residents #6 and #8. Staff #60 stated resident #8 started having behaviors and was being very aggressive with staff and other residents. Staff #60 stated resident #8 was moved to another unit due to the behaviors. Staff #60 stated she did not observe the incident, but was given report that that resident #8 had on the smoking patio. Staff #60 stated this behavior was out of character for resident #8. Regarding Residents # 8 and #10: -Resident #8 was admitted to the facility June 30, 2022 with diagnosis including polyneuropathy, unspecified, bipolar disorder, unspecified, major depressive disorder, single episode, severe with psychotic features, mild cognitive impairment of uncertain or unknown etiology, nicotine dependence, cigarettes, uncomplicated. A behavioral treatment care plan dated March 25, 2025 revealed current behaviors for verbal were disruptive behaviors. aggression, cursing and threats. Known triggers were identified as experiencing symptoms of depression. Past behaviors were identified a disruptive sound. Interventions included when exhibiting signs of anxiety, agitation, or restlessness, approach with a calm and soothing demeanor. If resident should become aggressive, provide space and do not confront directly- allow time for de-escalation. The care plan date-initiated September 7, 2022 with a revision on April 3, 2024 revealed the resident has a behavior problem as exhibited by yelling out, using profanities, opens urine bag and drains onto the floor, impaired cognitive function and impaired thought processes related to Bipolar disorder. Interventions include administer medications as ordered. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 06 indicating severe cognitive impairment; and that the resident had no indicators for mood or behaviors. A progress note dated March 25, 2025 revealed a psych follow-up. The note states the patient is being seen for follow up after being moved to Sunset after becoming physically aggressive. Patient previously underwent a GDR of antipsychotic which has seemingly failed. Will restart the patient on Seroquel 25mg. Remeron previously increased due to mood/irritability issues. Medication not effective in managing behaviors at current dose, will reduce to 15mg. Will also plan to stop Namenda during future encounters. Review of the room change notification indicates room change date on March 25, 2025. The interdisciplinary team determined the need for the room change was due to physical aggression. -Resident #10 was admitted to the facility February 11, 2025 with diagnosis including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, moderate, anxiety disorder, unspecified. A behavioral treatment care plan dated December 3, 2025 revealed current behaviors for verbal aggression (cursing, expressing anger at others), self-isolation, repetitive motions. Past behaviors for suicidal thoughts, throwing items, verbal aggression and poor boundaries. Known triggers are when staff assist with completing care needs. Interventions include; Assess for agitation/anxiety, check in with resident regularly throughout the day and historically, she has engaged with peers in conversation during smoke breaks. Review of the care plan-initiated February 20, 2025 revealed a focus for behavior problems, a smoker and has impaired cognitive function/dementia or impaired thought processes. Interventions include Administer medications as ordered. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating the resident cognition was intact; and that, the resident had no indicators for mood or behaviors. Review of the nurse assessment behavior charting dated March 26, 2025 reported no adverse behaviors noted at this time. Review of the progress notes revealed no documentation regarding the alleged altercation between residents #8 and #10. Review of the facility investigation with discover date of March 25, 2025 included that resident #10 was on the patio and when resident #8 came out on the patio and kicked resident #10 on her leg and hit her on her left arm. The conclusion states resident #8 kicked resident #10. An interview was conducted on April 1, 2025 at 4:00 pm with resident #10. Resident #10 stated she and resident were arguing over the placement of the ashtray. Resident #10 stated she had placed it in the middle where they could both reach it. Resident #10 stated resident #8 wanted it near him and when she tried to move it he folded the smoking apron and hit her over the head with it and kicked her on her right leg. An interview was conducted on April 1, 2025 at 4:03 pm with resident #8. Resident #8 stated I don't remember anything. An interview was conducted on April 1, 2025 at 4:10 p.m. with the LPN (staff #64) who stated she was walking by when she saw residents #8 and #10 on the smoking patio. Staff #64 stated the standing ashtray was in in the middle where resident #10 had moved it. Resident #8 went to move it back and when resident #10 tried to move it again, resident #8 kicked resident #10 in the leg and hit her with the smoking apron. Staff #64 stated resident #10 reported the same to her. Staff #64 stated they were separated and assessment of resident #10 was made with no noticeable injuries on the leg. Staff #64 stated the Director of Nursing (Staff #27) was called and the resident was moved from the unit. An interview was conducted on April 1, 2025 at 4:35 p.m. with Director of Nursing (DON/Staff #27). The DON stated it is the expectation that all residents are kept safe at all times. The DON stated staff are provided with education regarding abuse through monthly meetings and in-services so that they understand the process with reporting incidents. The DON stated she was informed by staff who witnessed the altercation between residents #2 and #4 that resident #2 had gone out to the hallway to get the nurse and when resident #4 came out of the bathroom resident #2 charged at resident #4 and hit her. The DON stated the residents were either moved to different units or different rooms for their safety. The DON stated it is her expectation that staff keep residents safe at all times and report anything concerning. An interview was conducted on April 1, 2025 at 4:47 p.m. with Administrator Abuse Coordinator (Staff #50). Staff #50 stated he became aware of the resident to resident altercations through his DON (Staff #27) Staff #50 stated all staff are aware from in-service and abuse trainings the process for reporting any concerns for abuse. Staff #50 stated the facility substantiated the report regarding residents #2 and #4 based on the interviews with staff and residents. Staff #50 stated the interventions made for the residents are they were separated and placed in different rooms, with increased monitoring and supervision. Staff #50 stated the facility substantiated the report regarding residents #4 and #6 based on their investigation and camera footage it could be seen that resident #8 did hit resident #6 on the head. Staff #50 stated the facility also substantiated the report regarding residents #8 and #10 as they were able to see from the camera footage that resident #8 did hit resident #10 on the head with a smoking apron and raise his leg and kick her. Review of the facility policy titled Abuse Policy (Revised December 2016) state Our residents have a 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, neglect, deprivation of goods or services, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#2) was provided services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for the resident. Findings include: Resident #2 was admitted on [DATE] diagnoses of borderline personality disorder, chronic systolic (congestive) heart failure, chronic pain syndrome, major depressive disorder, recurrent severe without psychotic features, type 2 diabetes mellitus with diabetic neuropathy, unspecified, morbid (severe) obesity due to excess calories, anxiety disorder, unspecified, opioid dependence. Review of the Care Plan date-initiated February 19, 2025 revealed the resident had a focus for chronic pain requiring opioid medication. Interventions included Administer medications and analgesia as per orders, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating resident's cognition is intact. Further review of the MDS revealed resident has upper extremity impairment on one side, is dependent for toileting hygiene, substantial/maximal assistance for showers and bathing, dependent for upper an lower body dressing, partial to moderate assistance with personal hygiene. Review of the bladder and bowel assessment revealed resident is always incontinent of bowel and bladder. Review of the skin conditions assessment of the MDS revealed resident at risk for developing pressure ulcers/injuries. Review of the medication assessment section revealed resident prescribed opioid medication. Review of physicians order dated February 21, 2025 revealed an order for oxycodone HCl Oral Tablet 15 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for pain order date February 21, 2025; Xtampza ER Oral Capsule Extended Release 12 Hour Abuse- Deterrent 27 MG (Oxycodone) Give 1 capsule by mouth two times a day for pain. Review of Medication Administration Record (MAR) for March 2025 revealed last dose administered of Xtampza extended release (ER) oral capsule ER 12-hour abuse-deterrent 27 MG (Oxycodone) Give 1 capsule by mouth two times a day for pain -start date- 02/20/2025 2000 given Monday March 17, 2025 at 10:00 pm. Further review of the MAR revealed 27MG of Xtampza ER was not administered as ordered at 08:00 am. Review of the Progress Notes revealed a nurse note text dated March 17, 2025 at 7:29 pm revealing the following text res will be out of her Xtampza after her dose tonight. This nurse called the pharmacy for refill and Dr. [NAME] will need to send a new (prescription) RX. Res needs for her AM dose 3/18/25 Review of the pain level summary dated March 18, 2025 at 10:47am for resident #2 revealed a documented numerical pain scale value of 8 out of a numerical scale of 1-10 with 10 being the worse. An interview was conducted on March 18, 2025 at 11:42 am with resident #2. Resident #2 reported being in pain and not having her long acting medication Xtampza. Resident #2 stated she has to wait to get it because the facility did not order her medication. Resident again stated I am in a lot of pain and they don't believe me. Resident #2 stated she is unhappy with the facility and provider and had asked to be moved to another facility. An interview was conducted on March 18, 2025 at 11:42 am with Licensed Practical Nurse (LPN/Staff #6). Staff #6 stated resident #2 had refused her blood pressure, diuretic, and bowel care medication in the morning and had also refused her supplements. Staff #6 stated the resident had reported to her that she had looked up the meds and said they were for schizo. Staff #6 stated she reassure the resident that the medications were not antipsychotics. Staff #6 stated when a resident refuses medication she will try to encourage and if they continue to refuse, she will document and notify her primary care physician and the psych provider. Staff #6 stated the resident had complained of shoulder pain, but has an order for Lidocaine. Staff#6 stated the resident is prescribed 27 mg of Xtampza, a scheduled pain medication. Staff #6 stated the medication was not pre-ordered and was scheduled for a dose at 8am. Staff #6 stated the process for obtaining an order for narcotics is contacting the provider. Staff #6 state the medication is on a card and the last nurse that pulls the meds would have got the script and passed the information in report. Staff #6 stated she was informed in report that she would need to re-order and that the medication was last administered on March 17, 2025 at 9:50 pm. Staff #6 stated the order still had not been signed by the provider , but that she also has the option to obtain an E-Script. Staff#6 stated the on call provider stated she can get an e-script if the provider is not in the building by 3pm on March 18, 2025. Staff #6 stated resident #2 had administered an as needed dose of 15mg of oxycodone in place of the ordered 27 mg of Xtampza at 8:00 am. Staff #6 stated the provider had been in the building earlier that day, but had forgot to have the provider sign the order. Staff #6 stated if the provider did not return to the facility by 3pm the nurse practitioner would sign for the medication. Staff #6 stated she could have checked the PIXIS for the medication, but had not at that time. Staff #6 stated the risks of not administering a resident pain medication as ordered can cause increased pain, lead to behavioral issues and defiance. On March 18, 2025 at 12:25pm LPN/Staff #6 stated she checked the PIXIS for the ordered 27 mg of Xtampza. Staff #6 stated there was none available in the PIXIS. An interview was conducted on March 18, 2025 at 12:40 pm with Registered Nurse/Assistant Director of Nursing (ADON/Staff #11). Staff #11 stated resident #2 is a meds seeker, refuses care at times, has not got up to take her bed bath and will call 911 to be taken to the hospital. Staff #11 stated the process for medication that will not be available for the next scheduled dose, is the expectation is that normally when they get down to the last 3-5 days of medications and if it is a script medication, have the doctor sign and fax to the pharmacy and hope to get the same day. Staff #11 stated it is obvious the order for 27 mg of Xtampza for resident #2 got looked over, the nurse practitioner passed over and did not sign the medication order. Staff #11 stated the nurse should have checked the PIXIS when the resident requested the medication or realize that the medication was not available. Staff #11 stated the risks of not providing a resident their scheduled medications as ordered by the provider for pain is increased pain, detox, irritation and agitation with not getting the pain medications. Staff #11 stated resident #2 is prescribed a scheduled deterrent which can cause increased pain, agitation aggravation if not given as scheduled because she has been taking them for a while and needs the regular scheduled dose An interview was conducted on March 18, 2025 at 12:51 pm with Registered Nurse/ Director of Nursing (DON/Staff #13). DON/Staff #13 stated her expectations for ordering medications is that staff order the medications when on the last row of the medications on the card, check the PIXIS, call the physician to order, call the physician for the script and have the pharmacy send it out STAT. The DON stated the providers can do it electronically, they can do it anywhere- staff do not have to wait for a wet signature and this would include narcotics as the provider can e-script. The DON stated the nurse should have been sent the order electronically and not waited for the script to be signed and she should have been informed where they were at with the process. The DON stated the risks with not administering pain medication as ordered can cause pain, increased behaviors and not eating. Review of the facility policy titled Pain Assessment and Management Revised October 2022 States The purpose of this procedure are to help the staff identify pain in a resident, and develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain. 1.The pain management program is based on a facility-wide commitment to appropriate assessment and treatment of pain, based on professional standards of practice, the comprehensive care plan, and the resident's choices related to pain management

Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure services/treatment and accommodation of needs are provided per plan of care and physician orders for one resident (#2) regarding the need for a bariatric bed and opioid medication. The deficient practice could result in residents not receiving the services as outlined in their care plan. Findings include: Resident #2 was admitted on [DATE] with diagnoses that included borderline personality disorder, chronic systolic (congestive) heart failure, chronic pain syndrome, major depressive disorder, recurrent severe without psychotic features, type 2 diabetes mellitus with diabetic neuropathy, unspecified, morbid (severe) obesity due to excess calories, anxiety disorder, unspecified, opioid dependence. Review of the Care Plan date-initiated February 19, 2025 revealed the resident had a focus for bowel and bladder incontinence. Interventions included providing peri-care after each incontinent episode and reporting any skin changes to the provider. Further review of the care plan revealed the resident had a focus has an ADL self-care performance deficit related to morbid obesity, immobility and respiratory failure. Interventions included the need for a bariatric bed. Review of the care plan revealed additional focus's for nutritional problem or potential nutritional problem, Obesity (494 lbs, BMI 68.9) and chronic pain requiring opioid medication. Interventions included to administer medications and analgesia as per orders, anticipate the resident's need for pain relief and respond immediately to any complaint of pain. Review of physicians order dated February 21, 2025 revealed a short turnaround time (STAT) order for an Electric bariatric bed 54x88 diagnosis (DX): Morbid Obesity. Height (HT)-66 WT-511.0 lbs.; resident may have bariatric mattress for pressure redistribution, every day and night shift, order date February 21, 2025; oxycodone HCl Oral Tablet 15 MG (Oxycodone HCl) Give 1 tablet by mouth every 6 hours as needed for pain order date February 21, 2025; Xtampza ER Oral Capsule Extended Release 12 Hour Abuse- Deterrent 27 MG (Oxycodone) Give 1 capsule by mouth two times a day for pain. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating resident's cognition is intact. Further review of the MDS revealed resident has upper extremity impairment on one side, is dependent for toileting hygiene, substantial/maximal assistance for showers and bathing, dependent for upper an lower body dressing, partial to moderate assistance with personal hygiene. Review of the bladder and bowel assessment revealed resident is always incontinent of bowel and bladder. Review of the skin conditions assessment of the MDS revealed resident at risk for developing pressure ulcers/injuries. Review of the medication assessment section revealed resident was prescribed opioid medication. Regarding Bariatric Bed: Review of the Progress Notes revealed a therapy screen text dated February 21, 2025 at 2:14 pm. Revealing the following note text New admission therapy screen completed on this date. Pt noted to be dep for functional transfers via Hoyer, Max/Dep for dressing and peri-care and setup for self-feeding tasks. No functional changes noted warranting therapy at this time; will continue to monitor pt's status for future changes. Review of the Progress Notes revealed a nurse note text dated February 21, 2025 at 4:12 pm revealing the following text Specialty Bari bed 54x88 ordered through Preferred Home Care [PHONE NUMBER]. Stated it will take 5-7days for insurance approval. Due to Preferred only working with insurances, bed was unable to be delivered and billed to facility while waiting on insurance approval. Preferred requested to change order to STAT and that would decrease approval time by half. Orders faxed and confirmation received. Review of the Progress Notes dated March 5, 2025 at 12:30 pm revealed a nurses' note that stated Followed up with Preferred. Was informed BariBed was denied by insurance. CM (Case Manager) notified. Review of the weight summary dated March 12, 2025 revealed a weight value of 492.5 pounds via mechanical lift. Regarding Medication: Review of the Progress notes revealed a nurse note dated March 17, 2025 at 7:29 pm revealing the following text resident will be out of her Xtampza after her dose tonight. This nurse called the pharmacy for refill and Dr. [NAME] will need to send a new (prescription) RX. Resident needs for her AM dose 3/18/25 Review of the pain level summary dated March 18, 2025 at 10:47am for resident #2 revealed a documented numerical pain scale value of 8 out of a numerical scale of 1-10 with 10 being the worse. An interview was conducted on March 18, 2025 at 11:42 am with resident #2. Initial observation of the resident revealed a strong odor of urine. Resident #2 was in bed uncovered in a hospital gown, with head of bed raised approximately 20-30 degrees. Residents head was at the uppermost edge at the top of the bed. Both of the resident's feet were pushed against the footboard of the bed. The residents girth allowed approximately 2-3 inches on each side of the resident with limited room for repositioning. The resident's upper arms were approximately 4-6 inches from touching the mobility bars located on both sides of the bed. The elevation of the bed placed the resident in a V-type position on her back. Resident #2 stated she was supposed to have a bariatric bed upon admission and per the resident had contacted the facility prior to admission to ensure the facility had a bariatric bed for her. Resident #2 stated she does not have enough room on the sides of the bed, is uncomfortable and is stuck in one position. Resident #2 became tearful describing her story. Resident #2 stated the staff have hard time turning her because there is not room and is pushed against the rails. Resident #2 stated it scares me, I feel like I am going to fall out and the rails hurt me when I'm pushed against them. Resident #2 reported being in pain and not having her long acting medication Xtampza. Resident #2 stated she has to wait to get it because the facility did not order her medication. Resident again stated I am in a lot of pain and they don't believe me. Resident #2 stated she is unhappy with the facility and provider and had asked to be moved to another facility. An interview was conducted on March 18, 2025 at 11:55 am with Licensed Practical Nurse (LPN/Staff #6). Staff #6 stated resident #2 had refused her blood pressure, diuretic, and bowel care medication in the morning and had also refused her supplements. Staff #6 stated the resident had reported to her that she had looked up the meds and said they were for schizo. Staff #6 stated she reassure the resident that the medications were not antipsychotics. Staff #6 stated when a resident refuses medication she will try to encourage and if they continue to refuse, she will document and notify her primary care physician and the psych provider. Staff #6 stated the resident had complained of shoulder pain, but has an order for Lidocaine. Staff#6 stated the resident is prescribed 27 mg of Xtampza, a scheduled pain medication. Staff #6 stated the medication was not pre-ordered and was scheduled for a dose at 8am. Staff #6 stated the process for obtaining an order for narcotics is contacting the provider. Staff #6 state the medication is on a card and the last nurse that pulls the meds would have got the script and passed the information in report. Staff #6 stated she was informed in report that she would need to re-order and that the medication was last administered on March 17, 2025 at 9:50 pm. Staff #6 stated the order still had not been signed by the provider , but that she also has the option to obtain an E-Script. Staff#6 stated the on call provider stated she can get an e-script if the provider is not in the building by 3pm on March 18, 2025. Staff #6 stated resident #2 had administered an as needed dose of 15mg of oxycodone in place of the ordered 27 mg of Xtampza at 8:00 am. Staff #6 stated the provider had been in the building earlier that day, but had forgot to have the provider sign the order. Staff #6 stated if the provider did not return to the facility by 3pm the nurse practitioner would sign for the medication. Staff #6 stated she could have checked the PIXIS for the medication, but had not at that time. Staff #6 stated the risks of not administering a resident pain medication as ordered can cause increased pain, lead to behavioral issues and defiance. On March 18, 2025 at 12:25pm LPN/Staff #6 stated she checked the PIXIS for the ordered 27 mg of Xtampza. Staff #6 stated there was none available in the PIXIS. An interview was conducted on March 18, 2025 at 12:40 pm with Registered Nurse/Assistant Director of Nursing (ADON/Staff #11). Staff #11 stated resident #2 is a meds seeker, refuses care at times, has not got up to take her bed bath and will call 911 to be taken to the hospital. Staff #11 stated the process for medication that will not be available for the next scheduled dose, is the expectation is that normally when they get down to the last 3-5 days of medications and if it is a script medication, have the doctor sign and fax to the pharmacy and hope to get the same day. Staff #11 stated it is obvious the order for 27 mg of Xtampza for resident #2 got looked over, the nurse practitioner passed over and did not sign the medication order. Staff #11 stated the nurse should have checked the PIXIS when the resident requested the medication or realize that the medication was not available. Staff #11 stated the risks of not providing a resident their scheduled medications as ordered by the provider for pain is increased pain, detox, irritation and agitation with not getting the pain medications. Staff #11 stated resident #2 is prescribed a scheduled deterrent which can cause increased pain, agitation aggravation if not given as scheduled because she has been taking them for a while and needs the regular scheduled dose Staff # 11 conducted on observation of resident #2 while in bed, stating the bed was provided by central supply. Staff #11 stated resident #2 has insufficient room to reposition herself in the bed and the bed looks like it is too small for her, she is close to the rails and her feet are at the end of the bed. Staff #11 stated the risks with not being provided with the correct bariatric bed is skin breakdown with inability to move in the bed. An interview was conducted on March 18, 2025 at 12:51 pm with Registered Nurse/ Director of Nursing (DON/Staff #13). The DON stated the order for the bariatric bed for resident #2 was denied by the insurance and the supplier does not deal with facilities directly, only through insurance. The DON stated she does not feel the bed is sufficient for the resident to reposition herself, but that the facility has been trying to obtain a bigger bed for the resident. The DON stated risks of not being able to reposition in a smaller bed is decreased mobility, contractures, and risks for skin breakdown. DON/Staff #13 stated her expectations for ordering medications is that staff order the medications when on the last row of the medications on the card, check the PIXIS, call the physician to order, call the physician for the script and have the pharmacy send it out STAT. The DON stated the providers can do it electronically, they can do it anywhere- staff do not have to wait for a wet signature and this would include narcotics as the provider can e-script. The DON stated the nurse should have been sent the order electronically and not waited for the script to be signed and she should have been informed where they were at with the process. The DON stated the risks with not administering pain medication as ordered can cause pain, increased behaviors and not eating. DON/Staff #13 invited (Case Manager/ LPN/Staff #52) and (Central Supply/Staff #16) to the interview at 1:18pm. Staff #52 stated resident #2 was provided a standard size bariatric bed [Medical bed dimensions of smaller bariatric models are approximately 88 inches long and 42 inches wide] and the Preferred Medical Supply did not have the size that the resident requires. Staff #16 she has been a part of the process in locating the physician ordered size bariatric bed for resident #2. Staff #16 stated that the plan was to start calling different companies and see if they have it there. Staff #16 stated she had contacted Synapse Supply and they did not have what the facility was looking for. Staff #16 stated that Preferred Medical Supply had placed the facility on the wait list for the bed as they did not have one available. Staff #16 stated that she had verbally informed (administrator/staff #26) that the bariatric bed for resident #2 was not available. An interview was conducted on March 18, 2025 at 1:38 pm with (administrator/staff #26) and (Admissions/Administrator in Training #8) Staff #26 stated the facility will try to locate a bed for resident #2 and had reached out to Legend Medical on March 14, 2025. Staff #26 stated he has also reached out to other administrators in the valley to see if they had one on loan. Review of the facility policy titled :Care Plans, Comprehensive Person-Centered Revised March 2022 states A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Review of the facility policy titled Accommodation of Needs Revised March 2021 states Our facility's environment and staff behaviors are directed toward assisting the resident in maintaining and/or achieving safe independent; functioning, dignity and well-being. Review of the facility policy titled Medication and Treatment Orders Revised July 2016 states Orders for medication and treatments will be consistent with principles of safe and effective order writing.

Based on review of clinical record review, staff interviews, facility policy and procedure, the facility failed to ensure incontinence care was provided for one resident (#2). The deficient practice could result in residents not receiving necessary care and services to maintain skin integrity and personal hygiene. Findings include: Resident #2 was admitted on [DATE] diagnoses of borderline personality disorder, chronic systolic (congestive) heart failure, chronic pain syndrome, major depressive disorder, recurrent severe without psychotic features, type 2 diabetes mellitus with diabetic neuropathy, unspecified, morbid (severe) obesity due to excess calories, anxiety disorder, unspecified, opioid dependence. Review of the Care Plan date-initiated February 19, 2025 revealed the resident had a focus for bowel and bladder incontinence. Interventions included providing peri-care after each incontinent episode and reporting any skin changes to the provider. Further review of the care plan revealed the resident had a focus has an ADL self-care performance deficit related to morbid obesity, immobility and respiratory failure. Interventions included the need for a bariatric bed. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating resident's cognition is intact. Further review of the MDS revealed resident has upper extremity impairment on one side, is dependent for toileting hygiene, substantial/maximal assistance for showers and bathing, dependent for upper an lower body dressing, partial to moderate assistance with personal hygiene. Review of the bladder and bowel assessment revealed resident is always incontinent of bowel and bladder. Review of the skin conditions assessment of the MDS revealed resident at risk for developing pressure ulcers/injuries. Review of the medication assessment section revealed resident prescribed opioid medication. Review of physicians order dated February 21, 2025 revealed a short turnaround time (STAT) order for an Electric bariatric bed 54x88 diagnosis (DX): Morbid Obesity. Height (HT)-66 WT-511.0 lbs.; resident may have bariatric mattress for pressure redistribution, every day and night shift, order date February 21, 2025. Review of the Progress Notes revealed a therapy screen text dated February 21, 2025 at 2:14 pm. Revealing the following note text New admission therapy screen completed on this date. Pt noted to be dep for functional transfers via Hoyer, Max/Dep for dressing and peri-care and setup for self-feeding tasks. No functional changes noted warranting therapy at this time; will continue to monitor pt's status for future changes. Review of the weight summary dated March 12, 2025 revealed a weight value of 492.5 pounds via mechanical lift. An interview was conducted on March 18, 2025 at 11:42 am with resident #2. Initial observation of the resident revealed a strong odor of urine. Resident #2 was in bed uncovered in a hospital gown, with head of bed raised approximately 20-30 degrees. Residents head was at the uppermost edge at the top of the bed. Both of the resident's feet were pushed against the footboard of the bed. The residents girth allowed approximately 2-3 inches on each side of the resident with limited room for repositioning. The resident's upper arms were approximately 4-6 inches from touching the mobility bars located on both sides of the bed. The elevation of the bed placed the resident in a V-type position on her back. Resident #2 stated she was supposed to have a bariatric bed upon admission and per the resident had contacted the facility prior to admission to ensure the facility had a bariatric bed for her. Resident #2 stated she does not have enough room on the sides of the bed, is uncomfortable and is stuck in one position. Resident #2 became tearful describing her story. Resident #2 stated the staff have hard time turning her because there is not room and is pushed against the rails. Resident #2 stated it scares me, I feel like I am going to fall out and the rails hurt me when I'm pushed against them. Resident #2 stated she is unhappy with the facility and provider and had asked to be moved to another facility. An interview was conducted on March 18, 2025 at 12:19 pm with Certified Nursing Assistant (CNA/Staff#9). Staff #9 stated she had been an employed with the facility since October 2024. Staff #9 stated she was familiar with resident #2 and was assigned for her care. Staff #9 stated resident #2 is incontinent and wears incontinence briefs, but will call when she wants to be changed. Staff #9 stated she had not checked resident #2 for incontinence since she had started her shift at 6:30am. Staff #9 stated I have been really busy doing room changes and showers and I didn't let the nurse know I hadn't changed her [resident #2]. Staff #2 stated resident #2 should have been checked every two hours but this morning has been really busy- I know I should have further stating I'll go check on her now. Staff #9 stated if she is delayed with care she will let the other CNA's know, because resident #2 is cares in pairs and let the nurse know. Staff #9 stated the unit is short staffed with three CNA's on the unit and that there should be four CNA's. Staff #9 stated she is assigned ten residents with most requiring cares in pairs. Staff #9 stated the staff have been requesting additional help. Staff #9 stated she is unable to get done what she needs to attend to for the resident because she has been too busy. Staff #9 stated she had not ben able to change resident #2 all day- not since her shift started I had showers and vitals and all the residents that I had to take care of today, we are always short lately and today has been really busy. An interview was conducted on March 18, 2025 at 12:40 pm with Registered Nurse/Assistant Director of Nursing (ADON/Staff #11). Staff #11 stated his expectations for checking on residents who are incontinent are that incontinent residents should be checked every two hours and if a resident had not had not been checked since the night prior it does not meet the two-hour timeframe for incontinence care. Staff #11 stated the risks of not providing incontinence care is skin breakdown and rash. An interview was conducted on March 18, 2025 at 12:51 pm with Registered Nurse/ Director of Nursing (DON/Staff #13). The DON stated her expectations in providing incontinence care for the residents is staff should round on them every two hours or if they need care in between they should provide it. Staff #13 stated not providing care since start of shift does not meet her expectation in providing incontinence care, stating the risks in not providing care are possible wounds, and infections. Review of the facility policy titled Activities of Daily Living (ADL), Supporting Revised March 2018 states Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs). Resident who are unable to carry out activities of daily living independently will receive the service necessary to maintain good nutrition, grooming and personal and oral hygiene.

Based on observations, clinical record reviews, interviews and policy review, the facility failed to provide a designated room to accommodate residents dining and activities while undergoing construction. The deficient practice could result in resident's individual needs and preferences not accommodated. Findings included: During a complaint survey on February 11, 2025 at 1:08 pm, the administrator/Staff #20 stated that one of their locked unit, had an emergency plumbing issue last week, Monday, so they moved residents from that unit to their open rooms throughout the facility and for the other remaining residents, they were moved in the dining room/activity room, day care room and medical record room. On February 11, 2025 at 1:18 pm the administrator ushered the surveyor to the dining room/activity room which is currently being use for ten resident beds and another room across the hallway from the dining room is the medical record room and day care room which is currently being use to place seven resident beds. An interview was conducted on February 11, 2025 at 1:40 pm with a lead certified nursing assistant (CNA)/Staff #102. Staff #102 stated that her responsibility is to oversee the CNAs. She also stated that the residents placed in the day care room are resident #9, resident #2, resident #10, and resident #6, and in the adjacent room separated by a dutch door are resident #11, resident #1 and resident #12. Present during the interview is assistant director of nursing (ADON)/Staff #234. The ADON stated that the residents were relocated since last Monday, February 3rd, due to a plumbing issue in their unit. During the interview, Staff #26 was present and stated that the setup of the beds included call bells at bedside for each resident and privacy curtains. In addition, during the interview, two CNAs arrived in the room, Staff #120 and staff #179, and then Staff #102 left the room once the two CNAs came in. Furthermore, the ADON stated that the room where they have four residents is called the day care room and the other room connected to the day care room is the medical records room for the other three residents. The medical record room has access to a restroom. An interview was conducted on February 11, 2025 at 2:32 pm with CNA/Staff #141. Staff #141 stated that the room were ten residents are in is used for dining and activity. But if there is no resident beds in the dining room, it is used for dining and for activities such karaoke. Staff stated that currently the residents' unit is being fixed and she does not know how long the residents had been staying in the dining room because this is not her usual unit, her unit is called the [NAME] lane. Staff stated that when a resident needs to be changed while is currently sleeping in the dining room, they use a privacy curtain, and she stated that there is only two residents that is incontinent and the rest of the residents are using the bathroom in the other room. Regarding staffing, she stated that she is the only CNA working at the dining room and there is a floater CNA in case they need assistant with anyone, and one nurse. The floater aid /CNA comes and peek in through the door to see if they need assistance but the floater aid/CNA does not stay. On February 11, 2025 at 3:27 pm , surveyor observed each resident has their own call bell at their bedside table, and a nurse with the medication cart between resident #4 and resident #5 beds. An interview was conducted on February 11, 2025 at 3:28 pm with resident #6. Resident #6 stated was moved in the room since Thursday because they were doing plumbing and tiling, and she was informed of the move couple days before. Resident stated that meal tray are placed at the bedside over the bed table. Resident wear briefs and takes bedbath. On February 11, 2025 at 3:32 pm, the ADON identified resident #1 who was talking on a cell phone on speaker, who is sitting in the middle of the day care room, speaking loud on the phone. Staff #233 stated that resident #1 likes to sit with them. An interview was conducted on February 11, 2025 at 4:17 pm with CNA/staff #3. Staff stated that work is being done in the locked unit so there is ten residents in the dining room. Staff #3 identified the residents as resident #8, resident #13, resident #14, resident #15, resident #7, resident #16, resident #17, resident #18, resident #5, and resident #4. Staff stated that each resident has a beside table and a call bell to ring. An interview was conducted on February 12, 2025 at 08:36 am with resident #4. Resident #4 is in the dining room sitting in his bed. Resident #4 stated that they are remodeling his room, he has been in the dining room for a week, they bring his food at the bedside table, the room has a bathroom located in the back of the dining room, they take him outside the dining room for shower, and he has a call bell at the bedside table. Review of clinical record revealed resident #4 has a Brief Interview for Mental Staus (BIMS) score of 15.0 indicating cognitively intact. An interview was conducted on February 12, 2025 at 08:40 am with resident #8. Resident is lying in bed in the dining room. Resident stated that he had been there for 5 years. Review of resident clinical record revealed a BIMS score of 15.0 indicating cognitively intact. An interview was conducted on February 12, 2025 at 08:41 am with resident #7. Resident is sitting in bed in the dining room. Resident stated that he has been in the dining area for 3 weeks due to plumbing issues. Resident stated that he eats on his bedside table, uses the bathroom located in the other room and they take him out of the dining room for showers. Resident has a call bell at bedside. Review of clinical record revealed a BIMS score of 14.0 indicating cognitively intact. An interview was conducted on February 12, 2025 at 8:46 am with speech therapist/Staff #259. She stated that she is here for resident #5. She stated that resident was in the unit but due to construction , resident was moved to the activityroom/dining room. Staff stated that she usually finds a quiet room in the resident's room to do by mouth trials, practice swallow strategies, aspiration precaution, , and for today she will be doing speech therapy at resident's bedside in the dining room. An interview was conducted on February 12, 2025 at 8:52 am with CNA/staff #148. Staff stated his unit is one of the locked unit which is under construction. He stated that he has been working for two days in the [NAME] dining room where the residents are placed. He stated that the [NAME] dining room is use to be the dining room for residents to eat. He stated that his unit has been closed for about a week. An interview was conducted on February 12, 2025 at 9:00 am with registered nurse (RN)/Staff #225. Staff #225 stated that they are doing work in the unit, tearing up plumbing, and the construction has been going on for one week and a half. She stated that she came to work on Wednesday, February 5, and the residents were already moved in the dining room. An interview was conducted on February 12, 2025 at 9:14 am with Maintenance director/Staff #41. Staff stated that his responsibility is to keep the building well maintained and make sure is within regulation. Staff stated that one of the unit's mainland plumbing failed and it has been an ongoing issue for a while. Then, on Monday , February 3, they finished prepping the two rooms, one room used to be a day care room and the medical record room, and the other room prepped was the [NAME] dining room. He stated that they cleared and cleaned the entire rooms, and made sure there is access to restroom. Staff stated that they moved twenty-six residents, some went to other units, and he does not know how many residents were moved in the [NAME] dining room, day care room and medical record room. Staff stated that they finished the plumbing on Friday, February 7, the concrete started on Saturday, February 8, and the flooring started on February 10, because the concrete needs to cure. At 9:24 am, Staff #41 and surveyor headed to the dining room. At 9:25 am, staff measured the square footage of the dining room. The measurement is 43 feet (ft) by 24.5 ft which equals to 1053.5 square feet. At 9:30 am, there are 4 residents in the day care room. Staff #41 measured the day care room square footage. The measurement is 24.5 ft by 17.5 ft which is 428.75 square feet. At 9:38 am, staff #41 is in the medical record room which has three residents. The medical record room measurement is 16.5 ft by 12.25 ft which equals to 200.95 plus a nook 5.5 ft by 6.0 ft which equals to 33 sq ft. The total square footage of the medical record room is 233.95 sq ft. At 9:47 am, staff remeasured dining room. The dining room measured 41.0 ft by 24.5 ft which equals to 1004.5 sq ft. An interview was conducted on February 12, 2025 at 10:43 am with CNA/Staff #120. Staff #120 stated that the residents in the day care room has been there since last Monday. Staff stated that all four residents eat in the room, the meal trays are placed at their bedside table, and they are offered activities if resident wants to go. During the interview, surveyor observed snacks such as yogurt, bananas, and jello, were on top of a table, and staff stated that the snacks were brought in at 10:00 am, and there is no refrigerator in the day care room. When asked about where they keep resident's clothes/belongings, staff #120 stated that residents' clothes were stored in the maintenance area and the residents important belongings such as lap tap, cellphone, and chargers are with them. At 10:50 am, staff #120 showed surveyor the maintenance area which is next room to the dining area and a door leading to the kitchen. The maintenance area was observed to have maintenance tools and housekeeping carts. At 10:54 am, Housekeeping/Staff #280 and housekeeping manager/Staff #24 identified the room as housekeeping and maintenance room for storage. Staff stated that the room has tools for maintenance, they keep the wet and dry pick up machine to clear all water/suck water if they do strip and wax floor, a machine for wet and dry for auto scrub for the floor, and two vacuums to vacuum the carpet. Staff #24 stated that they temporary put the residents clothes there in the maintenance area/storage. An interview was conducted on February 12, 2025 at 11:16 am with the interim director of nursing/clinical resource (RN/Staff #32). She stated that the unit is a plumbing nightmare, nothing would flush and go down, the back two rooms kept having flush problem. She stated that about 23 to 27 residents were moved on February 3. She stated that they started jack hammering by noon. The plumbing stuff is done tentatively today, February 12, and they will tile the floor, and then start moving resident back to the unit by tomorrow. Review of facility's policy titled, Shelter In Place and Procedure, no effective or revision date revealed Three potential types of sheltering in place have been identified: (2) Physical Plant related-This would typically be in response to an issue that has rendered a Zone uninhabitable. This situation might cause an evacuation from one zone to another. It also could be for a longer period of time. See Evacuation-Partial. Review of facility's policy titled, Facility Evacuation-Partial, no effective or revision date revealed it is everyone's responsibility to protect our residents, guests, and staff from injuries and fatalities in the event of a disaster. This procedure outlines steps that must be taken to safely evacuate residents to a safe area within the facility. Safe Area: Resident gathering areas: dining rooms, day rooms, activity rooms, therapy rooms. Review of facility's policy titled, Resident Rights, revised February 2021 revealed Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to : a. a dignified existence; b. be treated with respect, kindness, and dignity.

Based on clinical record review, resident and staff interviews, and facility documentation and policy, the facility failed to ensure care and treatment according to professional standards of practice was provided to one resident (#1). The deficient practice resulted in the hospitalization of the resident and amputation of his leg. Findings include: Resident #1 was admitted on [DATE] with diagnoses of borderline personality disorder, obsessive-compulsive disorder, epilepsy, and an anxiety disorder. Review of the clinical record revealed documentation that the resident was in a car accident, had metal pieces in his left foot; and that, in October and November of 2019, he was again noted to be limping and complaining of pain to right lower leg. The care plan initiated on 11/11/2022 revealed the resident had a goal related to his potential for impairment to skin integrity related to his potential for poor safety awareness. Interventions included following facility protocols for treatment of injury and identifying and documenting potential causative factors and eliminate and resolve where possible. The care plan dated 03/08/2023 included that the resident had diabetes mellitus and had the potential for pressure ulcer development. The goals were that the resident will not have complications related to diabetes and the resident will have intact skin, free of redness, blisters or discoloration. Interventions included to check all body for breaks in skin and treat promptly as ordered by the doctor; and, to follow facility policies/protocols for the prevention/treatment of skin breakdown. The follow-up encounter notes dated 04/04/2024 included that the resident had red/open areas to the right upper shoulder; and that, there was no edema noted on the extremities. The skin observation dated 04/09/2024 revealed a red area; however, the documentation did not identify the location of the red areas observed. The shower sheet dated 04/10/2024 included that the resident had swelling to his right leg. The clinical record revealed no documentation whether the swelling to the resident's right leg was reported to the nurse or the provider; and that, it was assessed and interventions were put in place to address this. The nursing weekly skin check dated 04/12/2024 revealed the resident had wound to the right bicep which was healing, scabbed and without drainage or swelling. However, there was no documentation of any redness or swelling to the resident's right leg. Per the documentation, the skin was expected color for ethnicity without lesions or rashes, was warm, dry with no edema, and had normal turgor with no tenting. The follow-up NP (nurse practitioner) note dated 04/16/2024 included the resident had red and open areas to the right upper shoulder; and, had no edema on the extremities. The nursing weekly skin check dated 04/18/2024 included the resident had a scab on the right shoulder and the rest of the skin was clean, dry and intact. It also included that the skin color was normal to ethnicity and skin turgor was good. The documentation did not include any redness or swelling to the resident's right leg. The wound progress note dated 04/18/2024 revealed there was no edema or tenderness to the right and left lower extremities. A progress note dated 04/25/2024 at 07:23am documented that a certified nursing assistant (CNA) alerted the nurse that the resident had redness to his right leg. The nurse completed an assessment and took the vitals: -Temperature of100.4 degrees Fahrenheit; -Pulse of 92 bpm (beats per minute); -Respiration-breaths per minutes; -Blood pressure-140/100; and, Oxygen saturation-90%. Per the documentation, these vital were reported to the NP who ordered a stat CBC (complete blood count), CMP (comprehensive metabolic panel), CRP (C-reactive proteins) labs and a chest -X-Ray. The NP progress note dated on 04/25/2024 revealed that a leakage to the right lower extremity sweat pants at groin/leg/thigh was noted; and that, the resident's leg appeared red and swollen from ankle to calf with some open/yellow slough dime-sized areas noted to distal shin on right lower extremity. Per the documentation, when the resident's pants were removed, a variety of items including snacks, straws, and toys fell out; and, these hoarded items were next to the skin which might be a component of the irritation. The documentation included that the NP requested the wound nurse consult promptly for evaluation and treatment and expressed concern for the sudden onset of symptoms. Physical exam included had 2+ edema on the extremities, red/open areas to the right lower extremity from the ankle to the knee, and swelling but no redness to the left lower extremity. Diagnoses included edema bilateral lower extremities and cellulitis on the right lower extremity. Plan was to start Doxycycline (antibiotic) for 7 days and Lasix (diuretic) twice daily for 3 days. Further, the documentation included that the stat labs (CBC, CMP and CRP) and ultrasound were pending: and, an oral antibiotic was to be started for seven days and Lasix (diuretic) for edema to be given twice a day for three days. The physician order dated 4/25/2024 included the following orders: -two STAT (immediate) orders for ultrasounds to his bilateral lower extremities to evaluate for deep vein thrombosis (DVT) related to redness on his leg and cellulitis; -Another STAT order for CBC, CMP and CRP labs; and, -Doxycycline 100 milligrams (mg) tablet by mouth twice a day until 05/02/2024. The Medication Administration Record (MAR) for April 2024 revealed documentation that Doxycycline was administered to the resident as ordered. The clinical record revealed that the orders for physician-ordered laboratory tests were completed on 4/25/2024 at 3:14 p.m. The following results from the STAT labs on 04/25/24 were flagged as high: -White blood cell count (WBC) was 22.9 thousand per cubic millimeter (Normal range was 4.0 to 11.0); -Absolute Neutrophil was 14.6 thousand per microliter (Normal range was 1.5 to 7.8); -Absolute Monocyte 4.3 thousand per microliter (Normal range was 0.2 to 1.0); -Absolute Immature Granulocytes 2.2 thousand per microliter (Normal range was 0.0 to 0.1); -CRP was 173.6 milligrams per liter (mg/L) (Normal range was less than or equal to 4.9 mg/L). The clinical record revealed no evidence that the provider was notified and had reviewed these lab results. The shower sheet dated 4/28/2024 included the resident had swelling and reddened right leg. A nursing progress note from 04/29/2024 revealed that the ultrasound was completed and results were pending. A wound note from 04/30/2024 included that the wound care team was consulted due to the worsening cellulitis of unknown origin in his right leg; and that, the resident was started on Doxycycline by attending NP with no improvement. Wound assessment included an unhealed full thickness cellulitis on the right lower leg measuring 34 cm (centimeters) length x 34 cm width x 0.2 cm depth; had moderate amount of yellow drainage noted; wound bed had 1-25% pink granulation, 51-75% epithelialization; and, periwound skin was warm, had edema and erythema and presented with signs and symptoms of infection. Active problems included cellulitis of the right lower limb. Plan included wound treatment. recommendation was for a wound culture and possible intravenous (IV) antibiotics for severe worsening cellulitis. The NP progress note dated 04/30/2024 revealed that the resident's right lower extremity appeared more swollen, red, and inflamed than previous exam. It also included that the ultrasound was negative and the stat labs were reviewed with concern for sepsis or osteomyelitis. Per the documentation, the NP discussed these concerns with the director of nursing (DON) and wound care provider and recommended sending the resident to the emergency room for prompt IV antibiotics and wound culture as a delay may compromise the patient. The nursing progress note dated 04/30/2024 included that the resident was sent out non-emergent per the wound provider and the NP. Per the documentation, the resident's dressings to the right leg were wet with exudate; there were large red areas and swelling on the right leg below the knee; and, toward the ankle there were blister like areas there was and open areas on the upper leg. The hospital history and physical dated 05/01/2024 included that the facility reported that the resident had been walking around the facility with no change in ADLs (activities of daily living) or mentation from baseline. Per the documentation, the facility noticed possible cellulitis of the right lower extremities initiated Doxycycline 100 mg BID since 04/26/2024; and that, the resident hoarding things and stuff things up his pan leg may have caused the infection. Physical examination included that the right lower extremity had erythema, edema and several areas of purulence extending from the ankle to the mid-upper thigh. Assessment included that the resident presented with a purulent right leg SSTI (skin and soft tissue infection); and, the facility began Doxycycline 100 mg twice daily on 04/26/2024 but the resident had worsening of infection and was transferred to the hospital. Per the documentation, the resident was afebrile, hypertensive, tachypneic (rapid and shallow breathing) and had a WBC of 21.2. Further, the documentation also included that CT scan showed that the resident had a tibial rod on the right lower leg. Active problems included severe purulent cellulitis and sepsis; and that, the right leg was marked to monitor extension of the infection. The hospital progress note dated 05/06/2024 included that the resident presented with chronic osteomyelitis in the setting of longstanding tibial nail that had spread the cellulitis proximally; and that, the resident's family would like to proceed with above the knee amputation. the infectious disease assessment included right lower extremity wounds/ulcerations with SSTI with extensive Pseudomonas. The nursing progress note dated 05/12/2024 included that the resident returned at the facility and that, the resident had an above the knee amputation to the right leg. Per the documentation, the area had multiple stitches with no signs and symptoms of infection noted. The skin evaluation dated 05/19/2024 revealed above the knee amputation to the right leg. The care plan was revised on 05/24/2024 to include a goal for wound care related to the above the knee amputation due to infection. The undated online reportable event record/report submitted by the facility included that a complaint was filed with the State Board of Nursing against the DON (Director of Nursing) alleging negligence on behalf of all the nurses; and that, a resident who was admitted to the behavior unit had severe infection on the right lower extremity that went unnoticed and untreated. It also included that when treatment was initiated, it was by oral antibiotics instead of IV (intravenous) antibiotics. The facility 5-day investigative report revealed an interview with the registered nurse (RN/staff #18) conducted by the facility on 6/24/2024. Per the documentation, The RN reported that he knew the resident had cellulitis and his leg got worse as far as redness, weeping, swelling, and hardness; and that, two providers were present and they originally wanted to treat the resident at the facility before ultimately sending Resident #1 out to the hospital. In an interview with a licensed practical nurse (LPN/staff #9) conducted by the facility included that the nurse recalled when the resident had an infection in his right leg, and that was when she was told the computers were down. She brought it to the DON's attention and was told there was an order for dressing and antibiotics. Continued review of the facility report revealed that based on their investigation, interviews and chart review, the facility cannot conclude that there was negligence on behalf of the nurses, management or practitioners. In an interview with a Licensed Practical Nurse (LPN/staff #45) conducted on 07/01/2024 at 2:42 p.m., the LPN stated that the turn-around time on stat labs can depend on the laboratory provider; and, it was usually sooner but can be up to 24 hours. During the interview, a review of the clinical record was conducted with the LPN who stated that it was not appropriate for labs completed and had results in on 04/25/2024 be reported/reviewed by the provider only on 04/30/2024 which was 5 days after. The LPN said that she would have been concerned and reported the lab result to the provider immediately because of the result on the WBC count of Resident #1. During an interview with a certified nursing assistant (CNA/Staff #23) conducted on 07/01/2024 at 2:49 p.m., the CNA stated that CNAs complete skin checks during showers; and, the CNAs were required to check the full body for redness, breakdown, or bruises. She stated she provided care for Resident #1; but, she does not recall noticing any redness on his leg from April 18- to April 25, 2024. Further, the CNA said that she was unsure if she gave resident #1 a shower during that time. An interview with the LPN (staff #9) was conducted on 07/01/2024 at 3:37 p.m. The LPN said that she knew resident #1 was on oral antibiotic and had an order for dressing, but the wound nurse comes weekly and does wound care. The LPN said that the stat laboratory orders were initially ordered during the shift; and they were taken and completed the same day it was ordered. The LPN said that the lab results were usually back within 24 hours; and that, if it was [NAME] who completed the test, the laboratory staff will call the facility to notify them of the results. The LPN said that if labs were ordered and pending, this was something that would need to be reported at shift change to the oncoming nurse. The LPN said that in her nursing experience, she would not expect a resident on antibiotics to be worsening, though antibiotics can take 7-10 days to be effective; and that, if it was worsening, she would call the doctor and let them know and then follow whatever orders received. Further, the LPN said that 5 days for a STAT lab result would be too long. During the interview, a review of the laboratory result on 04/25/2024 for resident #1 was conducted with the LPN who said that based on the lab results the doctor absolutely should have been called immediately; and that, waiting 5 days to report the results to the provider would be inappropriate, especially if those were the levels while patient was on an antibiotic. During an interview with the Internal Medicine NP (staff #15) conducted on 07/01/2024 at 3:58 p.m., the NP stated that the team first became aware of the concern with right lower leg of resident #1 on the date (04/25/2024) that she documented about it. The NP stated that staff had brought it to her due to the redness, but the resident denied he was in pain and there was no change in mentation. The NP said that her notes on 04/30/2024 was only when she found out about the lab results. She stated that this had been her concern in the past as there have been multiple instances of facility staff not telling her lab results; and, she had to go track down if the labs had come back and what the levels were. A review of the clinical record of resident #1 was conducted with the NP who stated that the length of time between when labs were ordered (04/25/2024) and when they were reviewed by a provider (04/30/2024) was egregiously long; and that, STAT means she wants to know the lab result immediately. Regarding resident #1, the NP stated that she sees the resident on Tuesdays and Thursdays; and that, on that particular Thursday (04/25/2024), resident #1 did not look good and on the following Tuesday (04/30/2024), the resident looked worse. The NP said that resident was not supposed to look worse if the resident was actively on an antibiotic, so the decision was made to send him out immediately. She stated she worked as fast as she could once she had the results and the resident was sent out emergent. The NP stated that with the resident's lab results and the visible physical worsening of his leg, an oral antibiotic would absolutely not suffice due to the speed at which he declined. Further, the NP said that the facility had no record of any hardware the resident had; but, the hospital found a rod in his right leg. The NP said that when she discussed this with the medical director, both she and the medical director agreed that had they known about the hardware, they would have sent him out the first day. She stated she was surprised to find out about the amputation; and, she was unsure if it would have changed the outcome if the resident had been sent earlier. In an interview with the acting DON (Staff #7) conducted on 07/01/2024 at 4:20 p.m., the acting DON stated that the expectation was that STAT lab results should be within 2-4 hours, though they can take longer depending on the day and time they were initially ordered. The acting DON also said that after getting results, nursing staff should have a conversation with the provider; and that, waiting 5 days for the provider to review labs would not be appropriate. The acting DON also said that the expectation was that the nursing staff will reach out to the provider for stat labs as soon as the results come in. During the interview, a review of the STAT lab results was conducted with the acting DON who stated that the facility received the STAT lab results on 04/25/2024 at 1:14 p.m.; and that, white blood cell count should have been reported to the provider immediately. The facility policy on Change in a Resident's Condition or Status last revised February 2021 revealed that the facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident's medical/mental condition and/or status. The nurse will notify the resident's attending physician or physician on call when there has been a significant change in the resident's physical/emotional/mental condition or of the need to alter the resident's medical treatment significantly. The policy also included that regardless of the resident's current medical or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. In another policy entitled Wound Care, last revised October 2010 it stated that documentation standards require staff document in the chart any change in the resident's condition, all assessment data (i.e., wound bed color, size, drainage, etc.) obtained when inspecting the wound, and that they report any other information in accordance with facility policy and professional standards of practice.

Based on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate supervision was provided for 1 of 3 sampled residents (#12) to prevent elopement; and, failed to ensure safety while providing care resulting to a fall for 1 of 3 sampled residents (#11). The deficient practice could result in avoidable accidents. Findings include: -Regarding Resident #11 Resident #11 was admitted on [DATE] with diagnoses of muscle weakness, history of falling, abnormal posture, anxiety disorder and mood disorder. A care plan initiated on April 10, 2017, revealed resident had self-care deficit. Interventions included limited to extensive assist with activity of daily living (ADL) and incontinent care as needed. A physician order dated April 20, 2020 included to admit resident to hospice for diagnosis of senile degeneration of the brain. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE]. 2020 revealed that the resident scored 99 on a Brief Interview of Mental Status (BIMS), which indicated that the interview could not be completed. The MDS included the resident had short-term and long-term memory problems, with rejection of care being exhibited on 1-3 days during the assessment dates, and required extensive assistance for toilet and personal hygiene, with one-person physical assist. The nursing note dated August 13, 2020 included resident was awake but was not responding to verbal stimuli like he used to, was not eating or drinking at this time. It also included that resident was responding to physical stimuli when repositioned or during hygiene care. A psychiatric evaluation note dated August 13, 2020 included that according to staff, the resident had an overall decline with little to no oral intake, had decrease responsiveness and was being followed by hospice for end of life care. Mental status exam included the resident was lethargic, disoriented, non-cooperative, confused and unfocused. The documentation also included the resident had a longstanding psychiatric history but was presenting with significant decline. Diagnosis was dementia with behavioral disturbance and undifferentiated schizophrenia. Plan was to discontinue psychotropic medications and to continue to monitor mood and behavior. The hospice physician order dated August 14, 2020 at 11:45 a.m. revealed that all routine and psychotropic medications were discontinued. This order also included orders for morphine (narcotic opioid) and Ativan (anti-anxiety). Review of nursing progress notes dated August 14, 2020 at 12:53 p.m. revealed the resident remained in bed with continued comfort cares due to expected death. Per the documentation, resident was sedated and occasionally responded to tactile stimuli. The documentation included that at approximately 10:00 a.m. a certified nursing assistant (CNA) was changing the resident who was lying on his left side while the CNA was providing care. It also included that the resident became agitated, rolled towards the wall; and when the resident rolled, the bed moved and the resident fell between the wall and the bed. Per the documentation, the resident sustained laceration to the left temporal area and a skin tear to the right elbow; and that, hospice, POA (power of attorney) and the provider were notified. The nursing progress note dated August 14, 2020 at 02:40 p.m., revealed that resident's comfort level was continued to be monitored; and that, respirations continued to be shallow and was decreasing rate steadily with no apnea. Per the documentation, at 2:27 p.m., resident was noted to be without respiration or apical pulse and with eyes fixed; and that, hospice and provider were notified. Review of a Facility Reportable Event Record/Report dated August 17, 2020 revealed that the resident was being changed by the CNA; and, the resident was lying on his side while the CNA was providing care, the resident became slightly agitated and rolled toward the wall. It also included that the bed moved from the wall when the resident rolled and the resident fell between the wall and the bed. Per the documentation, the resident sustained a temporal laceration measuring 3.8 x 3.8 cm and a J-shaped skin tear to the right elbow measuring 3.8 x 1.8 and was cleansed with saline, edges approximated and covered with tegaderm. Continued review of the facility report revealed that the wheels on the bed were unlocked at the time of the incident because the CNA was walking around the bed to provide care; and that, maintenance was contacted to ensure the bed was functioning properly. The facility report included a written statement from the involved CNA (staff #172) dated August 14, 2020. The documentation included that the CNA (staff #172) provided care at the time of the fall, wrote the resident started to resist during patient care and as the CNA continued patient care the resident rolled from a side position onto the floor. An interview was conducted on March 28, 2023 at 2:24 p.m. with a CNA (staff #97) who stated there would be no reason to move a resident's bed if there was one person providing incontinence care. She also stated that if the wheels of a bed were unlocked to move, the expectation was to re-lock the wheels once the bed had been moved and prior to starting incontinence care. The CNA said the expectation was that once the resident becomes agitated or becomes combative during continence care, staff was to stop care immediately, lower the bed, and ask a nurse to come in and talk to the resident. The CNA stated that if the resident does not agree to continue the care, then staff are to approach the resident later. Further, the CNA stated that if a resident becomes agitated or combative it was the resident's way of communicating to staff that they do not want to continue with the care. In an interview with a licensed practical nurse (LPN/staff #36) conducted on March 28, 2023 at 2:35 p.m., the LPN stated she would not move the bed away from the wall prior to providing incontinent care. She said that if she would move the bed away from the wall, she would re-lock the brakes prior to starting care to ensure the safety of the resident. The LPN further stated that it was the facility's expectation to step away if a resident becomes agitated/combative during incontinent care. An interview was conducted on March 28, 2023 at 3:23 p.m. with the Interim Director of Nursing (interim DON/staff #109) who stated that the expectation was for staff to relock the brakes on the bed after it was moved and prior to starting patient care. She further stated the only reason to move a bed from it being against a wall, would be if two staff were providing care. The interim DON stated that if a resident becomes agitated during care, staff should stop immediately, and call for assistance. During the interview, a review of the facility reportable event record/report was conducted with the interim DON who stated that per the CNA's interview, the care was not provided according to professional standards because the CNA did not stop the care when the resident resisted. The interim DON stated that the risk of continuing care when a resident was agitated and leaving the bed wheels unlocked during resident care could result in resident injury; and that, this did not meet the facility expectations. Review of a facility policy titled, Safety and Supervision of Residents, included that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. Environmental hazards include bed safety, safe lifting and movement of residents, and unsafe wandering. Review of a facility policy titled, Dignity, revealed that each resident shall be cared for in a manner that promotes and enhances his/her sense of well-being. Staff are expected to treat cognitively impaired residents with dignity and sensitivity. Residents are treated with dignity and respect at all times. When assisting with care, residents are supported in exercising their rights. -Regarding Resident #12 Resident #12 was admitted on [DATE] with diagnoses of hallucinations, encephalopathy, convulsions, cerebral aneurysm and mental disorder to known physiological condition. The elopement/wandering risk data set dated [DATE] revealed no history of elopement in the past 6 months and that the resident was able to transport self independently by ambulation. Per the assessment, the resident had predisposing diagnosis for elopement, had poor safety/environmental awareness and was at risk for elopement. Plan was to follow prevention of elopement protocols. The clinical record revealed no other elopement/wandering risk data set completed after March 6, 2019. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06, which indicated severe cognitive impact. The MDS also included that the resident had no behaviors or wandering behaviors exhibited within the look back period. The quarterly MDS assessment dated [DATE] revealed the resident had short and long-term memory problems, had modified independence for daily decision making and was not coded for the presence of wandering during the look back period. A psychiatric evaluation note dated August 11, 2020 included that the resident had a recent increase in agitation and was verbally aggressive with nursing staff; and that, this was an unusual behavior for the resident. Diagnoses included vascular dementia with behavior disturbance and alcohol-induced persisting dementia. Per the documentation recent aggression and threatening behavior occurred just prior to his diagnosis of COVID and likely represents a psychiatric manifestation of the illness. Further, the documentation included that the resident does not need further psychiatric medication at this time. A social service note dated September 3, 2020 at 6:11 p.m. revealed that social service director (SSD) called the police at 5:30 p.m. due to the resident missing from his doctor's appointment. Despite documentation that the resident was at risk for elopement, there was no evidence found in the clinical record that a care plan was developed with interventions to address the risk for elopement until September 3, 2020. The care plan dated September 3, 2020 included the resident had been successful with elopement. Goal was that the resident will not elope and choose to remain at the facility. Interventions included resident will have an escort for all appointments and to have psychotherapy consult for coping mechanisms. A nursing note dated September 4, 2020 at 9:31 a.m. revealed that at approximately 4:30 p.m., the director of nursing (DON) was notified that the resident did not return from his appointment at the cardiologist. Per the note, the resident's ride did not show up at the scheduled pick-up time; and that, the unit clerk (at approximately 12:10 p.m.) that a second pick up was called and was scheduled to be at the clinic in an hour. Further, the note included that cardiology clinic staff reported seeing the resident getting into a vehicle but did not give specific time. The clinical record revealed that the family and provider was notified of the resident's elopement. A review of the nursing progress note dated September 5, 2020 included the resident arrived at 9:00 p.m. and was placed on precautionary isolation and 15-minute monitoring. Per the documentation the resident appeared to be weak, unsteady when he stood up, was not able to walk and sat back down on the bed. It also included that the resident was alert and oriented x 3, had sunburn on his shoulders and back, both legs from above the knee down to his feet. According to the documentation, the resident reported that he went to another city, to the casino and to a friend's house and was walking to the park when he fell . The note included that the resident said he could not stand up so he crawled to a tree and sat under it all day. Review of a hospital note dated September 5, 2020 revealed the resident was brought into the emergency room for intoxication after he was found outside of a liquor store with altered level of consciousness. The documentation revealed the resident reported he was living in a nursing home facility up to 2 days ago when he escaped. Physical examination included a first-degree sunburn on bilateral anterior lower legs. The report also included that the resident was alert and oriented x 1 and could only reveal his name. Diagnoses were abdominal pain, dehydration, diabetic ketoacidosis, electrolyte imbalance, and confusion. The toxicology reports revealed ethanol, plasma 196, which indicated depression of the central nervous system. A nursing note dated September 6, 2020 included that the resident took the bus, got in the light rail to another city where he went to his friend's house, went to buy vodka bottle. The documentation also included that the resident slept next to the liquor store the first night and his friend made him a bed in the back for him to sleep on the second night. Review of a Facility Reportable Event Record/Report dated September 8, 2020 revealed that resident #12 went to a cardiologist appointment on September 3, 2020, unescorted. The report revealed that the staff member scheduled to escort the resident did not come in and the Director of Nursing and the other members of the management team decided the resident could go unaccompanied. Later in the day at 3:55 p.m., facility management was made aware the resident had not returned to the facility. Staff were dispatched to the physician office and surrounding areas to search on Friday and Saturday in an effort to locate the resident. The report included that the police, family, and state agency were made aware and a silver alert was activated on Friday; and that, the police located the resident at 1:00 p.m. on Saturday (September 5, 2020) and was transferred to the hospital for evaluation. An interview was conducted on March 24, 2023 at 11:51 a.m. with a Social Services Director (SSD/staff #56) who stated that all residents are transported to appointments with an escort, including those that have high risk for elopement. She said that if there was no escort available, the appointment would be rescheduled; and that, the facility expectation was to send all residents to appointments with an escort. The Social Services Director further stated that she could think of any reason that a resident who was an elopement risk would be sent to an appointment alone; and that, this could result in the resident being lost and vulnerable for injury. In an interview with a CNA (staff #103) conducted on March 24, 2023 at 12:22 p.m., the CNA stated that the facility process was to have an escort for all resident scheduled for an appointment; and that, at the time of the incident in September 2020, none of their residents are sent out to an appointment unescorted. The CNA stated this had been that way since she started working in the facility for the past [AGE] years. Regarding resident #12, the CNA stated she was familiar with the resident and that the resident was an elopement risk. The CNA also said she was in the building on the day the resident went to the appointment; and that, the resident's escort was on the way; but, transportation got in early. The CNA said that they called and informed the DON who made the decision to go send resident #12 by himself. She stated that evaluations for elopement risk are completed on admission and quarterly. An interview was conducted on March 24, 2023 at 12:06 p.m. with an LPN (staff #93) who stated that the facility process was to send an escort with the resident to all appointments outside of the facility. She stated the admitting nurse would complete an elopement risk upon resident admission; and that, residents assessed to be at risk for elopement would have an escort to medical appointments. Regarding resident #12, the LPN stated she was familiar with the resident; and that, the resident went out to an appointment and went with a friend to a casino. The LPN stated resident #12 told her he went off drinking and to the casino. The LPN further stated that if resident #12 was assessed as an elopement risk prior to the appointment at the time of the incident, resident #12 he should have had an escort to the appointment. During an interview with the administrator (staff #45) conducted on March 24, 2023 at 1:55 p.m., the administrator stated resident #12 was found to be an elopement risk and the DON at that time decided to send the resident to the appointment without an escort. A review of the clinical record was conducted with the administrator during the interview. The administrator stated there was no evidence that the provider or other administration had been consulted prior to the DON making the decision to send the resident to the appointment unescorted. She stated that she found no effort in the medical record that the DON followed up on the resident to see that he made it to the appointment and there was no evidence that they asked transport to stay. She stated that this did not follow the facility policy enacted on 2015. She stated that resident #12 was transported out of the facility unsafely, and could result in a severe detriment to the resident. She stated that her expectation was that all residents have an escort when transported to appointments In an interview with the Director of Nursing (DON/staff #95) conducted on March 24, 2023 at 2:39 p.m., the DON stated that all residents receive wandering/elopement assessments on admission and quarterly. She stated that if the resident was assessed to be at risk for wandering/elopement, this should be on the care plan. The DON stated that every resident whether high risk or low risk for elopement at the facility has an escort to all appointments. She stated that sending a resident out to an appointment without an escort does not meet the facility process. She stated that she would expect the facility policy for elopement to be followed; and that the risk for not following protocol could result in resident eloping from the appointment and be lost, resulting in possible resident injury. During the interview, the DON reviewed the care plan for resident #12 and stated that the resident was not care planned for an elopement risk. Further, the DON stated there was no evidence of quarterly elopement risk assessment; and that, this did not meet the facility expectations. Review of the facility policy titled, Transportation Dental Services, revealed that a member of nursing staff or social services will accompany the resident to the office when resident's family is not available. Review of the facility policy titled, Diagnostic Services Transportation, revealed that a member of the nursing staff, or social services, will accompany the resident to the diagnostic center when the resident's family is not available. Review of the facility policy titled, Behavioral Unit Policy for Residents and Staff, revealed that residents may go off the unit only when directly supervised. Review of the facility policy titled, Resident Outside Appointment Process, revealed that the Unit Coordinator will arrange appointments for residents that will include requesting an escort from the resident's insurance company or internal staffing. Lead CNAs on each unit will be responsible for making sure the resident has an appropriate escort with them prior to departure. Review of the facility policy titled, Wandering and Elopements, revealed that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm. If identified as a risk for wandering, elopement, the resident's care plan will include strategies and interventions to maintain the resident's safety. Review of a facility policy titled, Safety and Supervision of Residents, included the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. The individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs. Environmental hazards include bed safety, safe lifting and movement of residents, and unsafe wandering. Review of a facility policy titled, Elopement Protocol, revealed that the facility maintains a process to assess all residents for risk and elopement, implement prevention strategies of those identified as an elopement risk, institute measures for resident identification and conduct a missing resident procedure. All residents will be assessed on admission, quarterly and with changes of condition for risk factors that would place the resident at risk for elopement such as wandering or elopement. All residents who are identified at risk for elopement will have their picture taken and be placed in the elopement book and the care plan will be updated. If a resident is identified at risk for elopement an id bracelet containing the facility address and phone number will be placed on the resident.

Based on clinical review, staff and resident interviews, and the policy and procedures of the facility, the facility failed to ensure two residents (#3 and #8) were not abused by another resident (#12). The deficient practice could result in other residents being abused. Findings include: -Resident #3 was admitted to the facility on [DATE] with diagnoses that included Alzheimer disease with early onset, anxiety, and a traumatic brain injury. The Minimum Data Set (MDS) dated [DATE] included a staff assessment mental status score of 3 indicating the resident had a severe cognitive impairment. Review of the care plan dated January 23, 2023 revealed the resident had the potential for skin tears. On January 22, 2023, the resident had left shoulder swelling and abrasion of the left trapezium. On January 29, 2023 the resident had a one-centimeter open area on the back of his head. Interventions included that if skin tear occurs, treat per facility protocol and notify MD, family. A progress note dated January 22, 2023 revealed that the writer heard a loud noise down the hall, went to check what it was and saw resident #3 on the floor in resident #12's room near the dresser. The certified nursing assistants (CNAs) helped assist resident #3 up from the floor and redirected the resident back to his room. The resident was in bed resting. No injuries noted and neuro checks were started. A progress note dated January 29, 2023 at 8:45 p.m. stated that resident #12 came out of his room into the hallway and pointed at his room. The writer entered the room and found resident #3 on his buttocks on the floor near the bathroom door. Resident #3 was trembling, but there were no signs of seizure noted. The residents (#12 and #21) were both seen sitting on their beds. Resident #21 appeared concerned, and resident #12 noted to be relatively relaxed with no signs of aggression or agitation. The writer and co-nurse assessed resident #3 for any injuries and none noted at the time of the report. Range Of Motion (ROM) intact, neuros within limits. Staff slowly assisted the resident to a standing position and encouraged resident #3 to sit in a chair for further examination. The resident refused to sit in the chair and proceeded to walk in the hallway. The resident was showing signs of agitation, and continued to walk with close supervision. PRN (as needed) Ativan 0.5 ml (milliliter) given for agitation/restlessness. All responsible parties notified. Neuros continuing. Staff continuing to monitor. Resident was wearing non-skid socks at time of the fall. Review of the Order Summary Report revealed an order dated January 29, 2023 to monitor abrasion to back of head for serious symptoms of infection until healed. A progress note dated January 29, 2023 at 9:15 p.m. revealed that 2-hour post fall, staff noted blood from the back of resident's head, approximately one centimeter in length. Notified the Director of Nursing (DON) with orders to monitor and assess daily. Review of the care plan dated February 15, 2023 revealed resident #3 is an elopement risk/wanderer related to the resident wanders aimlessly. Interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book, and to reside on a locked unit due to wandering and elopement risk. -Resident #8 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, anxiety disorder and heart failure. The Minimum Data Set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 99, indicating the resident was not able to complete the interview. Review of the care plan dated February 9, 2023 revealed the resident is an elopement risk/wanderer related to the resident wanders aimlessly. Interventions included to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or a book, and to reside on a locked dementia unit. Progress note dated February 15, 2023 revealed that resident was ambulating and wandering in and out of other residents' rooms and when sitting in wheelchair, continues to get out of it. A progress note dated February 18, 2023 at 7:06 p.m. revealed that the writer was alerted by a CNA to resident #12's room. The writer entered the room and found resident #8 lying on the floor on his back. The resident's head was against the wall near the bathroom door. Upon inspection, a laceration was noted to the crown of his head: 4.5 x 0.5 x 0.1 centimeters. -Resident #12 was admitted to the facility on [DATE] with diagnoses that included undifferentiated schizophrenia, restlessness and agitation, and an anxiety disorder. The Minimum Data Set (MDS) dated [DATE] included a BIMS score of 99 indicating the resident was not able to complete the interview. A care plan dated February 18, 2023 revealed that the resident is/has the potential to be physically aggressive, related to dementia, history of harm to others, poor impulse control. On February 18, 2023 he kicked a resident in the stomach. Interventions included the resident triggers for physical aggression when his personal space is invaded, the belief that someone is approaching him to do harm. The resident's behaviors are deescalated by the intervention of staff, providing distractions like snacks and drinks, administer medications as needed, and to place a Velcro sign across the doorway to prevent others from wandering into the room. A progress note dated January 20, 2023 at 9:46 a.m. revealed that the night shift nurse reported that resident #12 was agitated and cussing at the new roommate last night. The resident was extremely territorial, not wanting anyone to come near him or in his room. The roommate is vulnerable and appears uneasy in the room. Reported behavior to administration. A progress note dated January 20, 2023 at 10:04 p.m. revealed that staff entered the room to pick up dishes and the resident started yelling, get the cup and get the fuck out of my room. The roommate was in resting in bed at the time and quickly got up and left the room. The behavior was reported to the administrator and staff was to continue to monitor the resident. A physician progress note dated January 29, 2023 revealed that the physician spoke with guardian who was able to provided that the resident had a history of significant physical aggression at prior placements against both other residents and staff members; had a history of elopement, at one facility he eloped out the window; and, used to live at another facility, from there he was placed at several group homes which he failed. According to the documentation, the guardian was unsure of the exact reason why the recent group home will not take him back; howver, belives that it was because he was cursing at other residents. He has a history of homelessness, history of Traumatic Brain Injury, alcohol dependence, cognitive impairment, and anxiety disorder. He has in the past refused medication which has led to decompensation and increase in physical aggression. A progress note dated January 30, 2023 at 9:29 a.m., revealed that the Psych provider was on the unit. This resident's roommate (resident #21) spoke with the provider, and made the statement that he witnessed resident #12 kick a man that came into their room. The provider sent out a message to leadership thread for further investigation. The psych provider met with resident #12 at this time. Per psych provider, resident #12 confirmed that he did kick a man after being threatened. Update was sent to leadership thread, continue awaiting instructions. A progress note dated January 30, 2022 at 9:42 a.m. revealed that the message received via thread from the DON. Social Services to follow up with residents regarding accusation. A progress note dated February 18, 2023 at 6:19 p.m. revealed that the resident continues 15-minute checks following an incident at approximately 3:05 p.m. when resident reported to staff that another resident was in his room and the other resident was found lying on the floor of the resident's room with a laceration to his head. Arizona Department of Health Services (DHS) notified via website at 4:53 p.m., DHS notified via website as well. Phoenix police (PPD) notified also, unable to give estimated time of arrival. One to one placed outside of resident's door for safety pending investigation. The staff will continue to monitor and await PPD arrival. A progress note dated February 18, 2023 at 7:28 p.m. revealed that at 3:00 p.m., resident #12 approached the nurse's desk asking to use the bathroom. He stated he could not use his own bathroom because there was a man in his room. The CNA entered the room to check and motioned for this writer. The writer entered the room and found resident #12 sitting cross legged on the bed and resident #8 lying on the floor. Resident #12 stated that the other resident came into his room and attacked him so he kicked him in the gut. 15-minute checks and one-to-one safety monitoring initiated. Facility documentation dated February 18, 2023 revealed a statement by a registered nurse (RN/staff #72), who stated that resident #12 stated that resident #8 attacked him and so resident #12 kicked resident #8 in the gut. Facility documentation dated February 20, 2023 revealed resident #12's statement in which he states that resident #8 wanted to fight and walked up to him while he was in bed, so he kicked him in the stomach. A physician's progress note dated February 23, 2023 at 2:37 p.m. revealed that upon exam, resident #12 is noted to be paranoid, states that another resident was trying to kill him and that he kicked him. An interview was conducted on February 23, 2023 at 2:15 p.m. with the Director of Nursing (DON/staff #1), who stated that resident #12 was transferred from the dementia unit to the behavioral unit today at 12:30 p.m. A second interview was conducted on February 23, 2023 at 3:00 p.m. with the (DON/staff #1), who stated the resident #12 originally had a roommate, resident #21, who stated on January 30, 2023 that he was afraid of resident #12 because he had seen him kick another resident, but he was not able to describe the other resident. When asked if it was possible that resident #21 was referring to resident #3, who was found on the floor in resident #12's room on January 29, 2023, she stated that it was possible. She also stated that there was supposed to be Velcro stop sign across resident #12's door to prevent other residents from entering, but it was often missing and easy to pull down. An interview was conducted on February 23, 2023 at 3:20 p.m. with a certified nursing assistant (CNA/staff #84), who stated that there is supposed to be one CNA, who monitors the hall, and is supposed to walk up and down the hall, but staff are too busy. She stated that resident #12 had prior altercations with other residents prior to resident #8 being found on the floor in resident #12's room. She stated that staff knew that resident #12 was not appropriate for the dementia unit. She stated that prior to resident #8 being found on the floor in resident #12's room, he had already stated that he had pushed resident #3. An interview was conducted February 23, 2023 at 3:31 with a licensed practical nurse (LPN/staff #156), who stated that there are residents who wander and there are residents who are aggressive on the dementia hall. She stated that they try to keep one CNA in the hallway to monitor, but they are busy and there is not a specific CNA assigned to monitor the hall. She stated that resident #12 needed supervision all the time. (CNA/staff #10) joined the interview and stated that resident #12 came to the nurse's station and asked to use the bathroom because there was another resident in his bathroom. She went with resident #12 to his room and found resident #3 on the floor. She asked resident #12 what happened and stated that he told her that resident #3 tried to attack him and he kicked him in the gut. An interview was conducted on February 24, 2023 at 9:12 a.m. with the Social Services Director (SS/staff #2), who stated that resident #12's room change occurred yesterday on February 23, 2023 and he was moved from the dementia unit to the behavior unit. She stated that resident #12 was moved because of the incidents that occurred with other residents (#3 and #8). She stated that resident #12 is territorial and doesn't understand that the other residents mean him no harm. She also stated that the residents on the dementia unit should be monitored and should not be wandering in to other residents' rooms. She stated that when resident #3 was found in resident #12's room on the floor, she tried to interview resident #12, but he told her to get the fuck out of his room, resident #3 is nonverbal, and she talked to staff, but did not document anything. She stated that resident #12's roommate, resident #21, requested a transfer to another room because he was afraid of resident #12. On January 31, 2023, resident #21 stated that he saw resident #12 kick another male resident, but he was not able to identify the resident. She stated that when resident #8 was found on the floor in resident #12's room, resident #12 told her that he kicked him in the stomach. She stated that resident #12 had a history of being aggressive at other facilities. On February 24, 2023 at 3:12 p.m. an interview was attempted with resident #12, who stated that he wanted to be left alone. An interview was conducted on February 24, 2023 at 3:18 p.m. with resident #21, who stated that he feels a lot better know that he is no longer a roommate with resident #12. He stated that resident #12 scared him a lot because he saw him kick resident #3. The facility's policy, Abuse and Neglect Policy, revised December 2016 states residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. Abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish.

Based on review of clinical records, staff interviews, facility investigations, and facility policy and procedures, the facility failed to ensure one resident (#5) did not physically abuse another resident (#6). The deficient practice could result in other residents being abused. Findings include: -Resident #6 was admitted on [DATE] with diagnoses of schizoaffective disorder, bipolar disorder, adrenocortical insufficiency, conversion disorder with seizures or convulsions, violent behavior, and personal history of other mental and behavioral disorders. -Resident #5 was admitted on [DATE] with diagnoses that included Schizoaffective disorder, major depressive disorder, nicotine dependence, and essential hypertension; and was the identified alleged perpetrator. The interim care plan dated November 4, 2022 revealed the resident had no cognitive impairment and was taking antipsychotic/psychotropic medications. However, the interim care plan did identify behaviors and did not include interventions to direct staff on how to deal with aggressive behaviors of resident #5. The admission summary dated November 4, 2022 included resident #5 was a smoker, was a little irritated that he did not have cigarettes. The physician order summary report revealed the resident was prescribed with the following antipsychotic medications: -Haloperidol 5 mg (milligrams) by mouth three times a day for psychosis (start date of November 4, 2022); and, -Latuda 40 mg two times a day for psychosis (start date of November 5, 2022) These medications were transcribed onto the MAR (medication administration record) for November 2022. However, the MAR revealed that on November 5, 2022, Haloperidol was not marked as administered on the night shift; and, Latuda was not marked as administered on the 8:00 a.m. and 2:00 p.m. shift. Both medications had a code of 9 that indicated to see progress notes. The administration note dated November 5, 2022 included that Latuda was pending delivery from pharmacy. Another administration note dated November 5, 2022 revealed Latuda was not available pending insurance approval; and that, the NP (nurse practitioner) was notified. Review of another administration note dated November 5, 2022 included that Haloperidol was not available; and that, delivery from pharmacy was pending. There was no evidence found in the clinical record that Haloperidol and Latuda was administered as ordered on November 5, 2022. A behavior report dated November 5, 2022 revealed that resident #5 attempted to reach and grab another resident; and that, staff had to get in-between the two residents. The documentation also included that resident #5 said he was trying to get the other resident's hat; and that, a staff asked the resident to keep his hands to his self. The report did include that the physician/provider was notified. A nursing note dated November 5, 2022 included that at approximately 7:25 a.m., the CNA (certified nurse assistant) reported that resident attempted to reach out to grab another resident while in the hall way. Per the documentation, the CNA got in between and resident #5 stated that he was trying to get the other resident's hat. It also included that the CNA attempted to redirect the resident who chose to wait for breakfast by the dining room door. The documentation did not indicate that the physician/provider was notified of the resident #5's behavior. A nursing note dated November 5, 2022 included that at approximately 2:00 p.m. resident #5 demanded to go outside during the smoke break was very agitated for not having cigarettes and was yelling/cursing at staff. Per the documentation, resident #5 stated fuck you I'm getting the hell out of here! You want me to jump the fence to get some 'cigs' I can do it if you want me to. Further, the note included the resident threw the ashtray bucket over the patio fence, went back inside the unit, punched the trash can, went to his bedroom and slammed his door shut. According to the documentation the provider and the psych NP were notified. A nursing note dated November 6, 2022 included that all medications were administered without difficulty and staff will continue to monitor. However, the MAR documentation on November 6, 2022 revealed the MAR coded 1 indicating absent from home without meds for Haloperidol on three shifts and for Latuda on two shifts. A care plan was initiated on November 6, 2022 for behavior problems related to aggressive behavior with a history of resident to resident incidents. The goal was that the resident would have fewer episodes of aggressive behavior. Interventions included to administer medications as ordered, monitor/document for side effects and effectiveness, intervene as necessary to protect the rights and safety of others, divert attention, remove from situation and take to an alternate location as needed, and to intervene before agitation escalates. A behavior report dated November 6, 2022 included that resident #5 told staff that the next time staff say huh to him, he was going to get aggressive with her. Another behavior note dated November 6, 2022 revealed the resident threatened to get physical with staff due to staff inability to understand him. The documentation did not include that the provider was notified. In another behavior note dated November 6, 2022 it included the resident was in the room throwing a trash can and a chair; and was yelling and screaming at staff. Per the note, the resident continued to yell out at staff, redirection was given but was not effective. The documentation did not include that the provider was notified of the resident's aggressive behavior. A nursing note dated November 6, 2022 included that on November 5, 2022 at approximately 5:30 pm, resident #5 was by nurses' station yelling and was demanding for cigarettes. The note included that resident #5 threw a spoon at the door; and, another resident (#8) yelled at resident #5 from the hall telling resident #5 to shut up and behave! The documentation included that resident #5 yelled back don't tell me to shut up!; and, ran towards resident #8 to try to strike at her. The note included that staff was able to get the female resident out of the way and resident #5 went to his bedroom, was laughing talking to self; and that, the staff continued to monitor resident #5 closely. Despite documentations that smoking triggered the resident's aggressive behaviors, smoking was not addressed in the care plan. A nursing note dated November 6, 2022 revealed that at approximately 6:10 a.m. resident #5 was sitting on a chair in the hallway yelling and cursing at staff; and was cursing another resident who was pacing in the hallway. The note also included that resident #5 yelled I will fuck all you pussies up! There's no fucking men down here. According to the documentation, staff attempted to deescalate resident #5; but was not effective. Despite the resident #5's escalating aggressive behavior towards staff and other residents, there was no evidence found in the clinical record that the provider was notified after each these episodes. Another nursing note dated November 6, 2022 included that resident #5 was in the hallway yelling/cursing at staff; and, at approximately 6:25 a.m. another resident (#6) yelled from his bed and told resident #5 .shut the fuck up. According to the documentation, resident #5 quickly went into resident #6's bedroom and got on top of him, punched the resident (#6) in the face multiple times. The note included that 911 was called immediately and extra staff was called to the unit to assist in de-escalation. It also included that resident #5 sat in wheelchair by unit exit door for a few minutes and then went to his bedroom willingly. According to the documentation, the administrator, DON (Director of Nursing), Psych NP (Nurse Practitioner), and medical provider were all notified; and, at 7:05 am resident #5 was escorted by police out of the facility. A review of another nurse progress note dated November 6, 2022 at 12:57 p.m. (approximately 6 hours after the incident) included that resident #6 had complained of chest pain and pain/blurriness to right eye, the physician was notified and an order was received to send resident #6 to the ER (emergency room ) via non-emergency transport for a CT (Computed tomography Scan) and CXR (chest x-ray). A psychiatric evaluation dated November 6, 2022 revealed staff reported resident #5 became angry in the morning of November 6, 2022 and had entered the room and hit resident (#6) in the face. The evaluation included that the NP recommended against accepting the resident back to the facility given his high level of physical aggression despite multiple psychiatric medications. A facility investigation dated November 11, 2022 included that resident #5 had a behavior problem related to aggressive behavior with a history of resident to resident incidents. The investigation included that resident #6 was assessed, had abrasions to the bridge of nose, right cheek, left and right forehead; and was given medication for reported discomfort and pain. The investigation included that due to the diagnoses and behaviors of both residents (#5 and #6) in the high acuity unit, the quick escalation of behaviors can occur and was expected. It also included that both residents had a history of verbal and physical aggression towards staff and residents. Interventions in place to de-escalate did not help. The investigation also included an interview with a CNA (certified nursing assistant) who reported that the doors to the resident rooms should have been shut to protect them while resident #5 was agitated. Further review of the facility investigation revealed that due to the diagnosis and behaviors of residents in high acuity unit, quick escalation of behaviors can occur and was expected; and that, interventions in place to de-escalate did not help resident #5 as he became aggressive towards staff as well. The report included that the facility determined that interventions placed will protect resident #6 and other residents from incidents to occur; and, was unable to substantiate abuse or neglect. An interview was conducted on January 5, 2023 at 1:05 p.m. with a CNA (staff #16) who stated she tries to read the admission paperwork to identify behaviors and triggers of residents being admitted on the high acuity behavioral unit; and that, the triggers and behaviors are communicated to the staff so they know how to approach them. Staff #16 also stated that rounding on the unit is completed every 10-15 minutes. Regarding resident #5, the CNA stated she was present when resident #5 was admitted ; and that, resident #5 was unkempt and looked wild; however, resident #5 was happy to be home because he had been at the facility before. Staff #16 stated resident #5 had been very aggressive; and trigger points for resident #5 included not being able to smoke, being told no, and other residents yelling at him. Staff #16 stated that based on the reviewing of resident's behavior from admission to the morning of November 6, 2022, resident #5 had been escalating. Staff #16 stated there was one regular staff and two agency staff working the unit the morning of November 6, 2022; and, they did not see the triggers. During an interview with a psychiatry NP (staff #22) conducted on January 5, 2023 at 2:26 p.m. the NP stated she was part of the admission process for resident #5; and her acceptance of a resident is based on medication compliance and recent physical aggression. Staff #22 stated that when resident #5 was admitted not all of his notes were beautiful; but, there was room with his medications to make adjustment if needed. Staff #22 stated the resident sort of laughed and his behaviors were sandwiched around good nights so she felt the resident was doing well; and, she knew he had a history of being verbally aggressive. The NP stated that prior to the resident hitting resident #6 in the face she was notified on November 6, 2022 about the behaviors of resident #5. The NP also said that cigarettes were a trigger for the resident in the past; and that, missed doses of medications were not good for him. An interview was conducted with a registered nurse (RN/staff #28) on January 5, 2023 at 3:14 p.m. The RN stated that she was completing a medication administration in the hallway and noted the female resident yelling to herself. Staff #28 stated that she did not know what triggered resident #5 the evening of November 5, 2022 but she just saw him going after the female resident who was removed from the area and was monitored until resident #5 de-escalated. Regarding the incident on November 6, 2022, the RN said she was getting report when she noticed resident #5 yelling in the hallway and she tried to get resident #5 away from other resident's doorways but resident #5 would not budge. The RN stated that was when resident #6 yelled out from his room because resident #5 woke him up; and then resident #5 ran into the room and jumped onto resident #6. During an interview conducted with the Director of Nursing via phone (DON/staff #33), the Assistant Director of Nursing (ADON/staff #40), and the Administrator (staff #37) on January 6, 2023 at 11:35 a.m., the DON stated the expectation was when admitting a resident to the behavior unit, staff had to review the medical record; and that, the staff on the unit have the experience to handle aggressive behavior and use de-escalation. The DON stated the expectation was that staff would call for assistance or the police when a resident continues to have aggression towards the staff and other residents and when de-escalation techniques were not working. The DON also stated that when the staff get the resident to calm down and keep other residents safe, staff will call the provider and document the notification of the behaviors. The DON stated she did not recall seeing much aggression from resident #5 in the hospital records but she knew the staff were concerned about his physical aggression. She stated that after the first aggression towards residents on November 5, 2022 the provider should have been notified. The Administrator who was present during the interview stated there were text messages to the provider but nothing documented in the electronic record that included details of what was discussed. The DON stated she thinks the doors to other resident rooms should have been closed when resident #5 was yelling up and down the hallway. The DON stated that the staff did get an order for Haldol PRN (as needed) after the incident for running in the hallway but it was not documented in the chart. The DON stated that there were communications with the nurse practitioner and the staff were instructed to keep monitoring and de-escalating the situation; and that, there was a huge delay in medications. A facility policy titled Behavioral Assessment, Intervention, and Monitoring (revised March 2019) included that the facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. The nursing staff will identify, document, and inform the physician about specific details regarding changes in an individuals' mental status, behavior, and cognition, including onset, duration, intensity and frequency of behavioral symptoms. New onset or changes in behavior will be documented regardless of the degree of risk to the resident or others. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. Continued review of the policy included that interventions and approaches will be based on a detailed assessment of physical, psychological and behavioral symptoms and their underlying causes, as well as the potential situational and environmental reasons for the behavior. The care plan will include, at a minimum: -Description of the behavioral symptoms; -Targeted and individualized interventions for the behavioral and/or psychosocial symptoms; -The rationale for the interventions and approaches; -Specific and measurable goals for targeted behaviors; and, -How the staff will monitor for effectiveness of the interventions. A facility policy titled Abuse Policy (reviewed/revised September 2022) included that the residents have the right to be free from abuse and includes but not limited to freedom from verbal, mental or physical abuse. Abuse is the willful infliction of injury, intimidation, or punishment with resulting physical harm, pain or mental anguish. The administration will protect residents from abuse by anyone including other residents.

Based on clinical record review, facility documentation, review of a video recording, resident and staff interviews, and review of policies and procedures, the facility failed to ensure that one resident (#1) was free from physical restraint imposed by four staff members (#15, #26, #36, #46) which resulted in physical and psychosocial harm to the resident. The deficient practice could result in the potential for other residents being restrained. The sample size was one. Findings include: -Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A History and Physical report dated May 12, 2020 included that resident #1 had been admitted with autism spectrum disorder from a behavioral health facility. The report included that resident #1 was known to not realize boundaries, was impulsive, can become aggressive and that the resident has assaulted peers. The report also included that resident #1 was resistant to care, was verbally and physically aggressive and intolerant of others. The report included that the resident had been admitted to this behavioral health facility after she had attacked a peer. An Admission MDS (Minimum Data Set) assessment dated [DATE] included that resident #1 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated that resident #1 was cognitively intact, and ambulated on the unit with supervision. The assessment included that resident #1 exhibited physical behavioral symptoms directed at others which put others at risk for physical injury, significantly intruded on the privacy of others, and significantly disrupted care or the living environment. A current written care plan which was undated, included that resident #1 had an alteration in cardiovascular status as evidenced by [MEDICAL CONDITION] to her lower extremities. Interventions listed in the care plan included to assess [MEDICAL CONDITION] status and report to physician if needed and to elevate extremities while in bed. A Behavioral Care Plan dated June, 2020 included that resident #1 had current behaviors like impulsive behavior that she is throwing objects, obsession and threatening behavior over phone use, and physical aggression. Intervention listed in the plan included the following: -Attempt to intervene with issues that arise between her and other residents and assist the resident with basic problem solving between other residents and herself. -If she becomes aggressive attempt to remove other residents from around her, and ask her to return to her room if she is in the day room or dining area to help calm her down. -Recognize when the resident's anxiety is getting elevated and try to de-escalate before she is extremely anxious or agitated and to look for shortening of breath, tense muscles, and raising of voice as clues to anxiety. Review of the Behavioral Care Plan dated June 20, 2020 did not reveal any additional intervention that staff were to force the resident onto the floor, or restrain the resident on the floor or immobilize the resident in any way. An NP (Nurse Practitioner) Progress Note dated August 20, 2020 included that resident #1 was known to not realize boundaries, can become aggressive and is impulsive, and has assaulted peers. The note included that resident #1, will present herself to nurses and wait until her needs are met then return to her room, and is very detail oriented. A nurses note dated August 25, 2020 at 6:07 a.m. included that at 8:50 p.m. (on August 24, 2020) resident #1 blocked a CNA (Certified Nursing Assistant) from bringing a confused male resident into the nurses station, and blocked nursing staff going in and out of the nurses station. The note included that the resident was redirected away from the nurses station, she refused, and as the CNA was wheeling the male patient towards the nurses station, resident #1 kicked the male patient and had physically aggressive behavior, and attempted to hit, kick, and pinch nursing staff. The note included that police were called and the resident was uncooperative with the police, until 20 minutes later when the police escorted her to her room. The note was completed by an LPN (Licensed Practical Nurse/staff #46). Continued review of the nurses note dated August 25, 2020 at 6:07 a.m. did not include any additional details that multiple staff (including the writer) had been involved in forcing the resident onto the floor, and that two staff had forced the resident to remain on the floor by pinning her upper and lower extremities down onto the floor for at least 20 minutes. A Social Service note dated August 26, 2020 at 3:23 p.m. included that a social worker had spoken with the family of resident #1 and that an investigation into the incident that had occurred on August 24, 2020 was ongoing and that more information had surfaced. The note included that the social worker informed the resident's family that resident #1 had been held down against her will on August 24, 2020. A nurses note dated August 26, 2020 at 6:13 p.m. included that on August 25, 2020 at 4:39 p.m. a video of the incident that had occurred on August 24, 2020 had been reviewed. The note included that video footage revealed a discrepancy with a nurses note relating to an incident that had been reported on August 24, 2020 as a resident to resident altercation, and that the status of the investigation had changed. The note included that the police were notified and requested onsite due to the status change (of the investigation) and that the resident had agreed to a forensic interview and was alert and oriented. The note included that bruising had been reported and that the resident had the following: -Light purple and blue bruising to the left lateral forearm that measured approximately 0.2 cm. (Centimeters) round in shape. -Light purple and blue 0.5 cm. bruise to the distal phalanx of the 5th digit. -A 3.0 cm. x 5.8 cm. light purple and blue bruising to the left inner upper thigh. -Left ankle 2 plus non-[MEDICAL CONDITION]. -Right ankle with 1-2 plus non-[MEDICAL CONDITION]. Review of a facility investigative report dated August 26, 2020 included that on August 24, 2020 at 8:50 p.m. an incident which had been re-classified as a staff to resident incident occurred on the Sunset Unit. The report included that a video recording showed the following: -Resident #1 was standing next to the nurses station, and a CNA/staff #36 attempted to get the resident to step back by poking her in her chest, after repeated attempts to get the resident to move back. -Staff #36 stepped behind resident #1, grabbed her under her arms and with the help of another CNA/staff #26, and a nurse (LPN/staff #46) pushed resident #1 down on the floor. -After being pushed down onto the floor another CNA/staff #15 assisted the other staff to hold resident #1 to the floor. The investigative report dated August 26, 2020 included a witness statement from a psychologist. The statement from the psychologist after reviewing video footage of the incident that occurred on August 24, said that the resident had been taken to the ground and restrained to the floor for approximately 20 minutes by three staff members. Further review of the facility investigative report revealed the following staff witness statements: -A written statement from a CNA/staff #36 dated August 26, 2020 at 4:36 p.m. included that on August 24, 2020 she heard the nurse and two CNAs telling resident #1 to back up away from the nurses station. The resident did not respond and held onto the gate (into the nurses station). The statement included that Resident #1 stepped back and to the side of staff #36 and within a split second resident #1 brought her foot up and full force kicked resident #4 in the groin. The statement included that resident #1 then fell back against me and I proceeded to take (resident #1) to the floor, and We stayed on the floor until the police came in. -A written statement from a CNA/staff #26 dated August 25, 2020 included that on August 24, 2020 resident #1 had been asked to move so that staff could being another resident into the nurses station and that when staff #36 put her hand on the resident's arm, the resident threw herself into staff #36, her left leg came up and made contact with another resident. The statement included that staff #36 took her to the ground and said hold her legs, and I did, -A written statement by a CNA/staff #15 dated August 25, 2020 included that on August 24, 2020 resident #1 stood in the doorway of the nurses station to prevent another resident from entering the nurses station. The statement included that another staff (staff #36) came and asked the resident to move, the resident refused, and that staff #36 went to grab resident #1, and another staff grabbed the resident's feet, resident #1 kicked the other resident (resident #4) in the groin. The statement included that the next thing staff #15 noticed, was resident #1, staff #36, and other staff were on the floor, and that resident #1 was crying. -A written statement from staff #46 dated August 27, 2020 included that on August 24, 2020 resident #1 was blocking the nurses station entrance and refused to move or speak when staff asked her what was wrong. The statement included that when staff #46 asked a CNA to bring a male resident (#4) into the nurses station, resident #1 kicked the male resident in the groin. The statement included that staff attempted to separate the residents but resident #1 Continued to fight, him (the resident) and one or two CNAs fell to the floor, she continued with her physical aggressive behavior, would not listen, to stop. Trying to hit, kick, pinch and bite. I tried to talk to her and tried to prevent her from hitting, biting a CNA, she was too strong and uncontrollable, . Continued review of the investigative report dated August 26, 2020 revealed that staff #15 and #46 did not mention that resident #1 had been forced onto the floor and held down onto the floor by staff for approximately 20 minutes prior to the arrival of the police. During an interview conducted on August 31, 2020 at 2:00 p.m. with resident #1 she stated that when the incident occurred (on August 24, 2020) that staff #36 was trying to squeeze my hands together, and staff #26 was pushing my legs and feet down hard on the floor. They pushed me forward and it hurt, and staff #26 did hurt my left ankle and I already have ankle problems. Resident #1 pointed at body areas where she stated that she had been hurt by being forced to the floor, including the left ankle, left inner thigh and the right side of the ribs. Resident #1 stated that when the staff forced her onto the floor It was embarrassing and I was crying, I cried and cried. They made me think I did something wrong, and that staff #46 said I should go to jail. A videotape recording was reviewed on September 1, 2020 at 9:30 a.m. with the Administrator/staff #19 and the DON (Director of Nursing/staff #147) present. Review of the video recording revealed that on August 24, 2020 at 8:50 p.m. resident #1 was standing at the door to the nurses station and was visibly agitated. A CNA/Staff #36 was seen in the video to grab resident #1 from behind by the shoulders, and forcefully pulled resident #1 quickly backwards to the floor from behind, at the same time that 2 additional CNA's (Staff #15, #26) and an LPN/Staff #46 moved quickly into the resident from the front. All four staff then simultaneously forced resident #1 to the floor, with staff #36 pinning the resident's shoulders and head to the floor, staff #26 pinning the resident's feet to the floor and staff #15 and #46 grabbing and pinning the resident's hands and arms to the floor. After a short period, staff #15 and #46 got up and removed themselves from the resident. However, staff #36 continued to hold resident #1 by the shoulders to the floor, pushing resident #1 repeatedly back down when she attempted to move, and staff #26 continued to hold the resident's feet to the floor by pinning both ankles. Staff #36 and #26 continued to restrain resident #1 to the floor for approximately 20 minutes until the police arrived. For the remainder of the videotape footage resident #1 is seen laying on the floor, attempting to rise and unable to rise or sit up, and staff #15 who is standing nearby does not attempt to assist the resident to get up from the floor. An interview was conducted on September 1, 2020 at 9:45 a.m. while the video recording was being viewed with the Administrator/staff #19 and the DON (Director of Nursing/staff #147). During the interview, the DON stated yes when asked if the video recording showed staff restraining resident #1 to the floor, and stated that the resident had a behavioral care plan in place for her behaviors. When the DON was asked if resident #1 could have sustained serious injury by being forcibly pulled backwards by staff onto the floor in the manner that staff had forced the resident to the floor the director stated yes. During an interview conducted on September 1, 2020 at 12:05 p.m. with staff #36, she stated staff were trying to move resident #4 into the nurses station, and when she tried to touch the resident's arm, resident #1 spun around, kicked another resident and she fell backwards on top of me, and I landed with her backwards on the ground. Staff #36 stated nobody forced her down and nobody held her down. Staff #36 stated that when police entered the facility, resident #1 started screaming and when the officer asked her repeatedly what was going on, she wouldn't tell him anything and kept screaming. Staff #36 stated I don't think I did anything wrong, and this is the fourth time she's whaled on a patient. I think I was in the right and I stand by what I did. Further review of the video recording of the incident that occurred on August 24, 2020 revealed details that were inconsistent with the description of the incident provided by staff #36. During an interview conducted on September 1, 2020 at 12:45 p.m. with staff #15 she stated that she heard staff #36 tell resident #1 repeatedly to move, and when staff #36 reached out to resident #1, resident #1 swung out at staff #36 and kicked resident #4 and that suddenly resident #1 was on the floor. Staff #15 stated that staff #26 grabbed the resident's feet and that the staff continued to hold resident #1 to the floor for 5 to 10 minutes. When she was asked if resident #1 complained of pain, staff #15 stated that resident #1 complained of nothing. However, staff #15 also stated that resident #1 was screaming and that when the police arrived, the resident continued to scream until the police told her to be quiet. During an interview conducted on September 1, 2020 at 2:20 p.m. with a CNA/staff #26, she stated that when staff #36 came up to resident #1 and told her it was time to go, she touched the resident's hand, and it made resident #1 jump back and push into staff #36. Staff #26 stated that when the resident pushed into staff #36, then staff #36 took the resident to the floor from behind. Staff #26 stated that resident #1 was thrashing and kicking, so I held her legs until the police got there, I'm not sure how long. When asked what the resident was doing while staff held the resident to the floor, staff #26 stated that resident #1 didn't try to grab, but she kept twisting and pulling her legs up and moving. Staff #26 stated that she did not know if restraining resident #1 was part of the resident's behavioral care plan because she never saw the behavioral care plan, and that if she hadn't been restrained she would have kept going after resident #4. On September 2, 2020 the following staff interviews were conducted on the Sunset Unit: -A CNA/staff #25 stated at 1:15 p.m. that physical restraints are not allowed to be used here at all. -A CNA/staff #50 stated at 1:20 p.m. that we are restraint free and holding a resident down on the floor for a period of time is a form of restraint. -A CNA/staff #117 stated at 1:25 p.m. that they (the staff) cannot restrain patients because they are not a licensed behavioral facility and that includes holding a patient on the floor. -An LPN/staff #22 stated at 1:40 p.m. that restraints include holding a patient to the floor and that restraints are not permitted. During an interview conducted on September 2, 2020 at 2:15 p.m. with the Administrator/staff #19, she stated that staff are not permitted to restrain patients. A policy and procedure titled Restraint Process included a stated purpose that read, To allow residents to be free from physical or chemical restraints unless medically necessary as outlined in Federal Regulatory Guideline-F 222 and MDS RAI guidelines. Any restraint order obtained must have a medical [DIAGNOSES REDACTED]. A policy and procedure titled Abuse Prohibition Standards of Practice included a statement that each resident has the right to be free from verbal, physical and mental abuse and corporal punishment, and the resident has the right to be free from mistreatment, and neglect. The policy included that the facility will train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents and supervise staff to identify behaviors such as using derogatory language, rough handling, or ignoring residents when giving care. The policy also includes that if abuse or neglect is witnessed, the person witnessing the abuse or neglect must immediately intervene for the protection and safety of the resident.

Based on clinical record review, facility documentation, review of a facility video recording, resident and staff interviews, and review of policies and procedures, the facility failed to ensure that one resident (#1) was free from physical, and mental abuse from multiple staff (#15, #26, #36, #46) which resulted in physical and psychosocial harm to the resident. The deficient practice could result in the potential for further abuse of residents. The sample size was one. Findings include: -Resident #1 was admitted on [DATE] with [DIAGNOSES REDACTED]. A History and Physical dated May 12, 2020 included that resident #1 had been admitted with autism spectrum disorder from a behavioral health facility. The report included that resident #1 was known to not realize boundaries, was impulsive, can become aggressive and that the resident has assaulted peers. The report also included that resident #1 was resistant to care, was verbally and physically aggressive and intolerant of others. The report included that the resident been admitted to this behavioral health facility after she attacked a peer. An Admission MDS (Minimum Data Set) assessment dated [DATE] included that resident #1 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated that resident #1 was cognitively intact, and ambulated on the unit with supervision. The assessment included that resident #1 exhibited physical behavioral symptoms directed at others which put others at risk for physical injury, significantly intruded on the privacy of others, and significantly disrupted care or the living environment. A current written care plan which was undated, included that resident #1 had an alteration in cardiovascular status as evidenced by [MEDICAL CONDITION] to her lower extremities. Interventions listed in the care plan included to assess [MEDICAL CONDITION] status and report to physician if needed and to elevate extremities while in bed. A Behavioral Care Plan dated June, 2020 included that resident #1 had current behaviors like impulsive behavior that she is throwing objects, obsession and threatening behavior over phone use, and physical aggression. Intervention listed in the plan included the following: -Attempt to intervene with issues that arise between her and other residents and assist the resident with basic problem solving between other residents and herself. -If she becomes aggressive attempt to remove other residents from around her, and ask her to return to her room if she is in the day room or dining area to help calm her down. -Recognize when the resident's anxiety is getting elevated and try to de-escalate before she is extremely anxious or agitated and to look for shortening of breath, tense muscles, and raising of voice as clues to anxiety. A NP (Nurse Practitioner) Progress Note dated August 20, 2020 included that resident #1 was known to not realize boundaries, can become aggressive and is impulsive, and has assaulted peers. The note included that resident #1 will present herself to nurses and wait until her needs are met then return to her room, and is very detail oriented. A nurses note dated August 25, 2020 at 6:07 a.m. included that at 8:50 p.m. (on August 24, 2020) resident #1 blocked a CNA (Certified Nursing Assistant) from bringing a confused male resident into the nurses station, and blocked nursing staff going in and out of the nurses station. The note included that the resident was redirected away from the nurses station, she refused, and as the CNA was wheeling the male patient towards the nurses station, resident #1 kicked the male patient in the groin. The note included that resident #1 had physically aggressive behavior and attempted to hit, kick, and pinch nursing staff. The note included that police were called and the resident was uncooperative with the police, until 20 minutes later when the police escorted her to her room. The note was completed by an LPN (Licensed Practical Nurse/staff #46). Continued review of the nurses note dated August 25, 2020 at 6:07 a.m. did not include any additional details that multiple staff (including the writer) had been involved in forcing the resident onto the floor, and that two staff had forced the resident to remain on the floor by pinning her upper and lower extremities down onto the floor for at least 20 minutes. A Social Service note dated August 26, 2020 at 3:23 p.m. included that a social worker had spoken with the family of resident #1 and that an investigation into the incident that had occurred on August 24, 2020 was ongoing and that more information had surfaced. The note included that the social worker informed the resident's family that resident #1 had been held down against her will on August 24, 2020. A nurses note dated August 26, 2020 at 6:13 p.m. included that on August 25, 2020 at 4:39 p.m. a video of the incident that had occurred on August 24, 2020 had been reviewed. The note included that video footage revealed a discrepancy with a nurses note relating to an incident that had been reported on August 24, 2020 as a resident to resident altercation, and that the status of the investigation had changed. The note included that the police were notified and requested onsite due to the status change (of the investigation) and that the resident had agreed to a forensic interview and was alert and oriented. The note included that bruising had been reported and that the resident had the following: -Light purple and blue bruising to the left lateral forearm that measured approximately 0.2 cm. (Centimeters) round in shape. -Light purple and blue 0.5 cm. bruise to the distal phalanx of the 5th digit. -A 3.0 cm. x 5.8 cm. light purple and blue bruising to the left inner upper thigh. -Left ankle 2 plus non-[MEDICAL CONDITION]. -Right ankle with 1-2 plus non-[MEDICAL CONDITION]. -Resident #4 was readmitted on [DATE] with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated [DATE] included that resident #4 had severely impaired cognition, required limited assistance from one person for locomotion on and off the unit, and used a wheelchair for mobility. A nurses note dated August 15, 2020 at 5:34 p.m. included that resident #4 had been kicked in the groin at 8:50 p.m. (on August 24, 2020) by an aggressive female resident (resident #1) he didn't say or do anything to the female resident. The note included that resident #4 was being escorted into the nurses station when the female resident (#1) stood in front of the entrance to the nurses station and refused to move after being directed away from the entrance to the nurses station. The note included that there was no injury to resident #4 and that he denied pain. The note was completed by an LPN/staff #46. Review of a facility investigative report dated August 26, 2020 included that on August 24, 2020 at 8:50 p.m. an incident occurred on the Sunset Unit which originally been reported as resident to resident incident, and that the facility investigation revealed that the incident was a staff to resident incident. The report included that a video recording showed resident #1 standing next to the nurses station and a CNA/staff #36 attempted to get the resident to step back by poking her in her chest, after repeated attempts to get the resident to move back, staff #36 stepped behind resident #1, grabbed her under her arms and with the help of another CNA/staff #26, and a nurse (LPN/staff #46) pushed resident #1 down on the floor. The report included that after being pushed down on the floor another CNA/staff #15 assisted the other staff to hold resident #1 on the floor. The report included that during the take down resident #1 had braced herself against the nurses station, and had made slight contact' with resident #4 who didn't seem to notice. Then report included that on August 25, 2020 at approximately 5:00 p.m. statements were obtained from staff #15, 26, 36, 46 and that all four staff were suspended from duty pending the outcome of the investigation. The investigative report dated August 26, 2020 included a witness statement from a psychologist. The witness statement included that the psychologist had reviewed video footage of the incident that occurred on August 24, which showed resident #1 standing at the nurses station, a CNA pushed her arm twice, then grabbed her from behind, The statement included that resident #1 kicked out at another patient in a wheelchair while three staff members took the resident to the ground, and staff then restrained (resident #1) to the floor for approximately 20 minutes. Review of the investigative report dated August 26, 2020 revealed a form titled Resident Abuse Questionnaire dated August 24, 2020 for resident #4 included a question that read Has anyone (staff/peers) hurt you in any way (hit, slapped, punched, handled you roughly? The questionnaire included an answer from resident #4 that read That lady kick me in my balls. Further review of the facility investigative report dated August 26, 2020 revealed the following staff witness statements: -A written statement from a CNA/staff #36 dated August 26, 2020 at 4:36 p.m. included that on August 24, 2020 she heard the nurse and two CNAs telling resident #1 to back up away from the nurses station. The resident did not respond and held onto the gate (into the nurses station). The statement included that Resident #1 stepped back and to the side of staff #36 and within a split second resident #1 brought her foot up and full force kicked resident #4 in the groin. The statement included that resident #1 then fell back against me and I proceeded to take (resident #1) to the floor, and we stayed on the floor until the police came in. -A written statement from a CNA/staff #26 dated August 25, 2020 included that on August 24, 2020 resident #1 had been asked to move so that staff could bring another resident into the nurses station and resident #1 didn't say anything, she was waving her hand. The statement included that staff #36 put her hand on the resident's arm, the resident threw herself into staff #36, and her left leg came up and made contact with another resident. The statement included that staff #36 took her to the ground and said hold her legs, and I did, -A written statement by a CNA/staff #15 dated August 25, 2020 included that on August 24, 2020 resident #1 stood in the doorway of the nurses station to prevent another resident from entering the nurses station. The statement included that another staff (staff #36) came and asked the resident to move, the resident refused, staff #36 reached for the resident's hand. The statement included that resident snatched her hand back. The statement stated that staff #36 went to grab resident #1, and another staff grabbed the resident's feet, and resident #1 kicked the other resident (resident #4) in the groin. The statement included that the next thing staff #15 noticed, was resident #1, staff #36, and other staff were on the floor, while resident #1 was trying to break her glasses and bite staff #36. The statement also included that resident #1 was crying. -A written statement from staff #46 dated August 27, 2020 included that on August 24, 2020 resident #1 was blocking the nurses station entrance and refused to move or speak when staff asked her what was wrong. The statement included that when staff #46 asked a CNA to bring a male resident (#4) into the nurses station, resident #1 kicked the male resident in the groin. The statement included that staff attempted to separate the residents but resident #1 Continued to fight, him (the resident) and one or two CNAs fell to the floor, she continued with her physical aggressive behavior, would not listen, to stop. Trying to hit, kick, pinch and bite. I tried to talk to her and tried to prevent her from hitting, biting a CNA, she was too strong and uncontrollable, . During an interview conducted on August 31, 2020 at 2:00 p.m. with resident #1 she stated that when the incident occurred (on August 24, 2020) she was standing at the nurses station and the staff tried to move (resident #4) around her into the nurses station and it was an accident with my leg, I'm trying to keep boundaries. I know I have a boundary problem and I try to practice my boundaries and social distancing. Resident #1 stated that staff #36 was trying to squeeze my hands together, and staff #26 was pushing my legs and feet down hard on the floor. They pushed me forward and it hurt, and staff #26 did hurt my left ankle and I already have ankle problems. Resident #1 pointed at body areas where she stated that she had been hurt by being forced to the floor, including the left ankle, left inner thigh and the right side of the ribs. Resident #1 stated that when the staff forced her onto the floor it was embarrassing and I was crying, I cried and cried. They made me think I did something wrong, and that staff #46 said I should go to jail. A videotape recording was reviewed on September 1, 2020 at 9:30 a.m. with the Administrator/staff #19 and the DON (Director of Nursing/staff #147) present. Review of the video recording revealed that on August 24, 2020 at 8:50 p.m. resident #1 was standing at the door to the nurses station and was visibly agitated and with an aggressive stance. A CNA/Staff #36 who stood to the left side of resident #1 was seen rapidly attempting to grab or poke resident #1 twice on her left side, then circled around behind resident #1 and attempted to poke or grab resident #1 once on her right side. Resident #1 reacted by turning suddenly to her left, and as resident #1 turned to the left side and kicked resident #4 in the groin as she struck out at staff. Videotape footage revealed that as resident #1 struck out, staff #36 grabbed resident #1 from behind by the shoulders, and forcefully pulled resident #1 quickly backwards to the floor from behind, at the same time that 2 additional CNAs (Staff #15, #26) and an LPN/Staff #46 moved quickly into the resident from the front. All four staff then simultaneously forced resident #1 to the floor, with staff #36 pinning the resident's shoulders and head to the floor, staff #36 pinning the resident's feet to the floor and staff #15 and #46 grabbing and pinning the resident's hands and arms to the floor. After a short period, staff #15 and #46 got up and removed themselves from the resident. However, staff #36 continued to hold resident #1 by the shoulders to the floor, pushing resident #1 repeatedly back down when she attempted to move, and staff #26 continued to hold the resident's feet to the floor by pinning both ankles. Staff #36 and #26 continued to restrain resident #1 to the floor for approximately 20 minutes until the police arrived. For the remainder of the videotape footage resident #1 is seen laying on the floor, attempting to rise and unable to rise or sit up, and staff #15 who is standing nearby does not attempt to assist the resident to get up from the floor, and staff when the resident is pointing at a shoe that had come off and was lying several feet away, staff #15 kicked the shoe at her, but did not assist the resident to put her shoe on which she was clearly unable to do. An interview was conducted on September 1, 2020 at 9:45 a.m. while the video recording was being viewed with the Administrator/staff #19 and the DON (Director of Nursing/staff #147). During the interview, the DON stated that staff should not have placed resident #4 directly in front of resident #1 when she was agitated. Also, the Administrator and the DON agreed that staff #15 had purposefully placed resident #4 directly in front of resident #1 while resident #1 was highly agitated, and that he was within close range to being kicked by resident #1, prior to being kicked in the groin. When the DON was asked if resident #1 could have sustained serious injury by being forcibly pulled backwards by staff onto the floor in the manner that staff had forced the resident to the floor the director stated yes. During an interview conducted on September 1, 2020 at 12:05 p.m. with staff #36, she stated that while she was coming down the hallway she heard staff telling resident #1 to move away from the nurses station. Staff #36 stated that she reached out her hand like I was going to put my arm around her so that resident #1 wouldn't be able to see resident #4 who was nearby, staff were trying to move resident #4 into the nurses station. Staff #36 stated that when she tried to touch the resident's arm, she spun around and kicked resident #4 in the groin and she fell backwards on top of me, and I landed with her backwards on the ground. Staff #36 stated nobody forced her down and nobody held her down. Staff #36 stated that when police entered the facility, resident #1 started screaming and when the officer asked her repeatedly what was going on, she wouldn't tell him anything and kept screaming. Staff #36 stated I don't think I did anything wrong, and this is the fourth time she's whaled on a patient. I think I was in the right and I stand by what I did. Further review of the video recording of the incident that occurred on August 24, 2020 revealed details that were inconsistent with the description of the incident provided by staff #36. During an interview conducted on September 1, 2020 at 12:45 p.m. with staff #15 she stated that the nurse (staff #46) had directed her to bring resident #4 into the nurses station and that every time she tried to move resident #4 into the nurses station, resident #1 moved forward to block them. Staff #15 stated that she heard staff tell resident #1 repeatedly to move, and when staff #36 reached out to resident #1, resident #1 swung out at staff #36 and kicked resident #4 and that suddenly resident #1 was on the floor. Staff #15 stated that staff #36 was shouting that the resident was biting her, and that staff #26 grabbed the resident's feet. Staff #15 stated that the staff continued to hold resident #1 to the floor for 5 to 10 minutes and when she was asked if resident #1 complained of pain, she stated that resident #1 complained of nothing. However, staff #15 also stated that resident #1 was screaming and that when the police arrived, the resident continued to scream until the police told her to be quiet. During an interview conducted on September 1, 2020 at 2:20 p.m. with a CNA/staff #26, she stated that the nurse had told a CNA to bring resident #4 into the nurses station so the nurse could watch resident, and that resident #1 stood in the doorway to the nurses station. Staff #26 stated that when resident #1 was redirected, she didn't move away or say anything she just stood there waving her hands around. Staff #26 stated that when staff #36 came up to resident #1 and told her it was time to go, she touched the resident's hand, and it made resident #1 jump back and push into staff #36. Staff #26 stated that when the resident pushed into staff #36, staff #36 put her hands around the resident's waist or ribs, and that was when resident #1 kicked resident #4, then staff #36 took the resident to the floor from behind. Staff #26 stated that resident #1 was thrashing and kicking, so I held her legs until the police got there, I'm not sure how long. When asked what the resident was doing while staff held the resident to the floor, staff #26 stated that resident #1 didn't try to grab, but she kept twisting and pulling her legs up and moving On September 2, 2020 the following staff interviews were conducted on the Sunset Unit: -A CNA/staff #25 stated at 1:15 p.m. that if resident #1 has an escalation in her behavior staff are to talk to her, and if she was blocking a doorway, they would clear the area of patients and re-approach the resident. Staff #25 stated that staff would not forcibly move resident #1, and that if he observed the resident being abused by another staff he would absolutely intervene to stop the abuse. -A CNA/staff #50 stated at 1:20 p.m. if resident #1 was acting out they would try to redirect her and sometimes she just needs to talk. Staff #50 stated that if resident #1 was blocking a door we don't put our hands on patients we would try to find something she likes to do to prompt her to move away. -A CNA/staff #117 stated at 1:25 p.m. that if resident #1 was acting out they would talk to her and if her behavior escalated they would move all of the residents away from resident #1, and would not force her to move if she was blocking a door. -An LPN/staff #22 stated at 1:40 p.m. that if he witnessed a staff abusing a resident he would immediately separate the staff from the resident and send the staff member home. Review of personnel records revealed the following: -LPN/staff #46 received inservice education titled: Elder Justice Act, and Respecting resident Rights on February 7, 2020. -CNA/staff #36 received inservice education titled Abuse, Neglect and Exploitation on March 4, 2020, Elder Justice Act on February 4, 2020 and Right on Target: Respecting Resident Rights on January 21, 2020. -CNA/staff #15 received inservice education titled Abuse on February 2, 2020, Abuse, Neglect and Exploitation Prevention on March 1, 2020, Elder Justice Act on March 2, 2020, Neglect on February 12, 2020, Right on Target: respecting Residents Rights on February 12, 2020. -CNA/staff #26 completed a quiz titled Abuse and Neglect Quiz on November 28, 2019. -Staff #'s 46, 36, 15 and 26 were all terminated from employment on August 27, 2020 for failure to follow the Abuse and Neglect policy and procedures, and failure to report an accurate account of incident to the Administrator/DON. A policy and procedure titled Abuse Prohibition Standards of Practice included a statement that each resident has the right to be free from verbal, physical and mental abuse and corporal punishment, and the resident has the right to be free from mistreatment, and neglect. The policy included that the following standards of practice will be operational in order that residents will not be subject to abuse by anyone, including, but not limited to facility staff or other individuals. The policy included a statement that read If resident abuse or neglect is witnesses, the person witnessing the abuse or neglect must immediately intervene for the protection and safety of the resident. The policy included that the facility will: -Train staff in appropriate interventions to deal with aggressive and/or catastrophic reactions by residents. -Recognize signs of burnout, frustration and stress in employees that may lead to abuse. -Supervise staff to identify behaviors such as using derogatory language, rough handling, or ignoring residents when giving care. The Abuse Prohibition Standards of Practice listed multiple definitions of which included that abuse is any willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or anguish, and includes verbal, mental/psychological, or physical abuse including corporal punishment. The policy also includes that if abuse or neglect is witnessed, the person witnessing the abuse or neglect must immediately intervene for the protection and safety of the resident. Further review of the Abuse Prohibition Standards of Practice revealed an addendum titled Attachment B, which included the following list of appropriate interventions to deal with aggressive and/or catastrophic reactions of resident: 1. Recognize warning signs (cursing, pacing, increased agitation). 2. Get help (avoid gathering a crowd with everyone talking if at all possible, one other quiet person may help diffuse the situation). 3. Speak in a in a calm quiet manner. 4. Move other residents out of reach and protect from harm. 5. Gently touch, if at all during the incident. (Touching could make matters worse). 6. Distract with conversation, showing object, offering food. 7. Let the situation defuse and then distract the resident to something constructive. 8. Do not back the resident into a corner-allow him/her to safely move away.

Based on observations, clinical record reviews, staff interviews and policies and procedures, the facility failed to ensure that thorough wound assessments were completed and/or the physician was notified of pressure ulcers when identified and/or that treatment orders were obtained timely and/or that treatments were provided as ordered for four of six sampled residents (#111, #105, #65 and #4) with pressure ulcers. The deficient practice resulted in residents not receiving adequate care and treatment for [REDACTED]. Findings include: -Resident #111 was admitted on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Regarding the right buttocks: The skin integrity care plan (with an onset date of December 19, 2018) included the resident was at risk for impaired skin integrity. Approaches included weekly skin checks, weekly wound monitoring, skin assessment quarterly and as needed and treatment as ordered. The quarterly MDS (Minimum Data Set) assessment dated [DATE] included the resident had moderate cognitive impairment with daily decision making skills, was at risk for pressure ulcers and did not have any unhealed pressure ulcers. The physician progress notes [REDACTED]. Per the documentation, the resident refused provider examination. The note did not include any skin findings. The NP (nurse practitioner) note dated June 10, 2019 included the resident was alert and oriented x 1 and skin was warm and dry, with no open areas. However, a nursing note dated June 10, 2019 included the resident had what appears to be a blister that had opened. The location of the blister was not documented. Treatment included cleaning and drying the area, applying barrier cream during each brief change and monitoring the site for any further skin breakdown and healing. A wound assessment report dated June 10, 2019 revealed the resident had an unstageable pressure ulcer to the right buttocks, which measured 4.5 cm (centimeter) x 3 cm with 100% slough, scant purulent drainage, normal periwound and no tunneling or undermining. Treatment included cleansing the wound with wound cleanser, pat dry, apply [MEDICATION NAME] gel topically, cover with [MEDICATION NAME] Ag and secure with adhesive [MEDICATION NAME] dressing every day. Despite documentation regarding a treatment, there was no physician's order for this treatment and there was no evidence in the clinical record that the treatment was provided from June 11 through June 18, 2019. The skin integrity care plan was revised on June 10, 2019. Per the care plan, the resident was at risk for skin integrity as evidenced by unstageable to the sacrum (was not documented as the right buttocks). The goal was for the resident to not have additional skin breakdown. Approaches included treatment as ordered, skin assessments quarterly and as needed and weekly skin checks. A nursing note dated June 19, 2019 included an unstageable to the right buttocks, which measured 4.5 cm x 3 cm, with 100% slough, scant purulent drainage, normal periwound,and no tunneling or undermining. Treatment included cleansing the wound with wound cleanser, pat dry, apply [MEDICATION NAME] gel topically, cover with [MEDICATION NAME] Ag and secure with adhesive [MEDICATION NAME] dressing every day. A physician's order dated June 19, 2019 (with a start date of June 20) now included to cleanse wound with wound cleanser, pat dry, apply [MEDICATION NAME] gel topically, cover with [MEDICATION NAME] Ag then secure with adhesive [MEDICATION NAME] dressing every day. This order was transcribed onto the TAR (treatment administration record) with a [DIAGNOSES REDACTED]. The treatment was started on June 20. The wound assessment report dated June 26, 2019 did not include any assessment documentation regarding the right buttocks. A nursing note dated June 26, 2019 included that wound care was provided by the wound team. However, the documentation did not include the location of the wound that was being treated. Review of the clinical record revealed no evidence that the right buttocks pressure ulcer was thoroughly assessed which included measurements, a description of the wound bed/edges, if any drainage was present, and a description of the surrounding skin from June 20 through July 2. According to the significant change MDS assessment dated [DATE], the resident was at risk for pressure ulcer development and had no unhealed pressure ulcers. The NP progress note dated July 3, 2019 included a chief complaint to evaluate the sacral wound with concerns for a KTU (Kennedy Terminal Ulcer). History of Present illness included resident was found with an area on his sacrum and there was concern it was a terminal ulcer forming. Physical examination revealed the sacral area was exposed and had a stage 2 area approximately 7 cm total, but interrupted areas with some granulation and some dermal exposure. Per the note, there was no undermining or depth and the wound was not shaped like a butterfly as would be seen in a KTU and that the wound had been present for more than 4-5 days. [DIAGNOSES REDACTED]. It also included that this area was a stage 2 with superficial breakdown due to shearing; and that the resident was continuously scooting on his back on and off the mattress and tried to slide out of chair when he's out of bed. The documentation did not address a wound to the right buttocks. The wound assessment report dated July 3, 2019 revealed a non-pressure, shearing wound to the right buttocks which measured 2.2 cm x 4.8 cm, with normal surrounding periwound, with denuded skin, no drainage, no tunneling and no undermining. According to the documentation, treatment included to cleanse wound with wound cleanser, pat dry, apply [MEDICATION NAME] gel topically, and cover with [MEDICATION NAME] Ag then secure with adhesive [MEDICATION NAME] dressing and change daily. Further review of the clinical record revealed that the right buttocks was not thoroughly assessed which included measurements, description of the wound bed/edges, if any drainage was present and condition of the surrounding skin from July 4 through July 30. The wound assessment report and a nursing note dated July 31, 2019 included an unstageable to the right buttock with measurements of 0.7 cm x 0.3 cm, dark purple, with no drainage, tunneling, undermining and with normal surrounding periwound. Treatment included cleansing wound with wound cleanser, pat dry, apply [MEDICATION NAME] gel topically, and cover with [MEDICATION NAME] Ag then secure with adhesive [MEDICATION NAME] dressing and change daily. The wound assessment report dated August 7, 2019 did not include measurements of the right buttocks pressure ulcer, a description of the wound bed/edges, any drainage and the condition of the surrounding skin. Per the report, the treatment to the right buttock included application of skin prep twice a day. A physician's order dated August 7, 2019 included to discontinue treatment to right buttocks and to apply skin prep to right buttocks twice daily. Per the skin inspection reports dated August 14 and 20, 2019, the resident's skin was intact. Further review of the clinical record revealed no evidence that the right buttocks was thoroughly assessed from August 8 through 20, which included measurements, a description of the wound bed/edges, any drainage and the condition of the surrounding skin. There was also no documentation if the right buttocks pressure ulcer healed. The nursing note dated [DATE] revealed the area on the buttocks was assessed and the area has resolved with preventive measures in place to prevent future breakdown. The specific location was not documented. The skin inspection report dated August 28, 2019 revealed the resident's skin was intact. Per the documentation in the TAR, the treatment to the right buttocks was discontinued on August 28. The IDT (interdisciplinary team) progress note dated August 28, 2019 revealed the wound has resolved and preventative treatment was in place. However, the documentation did not include the location of the wound. Regarding the left gluteus: The skin inspection report dated September 4, 2019 revealed the resident's skin was intact. A nursing note dated September 10, 2019 included an open area was noted on the left gluteus which measured 2 cm x 3 cm, and there were no signs or symptoms of infection. The wound assessment report dated September 10, 2019 revealed a new wound was identified located on the left buttock/gluteus area. The wound had an unknown cause and was described as an open area which measured 3 cm x 2 cm with no drainage. The report did not include a description of the wound bed/wound edges and the surrounding skin. Treatment included to clean area with wound cleanser, pat dry, apply barrier cream topically and cover with [MEDICATION NAME] dressing every shift and as needed. A physician's order dated September 10, 2019 included to cleanse the open area to the left gluteus with wound cleanser, pat dry, apply barrier cream and cover with [MEDICATION NAME] dressing. The order did not include the frequency. A quarterly MDS assessment dated [DATE] included the resident was at risk for pressure ulcers and did not have any unhealed pressure ulcers. Review of the clinical record revealed there was no evidence of a thorough assessment of the left gluteus pressure ulcer from September 11 through October 9, 2019. The Braden Risk Assessment Report dated October 10, 2019 included a score of 9, indicating the resident had a very high risk for the development of pressure ulcers. The care conference note dated October 14, 2019 included the resident had a wound on the buttocks. The location was not documented. Further review of the clinical record revealed no documentation if the left gluteus pressure ulcer had healed. A wound treatment observation was conducted on February 20, 2020 at 8:07 a.m., with a licensed practical nurse (LPN/staff #249), a certified nursing assistant (CNA/staff #32) and a CNA (staff #162). There were no open areas observed to the resident's right or left buttocks. The right buttocks area did have blanchable redness, which measured approximately 5 cm x 1.5 cm. Regarding the pressure ulcer to the coccyx: The NP note dated June 10, 2019 included the resident's skin was warm and dry, with no open areas. A nursing note dated June 10, 2019 revealed that during morning hygiene and assessment, the resident was noted to have a blister on his coccyx that opened. The physician was notified and there were no orders given at this time. Will continue with cleaning the area and applying skin barrier cream. Another nursing note dated June 10, 2019 included the resident had what appears to be a blister that had opened. Treatment included cleaning and drying the area, applying barrier cream during each brief change and monitoring the site for any further skin breakdown and healing. A wound assessment report dated June 10, 2019 included the resident had a new wound, an open blister to the sacrum, which was not present on admission. The cause of the wound was unknown. The wound measured 1 cm x 1 cm x 1 cm, with scant serous drainage. The report included that the wound would be cleaned and skin barrier applied, with every brief change. However, there was no physician's order for this treatment on June 10, 2019 found in the clinical record. A pressure ulcer care plan with an onset date of June 10, 2019 included the resident had a pressure ulcer to the coccyx. The care plan did not included the stage of the pressure ulcer. The goal was for the area to heal within 90 days. Approaches included treatment will be followed per order, placement of low air loss mattress to relieve pressure and weekly wound team. A physician's order dated June 11, 2019 included to cleanse the coccyx wound with normal saline and cover with [MEDICATION NAME] dressing every Monday, Wednesday, Friday and as needed. Review of the June 2019 TAR revealed the treatment order for the coccyx to be done every Monday, Wednesday and Friday and as needed. However, the scheduled times on the TAR were for 6:00 a.m. and the 6:00 p.m. As a result, the documentation showed that the wound treatment was provided twice a day. Review of the wound assessment report dated June 19, 2019 which was nine days after the last assessment (done June 10), revealed the resident now had an unstageable pressure ulcer to the sacrum, which measured 5 cm x 6.5 cm with scant, purulent drainage, 100% slough, clearly visible wound edges and normal surrounding skin. A physician's order dated June 19, 2019 included to cleanse wound with wound cleanser, pat dry, apply [MEDICATION NAME] gel topically, cover with [MEDICATION NAME] Ag then secure with adhesive [MEDICATION NAME] dressing daily for [DIAGNOSES REDACTED]. A nursing note dated June 19, 2019 included the hospice nurse came to evaluate the resident. The resident complained of sacral pain and sacral wound dressing was changed. The wound assessment report dated June 26, 2019 revealed the unstageable pressure ulcer to the sacrum measured 5 cm x 6.5 cm with slough/eschar. However, the assessment did not include a description of the wound edges and surrounding skin, if any drainage was present and if any tunneling or undermining were present. Under the treatment section, it was documented that no treatment was required. The significant change MDS assessment dated [DATE] revealed the resident was at risk for pressure ulcers and had no unhealed pressure ulcers. A wound assessment dated [DATE] included an update of irritation/excoriation to the sacrum which was identified on June 10, 2019 and caused by accident/other trauma. The area measured 2.2 cm x 4.8 cm. According to the documentation, skin irritation/excoriation was described as denuded skin. Wound status was documented as improved. Under the treatment section, it included to cleanse wound with wound cleanser, apply [MEDICATION NAME] gel topically, cover with [MEDICATION NAME] Ag then secure with adhesive [MEDICATION NAME] dressing daily for [DIAGNOSES REDACTED]. The NP progress note dated July 3, 2019 included chief complaint to evaluate sacral wound with concerns for a KTU (Kennedy Terminal Ulcer). History of Present Illness included the resident was found with an area on his sacrum and there was concern it was a terminal ulcer forming. Physical examination included the sacral area was exposed and had a stage 2 area approximately 7 cm total, but interrupted areas with some granulation and some dermal exposure. Per the note, there was no undermining or depth and the wound was not shaped like a butterfly as would be seen in a KTU and the wound had been present for more than 4-5 days. [DIAGNOSES REDACTED]. of bed. A nursing note dated [DATE] included that the dressing to the coccyx was dry, intact and dated. Review of the July 2019 TAR revealed that [MEDICATION NAME] gel, [MEDICATION NAME] Ag and adhesive [MEDICATION NAME] dressing continued to be administered through July 31, despite previous documentation that the wound had healed July 17. The TAR did not include the location of the wound that was being treated. Regarding the new wound to the sacrum: A wound assessment report dated July 24, 2019 included the resident had a new unstageable pressure ulcer to the sacrum, which was not present on admission. Per the documentation, the wound was unstageable due to a suspected deep tissue injury and measured 2.5 cm x 2 cm, with normal surrounding skin. Despite documentation that this was a new wound, in the treatment section of this assessment it included a treatment order from July 12, 2019 to cleanse the wound with wound cleanser, pat dry, apply [MEDICATION NAME] gel topically, cover with [MEDICATION NAME] Ag then secure with adhesive [MEDICATION NAME] dressing daily for [DIAGNOSES REDACTED]. The wound assessment report dated July 31, 2019 included the pressure ulcer to the sacrum was unstageable, due to a suspected deep tissue injury. The wound measured 0.7 cm x 0.3 cm, with normal surrounding skin. A wound assessment report dated August 7, 2019 included a pressure ulcer to the sacrum which was unstageable, due to a suspected deep tissue injury. The wound measured 0.6 cm x 0.4 cm, with normal surrounding skin. However, according to the documentation in the TAR, the wound treatment (location was not indicated) was discontinued on August 7, 2019. Continued review of the clinical record revealed no evidence that the unstageable sacrum pressure ulcer was thoroughly assessed from August 8 through 21. There was also no evidence that any treatment was provided to the sacrum from August 8 through the 21. The skin inspection reports dated August 14, 20, 21 and 28 revealed the resident's skin was intact. According to the IDT progress note dated August 28, 2019, the wound had resolved and preventative treatment was in place. However, the documentation did not include the location of the wound. Despite documentation on August 28, that the wound had resolved, a skin integrity care plan was initiated on September 10, 2019. Per the care plan, the resident was at risk for impaired skin integrity, as evidenced by unstageable to sacrum. Approaches were for weekly skin checks, turning and repositioning every 2 hours and as needed and treatment as ordered. The care plan included the resident had unavoidable pressure risk due to decline in health and hospice services. The skin inspection reports dated September 18 and 25 revealed the resident's skin was intact. The quarterly MDS assessment dated [DATE] included the resident was at risk for pressure ulcers, but did not have any unhealed pressure ulcers. The skin inspection report dated October 2, 2019 included the skin was intact. The skin inspection report dated October 10, 2019 documented skin not intact - existing. The documentation did not include any other details or description to include why the skin was not intact. The skin inspection report dated October 17, 2019 documented skin not intact - new. The documentation did not include what the new skin issue was or any other details as to why the skin was not intact. Review of a wound assessment report dated October 17, 2019 revealed a new stage 2 pressure ulcer to the sacrum, which measured 0.5 cm x .2 cm, with well-defined edges, red, indurated surrounding skin, no slough, eschar, tunneling or undermining. Per the documentation, the provider was notified and treatment orders were pending. However, there were no physician orders for the newly identified stage 2 pressure ulcer. Continued review of the clinical record revealed there were no thorough assessments of the sacrum stage 2 pressure ulcer that were conducted after October 18, 2019. The skin inspection reports dated October 23 and 30, and November 4, 6, and 13, 2019 revealed the skin was intact. The skin inspection reports dated November 20 and 27 documented skin not intact - existing. The documentation did not include any other details as to why the skin was not intact. There was no further clinical record documentation regarding the stage 2 pressure ulcer to the sacrum in November 2019. The skin inspection report dated December 4 2019 revealed skin was intact. The NP annual exam note dated December 5, 2019 included the skin was warm and dry, normal in color and had no rashes or [MEDICAL CONDITION]. The skin inspection reports dated December 11, 18 and 25 revealed the resident's skin was intact. However, in the quarterly MDS assessment dated [DATE], it was coded that the resident had one unhealed stage 2 pressure ulcer. A hospice physician order dated December 31, 2019 included to assess coccyx area for pressure ulcer to determine the grade, to assess wound integrity and to perform wound care no less than 3 x a week. The skin inspection report dated January 1, 2020 documented skin not intact - existing. The documentation did not include any other details as to why the skin was not intact. Despite the physician's order to assess the coccyx area, there was no evidence of a thorough assessment of the coccyx area done on December 31, 2019 or on January 1, 2020. The wound care consult note dated January 2, 2020 revealed a chief complaint of coccyx pressure injury. Physical examination included the skin was warm and dry with a rash and the wound to the sacrum measured 1 cm x 0.8 cm x 0.2 cm. The documentation did not include a description of the wound bed/edges or of the surrounding skin, and if any drainage, tunneling or undermining were present. The [DIAGNOSES REDACTED]. A physician's order dated January 2, 2020 included to cleanse stage 2 pressure injury to the sacrum with normal saline or wound cleanser, pat dry, apply [MEDICATION NAME] and absorptive dressing daily until healed. The order also included for consultation with wound care specialist. This order was transcribed onto the TAR and was administered as ordered. The pressure ulcer care plan was revised on [DATE] to reflect the resident had an open area to the coccyx. The skin integrity care plan was revised on January 8, 2020 to include the resident had a sacral wound. Approaches included treatment as ordered, reposition as needed to relieve pressure and wound consult as needed. The NP progress not dated January 9, 2020 revealed the skin was warm and dry, normal in color and had no rashes or [MEDICAL CONDITION]. The skin inspection reports dated January 15 and 22, 2020 revealed the skin was intact. Further review of the clinical record revealed no evidence that the wound to the coccyx/sacrum was thoroughly assessed to include any measurements, a description of the wound bed/edges and surrounding skin and if any drainage, tunneling or undermining were present from January 3 through January 23, 2020. The wound care follow up note dated January 23, 2020 revealed the skin was warm, dry, with no rash and wound to the sacrum was resolved. Per the documentation on the January 2020 TAR, the treatment to the coccyx was discontinued on January 31, 2020. However, skin inspection reports dated February 12 and 19, 2020 revealed skin not intact - existing. The documentation did not include any other details as to why the skin was not intact. A wound treatment observation was conducted on February 20, 2020 at 8:07 a.m. with a licensed practical nurse (staff #249), a CNA (staff #32) and another CNA (staff #162). There were no open areas observed to the sacrum/coccyx area. The area had blanchable redness, which measured approximately 5 cm x 1.5 cm. An interview with a licensed practical nurse (staff #249) was conducted on February 20, 2020 at 7:45 a.m. She stated the resident had pressure wounds to his bottom in the past, but she was not sure whether it resolved or not. In a later interview with staff #249 conducted on February 20, 2020 at 12:20 p.m., she stated that skin assessments are conducted on a weekly basis and she has a list of residents scheduled for skin assessments on a daily basis. She said when completing the skin assessment, the electronic record software will ask nurses whether the skin is intact or not. She said if the skin is not intact, the software will ask the nurse whether the skin issue is new or existing. She stated if the skin is not intact, she will assess the wound and she can identify the wound whether it is pressure injury or not. She stated her documentation will include the stage, description of the wound bed, if any drainage, measurements and whether the wound is blanchable or not. She said if there are multiple wounds/pressure ulcers, each wound will be documented separately. She stated treatment is written as a physician's order and will be implemented and documented in the TAR. She further stated that the facility does not have a wound nurse and she is not sure who is responsible for ensuring that wounds such as pressure ulcers are monitored. An interview with a registered nurse (RN/staff #191) was conducted on February 20, 2020 at 12:45 p.m. Staff #191 stated the skin is assessed every week during showers. She stated she will inspect the skin and when skin issues are identified, she will document it in the clinical record. She stated documentation includes the type of wound and the stage of the wound if it is a pressure ulcer, a description of the wound bed, edges, measurements and drainage. She stated the electronic record software prompts nurses to include all of this information. She said if there are multiple wounds/pressure ulcers, each wound is documented separately. She said the status of the wound will also be documented either as improving, the same or worsening. Further, she stated that the provider is notified of any wound or skin issues. She said that all treatments provided by the nurse are documented in the TAR. During an interview with the Director of Nursing (DON/staff #229) conducted on February 20, 2020 at 1:03 p.m., he stated the facility does not have a wound nurse in the building, but each nurse in the unit can do wound assessments and provide treatment. He said he conducts weekly rounds every Thursday with the wound physician and whatever the wound physician assesses the wound to be such as type, stage and measurements, trumps the assessment of the nurse. He said if there are multiple wounds, it can be documented in one assessment but the nurses are expected to identify the location and describe each wound. He said it is the responsibility of the nurse to ensure that treatment orders are accurate in the TAR to include the location of the wound that is being treated. Regarding resident #111, he stated he had been the DON at the facility from January 7, 2020 and will try to find documentation of assessments of the resident's wounds. However, the DON was unable to provide additional documentation related to assessments of the wounds of resident #111. -Resident #105 was admitted to the facility on [DATE] and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physician's history and physical dated [DATE] revealed the resident had no rashes or [MEDICAL CONDITION] of the skin. An admission MDS assessment dated [DATE] revealed the resident had cognitive impairment. Review of the clinical record revealed there was no documentation from December 13, 2019 through January 8, 2020, that the resident had a pressure ulcer to the left heel. A nurse progress note dated January 9, 2020 revealed this writer noted a small discoloration on the resident's left heel in which the skin was not open. Another nurse progress note dated January 9, 2020 revealed the wound care doctor visited and provided orders for treatment of [REDACTED]. A wound care consult dated January 9, 2020 revealed the chief complaint of a left heel Deep Tissue Injury DTI) which measured 1.5 cm by 1.5 cm with dark discoloration that was not open and had no drainage. The documentation included a plan for skin prep to the left heel and for an offloading boot in bed. A wound assessment report dated January 9, 2020 revealed that a pressure ulcer was identified on January 9, on the left heel. The pressure ulcer was described as a stage one, instead of a DTI as noted in the wound care consult note. The wound was described as purple and measured 2 centimeters (cm) by 2 cm with normal surrounding skin. The assessment included the wound was not present on admission and was a new wound. Review of a nurse progress note dated January 10, 2020 revealed the area on the inner aspect of the left heel measured 0.7 centimeters (cm) in width and 1 cm in length. The note included the wound was black in color, with some surrounding redness. An undated physician's order included to cleanse the left heal with wound cleanser, pat dry and apply skin prep daily until healed for a [DIAGNOSES REDACTED]. A physician's order dated January 10, 2020 included for an alternating air mattress, use PROFRO boots until alternating air mattress arrives, and reposition every two hours for a left heel pressure ulcer. Physician orders dated January 15, 2020 included for the following: physical therapy to evaluate for adaptive equipment and environmental adaptations for left heel wound; and left multipodus boot to be worn at all times when out of bed aside from bathing. Review of the January 2020 TAR revealed the order to cleanse left heal with wound cleanser, pat dry and apply skin prep daily until healed. Per the TAR, the treatment was completed through January 20. However, there was no documentation that the treatment was done on January 21 or 22 at 6:00 a.m. Review of the clinical record revealed there were no thorough assessments of the left heel pressure ulcer from January 11 through 22, 2020. Review of a discharge MDS assessment dated [DATE] revealed the resident had one or more unhealed pressure ulcers/injuries and had an unstageable/deep tissue injury. A nurse progress note dated January 22, 2020 revealed the resident was admitted to the hospital. A nurse progress note dated January 27, 2020 revealed the resident returned to the facility and had a foam dressing on the left heel. However, there was no documentation of an assessment of the left heel wound, which included any measurements, a description of the wound bed and surrounding skin, any drainage and if any tunneling or undermining were present. Review of a baseline care plan dated January 27, 2020 revealed no documentation of the presence of any pressure ulcers. Review of a wound assessment report dated January 27, 2020 reveled the resident had skin concerns, however, there was no documentation that the resident had a pressure ulcer to the left heel. Review of the clinical record revealed there was no physician's order to treat the left heel deep tissue injury, after the resident was readmitted to the facility on [DATE]. Despite that there was no physician's order for wound treatment, the January 2020 TAR revealed an entry dated January 28, 2020 to cleanse the left heal with wound cleanser, pat dry, and apply skin prep daily until healed for a [DIAGNOSES REDACTED]. The documentation showed that the treatment was completed through January 31. Review of the February 2020 TAR revealed the treatment to the left heel deep tissue injury was being administered through February 19. A care plan identified that the resident had a deep tissue injury to the left heel with a goal that the skin would remain intact. The interventions included the following; weekly skin checks; if complaint of pain during treatment, stop treatment, seek pain relief and return to complete treatment when pain is reported as acceptable; report symptoms of infections (odor, increase drainage, pain or redness); incontinent care as needed, adult briefs and barrier cream as indicated; skin assessment quarterly and as needed; and treatments as ordered for pressure ulcers. Further review of the clinical record revealed that from re-admission on January 27, 2020 to February 19, 2020, there was no evidence of any thorough assessments of the left heel pressure ulcer. An observation of the resident's heels was co(TRUNCATED)

Based on video footage review, clinical record reviews, staff and resident interviews, and policies and procedures, the facility failed to ensure two out of three sampled residents (#1 and #3) were free from abuse. The deficient practice could result in further abuse of residents. Findings include: -Review of the personnel record for a Licensed Practical Nurse (LPN/staff #76) revealed a hire date of (MONTH) 18, 2006. Review of the training records revealed staff #76 had received training for prevention of abuse and neglect in 2019. -Review of the personnel record for a Certified Nursing Assistant (CNA/staff #238) revealed a hire date of (MONTH) 24, 2010. Review of staff inservice sign-in sheets revealed that staff #238 attended directed inservice training for prevention of abuse and neglect on (MONTH) 9, 2019. -Review of the personnel record for a CNA/staff #239 revealed a hire date of (MONTH) 21, (YEAR). Review of the training records revealed staff #239 had received training for prevention of abuse and neglect in 2019. -Resident #1 was readmitted to the facility on (MONTH) 30, 2019, with [DIAGNOSES REDACTED]. Review of a behavioral care plan dated (MONTH) 13, 2019, revealed the resident would set herself on the floor when upset with staff, and was prone to romanticizing male staff relationships. Interventions included to use a soft approach with a smile, to use two staff to assist off the floor or escort the resident to her room when aggressive, and male staff to stay at arms length to prevent inappropriate touching. Review of the quarterly Minimum Data Set (MDS) assessment dated (MONTH) 4, 2019, revealed the resident had short and long term memory problems and moderately impaired cognitive skills for daily decision making. The assessment also included that the resident required supervision for transfers and limited assistance for walking on the unit. Review of a nursing note dated (MONTH) 6, 2019, revealed that while reviewing video footage of another incident involving the resident, footage of subsequent staff treatment of [REDACTED]. The note included that the resident was interviewed and assessed to have no injuries or complaints of pain or discomfort. The resident's behavior was described as appeared to be doing well. Review of the facility's investigation report revealed that on (MONTH) 5, 2019, at approximately 8:00 p.m., the resident was involved in an altercation with another resident. The report included that during review of the video footage after the incident, two Certified Nursing Assistants (CNA/staff #238 and #239) appeared to be handling the resident in an inappropriate manner by removing her walker by snatching it from her, pulling on her legs to remove her from sitting in the threshold of a door, blocking her from entering the dining room and television rooms, blocking her from sitting in a chair that was placed in the hallway, and making body gestures that were considered inappropriate for interaction with this resident. The report included a statement written by a Licensed Practical Nurse (LPN/staff #76), which included she had asked the CNAs to keep the resident out of the dining area so she would not hurt anyone else and to allow the resident into the television room, but the CNAs told her that the resident had tried to attack another resident there. The report included a statement written by staff #238, which included that she thought she was following protocol by making sure the resident was not hurting anyone or self and by keeping the residents separated. The report included a statement written by staff #239, which included she was not making punching gestures to mock the resident, she was re-enacting the gestures of another resident who had said the resident was fighting, and the reason the resident's walker had been taken away until she calmed down was because the resident was known to use her walker as a weapon. The report included that the allegations of abuse against staff #238 and #239 were substantiated and the two staff members were terminated. During the survey, video footage from (MONTH) 5, 2019, was reviewed on (MONTH) 15, 2019. Review of the footage revealed the following scenario: Resident #1 was seated in the dining room and she began to do stretching motions of reaching for the ceiling and reaching for her toes. She stood up and began to walk toward the door. Resident #1 became involved in an altercation with another resident as she tried to walk between a table and the other resident's chair. A Certified Nursing Assistant (CNA/staff #88) rushed into the room and separated the residents, and two other CNAs (staff #238 and #239) tried to escort resident #1 out of the dining room. Resident #1 began to walk with her walker, then she collapsed herself to the floor. Staff assisted the resident to stand up, the resident walked a couple more steps, then she put herself on the floor again. Staff stood near while the resident pulled herself to a standing position using the door handle of the dining room door, then staff #238 and #239 assisted the resident to walk a step or two before she put herself on the floor again. Staff #88 left the area and returned with a wheelchair, and the other two staff members stood near the resident while she sat on the floor against the dining room door for several minutes. A Licensed Practical Nurse (LPN/staff #76) entered the room. The resident stood herself up, and the four staff members assisted the resident into the wheelchair and tried to pick up the resident's walker. The resident continued to hold onto the walker while seated in the wheelchair, and one staff member supported the walker while another staff member pushed the resident's wheelchair toward her room. Several minutes passed, then Resident #1 walked out of her room with her walker. Staff #238 and #239 were in the hallway with the resident, and staff #238 closed the dining room door and stood in front of the door as the resident approached. The resident turned around and started walking toward another resident seated in a wheelchair in the hallway. Resident #1 reached out to touch the other resident, staff #238 and #239 rushed forward to intervene, and resident #1 collapsed herself to the floor. The other resident propelled his wheelchair into the television room. Resident #1 stood herself up using her walker and tried to walk into the television room, but staff #239 stood in the doorway of the room to block the resident. Resident #1 turned and started walking toward a chair in the hallway, and staff #238 rushed to the chair and sat down. As the staff member sat in the chair, staff #76 approached. The three staff members stood and talked with resident #1, who was standing with her walker. Then the resident moved to the dining room door and began to pound on the dining room door. Staff moved forward to intervene, and the resident collapsed herself to the floor. Staff #239 pulled the walker away from the resident and brought the wheelchair closer to the resident. Staff #238 held the dining room door shut. Staff #76, who had been standing and watching the interaction, left the area. The only people in the hallway at that point were resident #1, staff #238 and staff #239. The resident was sitting on the floor with her back against the dining room door, and staff #238 and #239 stood on the other side of the hall facing the resident. The resident reached out and pushed her wheelchair away, then she reached for her walker. Staff #239 moved the walker out of reach of the resident, then staff #239 started to do dancing and boxing motions in the direction of the resident. Staff #76 started to open the dining room door from the inside while the resident was sitting against it. Staff #239 reached forward and grabbed the resident's foot to pull her approximately 2.5 feet out of the doorway, while staff #238 moved forward to push against the resident's back as she slid out of the doorway. Staff #76 was facing the interaction as the resident was being pulled by her foot. The three staff members talked in the hallway while the resident remained seated on the floor, then staff #76 walked away. Staff #238 and #239 stood on the other side of the hall facing the resident and began to do dancing motions toward the resident. Resident #1 was still seated on the floor, and she began to do stretching motions of reaching for the ceiling and reaching for her toes for several minutes. Staff placed the walker in front of the resident, she sat on the floor for several more minutes, then she started to stand herself up using the walker. Staff #238 brought the walker behind the resident and staff #239 forcefully pulled the walker out of the resident's hands as the two staff members forced the resident to sit in the wheelchair. Staff #76 walked up as this was happening, and while resident #1 slid herself out of the wheelchair and onto the floor. The three staff members stood near while the resident pulled herself up using her walker, then staff #76 walked away. Staff #238 and #239 followed while the resident began to walk. Staff #238 moved to block the door to the television room and the resident stopped. Then the resident started walking toward the chair in the hallway. Staff #239 quickly moved the chair out of the resident's reach, as staff #76 re-entered the hallway. The resident was still standing and staff #76 walked away. The resident began to do stretching motions while standing with her walker. The resident walked to the chair in the hallway and sat down while staff #238 and #239 stood by. An interview was conducted with staff #76 on (MONTH) 15, 2019 at 12:32 p.m. She stated she remembered resident #1 had gotten into a fight with another resident, and when she arrived on the scene, other staff members were trying to help resident #1 out of the dining room and into her room. She said she had heard that staff #238 and #239 had allegations of abuse against them, but she did not witness any abuse. Regarding the video footage which revealed that staff #76 was present when the resident's walker was pulled away from her and when the resident was pulled out of the doorway by her foot, staff #76 stated she had not reviewed the footage and she did not know what was on it. She again stated she did not witness any abuse. An interview was conducted with staff #238 on (MONTH) 15, 2019 at 12:51 p.m. She stated resident #1 had been involved in an incident with another resident in the dining room, and staff #76 had instructed her to take resident #1 out of the dining room. She said resident #1 did not want to leave the dining room and kept collapsing to the floor. She said resident #1 was also blowing kisses at a resident in the television room, and the other resident was telling resident #1 to get away. She said she was trying to keep resident #1 from getting into another incident with another resident, and that is why she was trying to keep resident #1 out of the dining room and out of the television room. She said when staff #239 pulled the resident by her foot out of the doorway, she yelled at her coworker to stop, and she stopped. She said she had been trained in recognizing and reporting abuse, but she did not report the pulling by the foot because she did not think it was abusive. She said the video did not capture the overall feeling of the interaction with the resident, which was friendly and joking. She said the video showed laughing, but she and staff #239 were not taunting resident #1, they were joking with her. She said resident #1 was also laughing. An interview was conducted with the Director of Nursing (DON/staff #91) and the Administrator (staff #52) on (MONTH) 15, 2019 at 2:44 p.m. Staff #52 stated the expectation that if abuse was suspected, staff should first protect the residents, then report the allegations to their supervisor. He said the supervisor would notify the management team, who would come onsite or instruct staff on what to do regarding investigating and reporting the allegation. He stated he expected that allegations of abuse would be reported to the State Survey Agency within two hours. He said if an allegation of abuse was made against an employee, the employee would be suspended pending the results of the investigation. He said if an employee witnessed potential abuse and did not report it, there would also be an investigation conducted. He said the findings of abuse investigations involving staff members would be reported to the corporate office, who would advise the facility regarding the appropriate disciplinary action for the staff members. Regarding residents #2 and #3: -Resident #2 was admitted to the facility on (MONTH) 28, (YEAR) with [DIAGNOSES REDACTED]. Review of a Quarterly Minimum Data Set (MDS) assessment dated (MONTH) 15, 2019 revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 12, which indicated that the resident had moderately impaired cognition. The MDS included that the resident had verbal behavioral symptoms directed at others 1-3 days of the seven day look back period. -Resident #3 was admitted to the facility on (MONTH) 12, 2019 with [DIAGNOSES REDACTED]. Review of the admission MDS assessment dated (MONTH) 21, 2019 revealed the resident was not able to be interviewed for the BIMS. It is noted that the resident had short and long term memory problems, and severely impaired cognitive skills. The assessment included that the resident is short tempered and easily annoyed, with physical behavioral symptoms directed towards others 1-3 days of the seven day look back period, and that those symptoms interfere with the resident's care and participation in activities and social interactions, and puts the resident at significant risk for physical illness or injury. It is also noted that the resident's symptoms put others at risk for physical injury, and intrude on the privacy or activity of others. It is included that the resident wanders daily. Review of a nurse's progress note, written by a Licensed Practical Nurse (LPN/ staff #128) dated (MONTH) 30, 2019 revealed that resident #3 was found inside resident #2's room and was sitting on the floor. The note included that resident #2 and resident #3 had an altercation inside resident #2's room. Resident #3 was wandering and entered resident #2's room. Resident #2 yelled for resident #3 to leave at which point resident #3 became physically aggressive, reaching out and scratching resident #2 on the chest. Resident #2 pushed resident #3 and resident #3 fell to the floor, sustaining a skin tear to the right elbow. A nurse's note written (MONTH) 30, 2019 by an LPN (staff #54) noted resident #2 had no injury to his skin at the time. A nurse's note entered on (MONTH) 30, 2019 by staff #54 states resident #3's skin tear remains to right elbow, covered in dressing. The resident was refusing vitals and neuro checks at that time. A wound assessment report from (MONTH) 30, 2019 was reviewed for resident #3. It notes a skin tear on the resident's right elbow. The cause stated was altercation with another resident. The wound measured 1.5 centimeters (cm) in length by 1 cm wide, with a depth of .2 cm. Video footage prior to the incident on (MONTH) 29, 2019 was reviewed on (MONTH) 15, 2019. Review of the footage revealed the following: Resident #3 was seen pacing the halls of her unit, she was observed walking from one side of the unit to the other several times. There was some activity off screen and several staff members were seen moving towards that activity. At the same time, resident #3 enters resident #2's room. The door to resident #2's room was open at the time. Resident #3 was inside of resident#2's room for less than a minute when a Certified Nursing Assistant (CNA), later identified as staff #89, was seen entering resident #2's room. Shortly after staff #89 enters resident #2's room, additional staff are seen entering the room, later identified as CNA/ staff #88 and LPN/ staff #128. Staff #89 and staff #128 are seen exiting the room with resident #3 and accompany her back to her room. Review of the facility's investigation report revealed that on (MONTH) 29, 2019, at approximately 7:30 p.m., there was a resident to resident altercation between resident #2 and resident #3. A written witness statement from staff #89 provided details of the incident- another resident in the hall was having a medical issue and required the attention of multiple staff members. Staff #89 was the assigned hall monitor and was instructed by the nurse to assist with the resident. There was no hall monitor at the time of the incident between resident #2 and resident #3 because staff #89 and the other CNA and the nurse from the hall were in another resident's room. Staff #89's statement continues to state that staff #89 heard a scream coming from resident #2's room and staff #89 immediately went to see what happened. Staff #89's statement reports resident #3 was on the floor when he arrived, and he called for additional staff to assist. Staff #89 notes that he and staff #128 assisted resident #3 to her room and staff #128 took additional necessary action. A witness statement completed by staff #128 was reviewed. Staff #128 reports that resident #3 was sitting on the floor of resident #2's room when she arrived, and staff #128 separated the residents and noted a skin tear on resident #3's right elbow. Staff #128 reports she provided treatment to the wound and completed the investigation of the incident. The resident interview of incident form was completed by staff #54 on (MONTH) 30, 2019 with resident #2. Resident #2 reported that resident #3 got in his face and was cussing at him. He asked her to leave. He pushed her and she fell down and got hurt. Resident #2 reported that he sustained a scratch in the altercation. Staff #54 completed an abuse assessment at that time and noted no sign of injury, no redness/scratches or bruising on the resident's skin at the time of the assessment. The resident interview of incident form for resident #3 was completed by staff #128 on (MONTH) 29, 2019. The resident was not able to answer any of the questions on the form. Resident #3 was observed on (MONTH) 15, 2019 at 9:58 am. The resident was pacing the halls of her assigned unit, speaking softly to herself. Resident #3 was not interviewable, and attempts to engage her in conversation were not successful. The resident walked away each time she was approached. An interview was conducted with resident #2 on (MONTH) 15, 2019 at 2:03 pm. Resident #2 stated he remembers the incident and stated he was in his bed after dinner one evening and an old woman came into his room. He said he asked her to leave, and she would not. Resident #2 got up from his bed and stated when he did so, resident #3 put her hand up with her index finger out, as if she was accusing him of something, and resident #3's index finger contacted resident #2 on his chest. Resident #2 stated that following that contact, he pushed resident #3 back as if to push her out of his room, and resident #3 fell down to the floor. Resident #2 stated several staff members came to his room and removed resident #3 immediately after she fell . Resident #2 said he did not know if resident #3 was injured. Resident #2 stated the nurse examined him and the red mark on his chest from where resident #3 had scratched him did not have broken skin and the red mark had faded by the following morning. An interview was conducted with the Director of Nursing (DON/staff #91) and the Administrator (staff #52) on (MONTH) 15, 2019 at 2:44 p.m. The administrator stated that in any situation with an allegation of abuse, the facility's first priority is to protect the residents. The administrator stated that when investigating an allegation of resident to resident abuse, both residents should be safe and protected first, and then an investigation can occur. The administrator stated the building has a lot of staff who are available to intervene if needed to a resident to resident abuse situation. He stated there are hall monitors who can assist with supervision and to be another person to assist with redirection as needed. The administrator did state that the hall monitor might be called to help with a situation and then the hall would be unmonitored for the time the assigned hall monitor is assisting other residents. The administrator stated there are other staff members in the building who can be called over to assist when needed. The administrator stated all altercations between residents that result in an injury would be considered abuse. The facility's policy regarding abuse prohibition states that each resident has the right to be free from verbal, sexual, physical and mental abuse. It also states the resident has the right to be free from mistreatment, neglect and misappropriation of property. The policy states that residents will not be subject to abuse by anyone, including, but not limited to, facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident.

Based on clinical record review, facility documentation, review of a video recording, resident and staff interviews, and review of policies and procedures, the facility failed to ensure that one resident (#1) was free from physical, verbal, and mental abuse from staff which resulted in psychosocial harm to the resident. The sample size was one. Findings include: Resident #1 was admitted to the facility on (MONTH) 1, (YEAR) with [DIAGNOSES REDACTED]. A Nursing Admission data set dated (MONTH) 1, (YEAR) included that the resident was alert and oriented to person and place, was usually understood but had some difficulty communicating, used a wheelchair, and was unable to stand without assistance. An NP (Nurse Practitioner) monthly note dated (MONTH) 5, (YEAR) included that resident #1 resided on a secured behavioral unit at the facility due to the resident's behavioral management needs. The resident had been combative and resistive to care since his admission, and was focused on making phone calls. Behaviors observed included flailing around in his wheelchair and yelling when the resident was informed of limits on phone calls. The note included that the resident calmed with redirection. An MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR) included that the resident had memory problems, severely impaired cognitive skills, inattention and disorganized thinking. The resident was unable to complete a BIMS (Brief Interview for Mental Status). The assessment included that the resident had psychotic delusions and hallucinations, verbal behaviors towards others, he was intrusive, disruptive and interfered with the care of other residents. The resident used a wheelchair, did not walk, required extensive assistance from one person to transfer, did not have steady balance, and was able to balance only with staff assistance. A psychiatric evaluation note dated (MONTH) 12, (YEAR) included that the resident had previously suffered a TBI, and was paraplegic with left-sided weakness. The Resident had sexually inappropriate behaviors and was noted to need a lot of redirection. Review of a behavioral care plan dated (MONTH) 14, (YEAR) revealed that the resident had behaviors that included being uncooperative, sexually inappropriate to female staff, verbal and physical aggression, cursing, name calling, hitting/punching, and verbal threats towards staff and peers. the resident also had a behavior that included placing himself on the floor in the middle of the hallway when his needs are not met, mostly noted during phone calls. The behavior care plan included the following interventions: -Anticipate the resident's needs. -Explain all procedures and treatments. -Use a firm and respectful approach and tone. -Provide choice and flexibility as much as possible. -Set limits on inappropriate behavior and explain why the behavior is inappropriate; if he does not respond, redirect him to his room. -Help him onto his side and allow him to remain on the floor and assist him up as needed. -Ensure that resident #1 is not crowded, or that his personal space is invaded by others. Review of a nursing note dated (MONTH) 29, (YEAR) at 10:46 p.m., completed by an LPN (Licensed Practical Nurse/staff #241), included that the resident had an outburst with behavior that involved calling the nurse a f . b . after he was told that he could not use the phone. The resident was redirected to his room to cool off before trying to throw himself onto the floor. The note included that the resident was laying in his bed with eyes closed, the call light was within reach, he denied pain or discomfort, and was being monitored. Continued review of the nursing note revealed no additional details regarding whether or not the resident had actually thrown himself onto the floor, how the nurse redirected him to his room, or how he came to be lying on his bed after trying to throw himself onto the floor. Review of an Occurrence Report dated (MONTH) 14, 2019 revealed the following information: -The date of the occurrence was listed as unknown. -The resident listed as the involved resident was Resident #1 (and included the resident's room number). -The type of occurrence was listed as staff to resident verbal aggression, and staff to resident physical aggression. -The occurrence was listed to have happened On unit - hallway. A Short Narrative description of the incident in the occurrence report included that on (MONTH) 14, 2019 APS (Adult Protective Services) brought in a video from an anonymous sender, and the date and time of the video was unknown. The report included that the video showed resident #1 was on the floor being pulled by both legs by a staff member. The staff was heard on the video saying something similar to, Get your F ass off the floor. A handwritten note attached to the occurrence report included that the staff shown in the video included a Licensed Practical Nurse (LPN/staff #241) and a Certified Nursing Assistant (CNA/staff #31). On (MONTH) 15, 2019 at 8:46 a.m., video footage of the facility was received by the State Survey Agency. Review of the video footage revealed a male resident (resident #1) lying on his back on the floor in a hallway, flailing his arms and shouting while a nurse (staff #241) was dragging him by his legs along the hallway floor, around a corner and into the resident's room. Staff #241 was clearly heard to be saying, quit that screwing around and get your f .ing ass up on the bed A CNA (staff #31) was walking behind the resident while he was being dragged down the hallway by his legs. The resident flailed his arms and shouted at the nurse as he was dragged into his room. An interview was conducted on (MONTH) 15, 2019 at 11:30 a.m. with the administrator (staff #243). The administrator stated that APS had shown him the video footage on (MONTH) 14, 2019. He stated that the incident in the video footage occurred sometime in (MONTH) of (YEAR) and that he determined this because of the specific staff members who had been identified in the video and because of other details in the video. The resident was interviewed on (MONTH) 15, 2019 at 11:50 a.m. He stated that he remembered being dragged by his legs into his room by a nurse (staff #241) and stated, I was being angry, and I was bad, and they dragged me to my room. He said that he could not remember the names of the staff who had dragged him into the room and was unable to describe them. He stated that the incident began in the common room when he had an argument with staff, and he was told by staff to go to his room. He became angry and told the staff to f . off and refused to go to his room. He stated that, they grabbed my arms and legs and my head. He demonstrated being grabbed around his head and neck, then said, they pulled me around to the floor and pulled me to my bed. He then described that, they put me in the bed and left me in my room for time out and they closed the door and left me there. He was mad and angry after the incident. He added that he is not afraid of them, but does not trust them. He said that staff did not speak with him about the incident or discuss it with him later. During an interview with the administrator (staff #243) on (MONTH) 15, 2019 at 1:00 p.m., he stated that during the course of the investigation, the staff seen in the video footage were identified to be an LPN (staff #241), who was dragging the resident by his legs, and a CNA (staff #31), who was walking behind the resident. The administrator stated that staff #241 no longer worked at the facility, and staff #31 had been removed from patient care on (MONTH) 14, 2019 when she had been identified in the video. In an interview with a LPN (staff #241) on (MONTH) 15, 2019 at 1:32 p.m., she stated the resident was often verbally abusive, called a lot of nurses the b word, and was known to throw himself on the floor. She said she had never personally seen him throw himself on the floor. She denied at any point of her employment at the facility dragging the resident on the floor from the hallway to his room. She became upset and defensive during the interview by raising her voice, talking faster, and questioning why she was being accused. She reiterated that she did not remember pulling the resident into the room. A CNA (staff #31) was interviewed on (MONTH) 15, 2019 at 3:01 p.m. She stated she was well acquainted with this resident and said that there are certain things that can cause the resident to lose his temper including that if he does not get a soda or a snack when he wants it, or if he is told to wait for a shower after he has asked for a shower. She said the resident can be verbally aggressive and would swear at staff. She said that he puts himself onto the floor at times. She said she was unaware of the interventions in the resident's behavior care plan because she has never reviewed it. She said she saw the video of the incident and she is seen walking behind the resident. She said what happened was that she was in the dayroom when she heard a commotion in the hallway and went to locate it. She stepped around the nurse's station and saw that the resident was on the floor. She saw that staff #241 was already holding the resident's legs and was pulling the resident into his room. She said the resident was shouting and cursing at the nurse while being pulled. She said she was donning gloves when she was following staff #241 and the resident into the room. She said that when they were in the room, she assisted in picking the resident up from the floor and putting him onto his bed. Then she left the room. She said that staff #241 remained in the room, but she is not aware of what happened in the room or how long staff #241 was in the room with the resident. She could not recall if the door was shut or left open after she left the room. She did not recall if staff #241 had said anything to her or the resident. The nurse and her were the only staff on the unit at the time. She said that at the time of the incident, she did not think it was abuse because staff #241 was trying to get the resident out of the hallway to prevent other residents from acting out as well. She did not report the incident because she thought that staff #241 was going to report it. She said that looking back on it, she believes that it was abusive. She reviewed the nursing note dated (MONTH) 29, (YEAR) and stated that the note described the incident. In an interview with the administrator (staff #243) on (MONTH) 18, (YEAR) at 8:20 a.m., he stated that staff #31 was terminated from employment due to her participation in the events seen in the video footage. An interview was conducted on (MONTH) 18, (YEAR) at 3:02 p.m. with the Director of Nursing (DON/staff #82). She stated that when a resident has acting out behaviors that are a behavioral emergency and additional staff are required to provide assistance, staff will announce Dr. Strong over the intercom system which is heard throughout the facility. When Dr Strong is announced, all available staff are to respond to the situation to de-escalate the resident. The Director stated that there was no evidence that Dr. Strong was called and that staff #241 was seen in the video footage trying to handle the acting out resident on her own, and she did not call out for staff assistance. The Director stated that both staff #241, and staff #31 could have called for extra assistance with resident #1, but they failed to do so. Review of the facility's abuse policy and procedure revealed a standard of practice statement that each resident has the right to be free from verbal, physical, and mental abuse, corporal punishment, involuntary seclusion, and mistreatment. The policy included that staff training will be completed including reassuring staff that reporting a reasonable suspicion of a crime can be done without fear of retaliation. The policy included that the facility will be proactive in identifying events and occurrences that may contribute to abuse of residents including: -Verbal abuse of a resident overheard -Physical abuse of a resident observed -Psychological abuse of a resident observed -Evidence of photographs, videos or recordings of a resident that are demeaning or humiliating in nature, regardless of whether the resident provided consent and regardless of the residents cognitive status. The policy defined abuse as any willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain, or mental anguish. This includes verbal, physical, mental/psychological, and any abuse facilitated or enabled through the use of technology. The policy defined specific types of abuse including the following: -Mental and physical abuse is mistreatment not resulting in physical harm, but not limited to humiliation, harassment, threats of punishment, deprivation, or intimidation. -Physical abuse includes controlling behavior through corporal punishment -Verbal abuse as the use of oral or gestured language that includes derogatory terms to a resident or within the resident's hearing distance regardless of the resident's ability to comprehend.

Based on clinical record reviews, resident and staff interviews, facility documentation and policies and procedures, the facility failed to ensure one resident (#15) was free from sexual abuse by another resident (#76), failed to ensure one resident (#23) was free from physical abuse by one resident (#136) and failed to ensure one resident (#52) was free from physical abuse by one resident (#45). Findings include: -Resident #15 was readmitted on (MONTH) 12, 2007, with [DIAGNOSES REDACTED]. A quarterly MDS (Minimum Data Set) assessment dated (MONTH) 8, (YEAR) included the resident had moderate cognitive impairment for decision making. A nurses' note dated (MONTH) 30, (YEAR) at 7:00 p.m. revealed that resident #76 was found in the room of resident #15 and that resident #15's genitals were exposed. The nurse separated the resident's and the two residents would be kept apart and monitored. The note further included that the on-call ADON (Assistant Director of Nursing) and the physician had been notified. -Resident #76 was admitted on (MONTH) 19, (YEAR), with [DIAGNOSES REDACTED]. A care plan for resident #76 identified that resident #76 can be sexually inappropriate. An approach included to redirect the resident if being sexually inappropriate with female staff or peers. A quarterly MDS assessment dated (MONTH) 10, (YEAR) included the resident had moderate cognitive impairment for decision making and had disorganized thinking. The MDS included the resident had other behavioral symptoms not directed towards others such as; hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, and disruptive sounds, which occurred 4-6 days in the last 7 days of the assessment period, but less than daily. Review of a nursing note dated (MONTH) 31, (YEAR) at 4:46 p.m., revealed that resident #76 had numerous redirections, due to his inappropriate sexual behaviors. Per the note, resident #76 had been asking other residents for oral sex. Resident #76 had been redirected back to his room to which the resident responded by asking staff to come to his room and watch him masturbate. The note included that at 1:34 p.m., the nurse was approached by a CNA who reported inappropriate sexual contact between resident #76 and resident #15. The CNA reported that as she was monitoring the hallway, she entered the room of resident #15 and found resident #76 sitting on the bed of resident #15, and resident #15 was on his knees with the penis of resident #76 in his mouth. The resident's were immediately separated. Facility administration, physician, responsible parties, police, Adult Protective Services and the State Agency were notified. Review of the facility's investigation revealed that resident #15 was alert and oriented to person, place and time, ambulates independently and requires supervision with cares. Resident #15 has had no sexually inappropriate behaviors toward staff or other residents. Resident #76 was alert and oriented to person only, and tends to wonder and invade other residents space, by attempting to go in and out of other resident's rooms. Resident #76 has a history of being hypersexual and verbally inappropriate with staff, but has not been with peers. Per the report, staff entered the room of resident #15 and found resident #15 on his knees, performing oral sex on resident #76. According to a statement from resident #76, he had asked resident #15 to perform oral sex on him. An interview was conducted with a Certified Nursing Assistant (staff #291) on (MONTH) 5, (YEAR) at 9:35 a.m. Staff #291 stated that she was monitoring the hallway on (MONTH) 31, when she found resident #76 in the room of resident #15. She said that resident #76 was sitting on the bed of resident #15, and resident #15 was on his knees in front of resident #76, with resident #76's penis in his mouth. Staff #291 stated that there was no monitoring or 1:1 supervision of resident #76, prior to this incident. Staff #291 stated that she had heard from other staff that resident #76 had been wandering the hallways soliciting oral sex from staff. On (MONTH) 5, (YEAR) at 10:12 a.m., an interview was conducted with resident #15. Resident #15 stated that resident #76 had asked him to perform oral sex. Resident #15 stated he didn't want to do it, but he felt afraid. -Resident #136 was admitted to the facility on (MONTH) 26, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 15, (YEAR) revealed the resident had long and short term memory problems and had moderate cognitive impairment with decision making. The MDS also included the resident required supervision to limited assistance with activities of daily living. Review of a behavior care plan revealed the resident had behaviors of yelling, screaming and striking out at staff. One of the goals included will receive supportive services to maintain stability of mental/emotional health. Interventions were to approach in a calm manner, when confused or experiencing psychotic disturbances do not attempt to bring to reality, maintain low stimulus environment, remove resident from common areas during times of unacceptable behaviors, if resident refuses care or interventions assure safety and leave immediate area and approach in 5-10 minutes or provide alternate caregiver and to document the resident's response. Review of the nursing notes from (MONTH) and (MONTH) (YEAR) revealed that resident #136 had repeatedly been verbally abusive with attempts of physical abuse toward staff and peers. Review of a CNA note dated (MONTH) 25, (YEAR) at 2:17 p.m., revealed that resident #136 was coming in and out of his room screaming in anger and staff had to redirect him back to his room numerous times. The note included that the resident was monitored by staff for safety. A nursing note dated (MONTH) 25, (YEAR) at 3:29 p.m. revealed resident #136 continued with intermittent behaviors and was currently in bed appearing to be asleep and staff were continuing to monitor him. A nursing note dated (MONTH) 25, (YEAR) at 6:16 p.m. included that resident #136 had possible physical aggression toward a resident (#23). Another resident had reported that resident #136 had choked a resident (#23). Per the note, resident #136 was found on the floor behind the wheelchair of resident #23 and was removed by staff. Resident #136 was verbally aggressive and continued to yell with attempts to strike out. A nursing note dated (MONTH) 29, (YEAR) included that resident #136 had been placed on 1:1 supervision for aggression. -Resident #23 was admitted to the facility on (MONTH) 11, (YEAR), with [DIAGNOSES REDACTED]. Review of a quarterly MDS assessment dated (MONTH) 12, (YEAR) revealed that resident #23 had short and long term memory problems and had moderate cognitive impairment with decision making. Review of a care plan revealed the resident has a self care deficit, but was able to self-propel in a wheelchair for mobility. The resident exhibits alteration in mood/behavior as evidenced by yelling and striking out at others. A goal included that the resident will demonstrate absence of violent or aggressive behaviors. Interventions were to intervene immediately if demonstrates aggressive behaviors toward self or others, educate staff to recognize early signs of agitation and administer medications per order to reduce anxiety. A nursing note dated (MONTH) 25, (YEAR) revealed that at approximately 4:45 p.m., the nurse heard a resident yell He's choking her! Upon reaching the dayroom, a resident (#136) was noted to be on his knees behind the wheelchair of resident #23. The residents were immediately separated. When resident #23 was asked if someone choked her, resident #23 did not respond, but a skin evaluation showed slight redness to the right side of resident #23's neck. Review of the facility's investigation revealed that staff heard another resident yell out, He's choking her! A staff member heard a scream and saw resident #23 sitting in her wheelchair trying to remove resident #136's arm from around her neck. This staff member then assisted resident #23 in removing resident #136's arm from around her neck. Redness was noted to resident #23's neck after the incident. An interview was conducted on (MONTH) 5, (YEAR) at 10:42 a.m. with a LPN (staff #303), who stated that she did not witness the incident between resident #23 and #136, but heard a person whom she believes to be a resident yell out, He is choking her! Staff #303 stated that upon arrival, she saw resident #136 behind the wheelchair of resident #23. Staff #303 stated that she asked both resident's what had happened but neither resident provided a response. Staff #303 said that there was a red mark on resident #23's neck. Staff #303 stated that resident #136 can have very aggressive behaviors at times. Staff #303 said that the incident occurred in the front hallway outside the unit dining room and there are cameras everywhere, so the incident may have been on camera. An interview was conducted on (MONTH) 5, (YEAR) at 2:41 p.m. with the Director of Nursing (DON/staff #263), who stated that once abuse is suspected or identified, the expectation is for staff to immediately report it to the administrator. Staff #263 stated that staff are to immediately ensure resident's safety and then follow the reporting process. Staff #263 stated that staff are educated to look out for resident to resident abuse, as well as other types of abuse. An interview was conducted on (MONTH) 5, (YEAR) at 3:20 p.m. with a Certified Nursing Assistant (CNA/staff #87), who stated that she witnessed the incident which occurred between residents #23 and #136. Staff #87 stated that resident #23 was making loud noises in the hallway outside the dining room, which is located close to the room of resident #136. Staff #87 stated that resident #136 does not like a lot of noise and can be unpredictable when in a rage moment. Staff #87 stated that she saw resident #136 walk up behind resident #23 in her wheelchair, and suddenly grab resident #23 by putting his arm around her neck. She said that resident #23 screamed out and was trying to remove his arm. Staff #87 stated resident #136 is very strong and it took a lot of force to remove his arm and that it required two CNAs to assist in removal of his arm from her neck. Staff #87 stated that multiple staff members came to assist. She said that resident #136 had slid to the floor behind the wheelchair of resident #23, prior to other staff members arriving. Another interview was conducted on (MONTH) 6, (YEAR) at 1:05 p.m. with the DON, who stated that if the incident occurs in the view of a camera such as in the hallway, the camera footage can be reviewed. The DON stated that the incident between resident #23 and #136 happened in the hallway outside of the dining room on the unit. She said the video footage was reviewed by herself and an assistant DON. She said a CNA was watching the residents in the hallway and left the hallway to walk into the dining room. She said resident #136 then reached for resident #23 and possibly fell . She stated that this unit is difficult because it is all about watching the residents and that some residents have triggers and sometimes snap without warning. On (MONTH) 6, (YEAR) at 1:32 p.m., the DON provided a review of the video recording of the incident, which occurred on (MONTH) 25, (YEAR) at approximately 4:34 p.m. in the hallway outside of the Sunset dining room. Per the video, resident #23 was sitting in her wheelchair in the hallway with another resident. No staff were present. Resident #136 walked up behind resident #23 and put his left arm around her neck, eventually falling on his buttocks and continued to have his arm around her neck, causing resident #23 to tip backwards in her wheelchair, with the arm of resident #136 still around her neck. Resident #136 finally let go of her neck and resident #23's wheelchair went back to an upright position, without staff intervention. Per the video recording, staff then started to approach both residents. -Resident #45 was admitted to the facility on (MONTH) 25, (YEAR), with [DIAGNOSES REDACTED]. A quarterly MDS assessment dated (MONTH) 26, (YEAR) revealed the resident had moderate cognitive impairment with decision making and had short and long term memory problems. Review of a care plan revealed the resident had behaviors of striking, hitting and punching at staff and peers. The interventions included the following: -Monitor whereabouts when wandering and redirect as needed. -Approach in a calm manner. -When confused or experiencing psychotic disturbances, do not attempt to bring to reality. -If the resident refuses care, assure safety and leave the immediate area. Re-approach in 5-10 minutes or provide an alternate caregiver and document the response. -Avoid confrontation when the resident is agitated. -Refer to psych services as needed with exacerbation or inability to effectively redirect behaviors. A nursing note dated (MONTH) 29, (YEAR) revealed that when resident #45 was in the dining room, he became agitated when asked to get cleaned up and he kicked another resident. Review of the nursing notes from (MONTH) (YEAR) - (MONTH) (YEAR) revealed the resident had repeatedly been verbally and physically abusive towards staff and residents. A nursing note dated (MONTH) 23, (YEAR) included that resident #45 was in the dining room with other residents, when resident #52 reached out toward resident #45, and resident #45 then punched resident #52 on the left side of the face. -Resident #52 was admitted to the facility on (MONTH) 9, (YEAR), with [DIAGNOSES REDACTED]. Review of an annual MDS assessment dated (MONTH) 26, (YEAR) revealed the resident had severe cognitive impairment and had short and long term memory problems. Review of the facility's investigation revealed that on (MONTH) 23, (YEAR) at 9:30 p.m., several residents were sitting in the dining room watching television. Resident #45 and resident #52 were sitting at the same table. Resident #52 is diagnosed with [REDACTED]. At this time, resident #52 thrust out his arms toward resident #45 without hitting him and then resident #45 raised his arm and hit resident #52 on the left side of his face. A CNA (staff #130) witnessed the altercation and both residents were separated. No injuries were sustained by either resident. On (MONTH) 5, (YEAR) at 11:10 a.m., an interview was conducted with a CNA (staff #241). She stated that resident #52 has [MEDICAL CONDITION]'s disease and the disease causes him to spastically thrust his arms involuntarily. She also stated that resident #45 has a history of hitting, punching and kicking other residents on the unit. An interview was conducted on (MONTH) 6, (YEAR) at 1:32 p.m. with the nurse practitioner (staff #311). She stated that resident #45 has a history of striking out at other residents and is more aggressive in the evening. She stated he will strike out if someone is in his way or if it's noisy on the unit. She stated that he is unpredictable, has poor impulse control and staff have difficulty trying to keep him from striking out at other residents. An interview was conducted on (MONTH) 6, (YEAR) at 2:39 p.m., with staff #130. She stated that both residents were sitting next to each other watching television in the dining room. She stated that resident #52 does not have a history of being physically aggressive towards staff or other residents. She said that resident #52 started thrusting his arms out towards resident #45 and then resident #45 punched resident #52 in the face. She stated resident #45 has a history of being physically abusive towards staff and other residents. Review of the facility's Abuse Prohibition Standards of Practice policy revealed that each resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment and involuntary seclusion. The policy stated that residents will not be subject to abuse by anyone, including but not limited to facility staff, other residents, consultants and volunteers. Per the policy, tips for the prevention of abuse included to observe resident behavior and reactions to other residents and to assess, monitor and develop appropriate plans of care for residents with inappropriate sexual behaviors towards staff or other residents. The policy defined abuse as: any willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.