Every finding on record at Handmaker Home for the Aging

Based on clinical record review, staff interviews, facility investigation review, and review of facility policies and procedures, the facility failed to conduct a thorough investigation into neglect involving one of the three sampled residents (#1). The deficient practice could lead to failure in preventing further potential neglect. Findings Include: Resident #1 was admitted on [DATE], with diagnoses that included acute and chronic respiratory failure with hypoxia, heart failure, paroxysmal atrial fibrillation, muscle weakness, reduced mobility, gout, depression, hyperlipidemia, and hypertension. A care plan dated February 9, 2026, identified communication impairment related to hearing deficit and included interventions for communication support, safety monitoring and cognitive observation. A Significant Change Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating Resident #1 was cognitively intact. An incident note dated February 25, 2026, at 3:54 PM revealed that at approximately 06:45 AM, staff #2 observed marks with dried blood on Resident #1's bilateral neck. Resident #1 initially stated the injuries were scratch marks. At approximately 12:20 PM, when staff #2 reassessed and attempted to clean the area, staff #2 identified the injuries appeared more deep and re-questioned the resident who stated he had attempted to cut his carotid artery with a razor and expressed suicidal ideation. Resident #1 further stated that life was not worth living and verbalized continued intent for self-harm. Resident #1 was placed on one-to -one observation until emergency responders arrived. A razor, letter opener and pocket knife were removed from the resident's room. Review of the facility's 5 day investigation report dated February 25, 2026, revealed the investigation was incomplete and lacked resident interview, staff interviews, skin assessment documentation, detailed description of the events leading to the incident, and investigative conclusions. An interview was conducted on April 15, 2026 at 2:45 PM with Assisted Director of Nursing (ADON/Staff #4), who stated that the five-day report is completed within five day. She stated she is unsure what is included in the five-day report, but stated the DON (Director of Nursing) usually filled it out within the five day period which includes incident follow ups and any pertinent information regarding the incident. She stated the risk of not having completed the five-day report is to be non-compliant. Also stated the risk to the resident would be elapsed communication with the resident. An interview was conducted on April 15, 2026, at 2:54 PM with Administrator (Staff #6), who stated that the five day reports are completed within five business days after the event occurred. He stated in the five-day report, the witness, resident, and employee statements are included. Also, he stated that victim aggressors and other residents who might be affected by their statements are also included. He stated that he is the one who completes the five-day report, but previously, when an incident occurred for Resident #1, he did not have access to the system to complete the five-day report, and the previous DON (staff #3) was completing the five-day reports. He stated that in the five-day report for Resident #1 for suicidal ideation, there should have been statements on the incident that led up to it, what happened that day, what was done by the facility, and what happened afterwards. He stated that not having completed the five-day report could risk a potential further abuse incident and a lack of reformation. He also stated that the incomplete five-report does meet his or the facility's expectations. A Policy titled Abuse, Neglect, and Exploitation was revised in July 2025, revealing that an immediate investigation is warranted when suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect, or exploitation occur. Written procedures for investigation include identifying staff responsible for the investigation, exercising caution in handling evidence that could be used in a criminal investigation, investigating different types of alleged violations, identifying and interviewing all involved persons, such as the alleged victim, alleged perpetrator, the witness, and others who might know about the allegation. Also focusing the investigations on determining if abuse, neglect, exploitation, and or mistreatment has occurred, the extent, and causes, and providing complete, thorough documentation of the investigation.

Based on clinical record review, staff interviews and review of facility policy and procedures, the facility failed to ensure one out of three samples residents (#1) remained free from self-harm by failing to immediately assess, report, investigate, and implement protective interventions after staff observed injuries. The deficient practice could delay in identification of resident's suicide attempt and could place residents at risk for continued self harm, serous injury or death. Findings Include:Resident #1 was admitted on [DATE], with diagnoses that included acute and chronic respiratory failure with hypoxia, heart failure, paroxysmal atrial fibrillation, muscle weakness, reduced mobility, gout, depression, hyperlipidemia, and hypertension.A care plan initiated on February 09, 2026, identified a communication problem related to a hearing deficit and included interventions to anticipate and meet needs, discuss with the resident/family concerns or feelings regarding communication difficulties, encourage resident to continue stating thoughts even if the resident is having difficulty, focus on a word or phrase that makes sense, or responds to the feeling resident is trying to express, ensure hearing aids is in place, ensure/provide a safe environment: call light in reach, adequate low glare light, bed in lowest position and wheels locked, avoid isolation, and monitor/document residents ability to express and comprehend language, memory, reasoning ability, problem solving ability and ability to attend.A care plan initiated on February 09, 2026 also identified impaired visual function related to blindness and included interventions to identify/record factors affecting visual function, including physiological, environmental, and choice (reduces the need to wear glasses, use a magnifying glass, turn on lights), monitor/document/report, as needed, any signs of acute eye problems: change in ability to perform daily activities, decline in mobility, sudden vision loss, pupils dilated, gray or milky, complaints of halos around lights, double vision, blurred or hazy vision and tell the resident where you are placing their items and be consistent.A Significant Change Minimum Data Set (MDS) dated [DATE], revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. The MDS also documented that the resident was receiving hospice services.Skilled Daily Charting Nursing dated February 24, 2026, at 3:07 PM revealed Resident #1 had new skin changes.An incident note dated February 25, 2026, at 3:54 PM revealed that at approximately 06:45 AM, Licensed Practical Nurse (LPN, staff #2) observed marks with dried blood on Resident #1's bilateral neck during morning rounds. Staff #2 asked Resident #1 about the injuries, and the resident stated they were scratch marks. There were no further documentation after the observation that the staff #2 reported the signs of injuries to the provider, Director of Nursing (DON), or management. There were no documentation of further assessment or protective interventions immediately after the observation of the marks on resident's neck.At approximately 12:20 PM, when staff #2 returned to clean the area, Staff #2 observed the injuries appeared deeper than scratches and again questioned the resident. Resident #1 then disclosed attempting suicide by trying to cut his carotid artery with a razor and expressed ongoing suicidal intent. Resident #1 was subsequently placed on one-to-one observation until emergency services arrived. The provider and DON were notified, and potentially harmful items including razor, letter opener, and pocket knife, were removed from the resident's room.Multiple call attempts were made to the Resident #1 on April 15, 2026, however it was unsuccessful.During an interview on April 15, 2026, at 12:10 PM, Staff #2 stated facility protocol required staff to assess injuries, determine cause, and immediately notify the provider and DON. Staff #2 acknowledged initially observing the injuries and dried blood, accepting the resident's explanation without further investigation, and delaying notification until later when the wounds were identified as deep cuts. Staff further stated that she will notify right away of any scratches and stated there is a risk of resident harming themselves again if failed to notify.An interview was conducted on April 15, 2026, at 1:59 PM with a Certified Nursing Assistant (CNA/ Staff #7), who stated that when she witness scratches on a resident or dried blood on a resident, first, she will make sure the resident is safe, ask the resident what happened, get the nurse, and report to higher-ups. She stated that even if the resident has scratches on the body, she will report them immediately. CNA further stated that if injuries are not reported after an observation, the risk can be fatal. During an interview on April 15, 2026, at 2:45 PM, the Assistant Director of Nursing (ADON/Staff #4) stated staff were expected to immediately report observed injuries, dried blood, or changes in resident condition to nursing leadership. The ADON stated Resident #1's injuries should have been reported immediately, and failure to do so placed the resident at risk for further self-harm, including death.An interview was conducted on April 15, 2026, at 2:54 PM with the Administrator (Staff #6), who stated that the expectation of staff members noticing blood and scratches on a resident is to investigate where it came from, notifying the nurse right away, ADON or the DON. He stated that potential risks would be further injury.A Policy titled Abuse, Neglect, and Exploitation was revised in July 2025, revealing that the facility protects each resident to prevent abuse, neglect, exploitation, and misappropriation of resident property. Analyzing the occurrences to determine why neglect occurred, and what changes are needed to prevent its occurrence.

Based on observations, staff interviews, facility documentation, and review of facility's policy, the facility failed to ensure that enhanced barrier precautions(EBP) were followed during wound care for one resident(#6). The deficient practice could result in the spread of infection.Findings include:Resident # 6 was admitted to the facility on [DATE] with diagnosis that included nontraumatic intracerebral hemorrhage, age related osteoporosis, major depressive disorder, and need for assistance with personal care. An order initiated on February 5, 2025 revealed that Resident # 6 was on enhanced barrier precautions due to a left thigh wound. Review of care plan initiated on June 4, 2025 revealed that the resident had a stage 4 pressure ulcer with tunneling to left hip due to poor mobility. The interventions included to provide local wound care as prescribed and use of proper infection control measures such as hand hygiene and the use of personal protective equipment. An order initiated on January 5, 2026 for wound care was to be administered for a left hip chronic fistula with Dakin's solution and pat dry then covered every Monday, Wednesday, and Friday or as needed. A wound care observation was conducted on January 22, 2026 at 12:01 p.m. with Licensed Practical Nurse (LPN/Staff #30) and Certified Nursing Assistant (CNA/Staff #57) in Resident # 6's room. The following were observed:Staff #30 washed his hands then cleaned and wiped down a bedside table outside of the room.Observed Enhanced Barrier Precaution sign posted outside the room and a drawer was also outside the room. Staff #57 went inside Resident #6's room to assist with repositioning. It was observed Staff #57 put on gloves but did not put on a gown and Staff # 57's black uniform was touching the mattress. At 12:05 p.m. Staff #30 after moving a bedside table inside the resident's room placed a disposable blue pad on top of the table. Staff #30 put on new gloves.at 12:11 p.m. but did not put on a gown. Staff #57 was inside Resident #6's room with gloves on and no gown on while assisting the resident to turn on her right side. Staff #30 removed old dressing from left hip with gloves on but no gown. The dressing was saturated with a moderate amount of yellowish/pink drainage.At 12:14 p.m. Staff #30 removed gloves then put on new gloves and grabbed the wet gauze that was impregnated with Dakin's solution. During the wound care process Staff #30's green colored uniform was touching the resident's mattress. At 12:15 p.m. Staff #30 used the skin prep and wiped the resident's skin, then covered the wound with dry folded 4x4 gauze and the 6x6 border adhesive dressing then took off gloves and dated new dressing. At 12:18 p.m. Staff #30 performed hand hygiene by the sink using soap and water. Staff #57 repositioned resident onto her back with gloves on but did not have a gown on. An interview was conducted on January 22, 2026 at 12:20 p.m. with Staff #30 who revealed that the enhanced barrier precautions sign was for Resident #6. Staff #30 goes on to reveal that if there is contact with the resident then gloves and a gown need to be worn. Staff #30 stated he did not wear a gown during wound care.An interview was conducted on January 22, 2026 at 12:26 p.m. with Staff #57 who revealed that she forgot to put on a gown and only wore gloves for wound care. Staff # 57 also revealed that she should have worn a gown because the resident was on enhanced barrier precautions. Staff #57 stated that all staff should be wearing a gown and revealed that Staff #30 did not wear a gown. An interview was conducted on January 23, 2026 at 11:15 a.m. with Director of Nursing (DON/Staff # 160) who revealed that anyone who has an open wound is placed on enhanced barrier precautions and it is her expectation that any staff member providing direct care to a resident on enhanced barrier precautions need to have a gown on. The DON confirmed that Resident # 6 was on EBP precautions and staff should have worn a gown during wound care. Staff # 160 also revealed the concern for not wearing the proper PPE is infection could be spread to other residents. A review of facility's policy titled, Enhanced Barrier Precautions Policy, reviewed on June 1, 2022, revealed that it is the policy of the facility to implement enhanced barrier precautions for preventing transmission of novel or targeted multidrug-resistant organisms. The policy goes on to reveal that high contact resident care activities include wound care including any skin opening requiring dressing.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to ensure that one resident (Resident #99) was provided adequate supervision and interventions to prevent a preventable fall. The deficient practice places residents at risk for falls with serious injury.Findings Include:Resident # 99 was originally admitted to the facility on [DATE], with the most recent admission on [DATE]. The resident has diagnoses that consist of: type 2 diabetes mellitus without complications, other acute osteomyelitis, right ankle and foot, spinal stenosis, cervical region, major depressive disorder, recurrent, unspecified Bipolar disorder, current episode depressed, severe, without psychotic features. Acquired absence of the left leg below the knee. Morbid (severe) obesity due to excess calories. The record revealed that the resident's Brief Interview Mental Status (BIMS) score was 15 that indicated the resident is cognitively intact. No behaviors or moods were noted. A review of the resident's care plan revealed that the resident is at high risk for falls due to deconditioning. The resident had an actual fall with major injury on 01/10/2026. Interventions included: All staff were educated on the importance of not leaving the patient alone in the shower room as an intervention for the fall on 1/10/2026. Anticipate and meet The resident's needs, be sure The resident's call light is within reach and encourage the resident to use it for assistance as needed. The care plan included that the resident needs prompt response to all requests for assistance, facility fall protocol needs to be followed and staff needs to ensure that resident is wearing non-skid footwear when ambulating or mobilizing in wheelchair. Morse Fall Scale, dated December 31, 2025, at 6:01 pm, listed a score of 40, indicating that the Resident was at moderate risk for falling. Review of incident note under progress notes dated January 10, 2026 at 10:54 pm included that the resident had unwitnessed fall in shower room at 5pm. The note stated the resident stated she slipped off from her bed. The note included that xray was ordered to left hip and the resident had no open areas but only had left hip pain. General Nursing progress note dated January 11, 2026 at 1:42 am stated that the left hip xray showed acute fracture of the left hip at the intertrochanteric region, DON was notified and pt was send to ED around 12:22 am. Incident Note Text dated January 11, 2026 at 4:39 pm stated, resident sustained a fall inside the shower room, was left alone by CNA. CNA left resident alone twice to go get assistance to stand pt. Was relayed in report that she needs 2 person assist to transfer and Hoyer in which she did not follow safety protocol with transfer. resident found on floor, complaining of left hip pain. after informing NP xray ordered and confirmed fracture, resident was transferred to hospital. Incident Not Text dated January 12, 2026 at 10:31 am stated, IDT Team met to discuss fall with major injury on 1/10/26- staff and agency educated on fall precautions including not leaving resident in shower room unattended, also signs placed in shower room to remind staff, NO RESIDENT UNATTENDED IN SHOWER ROOM. During an interview with the DON (Director of Nursing, Staff #160) on January 22, 2026 at 9:50 am, Staff #160 stated that residents should never be left unattended in the shower. Staff # 160 stated that Resident # 99 Was only alone for a few brief seconds. Staff # 160 stated that the resident is typically able to ambulate with little assistance, but was feeling weak that day. An interview was conducted with a CNA (Certified Nursing Assistant, Staff # 97) on January 22, 2026 at 11:25am. Staff # 97 stated that she had been a CNA for over twenty years. When asked regarding the procedure for showing a resident, Staff #97 stated that it begins with positioning the wheelchair and shower chair to ensure stability during the transfer. Staff #97 stated that ideally, there are two people, but it can be done with one. Staff # 97 was asked if a resident should be left unattended in the shower, and she stated that it was never permissible. During an Interview with LPN (Licensed Practical Nursing, Staff # 164) on January 22, 2026 at 12:55 pm, Staff #164 revealed that she had provided assistance to Staff # 180 with pulling up Resident #99's pants and brief after her shower and in getting the Resident back on the shower chair. Once the Resident was back in the chair, Staff #180 told Staff #164 that she had it from there and that she could go. Staff #164 stated that had she known that once she was gone, Staff # 180 was going to leave the Resident unattended, she would have never left. Staff # 164 was asked if it was ever permissible to leave a resident unattended in the shower, and she said no. An attempt to contact Staff #180 was met with negative results. The facility 5-day report stated that after the LPN had assisted the CNA with pulling up the residents pants and brief the CNA told the LPN that she was good and the LPN could go. A few moments later the CNA went to get assistance to transfer the resident to the to the wheelchair per the residents request of two staff. While the CNA was getting assistance the resident attempted to reposition herself and slipped out of her chair onto the floor. A review of the facility policy titled Incident and Accidents, no date implementation, revision or review date revealed the following: In the event of an incident or accident, immediate assistance will be provided or securement of the area will be initiated unless it places one at risk of harm. Any injuries will be assessed by the licensed nurse or practitioner and the affected individual will not be moved until safe to do so. First aid will be given for minor injuries such as cuts or abrasions. The supervisor or other designee will be notified of the incident/accident. If necessary, law enforcement may be contacted for specific events. The nurse will contact the resident's practitioner to inform them of the incident/accident, report any injuries or other findings, and obtain orders, if indicated, which may include transportation to the hospital dependent upon the nature of the injury(ies). In the event of an unwitnessed fall or a blow to the head, the nurse will initiate neurological checks as per protocol and document on the neurological flow sheet. Abnormal findings will be reported to the practitioner. A review of the facility policy titled Resident Shower Policy, implemented April 01, 2021, and revised June 01, 2022, states, It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation, and help prevent skin issues per current standards of practice. Help the resident into the shower. If the resident needs to remain seated in the shower chair, ensure it is locked in place. Encourage the use of safety rails.

Based on clinical record review, staff interviews, and review of facility documentation and policies, the facility failed to protect the rights of one resident (#54) to be free from physical abuse by another resident (#13). The deficient practice could result in further physical abuse of residents when appropriate actions are not taken.Findings Include:-Regarding Resident #13 (alleged perpetrator):Resident #13 was admitted to the facility on [DATE] with diagnoses that included dementia, major depressive disorder, and anxiety disorder.The care plan dated October 2, 2025, revealed that the resident has a behavior problem of making sexually inappropriate comments to female staff and persistent yelling out, verbal and physical aggression toward staff during care related to Dementia. The interventions included to administer medications as ordered, and monitor and document for side effects and effectiveness; anticipate and meet the resident's needs; intervene as necessary to protect the rights and safety of others; approach/speak in a calm manner; divert attention; remove from situation; and take to alternate location as needed.A review of Resident's admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 5.0, indicating a severely impaired cognition. Per resident's behavioral symptoms assessment, the physical and verbal behavioral symptoms directed towards others occurred.The clinical census review revealed that Resident #13 and Resident #54 (alleged victim) were in the same unit since December 12, 2025.A review of a behavior notes progress note dated December 30, 2025, at 3:18 AM revealed per document that Resident was up and down all throughout the night looking for a family member, and said that he did not like another male resident looking at him and wants to know why they are here. The staff redirected Resident #13 several times and was ineffective. The resident was administered an anti-anxiety medication for increased restlessness and the Resident activity included watching a sports game on television.Another progress note regarding behavior dated December 31, 2025, at 4:56 AM revealed per documentation that Resident #13 refused his vital signs and medication. Per documentation, Resident #13 yelled at staff to get out of his house. Further, an incident note progress note dated December 31, 2025, at 1:17 PM, per documentation, Resident #13's family member was notified about his aggressive behavior.On December 31, 2025, at 1:20 PM, an incident notes in the progress note revealed, per documentation, that Resident #13 was seen by staff coming out of his room looking very angry moving quickly towards Resident #54. Resident #13 hit Resident #54's back of the head, knocking Resident #54's hat off. Resident #54 was sleeping at the time. Resident #13 kept on saying that Resident #54 just got out of prison and denied him a job. Two staff members stepped in between Resident #13 and Resident #54 to stop any further hitting. Resident #13 went back to his room. Per documentation, Resident #13 was watched closely by staff until Resident #54 was moved to another unit.A review of the resident's revised care plan revealed that on December 31, 2025, the care plan included the resident has potential to be physically and verbally aggressive related to Dementia. The goal included resident will not harm self or others. The interventions included to administer medications as ordered, and monitor/document for side effects and effectiveness; analyze times of day, places, circumstances, triggers, and deescalate behavior; provide physical and verbal cues to alleviate anxiety; give positive feedback; assist verbalization of source of agitation; assist to set goals for more pleasant behavior; encourage seeking out of staff member when agitated; give the resident as many choices as possible about care and activities; when the resident becomes agitated, intervene before agitation escalates; guide away from source of distress; engage calmly in conversation; and if response is aggressive, staff to walk calmly away, and approach later.On January 13, 2026, Resident #13 was transferred out to a hospital. -Regarding Resident #54 (alleged victim):Resident #54 was admitted to the facility on [DATE] with diagnoses of urinary tract infection (bladder infection), dementia, altered mental status, and anxiety disorder.The clinical census review revealed that Resident #54 and Resident #13 (alleged perpetrator) were in the same unit since December 12, 2025.A review of his admission MDS assessment dated [DATE] revealed a BIMS score of 6.0, indicating a severely impaired cognition. He did not exhibit behavioral symptoms, and there was no wandering behavior exhibited.A review of the incident note documented in the progress note dated December 31, 2025, revealed per document, that Resident #54 was sitting at the dining room table sleeping when Resident #13 came out of his room and was very angry. Resident #13 hit the back side of Resident #54's head. Resident #54's cowboy hat was knocked off. Two staff members stepped in between Resident #54 and Resident #13. Resident #13 who was identified as the aggressive resident went back to his room. Both residents were separated. The director of nursing (DON), assistant director of nursing (ADON), and the nurse practitioner (NP) were notified. Resident #54's family member was notified.On December 31, 2025, record review revealed that Resident #54 was moved to another unit.A review of the resident's revised care plan dated December 31, 2025, revealed a potential for psychosocial well-being problem related to resident- to- resident physical altercation. The interventions included to allow the resident time to answer questions and to verbalize feelings, perceptions, and fears; monitor and document resident's feelings relative to isolation, unhappiness, anger, and loss; and when conflict arises to remove resident to a calm safe environment.Further review of the resident's care plan revealed that on January 6, 2026, the resident has impaired cognitive function/dementia or impaired thought processes related to Dementia. The interventions included to administer medications as ordered and monitor and document for side effects and effectiveness; and cue, reorient and supervise as needed.Review of the facility's 5-day investigation report dated January 5, 2026 revealed that a certified nursing assistant (CNA/Staff #155) was interviewed and per report, Staff #155 saw Resident #13 smack the cowboy hat off Resident #54. Staff #155 quickly de-escalated the interaction, and Resident #13 was led by hand back to his room. Resident #13 and Resident #54 were immediately separated. Per report, both residents were unable to recall the event that occurred. Per report, a Registered Nurse (RN/Staff #90) was interviewed and she stated that she did not see the altercation between Resident #13 and Resident #54 that the CNA (Staff #155) reported to her. The investigation report conclusion revealed that the allegation of abuse was verified by the evidence collected during the facility's investigation.On January 21, 2026, at 1:24 PM, an interview was conducted with a CNA (Staff #112). Staff #112 stated that she works in the memory care unit of the facility. Her unit takes care of residents with dementia and Alzheimer's. She said that her responsibility included to assist and redirect the residents with their activities of daily living (ADLs). She stated that she observes for behaviors such as yelling or screaming that can tick off or make her residents feeling upset. She stated that her dementia care training before she started working involved a few weeks of training via online and following another staff in the unit before she can start working on her own. She stated that she also received abuse training. And, she stated that abuse could be verbal, restraining residents, and forcing residents to do what they do not want to do. She said that if a resident refuses care, she will leave the resident alone, and come back to the resident later. She does not recall any recent abuse incidents in her unit. She stated that if a resident who was wearing a hat and was smacked by another resident on the head, she stated that she considered it as abuse because somebody should not raise their hands towards somebody or their belongings. She stated that when it happens, she would separate the residents, and will notify her nurse so that the nurse can write a full report, and the nurse would be made aware of the incident. She stated that she was always told that if something happened to any resident that she should report to the nurse. She said that if she does not report the incident, the resident might continue to do it, the resident might think it is okay to do it, or the resident might think that it was funny.On January 21, 2026, at 1:40 PM, Resident #54 was observed sitting in the dining room wearing a cream-colored cowboy hat. Resident #54 stated that he used to live in another state. He stated that he does not remember anybody taking off his hat.On January 21, 2026, at 1:47 PM, an interview was conducted with CNA (Staff #155). Staff #155 stated that she works in the memory care unit of the facility. She said that she received dementia care training. For example, she stated that if her resident say no, she leaves and then will try again later. She said that her abuse training is once a year. She also said that abuse is verbal, physical, and financial. She stated that hitting and touching a resident while upset or mad at him or her, was an example of a physical abuse. Further, Staff #155 said that if she was made aware of or witnessed an abuse incident, she will report the incident to her supervisor immediately because if the abuse was not reported, she can get in trouble, and something else could happen to the resident. She said that she will report it to protect the residents' right and be an advocate for the resident. Staff #155 also stated that she recalled an abuse incident that happened recently, couple weeks ago between 12:30-1:00 PM after lunch. She said that the incident involved Resident #13, who was no longer in the facility, and Resident #54. She remembered Resident #54 was sitting with his back facing Resident #13. Staff #155 saw Resident #13 hand smacked the back of the head of Resident #54 who was asleep at the table. Staff #155 stated that Resident #13's room was near to the table were Resident #54 was sitting by the dining area. Staff #155 stated that after seeing what had happened, she immediately got up, and the nurse (Staff #90) came out from the nurses' station and followed her. Staff # 155 stated that she and Staff #90 redirected Resident #13 and helped Resident #13 to calm down. Staff #155 stated that Staff #90 notified the DON. Staff # 155 stated that she documented the incident in the electronic medical record but does not know how and where it went because she could not find it. Staff #155 stated that she considered the incident between Resident #13 and Resident #54 physical abuse.An interview was conducted on January 21, 2026 at 2:39 PM with the DON (staff #160). The DON stated that abuse is any physical, mental, financial, verbal, and psychosocial attack on another person. An example of a physical abuse is like pushing, hitting, slapping, kicking, and touching somebody in a way that they do not want. The DON also said that once she was made aware of an allegation of abuse, she will initiate an investigation. She said that if the incident involved a staff, the staff will be suspended pending investigation. She will report the incident to the health department, conduct interviews with the staff, interview the residents that can give her valid information, review documentation to understand what went on, and continue the investigation until the submission of the 5-day follow up report. Regarding the incident involving Resident #13 and Resident #54, the DON stated that she was notified of the incident. The DON stated that the nurse from the memory care unit called the ADON at 1:00 PM. The DON stated that a CNA saw Resident #13 ambulating towards Resident #54. The DON said that Resident #13 stated that Resident #54 was someone who just got out of prison and he would not give Resident #54 a job, and that upset Resident #13. The DON said that Resident #13 got up and just went straight to Resident #54 and smack Resident #54's hat off. The DON said that Resident #13 just hit the rim of Resident #54's hat. The DON stated that Resident #13 and Resident #54's incident was not allowed because Resident #13 can't hit someone's hat. She said that she considered the smacking of the hat a physical abuse because even though it did not hit Resident #54, it was not a friendly gesture and Resident #13 was angry. The DON stated that Resident #13 and Resident #54 were immediately separated, and the CNA led Resident #13 back in his. The DON stated that Resident #13 and Resident #54's families were immediately contacted, and their BHT (behavioral health team) was also contacted to evaluated both residents for psychosocial effect of the incident. The DON stated that Resident #54 was assessed, and there was no injury, and no psychosocial effect from the incident. The DON said that Resident #13 did not have an escalating behavior towards residents, there was no indication of it, and there was no prior incident nor indication that Resident #13 was agitated at the time. The DON stated that it was in her 5 -day report that she verified the incident between Resident #13 and Resident #54 as abuse. Furthermore, the DON stated that from a prior abuse incident, she said that there was something similar that had happened before so, ever since then she and her ADON started doing rounds, having discussion about any resident with an escalating behavior, and trainings were conducted with staff regarding escalating behavior.The administrator (Staff #46) was interviewed on January 23, 2026 at 11:19 AM. The administrator stated that the abuse process included to notify the administrator and or DON; report the alleged abuse within 2 hours to the department of health services, APS, and law enforcement; staff to separate individuals/residents; and if a staff was involved, the staff will be suspended immediately pending the outcome of the investigation. The administrator stated that abuse is any kind of exploitation or harm to the resident physically, emotionally, financially, or psychological harm. Further, the administrator stated that abuse in their memory care unit include resident hitting another resident, or taking another resident's belonging. Regarding Resident #13 and Resident #54 incident, the administrator stated that Resident #13 hit the back head of Resident #54 which he considered it abuse.Review of the policy titled Abuse, Neglect and Exploitation updated on July 2025, revealed the facility's policy ensuring the health and safety of each resident. The policy also included (V) Investigation of Alleged Abuse, Neglect and Exploitation which included (B.4) Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure that 1 of 2 sampled residents (Resident #1) was free from abuse by staff members (Staff #163 and Staff #202). The deficient practice could result in other residents being abused. Findings include:-Regarding Resident #1Resident #1 was admitted on [DATE], with diagnoses that include unspecified dementia without behavioral disturbance, Bipolar disorder, major depressive disorder, and anxiety disorder. A comprehensive care plan initiated on January 27, 2023 revealed that the resident had behavior problems using abusive language, yelling, screaming, and threatening behavior related to dementia, bipolar disorder, and anxiety. The care plan also revealed that the resident refuses to ask for help when transferring, causing multiple falls. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating moderate cognitive impairment. The MDS also revealed substantial maximum assistance required for shower assistance. An e-mail dated December 3, 2025 sent at 10:08 a.m. from Certified Nursing Assistant (CNA/Staff #7) sent to Nursing Home Administrator (ED/Staff #2) and the Director of Nursing (DON/Staff #69) revealed that on December 1, 2025 Staff # 7 was assigned to Resident #1 and was scheduled to provide a shower to Resident #1. It was revealed that Resident #1 had refused several attempts by Staff #7 to provide the shower, and he notified the Registered Nurse (RN/Staff #163), who was assigned to Resident #1. Staff #7 explained in the email that RN #163 told him not to ask Resident #1 for a shower, but just to take her into the shower. Staff # 7 opted to reapproach at a later time. Staff #7 revealed that the RN (Staff #163) had taken Resident #1 with the help of another CNA (Staff #202) against Resident #1's wishes into the shower and conducted a shower on Resident #1, Staff # 7 revealed that Resident # 1 was disagreeing being in the shower that she was cold and did not want wet hair. Staff #7 stated that both RN (Staff #163) and CNA (Staff #202) finished the shower and had CNA (Staff #7) dry the resident off and take her back to her room, where Staff # 7 describes Resident #1's mood as angry that this incident occurred. A late entry nursing note dated December 3, 2025, at 2:58 p.m. (created December 12, 2025, at 3:03 p.m.) revealed that Resident #1 was interviewed regarding the reported incident on December 1, 2025, and Resident # 1 reported that she felt safe in the facility and did not want to move rooms. Resident #1 denied any increase in depression and anxiety.A facility investigation interview with Resident #1, dated December 3, 2025 at 5:30 p.m., revealed that Resident #1 had stated that she was about ready to go to bed when Staff #163 and later identified Staff #202 pulled her out of bed by Resident #1's arms as she was yelling to stop. Resident #1 also revealed that they forced her to take a shower against her will. A nursing note dated December 3, 2025, revealed that police were present at the facility to look at red marks on Resident #1's arm and reported to the nurse that he did not think the red marks were from abuse. A comprehensive care plan initiated on December 9, 2025, revealed that Resident #1 has a potential for psychosocial well-being problem related to substantiated abuse that occurred on December 1, 2015. -Regarding Staff # 163Review of Staff # 163's (alleged perpetrator) personnel file revealed that she was employed as a Registered Nurse with a start date of June 29, 2023.An Employee Disciplinary Notice dated May 10, 2024, revealed that a written warning was presented to Staff # 163 for discourtesy toward resident, client, or other employee. The disciplinary notice revealed that Staff # 163 was treating kitchen staff disrespectfully on multiple occasions and being disrespectful in front of nursing students. An Employee Disciplinary Notice dated February 7, 2025, revealed that a written warning was presented to Staff # 163 for discourtesy toward resident, client, or other employee, Violation of / or failure to observe: company and/or departmental policies and work procedures, insubordination, and policies within code of conduct. Further review of the disciplinary notice revealed that Staff # 163 continued to have issues with attitude and behavior with other staff and being overly negative and vocal often complaining about duties expected of her. Staff # 163 was also noted for not following up on concerns with residents after issues are brought to her attention from CNAs, and she has told CNAs to falsify legal documents by making up numbers to complete vitals on residents.Further review of Staff #163's personnel record revealed an employee training checklist, which included topic of Resident Rights and Elder Justice/Abuse/Neglect/Exploitation, completed on February 24, 2025.Review of Staff # 163's personnel record also revealed a memo regarding Abuse Training Acknowledgement signed September 11, 2025. A Personnel and Payroll Notification form dated December 10, 2025, revealed that Staff # 163 was involuntarily terminated from the facility due to substantiated abuse, with her last day worked December 3, 2023. The personnel and payroll notification also revealed that Staff # 163 was found to exhibit neglectful behavior that resulted in endangering a resident. -Regarding Staff # 202Review of Staff # 202's (alleged perpetrator) personnel file revealed that she was employed as a CNA with a start date of January 2, 2025.Further review of Staff #202's personnel record revealed an employee training checklist which included the topic of Resident Rights, and Elder Justice/Abuse/Neglect/Exploitation completed on January 2, 2025, and February 28, 2025.An Employee Disciplinary Notice dated May 9, 2025, revealed that a written warning was presented to Staff # 202 for discourtesy toward resident, client, or other employee, Violation of / or failure to observe: company and/or departmental policies and work procedures, insubordination, policies within code of conduct, and failure to complete work assignments. Further review of the disciplinary notice revealed that Staff # 202 did not follow through and communicate to the nurse that a resident needed pain medication and was sitting at the nursing station when call lights were going off and not answering them, even when being told by the Assistant Administrator to respond. Review of Staff # 202's personnel record also revealed a memo regarding Abuse Training Acknowledgement signed September 11, 2025. A Personnel and Payroll Notification form dated December 10, 2025, revealed that Staff # 202 was involuntarily terminated from the facility due to substantiated abuse, with her last day worked December 3, 2023. The personnel and payroll notification also revealed that Staff # 202 was found to exhibit neglectful behavior that results in endangering a resident. The Facility Investigation report dated December 9, 2025, revealed that the facility verified the allegation of staff abuse to Resident #1 and terminated the employment of both Staff #163 and Staff #202.An attempt was made to contact Staff #7 on December 24, 2025, at 10:05 a.m., but the phone call was not returned by the staff member. An interview conducted on December 24, 2025, at 10:50 a.m. with Resident #1 revealed that Staff #163 and Staff #202 entered her room and pulled Resident #1 out of bed when she told them she did not want to shower. Resident #1 reported that it was cold and she did not want her hair wet. Resident #1 went on to reveal that a different staff member, Staff #7, dried her off and put her back into bed. Resident #1 revealed that she was upset because Staff #163 and #202 grabbed her.An interview was conducted with Licensed Practical Nurse (LPN/Staff #58) on December 24, 2025, at 11:30 a.m. revealed that she was scheduled on a different part of the unit that day and heard of the incident but did not witness it because Staff #163 was very territorial with her assignments and residents and no one could help Staff #163 with the care of the residents. Staff #58 also revealed that Staff #202 was known for not doing much work but just sitting at the nurses' station talking with Staff #163. Staff #58 also stated that Staff #7 was getting frustrated with all the work he was doing, and Staff #202 would not help. According to Staff #58, Staff #202 would only do tasks that Staff #163 would assign her, and Staff #7 appeared tired and drained. Staff #58 revealed that it is not common for the nurses to give scheduled showers unless the resident needed one, like they soiled themselves, and no one was around at the time. An interview with CNA (Staff #34) on December 24, 2025, at 11:45 a.m. revealed that Resident #1 does refuse showers, but when she does agree to take a shower, she does not resist. Staff #34 revealed that if a resident refuses a shower, they would come back another time and try again, and if they continue to refuse, then they will tell the nurse, and the nurse attempts to talk to the resident. If the resident says no to the nurse, then the resident and nurse sign a shower refusal sheet. Staff #34 stated that nurses don't perform the showers; it is the CNAs who do the showers. An interview with Assistant Director of Nursing (ADON/Staff #65) on December 24, 2025, at 11:56 a.m. revealed that the ED and DON received an email that Staff #202 and Staff #163 forced Resident #1 to get into the shower against Resident #1's wishes. The ADON stated that she had interviewed Resident #1 regarding the incident, and Resident #1 stated she was grabbed by the arm out of bed and into the shower. Staff #65 also revealed that there was a bruise that was in question on Resident #1's arm that was later determined to be present prior to the incident, and the police also looked at the arm and determined it was not from abuse. The ADON reported that the facility substantiated the allegation of abuse and terminated both Staff #202 and Staff #163. The ADON stated that the DON (Staff #69) had reported the licenses of Staff #163 and Staff #202 to the licensing board. A Policy and Procedure titled, Abuse, Neglect and Exploitation, updated on July 2025, revealed that it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. The policy goes on to define abuse as willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff-to-resident abuse.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to ensure 2 of 5 sampled residents (Resident #1 and #4) was free from abuse by another staff member & another resident (Staff #201 and Resident #5). The deficient practice could result in other residents being abused.Findings include:Regarding Resident #1:Resident # 1 (alleged victim) was re-admitted [DATE] with diagnoses that included hypertensive heart and chronic kidney disease, morbid obesity, major depressive disorder, anxiety disorder, and unspecified dementia.A comprehensive care plan initiated on August 15, 2025, revealed that the resident had an activity of daily living (ADL) performance deficit due to impaired balance and limited mobility. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating moderate cognitive impairment. The MDS also revealed that the resident was dependent on staff for toileting hygiene and lower body dressing. A Nursing Note dated November 1, 2025, revealed that Resident #1 had care concerns with Certified Nursing Assistant (CNA/Staff #201) being angry and aggressive in her care on October 30, 2025. The nursing note also revealed that that the resident felt safe in the community as long as Staff # 201 was not taking care of her. A Weekly Body Check assessment dated [DATE], revealed red dry flaky skin to bilateral lower extremities and scab on her left upper back. Review of the initial facility report of alleged abuse to the State Agency from the Operations Assistant (Staff # 8) dated November 1, 2025, revealed that Resident #1 stated she received abusive care from Staff # 201 on Thursday, October 30, 2025. The facility report also revealed that Staff #8 came to the facility and interviewed Resident # 1 and confirmed residents concerns with her care. Staff #201 was removed from the schedule. Regarding Staff #201Review of Staff #201's (alleged perpetrator) personnel file revealed that she was employed as a Certified Nursing Assistant (CNA) with a start date of August 6, 2025.Further review of Staff #201's personnel record revealed an employee training checklist which included the topics of Resident Rights, and Elder Justice/Abuse/Neglect/Exploitation signed August 6, 2025.Review of Staff #201's personnel record also revealed a memo regarding Abuse Training Acknowledgement signed September 10, 2025. A Personnel and Payroll Notification form dated November 4, 2025 revealed that Staff #201 involuntary terminated from the facility due to resident's complaint and report that she was abusive on October 31, 2025. The personnel notification goes on to reveal that residents reported Staff #201 was aggressive, angry, had an abusive tone, and threw chips at them. A Facility Investigation Report dated November 4, 2025 revealed that Resident #1 gave a statement on November 1, 2025 in which she reported that Staff # 201 was abusive during care provided on October 31, 2025 between 10:00 p.m.- 6:00 a.m. shift. Per Resident #1, Staff # 201 was aggressive during personal care, and displayed an angry attitude. Resident #1 further revealed that when she requested a snack, Staff #201 threw the snack at her. Resident #1 stated that she did not feel safe around Staff # 201. The facility report documented that during staff and resident interviews, it was confirmed by several residents that Staff #201 was rough with cares and displayed an angry demeanor toward other residents. An interview was conduct with a CNA (Staff # 165) on November 12, 2025 at 2:49 p.m., which revealed that Resident #1 had never resisted cares and she is usually the first one they get out of bed in the mornings. Staff #165 said that Resident #1 is good and helping with cares so it does not take as long as some of the other residents. CNA noted that hitting a resident, grabbing onto residents or being rough with residents can be considered physical abuse. An interview with the Director of Nursing (DON/Staff # 19) on November 12, 2025 at 3:45 p.m., revealed that she was not in the position of DON during the incident with Resident #1 and Staff #201. However, the DON confirmed that Staff #201 was suspended then terminated when the allegations were substantiated. An interview with the Operations Assistant (Staff #8) on November 12, 2025 at 4:08 p.m., revealed that Resident #1 told her that Staff #201 was extremely rough and that her hands felt like vice grips on her arms. Staff #8 revealed that a full body check was done on Resident #1 with no bruising discovered. Staff #8 discovered during her investigation that Staff #201 was verbally rude to residents, threw a bag of potato chips at a resident and was identified by three other residents as physically aggressive and angry toward them. Staff #8 noted that residents did not want Staff #201 to take care of them. According to Staff # 8, Staff #201 refused to give a statement. Therefore, the facility decided to terminate Staff #202 due to all the statements from the residents. Regarding Resident # 4:Resident #4 (alleged victim) was admitted [DATE] with diagnoses that included metabolic encephalopathy, anxiety disorder, and muscle weakness.A Behavior Noted dated November 5, 2025, revealed that the resident was wandering the unit talking to other residents, trying to encourage and help other to stand up when they cannot stand up alone. The note also revealed that she was taking gloves, garbage bags, clothing protectors, drinks off the tables, and eating food off an old tray. The noted documented that Resident #4 can be combative at times and difficult to redirect from other resident rooms after everyone is in bed. Physician was notified and a new order of Gabapentin for anxiety was initiated.A General Nursing Progress Note dated November 6, 2025, revealed that Resident #4 continues to wander into other rooms and pick up whatever she sees and thinks is hers. The note also documented that Resident #4 tries to help other residents to stand up and is difficult to redirect.A comprehensive care plan initiated on November 8, 2025, revealed that Resident #4 was a high risk for falls due to confusion, deconditioning, and gait balance problems. Further review of the care plan contained no indication of Resident #4's wandering behavior. An Orders - Administration Note dated November 8, 2025, documented that Gabapentin Oral Capsule was administered to Resident #4 for anxiety due to inability to sit still and wandering the hallways into other residents rooms and trying to put other residents to bed. The note documented that the nurse was unable to redirect her after trying food, music and coloring books. An incident note dated November 8, 2025, revealed that Resident #4 was hovering over Resident #5 to help Resident #5 when Resident #5 grabbed Resident #4's left arm with both hands and would not let go while she yelled at Resident #4. The incident note documented that it took two staff members to get Resident #5's hands off of Resident #4. Resident #4 ended up with a small scratch on her left hand with a small bruise about 2 centimeters round. A Weekly Body Check assessment dated [DATE], documented that the resident received a scratch and bruise to the back of left hand and skin tears to left and right elbows. A Behavioral Note dated November 8, 2025 at 9:36 p.m. revealed that Resident # 4 continued to wander into other residents' rooms removing items and helping other residents with standing up from wheelchairs. Staff were unable to get her into bed. Regarding Resident #5:Resident # 5 (alleged perpetrator) was admitted [DATE] with diagnoses that included unspecified dementia, major depressive disorder, and anxiety disorder.An admission MDS assessment dated [DATE] revealed a BIMS score of 2 which indicated severe cognitive impairment.A comprehensive care plan initiated on October 1, 2025 revealed that this resident had a history of behavioral problems which included verbal and physical aggression towards staff and other residents, and self-inflicted injury due to dementia. A Behavior Note dated November 8, 2025 at 6:49 p.m., revealed that Resident #5 grabbed Resident #4's arm with both hands and tried to pull her down over her while yelling, you are trying to kill me. Staff were able to get Resident #5's hands off of Resident #4 leaving small scratches on Resident #4. A Skin assessment dated [DATE], revealed that Resident # 5 had no open skin or redness. However, the assessment documented bruising on the back of her left and right hands.An incident note dated November 8, 2025 at 8:50 p.m. revealed that Resident #5 was moved to the nurses' station for one-on-one monitoring was provided until family was able to sit with her. The incident note also revealed that a skin check was performed on Resident # 5 which determined that the bruises on the back of her hands were old. The 5-day Facility Investigation report dated November 12, 2025 revealed that based on the incident being witnessed by staff and documentation the facility substantiated the abuse allegation. The Facility investigation report documented that the facility implemented and intervention and placed Resident #5 with a 1:1 sitter at all times. Additionally, a psychological consult with medication review was also put in place. An interview with a Licensed Practical Nurse (LPN/Staff #133) on November 12, 2025 at 2:04 p.m. revealed that they heard commotion and saw Resident #4 standing over Resident #5. Resident #5 was witnessed holding onto Resident #4's arms tightly resulting in a slight skin tear. Staff #133 revealed that the CNA was able to get the grip of Resident #5 off of Resident #4. However, Resident #5 gripped onto the CNA and grabbed Staff #133. The LPN revealed that she allowed Resident #5 to hold onto her to lead her away from Resident #4 to the nurses' station. Staff #133 noted that Resident #4 likes helping other residents and was trying to help Resident #5. Resident #5 thought Resident #4 was going to kill her so Resident #5 started fighting back. An interview with the DON (Staff #19) on November 12, 2025 at 3:45 p.m. revealed that the resident-to-resident altercation between Resident #4 and Resident #5 was substantiated. The DON stated that Resident #5 was placed on 1 to 1 sitter and a new social worker has been put into place. The DON noted that Resident #5's Preadmission and Screening Resident Review (PASRR) was under review.A Policy and Procedure titled, Abuse, Neglect and Exploitation updated on July, 2025 revealed that it is the policy of the facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, and exploitation and misappropriation of resident property. The policy goes on to define abuse as willful infliction of injury, intimidation, or punishment with resulting physical harm, pain, or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.

Based on observations, clinical record reviews, interviews, and review of facility policy and procedures, the facility failed to protect the rights of one resident (#1) to be free from verbal and physical abuse by another resident (#2). The deficient practice resulted in psychosocial harm to resident #1 and the potential for abuse of other residents. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care was identified.Findings include:On September 10, 2025, at 4:10 PM, a condition of IJ was identified. The administrator (staff #110) and the assistant administrator (staff #103) were informed of the facility's failure to ensure resident #1 was protected from abuse by resident #2. Review of the clinical record resident #2 revealed a pattern of verbal abuse that started in June and escalated to physical abuse on September 3, 2025. Staff interviews revealed that these incidents were reported to administration, however, there was no evidence that the facility took steps to protect resident #1 from further abuse by resident #2. Further, staff interviews revealed that these incidents were considered as behaviors and not abuse. On September 10, 2025 at 5:46 p.m., the administrator and assistant administrator submitted a removal plan which was not accepted because the the plan did not address how they were going to implement their plan, who is responsible in ensuring that plan was implemented, and when they will start and end their plan.On September 11, 2025, at 8:51 AM, the removal plan was not accepted because it failed to to include specific procedures and timelines involved in the removal plan.On September 11, 2025, at 11:27 AM, the administrator and the assistant administrator submitted the revised IJ removal plan which was not acceptable because it failed to include completion of resident interviews, in-service training to staff and new hires, specific procedures, and timelines involved.On September 12, 2025, at 8:46 AM, the revised Immediate Jeopardy (IJ) Removal Plan was accepted. The plan included the following actions:Resident #2 was assigned a 1:1 sitter and relocated to a different unit, with behavior monitoring for three days;Resident #1 was assessed for injuries, including possible psychosocial harm. Clinical documentation was reviewed, and behavior was tracked for three days;Individualized care plans were updated;Ongoing staff training was implemented on how to identify abuse;Ongoing staff training was provided on how to intervene and stop abuse;Ongoing staff training was conducted on the proper protocol for reporting abuse;All residents were interviewed to identify any potential abuse. For residents unable to be interviewed, the MDS nurse completed an assessment for signs or symptoms of abuse; and,Monthly Quality Assurance and Performance Improvement (QAPI) meetings were scheduled to review any incidents or concerns related to abuse.Multiple observations were conducted on the facility implementing their removal plan, including resident #2 placed on 1:1 sitter and moved to another unit, resident #1 was assessed for injury including psychosocial harm and in-service training completed. Staff interviews conducted revealed that staff acknowledged training had been completed according to the facility's removal plan.On September 12, 2025, at 1:55 PM, the administrator and the assistant administrator were informed that the condition of the IJ had been removed.-Resident #3 (witness) was admitted on [DATE] with diagnoses of dementia, abnormalities of gait and mobility and muscle weakness.The care plan dated December 22, 2020 included that the resident had behaviors of wandering, impaired safety awareness related to dementia and was receiving behavioral health services. Interventions included all ADLs (activities of daily living) will be met by staff daily and resident in the secured memory care unit.The late entry provider visit note dated August 19, 2025 revealed the resident was alert, oriented 2-3, ambulated with 1-person assist and had no focal neurological deficits. Assessment included dementia.-Resident #1 (alleged victim) was admitted on [DATE], with diagnoses of dementia, muscle weakness, and history of falling.Review of the care plan dated December 24, 2024, included the resident needed assistance with activities of daily living (ADL) and was an elopement risk. Interventions included encourage resident to participate in activities that promote exercise, daily staff assistance with ADL's, distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books that resident prefers and, to monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in functionThe MDS (Minimal Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. The NP (nurse practitioner) psychiatric progress note dated June 29, 2025 included that resident #1 had history of dementia without behaviors and had no issues or concerns regarding psychiatric needs. Diagnosis included dementia without behavioral disturbance. Recommendations included medication management, strategic skills to cope with stress, modulation of interpersonal/occupational/family/social dynamics to reduce stress and behavioral modification encouragement.A behavior note dated July 10, 2025 revealed that the resident was agitated, confused, wanted to go home and insisted that her car was parked right outside.The orders-administration note dated July 10, 2025 included that the resident had one episode of frustration regarding seeing someone outside her window; and, the resident asked if she could go home. The orders-administration note dated July 23, 2025 revealed that the resident was awake, confused, oriented to self and was tearful. Per the documentation, the resident told staff that she got to go; and when the staff told her that she would be staying, the resident asked the staff if she could come with the staff; and that, when the staff encouraged the resident to try to sleep, the resident appeared shocked and told staff that she thought it was morning. The documentation also included that the staff sat with the resident until the resident was calm; and reminded the resident that staff were there with her and she was not alone. According to the documentation, hourly and PRN (as needed) rounds were conducted throughout the night.The care plan dated August 15, 2025 revealed that with reminders, the resident was independent for meeting emotional, intellectual, physical and social needs. Intervention included to introduce the resident to residents with similar background, interests and encourage/facilitate interaction.A restorative nursing assistant note dated August 21, 2025 included that resident told staff that she was following another resident in her wheelchair and they were looking to see if they could find her husband.An infection note dated September 3, 2025 revealed that residents #1, #2, and #3 were sitting at the same table before dinner. Per the documentation, staff witnessed resident #2 standing over and yelling at resident #1; and that, staff intervened and moved resident #1 to the nurse's station and resident #2 returned to her room. The documentation also included that resident #3 told staff that resident #2 yelled and hit resident #1.A communication note dated September 6, 2025 included that the resident's family requested to speak with staff related to the resident's recent altercation with another resident (#2).The NP psychiatric progress note dated September 7, 2025 included that the resident was extremely hard of hearing, very confused, was not mobile, and required total care. The documentation also included that the resident had advanced dementia showing stable psychiatric symptoms and had no current behavioral issues reported by staff. -Resident #2 (alleged perpetrator) was admitted on [DATE], with diagnose of dementia, major depressive disorder, anxiety disorder, and schizoaffective disorder.Review of the care plan dated October 17, 2024, revealed resident was dependent on staff and family for all emotional, intellectual, physical, and social needs. Interventions included to encourage ongoing family involvement and inviting to attend special events, activities, and meals, introducing resident to residents with similar backgrounds, interests, and encourage/facilitate interaction, invite the resident to scheduled activities and assist to and from programs to help encourage participation. The care plan did not include that the resident had behaviors such as verbal or physical aggression towards staff and/or residents.The NP psychiatric note dated December 3, 2024 included that the resident was calm, attentive, communicative, casually groomed, with scanty speech and difficulty naming objects. Per the documentation resident had intact associations, fair judgment and logical thinking. Diagnoses included schizoaffective disorder, bipolar type, anxiety disorder, moderate dementia without behavioral/psychotic disturbance.A late entry provider visit note dated June 4, 2025 revealed the resident was alert and oriented to self and environment. Assessments included dementia, schizoaffective disorder, anxiety and depression.A behavior note, dated June 12, 2025, revealed resident #2 displayed anger every time resident #1 who was sitting near resident #3. Per documentation, resident #2 had paranoia and reported that resident #1 was taking resident #3 from her; and that, resident #2 threatened resident #1 with physical violence and yelled at resident #1 who remained seated and looked confused while being yelled at by resident #2. The documentation also included that this behavior of resident #2 happens every time resident #1 tried to sit by resident #3. The clinical record revealed no evidence of any intervention implemented to prevent altercation from happening again between resident #1 and #2.The behavior note dated July 2, 2025 included resident #2 yelled at and threatened resident #1 because resident #1 was looking at her at the dinner table.Review of a behavior note dated July 8, 2025 revealed that resident #2 told resident #3 that resident #1 was wearing her shirt; and that, resident #2 then approached resident #1, grabbed the shirt of resident #1 and told resident #1 to give the shirt back. Per the documentation, resident #2 told resident #3 that they should beat up resident #1; and that, resident #3 told resident #2 they should not do that because they would go to jail. The documentation also included that the CNA (certified nurse assistant) was able to separate the residents. Another behavior note dated July 8, 2025 included that resident #2 was sitting with resident #3 and other residents watching tv. Per the documentation, resident #1 was just passing down the hallway to her room and resident #2 yelled at resident #1 to go away and to get out of here; and, staff noticed this behavior from resident #2 before when resident #1 was sitting with resident #3. The documentation included that staff called a family member who explained that the brother of resident #2 had married a woman with the same first name as resident #1 and that person was very abusive to the family and her children; and that, the family of resident #2 believed the resident was reliving her past when she sees resident #1. Further, the documentation included that the NP and the DON (Director of Nursing) were notified.A late entry provider visit note dated July 9, 2025 revealed documentation of resident #2 yelling at other residents. Per the documentation the resident was alert & oriented x self/environment with normal affect. Assessments included dementia, schizoaffective disorder, anxiety and depression. Plan included for medications. The note did not include any interventions to address resident #2's verbal and physical aggression towards resident #1.A behavior note dated July 9, 2025 included resident #2 approached the dining room table where resident #1 was sitting at and yelled at resident #1. The documentation included that staff stepped in front of resident #1 to block the view of resident #2 who was then requested to return to her table. It also included that after a couple of minutes, resident #2 returned to her table but she was keeping an eye on resident #1.Another behavior note dated July 9, 2025 revealed that Psych was in to evaluate resident #2; and that, the ADON (Assistant Director of Nursing) notified the provider of the resident's behaviors. The documentation included that there were no new orders.The behavior note dated July 10, 2025 included that resident #2 continued to make comments about resident #1 at meal times; and that, all 3 residents (#1, #2, and #3) were placed at different tables during meals.Despite documentation of verbal and physical aggression of resident #2 towards resident #1, there was no evidence found that interventions such as increased supervision or monitoring of resident #2 were put in place and were implemented.The psychiatric NP note dated July 14, 2025 included that staff reported that the resident had become irritable with certain resident, specifically with a resident (#1) with a certain name who she associated with someone that her husband had an affair with; and that, the resident was unable to recall being upset with any resident. Recommendations included to to continue to monitor the resident's mood and to redirect resident as needed.A general nursing progress note dated July 15, 2025 revealed that during dinner time, resident #2 was verbally aggressive toward resident #1; and that, resident #2 accused resident #1 of stealing her clothes and demanded that they were returned. Further, the documentation included that this behavior appear to frighten and intimidate resident #1; and that, situation was de-escalated and redirected and both residents were separated during meals.The behavior note dated July 16, 2025 included resident #2 had a verbal altercation with resident #1 regarding a cat blanket which resident #2 claimed to belong to resident #3 who acknowledged that the blanket looked similar to what resident #3 has. Per the documentation, staff reassured resident #3 that her blanket was in her room but resident #2 continued to raise her voice towards resident #1. The documentation included that all 3 residents were separated redirected to different areas. The quarterly MDS assessment dated [DATE], revealed a BIMS score of 05, indicating severe cognitive impairment. The assessment also included that the resident was coded for verbal behaviors directed toward others exhibited within the last four to six days.Review of a behavior note dated July 20, 2025 included resident #2 yelled at and accused resident #1 of wearing a shirt that does belong to resident #3; and that resident #1 and #3 were moved away from resident #2 who continued to yell at accused staff of being prejudiced of her. The documentation revealed that staff were unable to convince resident #2 that resident #1 was not wearing the shirt of resident #3. It also included that resident #1 told staff that she did nothing wrong.A behavior note dated July 20, 2025 revealed that the ADON and the NP were updated on the behaviors of resident #2.The psychiatric NP note dated July 20, 2025 revealed that the resident was seen for a follow-up psychiatric evaluation; and that, the resident was not aware of her current situation, had periods of confusion with disorientation and memory problems, had diffuse memory loss for recent and remote events; and, was psychiatrically stable at this time. The documentation did not include any verbal and physical aggressive behaviors exhibited by resident #2. Plan included medication management, strategic skills to cope with stress, modulation of interpersonal/occupational/family/social dynamics to reduce stress, behavioral modification encouragement and to continue to monitor resident and to coordinate with staff regarding moods/behavior. A late entry behavior note dated July 31, 2025 revealed that staff spoke with BHT (behavioral health tech) related to increased behaviors and noted agitation towards other peers.Another behavior note dated July 31, 2025 included resident #2 was overheard telling another resident that she was going to get a stick and put her, (referring to resident #1), in the ground. Per the documentation, resident #1 was not even speaking to resident #2 at the time.The behavior note dated August 21, 2025 included that resident #2 was sitting at the table with resident #3 when resident #1 came over to the table. Per the documentation, resident #2 then yelled at and called resident #1 a liar and a thief. The documentation included that all residents were separated and calmed down.Despite documentation that resident #2 continued to to be verbally abusive to resident #1, there was no evidence found that interventions were put in place to protect and prevent resident #1 from continued abuse by resident #2. On September 4, 2025, a complaint was filed with the State Agency (SA) regarding 2 staff witnessing resident #2 pushed and hit resident #1 in the dementia unit; and that, this incident was reported to administration by staff.However, review of the clinical record revealed no documentation of this incident until September 10, 2025 (approximately 6 days after the alleged incident).A communication note dated September 10, 2025 included that staff spoke with the family of resident #2 regarding resident's behavior of perseverating on one particular resident; and that the resident would be moved to another unit and the resident having a sitter in place to ensure safety of all parties.The social service note dated September 11, 2025 revealed that the resident was informed by her family that she had slapped someone; and that, resident #2 was upset that she slapped someone.The care plan for resident #2 was revised on September 11, 2025 to include that the resident had been physically and verbally aggressive towards other residents related to dementia. The goal was that the resident will not harm self or others. Interventions included 1:1 sitter in place, moved to another unit, remove other residents from resident #2 when her aggression escalates, intervene before agitation escalates, guide away from source of distress, administer medications as ordered and BHT services to evaluate and treat.The TAR (treatment administration record) for July through September 2025 revealed that the resident was being monitored for behaviors of inability to sleep and verbalization of sadness were monitored. However, the resident was monitored for verbal and physical aggressive behaviors. An interview with the family of Resident #1 was conducted on the patio on September 10, 2025, at 10:33 AM. During the interview, Resident #1 became visibly upset, repeatedly asking her family, You're not leaving, are you? and You're coming back, right? The family said that Resident #1 and Resident #3 had been very close friends until Resident #2 moved into the facility; and that, resident #2 became possessive of resident #3 and did not want resident #1 or any other residents interacting with resident #3. The family reported receiving a phone call from a staff member on September 3, 2025, stating that Resident #1 had been slapped by Resident #2, and that the incident was witnessed by Resident #3; and, when she visited resident #1 the next day, she noticed a bruise on the side of the face of resident #1. She also said she was aware of ongoing comments that resident #2 had been bullying resident #1, and, the facility failed to take action to stop it. The family stated that it was not until the day after the slapping incident that staff told her that resident #2 would be separated from Resident #1. The family further stated that while she understands that resident #1 was in a dementia unit where residents in the unit have behaviors, she did not want resident #1 to be harmed. Further, the family stated that since the slapping incident, resident #1 had been more agitated and had now resisted going to bed at night.An interview was conducted on September 10, 2025 at 10:51 AM with Certified Nursing Assistant (CNA/staff #101) who stated that the incident between resident #1 and resident #2 happened around dinner time. The CNA said she was at the nurse's station when she heard shouting. She said she then went to the dining room where resident #2 was standing over resident #1, who was in her wheelchair, and resident #1's eye looked red. The CNA stated that she and a Licensed Practical Nurse (LPN/staff #102) deescalated the situation; and that, resident #3 approached her and reported that resident #2 pushed resident #1 who pushed resident #2 back which resulted in resident #2 punching resident #1 in the eye. The CNA said there was a history of resident #2 being verbally aggressive/abusive towards resident #1 and it escalated to the point of physical abuse. The CNA said she had seen resident #2 was very possessive of resident #3 and resident #2 did not not want resident #1 to associate with resident #3. The CNA stated the unit attempted to keep both resident #1 and resident #2 separated as much as possible but it could be difficult staff were also attending to other residents in the unit. The CNA further stated that resident #1 was fearful to go to bed at night, always the last to go into her room and when the CNA get resident #1 in her room, resident #1 would constantly ask her if she was staying and was not leaving. The CNA stated there were no issues between resident #1 and any other residents in the unit. In another interview with the CNA (staff#101) conducted on September 10, 2025 at 4:50 PM, the CNA stated that a room change was initiated by the family of resident #1 on July 7, 2025, because the family wanted resident #1 off the back hallway and closer to the dining area. The CNA said that the move was not encouraged by the staff due to the fact that resident #1 would be closer to the room of resident #2; and, all the verbal altercations between resident #1 and resident #2 occurred in the dining area. However, the CNA stated that the family was insistent on the move. Further, the CNA stated it was that after the move that issues began with resident #1 not wanting to go to bed and became fearful of being alone in her room.An interview was conducted with another CNA (staff #106) on September 10, 2025 at 5:04 PM, The CNA (staff #106) said that resident #1 has suffered from harm from the verbal and physical abuse by resident #2. She stated staff in the unit were doing the best they could to keep both residents #1 and resident #2 separated from each other but it can be difficult at times. Further, the CNA said that when staff reported these incidents to management, the management team did not listen, and nothing was done to address the behavior or resident #2.An interview was conducted on September 10, 2025 at 5:08 PM with an LPN (staff #102) who stated that on the evening of September 3, 2025, she was at the nurse's station when she heard a commotion and looked over to the dining room. She said that resident #2 was standing over and was yelling at resident #1 who in her wheelchair; and that, resident #3 told the LPN that resident #2 slapped resident #1. The LPN said she believed resident #3 because resident #3 can tell staff what happened at a particular time or instance. The LPN further stated that she interviewed resident #1 who reported that resident #2 had called her a b*&#ch and had placed her hand on the shoulder of resident #1. However, the LPN stated that resident #1 could not remember if she was hit by resident #2. An observation of the dementia unit was conducted on September 10, 2025 at 8:26 PM. There were several residents sitting in the common area watching television. Residents #2 and #3 were going down the hall with the CNA (staff #101), when resident #1 called for the CNA. Resident #2 then stopped, turned around, and told the CNA that resident #1 was not her boss.Another observation of the dementia unit was conducted on September 10, 2025 at 8:40 PM. The CNA (staff #101) was trying to get resident #1 to go to her room and get ready for bed. Resident #1 was very resistant to go to her room and told the CNA that she will just go with another resident to her room for the night. When the staff got resident #1 to her room, resident #1 asked the CNA not to go anywhere to stay with her and for the CNA to be with her as she might climb out the window. The CNA calmed resident #1 and settled her in bed. When the CNA was going to exit the room, resident #1 told the CNA to turn the light on if the CNA was going to leave her in the room. An attempt to interview resident #2 was conducted on September 11, 2025 at 9:28 AM but was unsuccessful because the resident became very agitated. Resident #2 was in the dementia unit; had a 1:1 sitter and was watching television.In an interview with the ADON (staff #104) conducted on September 11, 2025 at 11:09 AM, the ADON stated that yelling, swearing at, and taunting were considered as verbal abuse even if these behaviors happened in the dementia unit. She stated she was made aware of incidents of verbal aggression between resident #1 and resident #2 after it happened; and, she reported it the DON, who had been gone roughly 10 days. The ADON further stated, at that time, she was told to have the psychiatrist see resident's #1 and #2.An interview was conducted on September 11, 2025, at 11:37 AM, with the Administrator (staff #110), and the Assistant Administrator (staff #103). Both staffs (#110 and #103) stated that abuse was defined as sexual, verbal, financial, physical, exploitation, derogatory speech, belittling, yelling, intimidation, and having an aggressive tone. The assistant administrator stated that if a resident had cognitive issues or if something was witnessed on the dementia unit, it was still considered to be abuse. She stated she was aware of the incident on September 3, 2025 between resident #1 and resident #2; however, she stated that the only witness to the incident was another resident (#3) and resident #1 was interviewed by staff, resident #1 could not remember being hit. The assistant administrator denied receiving verbal abuse allegations related to resident #1 prior to the slapping incident ; and the only incident between resident #1 and #2 that the facility was aware of was the slapping incident on September 3, 2025.An interview with a CNA (staff #109) was conducted on September 12, 2025 at 9:29 AM. The CNA stated she was the 1:1 sitter assigned to resident #2, who was now very calm, relaxed, was not tense or agitated, and was smiling after she had moved to a different unit. In another interview with CNA (staff #101) conducted on September 12, 2025, at 1:45 PM, the CNA stated that resident #2 was transferred to another unit, resident #1 went to bed early and did not ask her to stay; and that, resident slept well. Review of the facility's policy on Abuse, Neglect, and Exploitation, dated July 2025 revealed that it was their policy to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Verbal abuse was defined as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. The policy also included that the facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents; and, the facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to increased supervision of the alleged victim and residents, room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.

Based on clinical record reviews, interviews and review of facility documentation, policies and procedures, the facility failed to ensure allegations of verbal and physical abuse of one resident (#1) by another resident (#2) were thoroughly investigated and appropriate corrective actions were taken. The deficient practice could result in resident not protected from further abuse.Findings include:-Resident #3 (witness) was admitted on [DATE] with diagnoses of dementia, abnormalities of gait and mobility and muscle weakness.The late entry provider visit note dated August 19, 2025 revealed the resident was alert, oriented 2-3, ambulated with 1-person assist and had no focal neurological deficits. Assessment included dementia.-Resident #1 (alleged victim) was admitted on [DATE], with diagnoses of dementia, muscle weakness, and history of falling.The MDS (Minimal Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. An infection note dated September 3, 2025 revealed that residents #1, #2, and #3 were sitting at the same table before dinner. Per the documentation, staff witnessed resident #2 standing over and yelling at resident #1; and that, staff intervened and moved resident #1 to the nurse's station and resident #2 returned to her room. The documentation also included that resident #3 told staff that resident #2 yelled and hit resident #1.A communication note dated September 6, 2025 included that the resident's family requested to speak with staff related to the resident's recent altercation with another resident (#2). -Resident #2 (alleged perpetrator) was admitted on [DATE], with diagnose of dementia, major depressive disorder, anxiety disorder, and schizoaffective disorder.A behavior note, dated June 12, 2025, revealed resident #2 displayed anger every time resident #1 who was sitting near resident #3. Per documentation, resident #2 had paranoia and reported that resident #1 was taking resident #3 from her; and that, resident #2 threatened resident #1 with physical violence and yelled at resident #1 who remained seated and looked confused while being yelled at by resident #2. The documentation also included that this behavior of resident #2 happens every time resident #1 tried to sit by resident #3. There was no evidence found in the clinical record and facility documentation that the facility initiated and conducted an investigation of this incident. The behavior note dated July 2, 2025 included resident #2 yelled at and threatened resident #1 because resident #1 was looking at her at the dinner table.Review of a behavior note dated July 8, 2025 revealed that resident #2 told resident #3 that resident #1 was wearing her shirt; and that, resident #2 then approached resident #1, grabbed the shirt of resident #1 and told resident #1 to give the shirt back. Per the documentation, resident #2 told resident #3 that they should beat up resident #1; and that, resident #3 told resident #2 they should not do that because they would go to jail. The documentation also included that the CNA (certified nurse assistant) was able to separate the residents. Another behavior note dated July 8, 2025 included that resident #2 was sitting with resident #3 and other residents watching tv. Per the documentation, resident #1 was just passing down the hallway to her room and resident #2 yelled at resident #1 to go away and to get out of here; and, staff noticed this behavior from resident #2 before when resident #1 was sitting with resident #3. The documentation included that staff called a family member who explained that the brother of resident #2 had married a woman with the same first name as resident #1 and that person was very abusive to the family and her children; and that, the family of resident #2 believed the resident was reliving her past when she sees resident #1. Further, the documentation included that the NP and the DON (Director of Nursing) were notified.A behavior note dated July 9, 2025 included resident #2 approached the dining room table where resident #1 was sitting at and yelled at resident #1. The documentation included that staff stepped in front of resident #1 to block the view of resident #2 who was then requested to return to her table. It also included that after a couple of minutes, resident #2 returned to her table but she was keeping an eye on resident #1.Another behavior note dated July 9, 2025 revealed that the ADON (Assistant Director of Nursing) notified the provider of the resident's behaviors. The behavior note dated July 10, 2025 included that resident #2 continued to make comments about resident #1 at meal times; and that, all 3 residents (#1, #2, and #3) were placed at different tables during meals. A general nursing progress note dated July 15, 2025 revealed that during dinner time, resident #2 was verbally aggressive toward resident #1; and that, resident #2 accused resident #1 of stealing her clothes and demanded that they were returned. Further, the documentation included that this behavior appear to frighten and intimidate resident #1.The behavior note dated July 16, 2025 included resident #2 had a verbal altercation with resident #1 regarding a cat blanket which resident #2 claimed to belong to resident #3 who acknowledged that the blanket looked similar to what resident #3 has. Per the documentation, staff reassured resident #3 that her blanket was in her room but resident #2 continued to raise her voice towards resident #1. Review of a behavior note dated July 20, 2025 included resident #2 yelled at and accused resident #1 of wearing a shirt that does belong to resident #3. Another behavior note dated July 31, 2025 included resident #2 was overheard telling another resident that she was going to get a stick and put her, (referring to resident #1), in the ground. Per the documentation, resident #1 was not even speaking to resident #2 at the time.The behavior note dated August 21, 2025 included that resident #2 was sitting at the table with resident #3 when resident #1 came over to the table. Per the documentation, resident #2 then yelled at and called resident #1 a liar and a thief. Despite documentation of verbal and physical aggression of resident #2 towards resident #1 and staff knowledge of these incidents, there was no evidence found that the facility initiated, conducted a thorough investigation of these incidents and took appropriate corrective actions to prevent and protect resident #1 from further abuse by resident #2. On September 4, 2025, a complaint was filed with the State Agency (SA) regarding 2 staff witnessing resident #2 pushed and hit resident #1 in the dementia unit; and that, this incident was reported to administration by staff.However, review of the clinical record revealed no documentation of this incident until September 10, 2025 (approximately 6 days after the alleged incident).The social service note dated September 11, 2025 revealed that the resident was informed by her family that she had slapped someone; and that, resident #2 was upset that she slapped someone.There was also no evidence that the facility initiated and conducted a thorough investigation of this incident. An interview with the family of Resident #1 was conducted on the patio on September 10, 2025, at 10:33 AM. The family reported receiving a phone call from a staff member on September 3, 2025, stating that Resident #1 had been slapped by Resident #2, and that the incident was witnessed by Resident #3; and, when she visited resident #1 the next day, she noticed a bruise on the side of the face of resident #1. An interview was conducted on September 10, 2025 at 10:51 AM with Certified Nursing Assistant (CNA/staff #101) who stated that the incident between resident #1 and resident #2 happened around dinner time. The CNA said she was at the nurse's station when she heard shouting. She said she then went to the dining room where resident #2 was standing over resident #1, who was in her wheelchair, and resident #1's eye looked red. The CNA stated that she and a Licensed Practical Nurse (LPN/staff #102) deescalated the situation; and that, resident #3 approached her and reported that resident #2 pushed resident #1 who pushed resident #2 back which resulted in resident #2 punching resident #1 in the eye. An interview with another CNA (staff #105) was conducted on September 10, 2025, at 11:01 AM The CNA (staff #105) stated that if she witnessed an abuse, she would first ensure the safety of the residents involved and then report the incident to either a floor nurse, the ADON, or the Director of Nursing (DON). However, the CNA said that depending on the severity of the abuse, such as resident slapping another, she would just report to the ADON or human resources and skip the floor nurse. An interview was conducted with another CNA (staff #106) on September 10, 2025 at 5:04 PM, The CNA (staff #106) said that resident #1 has suffered from harm from the verbal and physical abuse by resident #2. She stated staff in the unit were doing the best they could to keep both residents #1 and resident #2 separated from each other but it can be difficult at times. Further, the CNA said that when staff reported these incidents to management, the management team did not listen, and nothing was done to address the behavior or resident #2.In another interview with the CNA (staff #101) conducted on September 10, 2025, at 8:21 PM. The CNA said that in the evening of September 10, 2025, the vice president of human resources (HR/staff #145), the assistant administrator (staff #103), the ADON (staff#104), and the human resources coordinator (HRC/staff #132), provided her with abuse education, and instructions to call the abuse hotline if she witness an incident of abuse. The CNA further stated that the HRC (staff #132) told her to go through the facility's chain of command and do not report the incident to the SA. In an interview with the ADON (staff #104) conducted on September 11, 2025 at 11:09 AM, the ADON stated that yelling, swearing at, and taunting were considered as verbal abuse even if these behaviors happened in the dementia unit. She stated she was made aware of incidents of verbal aggression between resident #1 and resident #2 after it happened; and, she reported it the DON, who had been gone roughly 10 days. The ADON further stated, at that time, she was told to have the psychiatrist see resident's #1 and #2.An interview was conducted on September 11, 2025, at 11:37 AM, with the Administrator (staff #110), and the Assistant Administrator (staff #103). Both staffs (#110 and #103) stated that abuse was defined as sexual, verbal, financial, physical, exploitation, derogatory speech, belittling, yelling, intimidation, and having an aggressive tone. The assistant administrator stated that if a resident had cognitive issues or if something was witnessed on the dementia unit, it was still considered to be abuse. She stated she was aware of the incident on September 3, 2025 between resident #1 and resident #2; however, she stated that the only witness to the incident was another resident (#3) and resident #1 was interviewed by staff, resident #1 could not remember being hit. Further, the assistant administrator said that the incident was determined to be not reportable; and that, if an incident was not witnessed, the facility investigates the incident first and then decide if the incident needed to be reported. The assistant administrator denied receiving verbal abuse allegations related to resident #1 prior to the slapping incident ; and the only incident between resident #1 and #2 that the facility was aware of was the slapping incident on September 3, 2025.The facility's policy on Abuse, Neglect, and Exploitation, dated July 2025, defines verbal abuse as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. It defines mental abuse as includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. It defines physical abuse as includes, but is not limited to hitting, slapping, punching, biting, and kicking. The policy states it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.

Based on clinical record reviews, interviews, and review of facility policy and procedures, the facility failed to ensure allegations of verbal and physical abuse of one resident (#1) by another resident (#2) was reported to the State Agency (SA) and Adult Protective Services (APS). The deficient practice could result in abuse not investigated and resident not protected from further abuse.Findings include:-Resident #3 (witness) was admitted on [DATE] with diagnoses of dementia, abnormalities of gait and mobility and muscle weakness.The late entry provider visit note dated August 19, 2025 revealed the resident was alert, oriented 2-3, ambulated with 1-person assist and had no focal neurological deficits. Assessment included dementia.-Resident #1 (alleged victim) was admitted on [DATE], with diagnoses of dementia, muscle weakness, and history of falling.The MDS (Minimal Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. An infection note dated September 3, 2025 revealed that residents #1, #2, and #3 were sitting at the same table before dinner. Per the documentation, staff witnessed resident #2 standing over and yelling at resident #1; and that, staff intervened and moved resident #1 to the nurse's station and resident #2 returned to her room. The documentation also included that resident #3 told staff that resident #2 yelled and hit resident #1.A communication note dated September 6, 2025 included that the resident's family requested to speak with staff related to the resident's recent altercation with another resident (#2). -Resident #2 (alleged perpetrator) was admitted on [DATE], with diagnose of dementia, major depressive disorder, anxiety disorder, and schizoaffective disorder.A behavior note, dated June 12, 2025, revealed resident #2 displayed anger every time resident #1 who was sitting near resident #3. Per documentation, resident #2 had paranoia and reported that resident #1 was taking resident #3 from her; and that, resident #2 threatened resident #1 with physical violence and yelled at resident #1 who remained seated and looked confused while being yelled at by resident #2. The documentation also included that this behavior of resident #2 happens every time resident #1 tried to sit by resident #3. There was no evidence found in the clinical record and facility documentation that this incident was reported to the SA and APS.The behavior note dated July 2, 2025 included resident #2 yelled at and threatened resident #1 because resident #1 was looking at her at the dinner table.Review of a behavior note dated July 8, 2025 revealed that resident #2 told resident #3 that resident #1 was wearing her shirt; and that, resident #2 then approached resident #1, grabbed the shirt of resident #1 and told resident #1 to give the shirt back. Per the documentation, resident #2 told resident #3 that they should beat up resident #1; and that, resident #3 told resident #2 they should not do that because they would go to jail. The documentation also included that the CNA (certified nurse assistant) was able to separate the residents. Another behavior note dated July 8, 2025 included that resident #2 was sitting with resident #3 and other residents watching tv. Per the documentation, resident #1 was just passing down the hallway to her room and resident #2 yelled at resident #1 to go away and to get out of here; and, staff noticed this behavior from resident #2 before when resident #1 was sitting with resident #3. The documentation included that staff called a family member who explained that the brother of resident #2 had married a woman with the same first name as resident #1 and that person was very abusive to the family and her children; and that, the family of resident #2 believed the resident was reliving her past when she sees resident #1. Further, the documentation included that the NP and the DON (Director of Nursing) were notified.However, there was no evidence that these incidents of verbal and physical abuse of resident #1 by resident #2 was reported to the SA and APS. A behavior note dated July 9, 2025 included resident #2 approached the dining room table where resident #1 was sitting at and yelled at resident #1. The documentation included that staff stepped in front of resident #1 to block the view of resident #2 who was then requested to return to her table. It also included that after a couple of minutes, resident #2 returned to her table but she was keeping an eye on resident #1.Another behavior note dated July 9, 2025 revealed that the ADON (Assistant Director of Nursing) notified the provider of the resident's behaviors. The behavior note dated July 10, 2025 included that resident #2 continued to make comments about resident #1 at meal times; and that, all 3 residents (#1, #2, and #3) were placed at different tables during meals. A general nursing progress note dated July 15, 2025 revealed that during dinner time, resident #2 was verbally aggressive toward resident #1; and that, resident #2 accused resident #1 of stealing her clothes and demanded that they were returned. Further, the documentation included that this behavior appear to frighten and intimidate resident #1.The behavior note dated July 16, 2025 included resident #2 had a verbal altercation with resident #1 regarding a cat blanket which resident #2 claimed to belong to resident #3 who acknowledged that the blanket looked similar to what resident #3 has. Per the documentation, staff reassured resident #3 that her blanket was in her room but resident #2 continued to raise her voice towards resident #1. Review of a behavior note dated July 20, 2025 included resident #2 yelled at and accused resident #1 of wearing a shirt that does belong to resident #3. Another behavior note dated July 31, 2025 included resident #2 was overheard telling another resident that she was going to get a stick and put her, (referring to resident #1), in the ground. Per the documentation, resident #1 was not even speaking to resident #2 at the time.The behavior note dated August 21, 2025 included that resident #2 was sitting at the table with resident #3 when resident #1 came over to the table. Per the documentation, resident #2 then yelled at and called resident #1 a liar and a thief. Despite documentation of verbal and physical aggression of resident #2 towards resident #1 and staff knowledge of these incidents, there was no evidence found that these incidents were reported to the SA and APS. On September 4, 2025, a complaint was filed with the State Agency (SA) regarding 2 staff witnessing resident #2 pushed and hit resident #1 in the dementia unit; and that, this incident was reported to administration by staff.However, review of the clinical record revealed no documentation of this incident until September 10, 2025 (approximately 6 days after the alleged incident).The social service note dated September 11, 2025 revealed that the resident was informed by her family that she had slapped someone; and that, resident #2 was upset that she slapped someone.There was also no evidence that this incident was reported by the facility to the SA and APS. An interview with the family of Resident #1 was conducted on the patio on September 10, 2025, at 10:33 AM. The family reported receiving a phone call from a staff member on September 3, 2025, stating that Resident #1 had been slapped by Resident #2, and that the incident was witnessed by Resident #3; and, when she visited resident #1 the next day, she noticed a bruise on the side of the face of resident #1. An interview was conducted on September 10, 2025 at 10:51 AM with Certified Nursing Assistant (CNA/staff #101) who stated that the incident between resident #1 and resident #2 happened around dinner time. The CNA said she was at the nurse's station when she heard shouting. She said she then went to the dining room where resident #2 was standing over resident #1, who was in her wheelchair, and resident #1's eye looked red. The CNA stated that she and a Licensed Practical Nurse (LPN/staff #102) deescalated the situation; and that, resident #3 approached her and reported that resident #2 pushed resident #1 who pushed resident #2 back which resulted in resident #2 punching resident #1 in the eye. The CNA stated that the incident was reported to the Assistant Director of Nursing (ADON/staff #104) and the assistant administrator (staff #103) who then instructed staff to let the incident go, stop escalating it as it involved residents in the behavior unit and these residents would forget about it.An interview with another CNA (staff #105) was conducted on September 10, 2025, at 11:01 AM The CNA (staff #105) stated that if she witnessed an abuse, she would first ensure the safety of the residents involved and then report the incident to either a floor nurse, the ADON, or the Director of Nursing (DON). However, the CNA said that depending on the severity of the abuse, such as resident slapping another, she would just report to the ADON or human resources and skip the floor nurse.An interview with the ADON (staff #104) was conducted on September 10, 2025, at 11:31 AM. She stated that abuse is defined as emotional, physical, or financial; and that, if an allegation of abuse involved residents with severe cognitive impairment, it would depend on the resident's behaviors before it could be determined that the incident was abuse. She said if an allegation of abuse was brought to her attention, she would report it to the administrative assistant (staff #103), the social services department, and the DON. However, the ADON said they currently do not have a DON. Further the ADON stated she would not report the abuse allegation to the SA, because the administrator was responsible for doing this; and once she reported it to the administrator or the assistant administrator, it was out of her hands. An interview was conducted with another CNA (staff #106) on September 10, 2025 at 5:04 PM, The CNA (staff #106) said that resident #1 has suffered from harm from the verbal and physical abuse by resident #2. She stated staff in the unit were doing the best they could to keep both residents #1 and resident #2 separated from each other but it can be difficult at times. Further, the CNA said that when staff reported these incidents to management; but, management team did not listen, and nothing was done to address the behavior of resident #2.An interview was conducted on September 10, 2025 at 5:08 PM with an LPN (staff #102) who stated that on the evening of September 3, 2025, she was at the nurse's station when she heard a commotion and looked over to the dining room. She said that resident #2 was standing over and was yelling at resident #1 who in her wheelchair; and that, resident #3 told the LPN that resident #2 slapped resident #1. The LPN said she believed resident #3 because resident #3 can tell staff what happened at a particular time or instance. The LPN further stated that she interviewed resident #1 who reported that resident #2 had called her a b*&#ch and had placed her hand on the shoulder of resident #1. The LPN said she notified the ADON (staff #104) of the incident, and she received a call from the assistant administrator (staff #103) who told her that if the resident cannot remember getting hit, then it does not have to be reported to the SA.An interview with the CNA/staff #101 was conducted on September 10, 2025, at 8:21 PM. The CNA said that in the evening of September 10, 2025, the vice president of human resources (HR/staff #145), the assistant administrator/staff #103, the ADON/staff#104, and the human resources coordinator (staff #132), provided her with abuse education, and instructions to call the abuse hotline for the facility if they witness an incident of abuse. The HR coordinator told her to go through the chain of command and do not report the incident to the SA. In an interview with the ADON (staff #104) conducted on September 11, 2025 at 11:09 AM, the ADON stated yelling, swearing at, and taunting were considered as verbal abuse even if these behaviors happened in the dementia unit. She stated she was made aware of incidents of verbal aggression between resident #1 and resident #2 after it happened; and, she reported it the DON, who had been gone roughly 10 days. The ADON further stated, at that time, she was told to have the psychiatrist see resident's #1 and #2. An interview was conducted on September 11, 2025, at 11:37 AM, with the Administrator (staff #110), and the Assistant Administrator (staff #103). Both staffs (#110 and #103) stated that abuse was defined as sexual, verbal, financial, physical, exploitation, derogatory speech, belittling, yelling, intimidation, and having an aggressive tone. The assistant administrator stated that if a resident had cognitive issues or if something was witnessed on the dementia unit, it was still considered to be abuse. She stated she was aware of the incident on September 3, 2025 between resident #1 and resident #2; however, she stated that the only witness to the incident was another resident (#3) and resident #1 was interviewed by staff, resident #1 could not remember being hit. Further, the assistant administrator said that the incident was determined to be not reportable; and that, if an incident was not witnessed, the facility investigates the incident first and then decide if the incident needed to be reported. The assistant administrator denied receiving verbal abuse allegations related to resident #1 prior to the slapping incident ; and the only incident between resident #1 and #2 that the facility was aware of was the slapping incident on September 3, 2025. The assistant administrator further stated stated that if staff witnessed any abuse or think that abuse was occurring, staff were to report the incident to their direct supervisor who would then report the allegation to her; and that, she would then notify the administrator (staff #110) of the incident. Further, the assistant administrator said that she and the administrator would report the allegation, complete a five-day investigation to the SA, and would also report to the local police, Adult Protective Services (APS), the Ombudsman, and to the resident's families. The facility's policy on Abuse, Neglect, and Exploitation, dated July 2025, stated the facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The administrator will follow-up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on clinical record reviews, interviews, and review of facility policy and procedures, the facility failed to implement their policies and procedures on resident protection, abuse reporting and investigation of an allegation of verbal and physical abuse for one resident (#1) by another resident (#2). The deficient practice resulted in further abuse of resident #1 Findings include:-Resident #3 (witness) was admitted on [DATE] with diagnoses of dementia, abnormalities of gait and mobility and muscle weakness.The late entry provider visit note dated August 19, 2025 revealed the resident was alert, oriented 2-3, ambulated with 1-person assist and had no focal neurological deficits. Assessment included dementia.-Resident #1 (alleged victim) was admitted on [DATE], with diagnoses of dementia, muscle weakness, and history of falling.The MDS (Minimal Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. An infection note dated September 3, 2025 revealed that residents #1, #2, and #3 were sitting at the same table before dinner. Per the documentation, staff witnessed resident #2 standing over and yelling at resident #1; and that, staff intervened and moved resident #1 to the nurse's station and resident #2 returned to her room. The documentation also included that resident #3 told staff that resident #2 yelled and hit resident #1.A communication note dated September 6, 2025 included that the resident's family requested to speak with staff related to the resident's recent altercation with another resident (#2). -Resident #2 (alleged perpetrator) was admitted on [DATE], with diagnose of dementia, major depressive disorder, anxiety disorder, and schizoaffective disorder.A behavior note, dated June 12, 2025, revealed resident #2 displayed anger every time resident #1 who was sitting near resident #3. Per documentation, resident #2 had paranoia and reported that resident #1 was taking resident #3 from her; and that, resident #2 threatened resident #1 with physical violence and yelled at resident #1 who remained seated and looked confused while being yelled at by resident #2. The documentation also included that this behavior of resident #2 happens every time resident #1 tried to sit by resident #3. There was no evidence found in the clinical record and facility documentation that this incident was reported to the SA and APS; and, there was no evidence that the facility initiated and conducted an investigation of this incident. The clinical record revealed no evidence of any intervention implemented to prevent altercation from happening again between resident #1 and #2.The behavior note dated July 2, 2025 included resident #2 yelled at and threatened resident #1 because resident #1 was looking at her at the dinner table.Review of a behavior note dated July 8, 2025 revealed that resident #2 told resident #3 that resident #1 was wearing her shirt; and that, resident #2 then approached resident #1, grabbed the shirt of resident #1 and told resident #1 to give the shirt back. Per the documentation, resident #2 told resident #3 that they should beat up resident #1; and that, resident #3 told resident #2 they should not do that because they would go to jail. The documentation also included that the CNA (certified nurse assistant) was able to separate the residents. Another behavior note dated July 8, 2025 included that resident #2 was sitting with resident #3 and other residents watching tv. Per the documentation, resident #1 was just passing down the hallway to her room and resident #2 yelled at resident #1 to go away and to get out of here; and, staff noticed this behavior from resident #2 before when resident #1 was sitting with resident #3. The documentation included that staff called a family member who explained that the brother of resident #2 had married a woman with the same first name as resident #1 and that person was very abusive to the family and her children; and that, the family of resident #2 believed the resident was reliving her past when she sees resident #1. Further, the documentation included that the NP and the DON (Director of Nursing) were notified.A behavior note dated July 9, 2025 included resident #2 approached the dining room table where resident #1 was sitting at and yelled at resident #1. The documentation included that staff stepped in front of resident #1 to block the view of resident #2 who was then requested to return to her table. It also included that after a couple of minutes, resident #2 returned to her table but she was keeping an eye on resident #1.Another behavior note dated July 9, 2025 revealed that the ADON (Assistant Director of Nursing) notified the provider of the resident's behaviors. The behavior note dated July 10, 2025 included that resident #2 continued to make comments about resident #1 at meal times; and that, all 3 residents (#1, #2, and #3) were placed at different tables during meals. A general nursing progress note dated July 15, 2025 revealed that during dinner time, resident #2 was verbally aggressive toward resident #1; and that, resident #2 accused resident #1 of stealing her clothes and demanded that they were returned. Further, the documentation included that this behavior appear to frighten and intimidate resident #1.The behavior note dated July 16, 2025 included resident #2 had a verbal altercation with resident #1 regarding a cat blanket which resident #2 claimed to belong to resident #3 who acknowledged that the blanket looked similar to what resident #3 has. Per the documentation, staff reassured resident #3 that her blanket was in her room but resident #2 continued to raise her voice towards resident #1. Review of a behavior note dated July 20, 2025 included resident #2 yelled at and accused resident #1 of wearing a shirt that does belong to resident #3. Another behavior note dated July 31, 2025 included resident #2 was overheard telling another resident that she was going to get a stick and put her, (referring to resident #1), in the ground. Per the documentation, resident #1 was not even speaking to resident #2 at the time.The behavior note dated August 21, 2025 included that resident #2 was sitting at the table with resident #3 when resident #1 came over to the table. Per the documentation, resident #2 then yelled at and called resident #1 a liar and a thief. The TAR (treatment administration record) for July through September 2025 revealed that the resident was being monitored for behaviors of inability to sleep and verbalization of sadness were monitored. However, the resident was monitored for verbal and physical aggressive behaviors. Despite documentation of verbal and physical aggression of resident #2 towards resident #1 and staff knowledge of these incidents, there was no evidence found that interventions such as increased supervision or monitoring of resident #2 were put in place and were implemented.There was no evidence found that these incidents were reported to the SA and APS; and that, the facility initiated, conducted a thorough investigation of these incidents and took appropriate corrective actions to prevent and protect resident #1 from further abuse by resident #2. On September 4, 2025, a complaint was filed with the State Agency (SA) regarding 2 staff witnessing resident #2 pushed and hit resident #1 in the dementia unit; and that, this incident was reported to administration by staff. Review of the clinical record revealed no documentation of this incident until September 10, 2025 (approximately 6 days after the alleged incident). Further, the clinical record revealed that facility did not take appropriate corrective actions to prevent and protect resident #1 from further abuse by resident #2 until September 10, 2025 (approximately 6 days after the alleged incident).There was also no evidence that this incident was reported by the facility to the SA and APS; and that, the facility initiated, conducted an investigation of the incident. A communication note dated September 10, 2025 included that staff spoke with the family of resident #2 regarding resident's behavior of perseverating on one particular resident; and that the resident would be moved to another unit and the resident having a sitter in place to ensure safety of all parties.The general nursing progress note dated September 11, 2025 revealed that the resident was on 24 hour one to one sitter at all times; and that, there were no behaviors noted. The social service note dated September 11, 2025 revealed that the resident was informed by her family that she had slapped someone; and that, resident #2 was upset that she slapped someone.An interview with the family of Resident #1 was conducted on the patio on September 10, 2025, at 10:33 AM. During the interview, Resident #1 became visibly upset, repeatedly asking her family, You're not leaving, are you? and You're coming back, right? The family said that Resident #1 and Resident #3 had been very close friends until Resident #2 moved into the facility; and that, resident #2 became possessive of resident #3 and did not want resident #1 or any other residents interacting with resident #3. The family reported receiving a phone call from a staff member on September 3, 2025, stating that Resident #1 had been slapped by Resident #2, and that the incident was witnessed by Resident #3; and, when she visited resident #1 the next day, she noticed a bruise on the side of the face of resident #1. She also said she was aware of ongoing comments that resident #2 had been bullying resident #1, and, the facility failed to take action to stop it. The family stated that it was not until the day after the slapping incident that staff told her that resident #2 would be separated from Resident #1. The family further stated that while she understands that resident #1 was in a dementia unit where residents in the unit have behaviors, she did not want resident #1 to be harmed. Further, the family stated that since the slapping incident, resident #1 had been more agitated and had now resisted going to bed at night.An interview was conducted on September 10, 2025 at 10:51 AM with Certified Nursing Assistant (CNA/staff #101) who stated that the incident between resident #1 and resident #2 happened around dinner time. The CNA said she was at the nurse's station when she heard shouting. She said she then went to the dining room where resident #2 was standing over resident #1, who was in her wheelchair, and resident #1's eye looked red. The CNA stated that she and a Licensed Practical Nurse (LPN/staff #102) deescalated the situation; and that, resident #3 approached her and reported that resident #2 pushed resident #1 who pushed resident #2 back which resulted in resident #2 punching resident #1 in the eye. The CNA said there was a history of resident #2 being verbally aggressive/abusive towards resident #1 and it escalated to the point of physical abuse. The CNA said she had seen resident #2 was very possessive of resident #3 and resident #2 did not not want resident #1 to associate with resident #3. The CNA stated the unit attempted to keep both resident #1 and resident #2 separated as much as possible but it could be difficult staff were also attending to other residents in the unit. The CNA further stated that resident #1 was fearful to go to bed at night, always the last to go into her room and when the CNA get resident #1 in her room, resident #1 would constantly ask her if she was staying and was not leaving. The CNA stated there were no issues between resident #1 and any other residents in the unit. The CNA stated that the incident was reported to the Assistant Director of Nursing (ADON/staff #104) and the assistant administrator (staff #103) who then instructed staff to let the incident go, stop escalating it as it involved residents in the behavior unit and these residents would forget about it.An interview with another CNA (staff #105) was conducted on September 10, 2025, at 11:01 AM The CNA (staff #105) stated that if she witnessed an abuse, she would first ensure the safety of the residents involved and then report the incident to either a floor nurse, the ADON, or the Director of Nursing (DON). However, the CNA said that depending on the severity of the abuse, such as resident slapping another, she would just report to the ADON or human resources and skip the floor nurse.An interview with the Assistant Director of Nursing (ADON/staff #104) was conducted on September 10, 2025, at 11:31 AM. She stated that abuse is defined as emotional, physical, or financial; and that, if an allegation of abuse involved residents with severe cognitive impairment, it would depend on the resident's behaviors before it could be determined that the incident was abuse. She said if an allegation of abuse was brought to her attention, she would report it to the administrative assistant (staff #103), the social services department, and the DON. However, the ADON said they currently do not have a DON. Further the ADON stated she would not report the abuse allegation to the SA, because the administrator was responsible for doing this; and once she reported it to the administrator or the assistant administrator, it was out of her hands. In another interview with the CNA (staff#101) conducted on September 10, 2025 at 4:50 PM, the CNA stated that a room change was initiated by the family of resident #1 on July 7, 2025, because the family wanted resident #1 off the back hallway and closer to the dining area. The CNA said that the move was not encouraged by the staff due to the fact that resident #1 would be closer to the room of resident #2; and, all the verbal altercations between resident #1 and resident #2 occurred in the dining area. However, the CNA stated that the family was insistent on the move. Further, the CNA stated it was that after the move that issues began with resident #1 not wanting to go to bed and became fearful of being alone in her room.An interview was conducted with another CNA (staff #106) on September 10, 2025 at 5:04 PM, The CNA (staff #106) said that resident #1 has suffered from harm from the verbal and physical abuse by resident #2. She stated staff in the unit were doing the best they could to keep both residents #1 and resident #2 separated from each other but it can be difficult at times. Further, the CNA said that when staff reported these incidents to management, the management team did not listen, and nothing was done to address the behavior or resident #2.An interview was conducted on September 10, 2025 at 5:08 PM with an LPN (staff #102) who stated that on the evening of September 3, 2025, she was at the nurse's station when she heard a commotion and looked over to the dining room. She said that resident #2 was standing over and was yelling at resident #1 who in her wheelchair; and that, resident #3 told the LPN that resident #2 slapped resident #1. The LPN said she believed resident #3 because resident #3 can tell staff what happened at a particular time or instance. The LPN further stated that she interviewed resident #1 who reported that resident #2 had called her a b*&#ch and had placed her hand on the shoulder of resident #1. The LPN said she notified the ADON (staff #104) of the incident, and she received a call from the assistant administrator (staff #103) who told her that if the resident cannot remember getting hit, then it does not have to be reported to the SA. An interview with the CNA/staff #101 was conducted on September 10, 2025, at 8:21 PM. The CNA said that in the evening of September 10, 2025, the vice president of human resources (HR/staff #145), the assistant administrator/staff #103, the ADON/staff#104, and the human resources coordinator (staff #132), provided her with abuse education, and instructions to call the abuse hotline for the facility if they witness an incident of abuse. The HR coordinator told her to go through the chain of command and do not report the incident to the SA. In an interview with the ADON (staff #104) conducted on September 11, 2025 at 11:09 AM, the ADON stated yelling, swearing at, and taunting were considered as verbal abuse even if these behaviors happened in the dementia unit. She stated she was made aware of incidents of verbal aggression between resident #1 and resident #2 after it happened; and, she reported it the DON, who had been gone roughly 10 days. The ADON further stated, at that time, she was told to have the psychiatrist see resident's #1 and #2.An interview was conducted on September 11, 2025, at 11:37 AM, with the Administrator (staff #110), and the Assistant Administrator (staff #103). Both staffs (#110 and #103) stated that abuse was defined as sexual, verbal, financial, physical, exploitation, derogatory speech, belittling, yelling, intimidation, and having an aggressive tone. The assistant administrator stated that if a resident had cognitive issues or if something was witnessed on the dementia unit, it was still considered to be abuse. She stated she was aware of the incident on September 3, 2025 between resident #1 and resident #2; however, she stated that the only witness to the incident was another resident (#3) and resident #1 was interviewed by staff, resident #1 could not remember being hit. Further, the assistant administrator said that if an incident was not witnessed, the facility investigates the incident first and then decide if the incident needed to be reported. The assistant administrator denied receiving verbal abuse allegations related to resident #1 prior to the slapping incident. The assistant administrator further stated stated that if staff witnessed any abuse or think that abuse was occurring, staff were to report the incident to their direct supervisor who would then report the allegation to her; and that, she would then notify the administrator (staff #110) of the incident. Further, the assistant administrator said that she and the administrator would report the allegation, complete a five-day investigation to the SA, and would also report to the local police, Adult Protective Services (APS), the Ombudsman, and to the resident's families. Review of the facility's policy on Abuse, Neglect, and Exploitation, dated July 2025 revealed that it was their policy to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Verbal abuse was defined as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. The policy also included that the facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents; and, the facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to increased supervision of the alleged victim and residents, room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator. The facility's policy also included that the facility will have written procedures that include: Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes: Immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. The administrator will follow-up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on clinical record review, staff and family interviews, facility documentation and policy review, the facility failed to ensure the care plan for one resident (#2) was revised with interventions to address the resident's verbal and physical aggression towards other residents. The deficient practice could result in resident not meeting their needs according to their comprehensive assessment. Resident #2 was admitted on [DATE] with diagnoses including unspecified dementia, major depressive disorder, anxiety disorder. schizoaffective disorder-bipolar type and other idiopathic peripheral autonomic neuropathy.Review of the care plan dated October 17, 2024, revealed resident was dependent on staff and family for all emotional, intellectual, physical, and social needs. Interventions included to encourage ongoing family involvement and inviting to attend special events, activities, and meals, introducing resident to residents with similar backgrounds, interests, and encourage/facilitate interaction, invite the resident to scheduled activities and assist to and from programs to help encourage participation. The care plan did not include that the resident had behaviors such as verbal or physical aggression towards staff and/or residents.Review of the clinical record revealed documentation that the resident was verbally aggressive towards, yelled at and threatened another resident. A review of the quarterly MDS (minimum data set) dated July 17, 2025 revealed a BIMS (brief interview of mental status) score of 5, indicating severe cognitive impairment. The behavior section of the MDS revealed that resident #2 manifested verbal behavioral symptoms directed toward others 4 to 6 days a week.A review of the facility documentation revealed no evidence that the IDT (interdisciplinary team) had met and reviewed the quarterly MDS assessment for behaviors and updated the care plan accordingly at that time.Despite documentation that resident #2 exhibited verbal and physical aggression towards another resident, the care plan for resident #2 was not revised until September 11, 2025.The care plan initiated on September 11, 2025 revealed the resident had been physically and verbally aggressive towards other residents related to dementia. The goal was that the resident will not harm self or others. Interventions included 1:1 sitter in place, moved to another unit, remove other residents from resident #2 when her aggression escalates, intervene before agitation escalates, guide away from source of distress, administer medications as ordered and BHT services to evaluate and treat.An interview was conducted on September 11, 2025 at 9:39 A.M. with a registered nurse (RN/staff #108) who stated the MDS assessment resident #2 was done by a licensed practical nurse (LPN/staff #107). The RN stated that a unit staff will look at the MDS but do not enter information into the MDS; and that, information from the MDS gets pulled over into the resident's care plan. The RN said that care plans were utilized by the nursing staff to help identify the appropriate interventions for residents with behaviors and that everyone on the unit where resident #2 was residing had a behavioral focus area build into their care plan. During the interview, a review of the clinical record was conducted with the RN who stated that the resident's care plan did not have previous entries related to behaviors until September 11, 2025. The RN further stated that a behavioral component/focus of care should have been entered prior to September 11, 2025; and that, the lack of interventions in the care plan had a potential risk could be outbursts from the resident that staff might not be able to control.An interview was conducted on September 11, 2025 at 10:38 with the MDS nurse/LPN (staff #107) who stated that an MDS assessment was required on multiple occasions, which could include at admission, 5-day, quarterly, annual, change of condition, discharge or even coming on or off hospice. The LPN said that for behaviors on an existing resident, she would receive notification from nursing staff or the social worker that there was a behavior that a resident exhibited and what the behavior was. She stated that the documentation in the MDS, would determine if there was a need for care planning. During the interview, a review of the clinical record was conducted with the LPN who stated that there were verbal behaviors documented in the clinical record that should have been care planned. However, the LPN stated that the resident's care plan did not include the behaviors as a focus of care and had not been documented in the care plan. She stated that the resident had verbal behaviors and these should have been documented on the care plan. Further, the LPN stated that the risk for not documenting these in the care plan could impede behavior identification, de-escalation and continuance of the problem.An interview was conducted on September 11, 2025 at 11:09 A.M. with the assistant director of nursing (ADON/staff #104) who stated that if there was something identified on the MDS then it should be transferred to the care plan to address any concerns. A review of the clinical record was conducted by the ADON who stated that the clinical record documented the resident had identified verbal behaviors; but, behaviors were not care planned with interventions prior to the September 11, 2025. She stated that the risk could include lack of clear communication to staff and to ensure that interventions were in place.An interview with the Assistant Administrator (staff #103) and the Administrator (staff #110) was conducted on September 11, 202 at 11:37 A.M. The Assistant Administer stated that the expectations were for the care plan to include a full detail of what services were being provided, resident profile, historical data, daily care needs, and the management of behavioral interventions. The Assistant Administrator reviewed the clinical record and stated that the MDS assessment for resident #2 identified the verbal behaviors at 4 to 6 days per week. However, a upon reviewing the resident's care plan she stated that resident's verbal behaviors had not been included as a focus of care and it should have been. Further, the assistant administrator stated that the risk for not documenting the behaviors in the care plan could include staff not knowing what to watch for which could lead to an incident occurring.In an interview with Social Services (staff #242) conducted on September 11, 2025 at 2:25 P.M., staff #242 stated that part of her role regarding care plans included identifying the needs of the residents and talking to the MDS coordinator to enter those needs into the care plan. She stated that a variety of things get entered into the care plan to include psycho-social needs, depression, activities of daily living, behaviors and advanced directives. She stated that unless something was brought to her attention, she only reviews the resident notes on a quarterly basis; and, she was not aware of the behavioral notes for resident #2. Further, staff #242 stated that ideally these should have been noted in the care plan; and, there really would not be a risk as the behaviors had been documented elsewhere in the record, but could include a lack of not communicating appropriately.A review of the policy entitled Comprehensive Care Plans with a review date of September 11. 2025 revealed that the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment.

Based on observations, clinical record reviews, interviews, and a review of facility policies and procedures, the facility failed to take steps to remove or reduce Resident #2's exposure to a known behavioral trigger. As a result, Resident #2 continued to be exposed to the trigger, leading to aggressive behaviors.Findings include:-Resident #1 (alleged trigger) was admitted on [DATE], with diagnoses of dementia, muscle weakness, and history of falling.Review of the care plan dated December 24, 2024, included the resident needed assistance with activities of daily living (ADL) and was an elopement risk. Interventions included encourage resident to participate in activities that promote exercise, daily staff assistance with ADL's, distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books that resident prefers and, to monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in functionThe MDS (Minimal Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. The care plan dated August 15, 2025 revealed that with reminders, the resident was independent for meeting emotional, intellectual, physical and social needs. Intervention included to introduce the resident to residents with similar background, interests and encourage/facilitate interaction. An incident note dated September 3, 2025, documented that Residents #1, #2, and another resident were seated at the same table before dinner. According to the documentation, staff observed Resident #2 standing over and yelling at Resident #1. Staff intervened by moving Resident #1 to the nurses' station, and Resident #2 returned to her room. The note also documented that the other resident reported seeing Resident #2 yell at and hit Resident #1.-Resident #2 was admitted on [DATE], with diagnose of dementia, major depressive disorder, anxiety disorder, and schizoaffective disorder.Review of the care plan dated October 17, 2024, revealed resident was dependent on staff and family for all emotional, intellectual, physical, and social needs. Interventions included to encourage ongoing family involvement and inviting to attend special events, activities, and meals, introducing resident to residents with similar backgrounds, interests, and encourage/facilitate interaction, invite the resident to scheduled activities and assist to and from programs to help encourage participation. The care plan did not include that the resident had behaviors such as verbal or physical aggression towards staff and/or residents.The NP psychiatric note dated December 3, 2024 included that the resident was calm, attentive, communicative, casually groomed, with scanty speech and difficulty naming objects. Per the documentation resident had intact associations, fair judgment and logical thinking. Diagnoses included schizoaffective disorder, bipolar type, anxiety disorder, moderate dementia without behavioral/psychotic disturbance.A late entry provider visit note dated June 4, 2025 revealed the resident was alert and oriented to self and environment. Assessments included dementia, schizoaffective disorder, anxiety and depression.A behavior note, dated June 12, 2025, revealed resident #2 displayed anger every time another resident (#1) who was sitting near another resident. Per documentation, resident #2 had paranoia and reported that the other resident (#1) was taking resident #3 from her; and that, resident #2 threatened resident #1 with physical violence and yelled at resident #1 who remained seated and looked confused while being yelled at by resident #2. The documentation also included that this behavior of resident #2 happens every time resident #1 tried to sit by resident #3. The behavior note dated July 2, 2025 included resident #2 yelled at and threatened resident #1 because resident #1 was looking at her at the dinner table.Review of a behavior note dated July 8, 2025 revealed that resident #2 told resident #3 that resident #1 was wearing her shirt; and that, resident #2 then approached resident #1, grabbed the shirt of resident #1 and told resident #1 to give the shirt back. Per the documentation, resident #2 told resident #3 that they should beat up resident #1; and that, resident #3 told resident #2 they should not do that because they would go to jail. The documentation also included that the CNA (certified nurse assistant) was able to separate the residents. Another behavior note dated July 8, 2025 included that resident #2 was sitting with resident #3 and other residents watching tv. Per the documentation, resident #1 was just passing down the hallway to her room and resident #2 yelled at resident #1 to go away and to get out of here; and, staff noticed this behavior from resident #2 before when resident #1 was sitting with resident #3. The documentation included that staff called a family member who explained that the brother of resident #2 had married a woman with the same first name as resident #1 and that person was very abusive to the family and her children; and that, the family of resident #2 believed the resident was reliving her past when she sees resident #1. Further, the documentation included that the NP and the DON (Director of Nursing) were notified.A late entry provider visit note dated July 9, 2025 revealed documentation of resident #2 yelling at other residents. Per the documentation the resident was alert & oriented x self/environment with normal affect. Assessments included dementia, schizoaffective disorder, anxiety and depression. Plan included for medications. The note did not include any interventions to address resident #2's verbal and physical aggression towards resident #1.A behavior note dated July 9, 2025 included resident #2 approached the dining room table where resident #1 was sitting at and yelled at resident #1. The documentation included that staff stepped in front of resident #1 to block the view of resident #2 who was then requested to return to her table. It also included that after a couple of minutes, resident #2 returned to her table but she was keeping an eye on resident #1.Another behavior note dated July 9, 2025 revealed that Psych was in to evaluate resident #2; and that, the ADON (Assistant Director of Nursing) notified the provider of the resident's behaviors. The documentation included that there were no new orders.The behavior note dated July 10, 2025 included that resident #2 continued to make comments about resident #1 at meal times; and that, all 3 residents (#1, #2, and another resident) were placed at different tables during meals.Despite documentation of verbal and physical aggression of resident #2 towards resident #1, there was no evidence found that any intervention implemented to prevent altercation from happening again between resident #1 and #2.The psychiatric NP note dated July 14, 2025 included that staff reported that the resident had become irritable with certain resident, specifically with a resident (#1) with a certain name who she associated with someone that her husband had an affair with; and that, the resident was unable to recall being upset with any resident. Recommendations included to to continue to monitor the resident's mood and to redirect resident as needed.A general nursing progress note dated July 15, 2025 revealed that during dinner time, resident #2 was verbally aggressive toward resident #1; and that, resident #2 accused resident #1 of stealing her clothes and demanded that they were returned. Further, the documentation included that this behavior appear to frighten and intimidate resident #1; and that, situation was de-escalated and redirected and both residents were separated during meals.The behavior note dated July 16, 2025 included resident #2 had a verbal altercation with resident #1 regarding a cat blanket which resident #2 claimed to belong to another resident who acknowledged that the blanket looked similar to what resident #3 has. Per the documentation, staff reassured resident #3 that her blanket was in her room but resident #2 continued to raise her voice towards resident #1. The documentation included that all 3 residents were separated redirected to different areas. The quarterly MDS assessment dated [DATE], revealed a BIMS score of 05, indicating severe cognitive impairment. The assessment also included that the resident was coded for verbal behaviors directed toward others exhibited within the last four to six days.Review of a behavior note dated July 20, 2025 included resident #2 yelled at and accused resident #1 of wearing a shirt that does belong to another resident; and that, resident #1 and the other resident were moved away from resident #2 who continued to yell at accused staff of being prejudiced of her. The documentation revealed that staff were unable to convince resident #2 that resident #1 was not wearing the shirt of the other resident. It also included that resident #1 told staff that she did nothing wrong.A behavior note dated July 20, 2025 revealed that the ADON and the NP were updated on the behaviors of resident #2.The psychiatric NP note dated July 20, 2025 revealed that the resident was seen for a follow-up psychiatric evaluation; and that, the resident was not aware of her current situation, had periods of confusion with disorientation and memory problems, had diffuse memory loss for recent and remote events; and, was psychiatrically stable at this time. The documentation did not include any verbal and physical aggressive behaviors exhibited by resident #2. Plan included medication management, strategic skills to cope with stress, modulation of interpersonal/occupational/family/social dynamics to reduce stress, behavioral modification encouragement and to continue to monitor resident and to coordinate with staff regarding moods/behavior. A late entry behavior note dated July 31, 2025 revealed that staff spoke with BHT (behavioral health tech) related to increased behaviors and noted agitation towards other peers.Another behavior note dated July 31, 2025 included resident #2 was overheard telling another resident that she was going to get a stick and put her, (referring to resident #1), in the ground. Per the documentation, resident #1 was not even speaking to resident #2 at the time.The behavior note dated August 21, 2025 included that resident #2 was sitting at the table with the other resident when resident #1 came over to the table. Per the documentation, resident #2 then yelled at and called resident #1 a liar and a thief. The documentation included that all residents were separated and calmed down.Despite documentation that resident #2 continued to to be verbally abusive to resident #1, there was no evidence that interventions were developed or implemented to minimize or eliminate Resident #2's exposure to the known behavioral trigger, Resident #1. A communication note dated September 10, 2025 included that staff spoke with the family of resident #2 regarding resident's behavior of perseverating on one particular resident (#1); and that, resident #2 would be moved to another unit and the resident having a sitter in place to ensure safety of all parties.The social service note dated September 11, 2025 revealed that the resident was informed by her family that she had slapped someone; and that, resident #2 was upset that she slapped someone.The care plan for resident #2 was revised on September 11, 2025 to include that the resident had been physically and verbally aggressive towards other residents related to dementia. The goal was that the resident will not harm self or others. Interventions included 1:1 sitter in place, moved to another unit, remove other residents from resident #2 when her aggression escalates, intervene before agitation escalates, guide away from source of distress, administer medications as ordered and BHT services to evaluate and treat.The TAR (treatment administration record) for July through September 2025 revealed that the resident was being monitored for behaviors of inability to sleep and verbalization of sadness were monitored. However, the resident was monitored for verbal and physical aggressive behaviors. An interview with the family of Resident #1 was conducted on the patio on September 10, 2025, at 10:33 AM. During the interview, Resident #1 became visibly upset, repeatedly asking her family, You're not leaving, are you? and You're coming back, right? The family said that Resident #1 and Resident #3 had been very close friends until Resident #2 moved into the facility; and that, resident #2 became possessive of resident #3 and did not want resident #1 or any other residents interacting with resident #3. The family reported receiving a phone call from a staff member on September 3, 2025, stating that Resident #1 had been slapped by Resident #2, and that the incident was witnessed by Resident #3; and, when she visited resident #1 the next day, she noticed a bruise on the side of the face of resident #1. She also said she was aware of ongoing comments that resident #2 had been bullying resident #1, and, the facility failed to take action to stop it. The family stated that it was not until the day after the slapping incident that staff told her that resident #2 would be separated from Resident #1. The family further stated that while she understands that resident #1 was in a dementia unit where residents in the unit have behaviors, she did not want resident #1 to be harmed. Further, the family stated that since the slapping incident, resident #1 had been more agitated and had now resisted going to bed at night.An interview was conducted on September 10, 2025 at 10:51 AM with Certified Nursing Assistant (CNA/staff #101) who stated that the incident between resident #1 and resident #2 happened around dinner time. The CNA said she was at the nurse's station when she heard shouting. She said she then went to the dining room where resident #2 was standing over resident #1, who was in her wheelchair, and resident #1's eye looked red. The CNA stated that she and a Licensed Practical Nurse (LPN/staff #102) deescalated the situation; and that, resident #3 approached her and reported that resident #2 pushed resident #1 who pushed resident #2 back which resulted in resident #2 punching resident #1 in the eye. The CNA said there was a history of resident #2 being verbally aggressive/abusive towards resident #1 and it escalated to the point of physical abuse. The CNA said she had seen resident #2 was very possessive of resident #3 and resident #2 did not not want resident #1 to associate with resident #3. The CNA stated the unit attempted to keep both resident #1 and resident #2 separated as much as possible but it could be difficult staff were also attending to other residents in the unit. The CNA further stated that resident #1 was fearful to go to bed at night, always the last to go into her room and when the CNA get resident #1 in her room, resident #1 would constantly ask her if she was staying and was not leaving. The CNA stated there were no issues between resident #1 and any other residents in the unit. In another interview with the CNA (staff#101) conducted on September 10, 2025 at 4:50 PM, the CNA stated that a room change was initiated by the family of resident #1 on July 7, 2025, because the family wanted resident #1 off the back hallway and closer to the dining area. The CNA said that the move was not encouraged by the staff due to the fact that resident #1 would be closer to the room of resident #2; and, all the verbal altercations between resident #1 and resident #2 occurred in the dining area. However, the CNA stated that the family was insistent on the move. Further, the CNA stated it was that after the move that issues began with resident #1 not wanting to go to bed and became fearful of being alone in her room.An interview was conducted with another CNA (staff #106) on September 10, 2025 at 5:04 PM, The CNA (staff #106) said that resident #1 has suffered from harm from the verbal and physical abuse by resident #2. She stated staff in the unit were doing the best they could to keep both residents #1 and resident #2 separated from each other but it can be difficult at times. Further, the CNA said that when staff reported these incidents to management, the management team did not listen, and nothing was done to address the behavior or resident #2.An interview was conducted on September 10, 2025 at 5:08 PM with an LPN (staff #102) who stated that on the evening of September 3, 2025, she was at the nurse's station when she heard a commotion and looked over to the dining room. She said that resident #2 was standing over and was yelling at resident #1 who in her wheelchair; and that, resident #3 told the LPN that resident #2 slapped resident #1. The LPN said she believed resident #3 because resident #3 can tell staff what happened at a particular time or instance. The LPN further stated that she interviewed resident #1 who reported that resident #2 had called her a b*&#ch and had placed her hand on the shoulder of resident #1. However, the LPN stated that resident #1 could not remember if she was hit by resident #2. An observation of the dementia unit was conducted on September 10, 2025 at 8:26 PM. There were several residents sitting in the common area watching television. Residents #2 and #3 were going down the hall with the CNA (staff #101), when resident #1 called for the CNA. Resident #2 then stopped, turned around, and told the CNA that resident #1 was not her boss.Another observation of the dementia unit was conducted on September 10, 2025 at 8:40 PM. The CNA (staff #101) was trying to get resident #1 to go to her room and get ready for bed. Resident #1 was very resistant to go to her room and told the CNA that she will just go with another resident to her room for the night. When the staff got resident #1 to her room, resident #1 asked the CNA not to go anywhere to stay with her and for the CNA to be with her as she might climb out the window. The CNA calmed resident #1 and settled her in bed. When the CNA was going to exit the room, resident #1 told the CNA to turn the light on if the CNA was going to leave her in the room. An attempt to interview resident #2 was conducted on September 11, 2025 at 9:28 AM but was unsuccessful because the resident became very agitated. Resident #2 was in the dementia unit; had a 1:1 sitter and was watching television.In an interview with the ADON (staff #104) conducted on September 11, 2025 at 11:09 AM, the ADON stated that yelling, swearing at, and taunting were considered as verbal abuse even if these behaviors happened in the dementia unit. She stated she was made aware of incidents of verbal aggression between resident #1 and resident #2 after it happened; and, she reported it the DON, who had been gone roughly 10 days. The ADON further stated, at that time, she was told to have the psychiatrist see resident's #1 and #2.An interview was conducted on September 11, 2025, at 11:37 AM, with the Administrator (staff #110), and the Assistant Administrator (staff #103). Both staffs (#110 and #103) stated that abuse was defined as sexual, verbal, financial, physical, exploitation, derogatory speech, belittling, yelling, intimidation, and having an aggressive tone. The assistant administrator stated that if a resident had cognitive issues or if something was witnessed on the dementia unit, it was still considered to be abuse. She stated she was aware of the incident on September 3, 2025 between resident #1 and resident #2; however, she stated that the only witness to the incident was another resident (#3) and resident #1 was interviewed by staff, resident #1 could not remember being hit. The assistant administrator denied receiving verbal abuse allegations related to resident #1 prior to the slapping incident ; and the only incident between resident #1 and #2 that the facility was aware of was the slapping incident on September 3, 2025.An interview with a CNA (staff #109) was conducted on September 12, 2025 at 9:29 AM. The CNA stated she was the 1:1 sitter assigned to resident #2, who was now very calm, relaxed, was not tense or agitated, and was smiling after she had moved to a different unit. In another interview with CNA (staff #101) conducted on September 12, 2025, at 1:45 PM, the CNA stated that resident #2 was transferred to another unit, resident #1 went to bed early and did not ask her to stay; and that, resident slept well.

Based on observations, clinical record reviews, interviews, and a review of facility policies and procedures, the facility failed to develop and implement a person-centered care plan that addressed resident compatibility and environmental triggers for Resident #1. As a result, the facility failed to provide an environment that supported Resident #1's highest practicable physical, mental, and psychosocial well-being. Resident #1 continued to be exposed as a known behavioral trigger for Resident #2.Findings include:-Resident #1 (alleged victim) was admitted on [DATE], with diagnoses of dementia, muscle weakness, and history of falling.Review of the care plan dated December 24, 2024, included the resident needed assistance with activities of daily living (ADL) and was an elopement risk. Interventions included encourage resident to participate in activities that promote exercise, daily staff assistance with ADL's, distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books that resident prefers and, to monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in functionThe MDS (Minimal Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. The NP (nurse practitioner) psychiatric progress note dated June 29, 2025 included that resident #1 had history of dementia without behaviors and had no issues or concerns regarding psychiatric needs. Diagnosis included dementia without behavioral disturbance. Recommendations included medication management, strategic skills to cope with stress, modulation of interpersonal/occupational/family/social dynamics to reduce stress and behavioral modification encouragement.A behavior note dated July 10, 2025 revealed that the resident was agitated, confused, wanted to go home and insisted that her car was parked right outside.The orders-administration note dated July 10, 2025 included that the resident had one episode of frustration regarding seeing someone outside her window; and, the resident asked if she could go home. The orders-administration note dated July 23, 2025 revealed that the resident was awake, confused, oriented to self and was tearful. Per the documentation, the resident told staff that she got to go; and when the staff told her that she would be staying, the resident asked the staff if she could come with the staff; and that, when the staff encouraged the resident to try to sleep, the resident appeared shocked and told staff that she thought it was morning. The documentation also included that the staff sat with the resident until the resident was calm; and reminded the resident that staff were there with her and she was not alone. According to the documentation, hourly and PRN (as needed) rounds were conducted throughout the night.The care plan dated August 15, 2025 revealed that with reminders, the resident was independent for meeting emotional, intellectual, physical and social needs. Intervention included to introduce the resident to residents with similar background, interests and encourage/facilitate interaction. However, the care plan did not include interventions to address compatibility and environmental triggers.A restorative nursing assistant note dated August 21, 2025 included that resident told staff that she was following another resident in her wheelchair and they were looking to see if they could find her husband.An infection note dated September 3, 2025 revealed that residents #1, #2, and #3 were sitting at the same table before dinner. Per the documentation, staff witnessed resident #2 standing over and yelling at resident #1; and that, staff intervened and moved resident #1 to the nurse's station and resident #2 returned to her room. The documentation also included that resident #3 told staff that resident #2 yelled and hit resident #1.A communication note dated September 6, 2025 included that the resident's family requested to speak with staff related to the resident's recent altercation with another resident (#2).The NP psychiatric progress note dated September 7, 2025 included that the resident was extremely hard of hearing, very confused, was not mobile, and required total care. The documentation also included that the resident had advanced dementia showing stable psychiatric symptoms and had no current behavioral issues reported by staff. -Resident #2 (alleged perpetrator) was admitted on [DATE], with diagnose of dementia, major depressive disorder, anxiety disorder, and schizoaffective disorder.Review of the care plan dated October 17, 2024, revealed resident was dependent on staff and family for all emotional, intellectual, physical, and social needs. Interventions included to encourage ongoing family involvement and inviting to attend special events, activities, and meals, introducing resident to residents with similar backgrounds, interests, and encourage/facilitate interaction, invite the resident to scheduled activities and assist to and from programs to help encourage participation. The care plan did not include that the resident had behaviors such as verbal or physical aggression towards staff and/or residents.The NP psychiatric note dated December 3, 2024 included that the resident was calm, attentive, communicative, casually groomed, with scanty speech and difficulty naming objects. Per the documentation resident had intact associations, fair judgment and logical thinking. Diagnoses included schizoaffective disorder, bipolar type, anxiety disorder, moderate dementia without behavioral/psychotic disturbance.A late entry provider visit note dated June 4, 2025 revealed the resident was alert and oriented to self and environment. Assessments included dementia, schizoaffective disorder, anxiety and depression.A behavior note, dated June 12, 2025, revealed resident #2 displayed anger every time resident #1 who was sitting near resident #3. Per documentation, resident #2 had paranoia and reported that resident #1 was taking resident #3 from her; and that, resident #2 threatened resident #1 with physical violence and yelled at resident #1 who remained seated and looked confused while being yelled at by resident #2. The documentation also included that this behavior of resident #2 happens every time resident #1 tried to sit by resident #3. The clinical record revealed no evidence of any intervention implemented to prevent altercation from happening again between resident #1 and #2.The behavior note dated July 2, 2025 included resident #2 yelled at and threatened resident #1 because resident #1 was looking at her at the dinner table.Review of a behavior note dated July 8, 2025 revealed that resident #2 told resident #3 that resident #1 was wearing her shirt; and that, resident #2 then approached resident #1, grabbed the shirt of resident #1 and told resident #1 to give the shirt back. Per the documentation, resident #2 told resident #3 that they should beat up resident #1; and that, resident #3 told resident #2 they should not do that because they would go to jail. The documentation also included that the CNA (certified nurse assistant) was able to separate the residents. Another behavior note dated July 8, 2025 included that resident #2 was sitting with resident #3 and other residents watching tv. Per the documentation, resident #1 was just passing down the hallway to her room and resident #2 yelled at resident #1 to go away and to get out of here; and, staff noticed this behavior from resident #2 before when resident #1 was sitting with resident #3. The documentation included that staff called a family member who explained that the brother of resident #2 had married a woman with the same first name as resident #1 and that person was very abusive to the family and her children; and that, the family of resident #2 believed the resident was reliving her past when she sees resident #1. Further, the documentation included that the NP and the DON (Director of Nursing) were notified.A late entry provider visit note dated July 9, 2025 revealed documentation of resident #2 yelling at other residents. Per the documentation the resident was alert & oriented x self/environment with normal affect. Assessments included dementia, schizoaffective disorder, anxiety and depression. Plan included for medications. The note did not include any interventions to address resident #2's verbal and physical aggression towards resident #1.A behavior note dated July 9, 2025 included resident #2 approached the dining room table where resident #1 was sitting at and yelled at resident #1. The documentation included that staff stepped in front of resident #1 to block the view of resident #2 who was then requested to return to her table. It also included that after a couple of minutes, resident #2 returned to her table but she was keeping an eye on resident #1.Another behavior note dated July 9, 2025 revealed that Psych was in to evaluate resident #2; and that, the ADON (Assistant Director of Nursing) notified the provider of the resident's behaviors. The documentation included that there were no new orders.The behavior note dated July 10, 2025 included that resident #2 continued to make comments about resident #1 at meal times; and that, all 3 residents (#1, #2, and #3) were placed at different tables during meals.Despite documentation of verbal and physical aggression of resident #2 towards resident #1, there was no evidence that interventions were developed or implemented to minimize or eliminate Resident #2's exposure to the known behavioral trigger, Resident #1. The psychiatric NP note dated July 14, 2025 included that staff reported that the resident had become irritable with certain resident, specifically with a resident (#1) with a certain name who she associated with someone that her husband had an affair with; and that, the resident was unable to recall being upset with any resident. Recommendations included to to continue to monitor the resident's mood and to redirect resident as needed.A general nursing progress note dated July 15, 2025 revealed that during dinner time, resident #2 was verbally aggressive toward resident #1; and that, resident #2 accused resident #1 of stealing her clothes and demanded that they were returned. Further, the documentation included that this behavior appear to frighten and intimidate resident #1; and that, situation was de-escalated and redirected and both residents were separated during meals.The behavior note dated July 16, 2025 included resident #2 had a verbal altercation with resident #1 regarding a cat blanket which resident #2 claimed to belong to resident #3 who acknowledged that the blanket looked similar to what resident #3 has. Per the documentation, staff reassured resident #3 that her blanket was in her room but resident #2 continued to raise her voice towards resident #1. The documentation included that all 3 residents were separated redirected to different areas. The quarterly MDS assessment dated [DATE], revealed a BIMS score of 05, indicating severe cognitive impairment. The assessment also included that the resident was coded for verbal behaviors directed toward others exhibited within the last four to six days.Review of a behavior note dated July 20, 2025 included resident #2 yelled at and accused resident #1 of wearing a shirt that does belong to resident #3; and that resident #1 and #3 were moved away from resident #2 who continued to yell at accused staff of being prejudiced of her. The documentation revealed that staff were unable to convince resident #2 that resident #1 was not wearing the shirt of resident #3. It also included that resident #1 told staff that she did nothing wrong.A behavior note dated July 20, 2025 revealed that the ADON and the NP were updated on the behaviors of resident #2.The psychiatric NP note dated July 20, 2025 revealed that the resident was seen for a follow-up psychiatric evaluation; and that, the resident was not aware of her current situation, had periods of confusion with disorientation and memory problems, had diffuse memory loss for recent and remote events; and, was psychiatrically stable at this time. The documentation did not include any verbal and physical aggressive behaviors exhibited by resident #2. Plan included medication management, strategic skills to cope with stress, modulation of interpersonal/occupational/family/social dynamics to reduce stress, behavioral modification encouragement and to continue to monitor resident and to coordinate with staff regarding moods/behavior. A late entry behavior note dated July 31, 2025 revealed that staff spoke with BHT (behavioral health tech) related to increased behaviors and noted agitation towards other peers.Another behavior note dated July 31, 2025 included resident #2 was overheard telling another resident that she was going to get a stick and put her, (referring to resident #1), in the ground. Per the documentation, resident #1 was not even speaking to resident #2 at the time.The behavior note dated August 21, 2025 included that resident #2 was sitting at the table with resident #3 when resident #1 came over to the table. Per the documentation, resident #2 then yelled at and called resident #1 a liar and a thief. The documentation included that all residents were separated and calmed down.Despite documentation that resident #2 continued to to be verbally abusive to resident #1, there was no evidence found that interventions were put in place to protect and prevent resident #1 from continued abuse by resident #2. The clinical record of both residents revealed no evidence that modifications were made after repeated yelling incidents between residents #1 and #2, even after the underlying reason was identified.On September 4, 2025, a complaint was filed with the State Agency (SA) regarding 2 staff witnessing resident #2 pushed and hit resident #1 in the dementia unit; and that, this incident was reported to administration by staff.However, review of the clinical record revealed no documentation of this incident until September 10, 2025 (approximately 6 days after the alleged incident).A communication note dated September 10, 2025 included that staff spoke with the family of resident #2 regarding resident's behavior of perseverating on one particular resident; and that the resident would be moved to another unit and the resident having a sitter in place to ensure safety of all parties.The social service note dated September 11, 2025 revealed that the resident was informed by her family that she had slapped someone; and that, resident #2 was upset that she slapped someone.The care plan for resident #2 was revised on September 11, 2025 to include that the resident had been physically and verbally aggressive towards other residents related to dementia. The goal was that the resident will not harm self or others. Interventions included 1:1 sitter in place, moved to another unit, remove other residents from resident #2 when her aggression escalates, intervene before agitation escalates, guide away from source of distress, administer medications as ordered and BHT services to evaluate and treat.The TAR (treatment administration record) for July through September 2025 revealed that the resident was being monitored for behaviors of inability to sleep and verbalization of sadness were monitored. However, the resident was monitored for verbal and physical aggressive behaviors. An interview with the family of Resident #1 was conducted on the patio on September 10, 2025, at 10:33 AM. During the interview, Resident #1 became visibly upset, repeatedly asking her family, You're not leaving, are you? and You're coming back, right? The family said that Resident #1 and Resident #3 had been very close friends until Resident #2 moved into the facility; and that, resident #2 became possessive of resident #3 and did not want resident #1 or any other residents interacting with resident #3. The family reported receiving a phone call from a staff member on September 3, 2025, stating that Resident #1 had been slapped by Resident #2, and that the incident was witnessed by Resident #3; and, when she visited resident #1 the next day, she noticed a bruise on the side of the face of resident #1. She also said she was aware of ongoing comments that resident #2 had been bullying resident #1, and, the facility failed to take action to stop it. The family stated that it was not until the day after the slapping incident that staff told her that resident #2 would be separated from Resident #1. The family further stated that while she understands that resident #1 was in a dementia unit where residents in the unit have behaviors, she did not want resident #1 to be harmed. Further, the family stated that since the slapping incident, resident #1 had been more agitated and had now resisted going to bed at night.An interview was conducted on September 10, 2025 at 10:51 AM with Certified Nursing Assistant (CNA/staff #101) who stated that the incident between resident #1 and resident #2 happened around dinner time. The CNA said she was at the nurse's station when she heard shouting. She said she then went to the dining room where resident #2 was standing over resident #1, who was in her wheelchair, and resident #1's eye looked red. The CNA stated that she and a Licensed Practical Nurse (LPN/staff #102) deescalated the situation; and that, resident #3 approached her and reported that resident #2 pushed resident #1 who pushed resident #2 back which resulted in resident #2 punching resident #1 in the eye. The CNA said there was a history of resident #2 being verbally aggressive/abusive towards resident #1 and it escalated to the point of physical abuse. The CNA said she had seen resident #2 was very possessive of resident #3 and resident #2 did not not want resident #1 to associate with resident #3. The CNA stated the unit attempted to keep both resident #1 and resident #2 separated as much as possible but it could be difficult staff were also attending to other residents in the unit. The CNA further stated that resident #1 was fearful to go to bed at night, always the last to go into her room and when the CNA get resident #1 in her room, resident #1 would constantly ask her if she was staying and was not leaving. The CNA stated there were no issues between resident #1 and any other residents in the unit. In another interview with the CNA (staff#101) conducted on September 10, 2025 at 4:50 PM, the CNA stated that a room change was initiated by the family of resident #1 on July 7, 2025, because the family wanted resident #1 off the back hallway and closer to the dining area. The CNA said that the move was not encouraged by the staff due to the fact that resident #1 would be closer to the room of resident #2; and, all the verbal altercations between resident #1 and resident #2 occurred in the dining area. However, the CNA stated that the family was insistent on the move. Further, the CNA stated it was that after the move that issues began with resident #1 not wanting to go to bed and became fearful of being alone in her room.An interview was conducted with another CNA (staff #106) on September 10, 2025 at 5:04 PM, The CNA (staff #106) said that resident #1 has suffered from harm from the verbal and physical abuse by resident #2. She stated staff in the unit were doing the best they could to keep both residents #1 and resident #2 separated from each other but it can be difficult at times. Further, the CNA said that when staff reported these incidents to management, the management team did not listen, and nothing was done to address the behavior or resident #2.An interview was conducted on September 10, 2025 at 5:08 PM with an LPN (staff #102) who stated that on the evening of September 3, 2025, she was at the nurse's station when she heard a commotion and looked over to the dining room. She said that resident #2 was standing over and was yelling at resident #1 who in her wheelchair; and that, resident #3 told the LPN that resident #2 slapped resident #1. The LPN said she believed resident #3 because resident #3 can tell staff what happened at a particular time or instance. The LPN further stated that she interviewed resident #1 who reported that resident #2 had called her a b*&#ch and had placed her hand on the shoulder of resident #1. However, the LPN stated that resident #1 could not remember if she was hit by resident #2. An observation of the dementia unit was conducted on September 10, 2025 at 8:26 PM. There were several residents sitting in the common area watching television. Residents #2 and #3 were going down the hall with the CNA (staff #101), when resident #1 called for the CNA. Resident #2 then stopped, turned around, and told the CNA that resident #1 was not her boss.Another observation of the dementia unit was conducted on September 10, 2025 at 8:40 PM. The CNA (staff #101) was trying to get resident #1 to go to her room and get ready for bed. Resident #1 was very resistant to go to her room and told the CNA that she will just go with another resident to her room for the night. When the staff got resident #1 to her room, resident #1 asked the CNA not to go anywhere to stay with her and for the CNA to be with her as she might climb out the window. The CNA calmed resident #1 and settled her in bed. When the CNA was going to exit the room, resident #1 told the CNA to turn the light on if the CNA was going to leave her in the room. An attempt to interview resident #2 was conducted on September 11, 2025 at 9:28 AM but was unsuccessful because the resident became very agitated. Resident #2 was in the dementia unit; had a 1:1 sitter and was watching television.In an interview with the ADON (staff #104) conducted on September 11, 2025 at 11:09 AM, the ADON stated that yelling, swearing at, and taunting were considered as verbal abuse even if these behaviors happened in the dementia unit. She stated she was made aware of incidents of verbal aggression between resident #1 and resident #2 after it happened; and, she reported it the DON, who had been gone roughly 10 days. The ADON further stated, at that time, she was told to have the psychiatrist see resident's #1 and #2.An interview was conducted on September 11, 2025, at 11:37 AM, with the Administrator (staff #110), and the Assistant Administrator (staff #103). Both staffs (#110 and #103) stated that abuse was defined as sexual, verbal, financial, physical, exploitation, derogatory speech, belittling, yelling, intimidation, and having an aggressive tone. The assistant administrator stated that if a resident had cognitive issues or if something was witnessed on the dementia unit, it was still considered to be abuse. She stated she was aware of the incident on September 3, 2025 between resident #1 and resident #2; however, she stated that the only witness to the incident was another resident (#3) and resident #1 was interviewed by staff, resident #1 could not remember being hit. The assistant administrator denied receiving verbal abuse allegations related to resident #1 prior to the slapping incident ; and the only incident between resident #1 and #2 that the facility was aware of was the slapping incident on September 3, 2025.An interview with a CNA (staff #109) was conducted on September 12, 2025 at 9:29 AM. The CNA stated she was the 1:1 sitter assigned to resident #2, who was now very calm, relaxed, was not tense or agitated, and was smiling after she had moved to a different unit. In another interview with CNA (staff #101) conducted on September 12, 2025, at 1:45 PM, the CNA stated that resident #2 was transferred to another unit, resident #1 went to bed early and did not ask her to stay; and that, resident slept well.

Based on interviews, facility documentation and postings, the facility failed to ensure the assistant administrator was duly appointed by the governing board. The deficient practice could contribute to actions, inactions or decisions regarding facility deficiencies, as related to attaining or maintaining the highest practicable physical, mental and psychosocial well-being of each resident.Findings include:A review of the personnel file for the assistant administrator (staff #103) revealed a job description dated September 1, 2023. The job description revealed that the position of an for assistant administrator was signed on September 13, 2023 by staff #103. The approval line within the document noting CEO (chief executive officer) approval was blank. Further, a handwritten line had been added which noted HR (human resources) containing the signature of staff #103 and dated on September 13, 2023.Review of the resume for staff #103 revealed that from September 17, 2024 to current, staff #103 had the title of an Assistant Administrator/ Marketing/Admissions Director for the facility. It also included that from October 25, 2025 to September 16, 2024 staff #103 had a job title of Marketing/admission Coordinator for the facility. Subsequent entries revealed a job title of Marketing Representative, and Receptionist for the facility. It was noted that staff #103 was self-employed from 1976 through 2000, training horses and giving riding lessons. The educational component of the resume revealed attendance at a community college from 1978 to 1980, with no notated degree. No licenses or certifications were documented in the resume.A facility business card for staff #103 revealed a title of Assistant Administrator.The staff list provided by the facility noted staff #103 as the Assistant Administrator.Further review of the facility documentation revealed a letter dated July 30, 2025 noting that under the Arizona Administrative Code R9-10-303, subsection (B)(3) staff #103, the assistant administrator, was designated as the individual who was present and accountable for the nursing care institution when the administrator was not present on the premises. The letter was signed by Licensed Nursing Home Administrator (staff #110).There was no evidence found in the facility documentation the Assistant Administrator (staff #103) was the qualified assistant administrator appointed by the facility's governing board.An interview was conducted on September 10, 2025 at 10:51 A.M. with a certified nursing assistant (CNA/staff #101) who stated that an incident of abuse had been reported to the Assistant Director of Nursing (ADON/staff #104) and to the Assistant Administrator (staff #103). The CNA stated that the incident was reported and the intruction from ADON and Assistant Administer was to let the incident go and to stop escalating it, as it involved residents in behavioral unit and that the residents would forget about it. However, both verbal abuse and intimidation, per staff interviews and facility documentation continued after the initial incident and no evidence of a thorough investigation or report to the state agency were observed in the facility documentation.An interview was conducted on September 11, 2025 at 9:39 A.M with RN (registered nurse/ staff #108). The RN stated that if resident to resident abuse occurred, she would separate the residents, ensure that there were no injuries, make sure they are safe and then report to the ADON (staff #104), the Assistant Administrator (staff #103) and the Administrator (staff #110). Staff #108 identified the ADON, Assistant Administrator and Administrator by first name and title. The RN stated that they would conduct the investigations and ensure that the proper notifications transpired.An interview was conducted on September 11, 2025 at 11:37 A.M. with staff #103 and staff #110. During the interview staff#103 identified herself as the Assistant Administrator. Staff #110 further stated that the facility did not have a policy for Assistant Administrator appointment, nor was he aware that the assistant administrator had to be appointed by the governing board. No risk was identified by staff #110.The facility did not have a policy for Assistant Administrator appointment.

Based on a closed clinical record review, interviews, facility documentation, and review of facility policy, the facility failed to ensure that abnormal respiratory rates for resident #7 were monitored and that a change in condition was relayed to the physician. The deficient practice could result in resident injury if abnormal vitals are neglected. Findings include: Resident #7 was admitted on [DATE] with diagnosis including chronic obstructive pulmonary disease, atrial fibrillation, obstructive sleep apnea, scoliosis, kyphosis-cervical region, heart failure, asthma, type 2 diabetes, morbid obesity, muscle weakness and reduced mobility. It was noted that the resident died on [DATE] while at the facility. A review of the admission MDS (minimum data set) dated [DATE] revealed a BIMS (brief interview of mental status) score of 15. The MDS further revealed no evidence of delirium, psychosis or behaviors. An admit summary note on [DATE] revealed that the resident had been admitted to Banner hospital for shortness of breath, congestive heart failure exacerbation. A provider visit note dated [DATE] revealed that the resident was being admitted for strengthening therapies post hospitalization for sepsis, pneumonia and heart failure. A progress note entry on [DATE] revealed that the resident was at 92% for oxygen saturation on room air while at rest. It was further noted that the resident was alert but was making claims of abnormal readings on her personal pulsometer. A review of the resident's vital signs revealed a respiratory rate of 28 breaths per minute on [DATE] at 07:37A.M. and at 3:12 P.M. The electronic health record further revealed triggered warnings, noting that the reading was high and exceeded 25. A further review of the resident's record revealed no evidence that the physician was notified of the respiratory rate. A telephone call was placed to LPN (licensed practical nurse, staff #101) on [DATE] at 10:56 A.M. -a message was left on voicemail requesting a call back; however, no return call was received. A telephone call was placed to LPN, staff #73 on [DATE] at 10:58 A.M.-a message was left on the voicemail requesting a call back. No return call was received. An interview was conducted on [DATE] at 11:36 A.M. with RN (registered nurse, staff # 3). Staff #3 stated that she was not there when the resident had passed away, but stated that she knew the resident would refuse to wear her CPAP (continuous positive airway pressure) and was on oxygen during the day. An interview was conducted on [DATE] at 12:31 P.M. with CNA (certified nursing assistant, staff #22). The CNA stated that respiratory rate is checked as part of the vitals. The CNA further stated that respirations outside of ,d+[DATE] per minute would require notification to the nurse on duty. She stated that a reading of 28 respirations per minute would be considered abnormal and would require the nurse to be notified. An interview was conducted on [DATE] at 12:33 P.M. with RN, staff #3. The RN stated that a normal respiratory rate is generally between ,d+[DATE] breaths per minute. Staff #3 stated that if it is outside of the normal range, it should be re-checked. If the re-check was still abnormal, the provider should be notified. Staff #3 reviewed the residents medical record and stated that she did not see evidence of documentation that the abnormal respiratory rate was communicated to the provider. An interview was conducted on [DATE] at 2:01 P.M. with DON (director of nursing, staff #10). The DON stated that normal respiration would fall between ,d+[DATE]. She stated that above 24 or lower than 14 would require physician notification. Staff #10 stated that the expectation for the procedure would be as follows, the CNA would notify the nurse if the respiratory readings were abnormal and the nurse would then notify the doctor. She stated that her expectation would be that the physician notification would be documented in the electronic health record. Staff #10 reviewed the record for resident #7 and stated that the respiratory rate was out of parameters twice on [DATE] and that physician notification should have taken place. She stated that there was no indication in the electronic health record that the physician had been notified. Staff #10 stated that the risk to the resident could be increased anxiety and a potential for hospitalization . A review of the facility policy entitled Notification of Changes Policy updated on October, 2024 revealed that the purpose of the policy is to ensure the facility promptly informs the resident, consults the resident's physician and notifies, consistent with his/ her authority, the resident's representation when there is a change requiring notification. The policy further states that circumstances requiring notification include a significant change in the resident's physical, mental or psychosocial condition such as deterioration in health, mental or psychosocial status The policy titled Abuse, Neglect and Exploitation updated on [DATE] included the definition of Neglect which states that Neglect means failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. The policy included prevention of abuse, neglect and exploitation which stated the facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property and exploitation that achieves the identification, ongoing assessment, care planning for appropriate interventions, monitoring of residents with needs and behaviors which might lead to conflict or neglect.

Based on staff interviews, clinical record review and facility policy, the facility failed to ensure that resident #16 was provided with assistance with activities of daily living (ADL) to maintain personal hygiene. Failure to meet this requirement could lead to issues with skin integrity and impairing resident dignity. Findings include: Resident #16 was admitted [DATE] with diagnoses of dementia, Bipolar disorder and Major Depressive Disorder. An quarterly Minimum Data Set, dated dated dated [DATE] included that this resident was severely cognitively impaired and was dependent for showering/bathing self and dependant for the ability to get in or out of a tub/shower. A care plan dated June 9, 2020 included that this resident has an ADL self-care deficit related to dementia. This care plan included that this resident will have all ADL's met with staff assistance daily. A review of facility records included that this resident received or was offered a shower 6 times in November 2023 (on the 2, 6, 9, 13, 16, and 27th), 3 times in December 2023 (on the 11, 14, and 28th) An Interview was conducted on January 24, 2025 with a Certified Nursing Assistant (CNA/staff #12) who said that when staff first comes in, they are assigned their section and what showers they have to do. This staff said that if her area only has 3 CNA's that it can be hard to get them done. She said that if they are unable to get them done, they are supposed to tell their nurse and ask if the evening shift can get the shower done. This staff said that residents are supposed to be showered twice a week and that there is a sheet which states which room numbers get showers on which days. An interview was conducted on January 24, 2025 with a Licensed Practical Nurse, who said that the nurses role in showers is doing the skin checks and making sure the shower sheets get done and to try to convince residents if they refuse. This nurse said that showers are twice a week and should be every 2-3 days. This nurse said that each room is scheduled on certain days and whether its evening or day shift. This nurse said that there is not a dedicated shower person, and that the CNA's will divide the shower assignments in the morning. An interview was conducted with the MDS nurse (staff #78) who said that she was filling in for the Director of Nursing. This nurse said that residents are supposed to get their showers on their bath days when they are scheduled and that they are scheduled twice a week. A policy titled Resident Showers Policy updated October 2024, included It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. This policy included Residents will be provided showers as per facility schedule protocols.

Based on staff interviews, clinical record review and facility policy, the facility failed to ensure that an allegation of abuse was reported in a timely manner. Findings include: Resident #24 was admitted on [DATE] with diagnoses of multiple fractures. An admission Minimum Data Set, dated dated dated [DATE] included that this resident was cognitively intact. A care plan dated January 6, 2025 included the resident is independent for meeting emotional, intellectual, physical, and social needs. A social services note dated January 3, 2025 included, This writer met with resident andher daughter after receiving report that (a family member) was aggressively trying to get residents' debit card. (Family member) states she is trying to pay her mother's rent and it is on an app on her cell phone. Explained to (Family member) why we were there and that there was concern over how she was talking to (this resident) and her attempt to get money from (this resident). This writer talked to resident privately and asked if she feels safe and she said she does and she is a good (family member). This writer with residents' permission attempted to assist with finding the app and pay her rent. There were no apps that looked like they are to the apartment complex and resident said she just hands her phone to the office, and they pay the rent. (Family member) took residents' phone, debit card, and keys with residents' permission. She said she is going to pay the rent, take some money out of the account, with residents' permission, and check the mail. This information was conveyed to nurses. Will continue to monitor for any potential episodes of abuse. A social services note dated January 6, 2025 included This writer was called to unit urgently. Went to unit and nurse and ADON stated residents' (family member) was there earlier and she started yelling and banging on the door to the nurses' station. She was aggressive with nurse and said (this resident) needs a pain pill now. The resident hadn' t requested one but nurse said she would bring one. When nurse gave the pill to the resident she pulled her tongue to the sidefor the nurse to put it under her tongue. The nurse said this doesn't go under your tongue, you can swallow it. (This family member) and resident said she can't swallow it. Nurse was surprised as resident hasn't had any difficulty swallowing her medications but quickly stepped outside to her cart to get applesauce to help the resident swallow her pill. When she returned the pill was gone and her (family member) said Oh, she swallowed it.The resident turned her eyes to the side and looked at her (family member) but didn't say anything. When resident asked for other medication, the nurse crushed the medication and put it in applesauce. Per the nurse the (family member) remarked and said are you going to crush all her medications now? When this story was relayed to me the (family member) had already left. I discussed the matter with my supervisor, and we met with the nurse and put a safety plan in place. However, review of the clinical record and facility documents do not include that these incidents were reported to the Long Term Care Licensing as required. An interview was conducted on January 24, 2025 at 10:17 A.M. with a Certified Nursing Assistant (CNA/staff #10) who said that she worked when this resident's family member was here and asking for for money kinda aggressively. This staff said that the family member was saying it was for her rent and that when a staff member talked to her she changed the story to paying the resident's rent. This staff said that the family member had a chemically odor and was jittery. This staff member said that she has not seen the family member since. This CNA said that she had abuse training and knows the types of abuse and reports to her nurse. An interview was conducted on January 24, 2025 at 10:26 A.M. with a Licensed Practical Nurse (LPN/staff #57) who said that she was familiar with this resident's family member because she came here and she was demanding money from this resident. This nurse also said that the nurse on shift was giving oxycodone, and that the resident kept the pill in her mouth and gave to the family member. This nurse said that she had not seen this family member since. This nurse said that the plan is to just keep an eye out and let the Director of Nursing (DON) know if the family member arrives. This nurse said the resident said that her family member is not working and she's trying to help her. This nurse said that they have regular trainings about abuse and reporting it to management. An interview was conducted on January 24, 2025 at 1:36 P.M. with the Assistant Administrator (staff #35) who said that whatever staff member hears of the abuse is expected to go the direct charge nurse to report it to management immediately, and then staff are expected to take the pieces, interview the abused person, verify it happened, then report within 2 hours. This staff said that if the person being abused says they are being abused, we report it, and if not cognizant then their representative. This staff member said that it is possible for a person to be abused and not say they are abused and that not every suspicion of abuse is reported. This staff said that our social worker went over the financial stuff and the resident is cognizant and the social worker did report to Adult Protective services (APS) and said that the resident willing divulged her money so the appropriate action was to go to APS. This staff said that the family member's actions are borderline that it is abuse but that this staff put the nurses on high alert that she is to be notified if the daughter comes in. A policy titled Abuse Neglect and Exploitation implemented 2003 and updated April, 2024 included that It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. This policy included Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse. This policy included that the Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on staff interviews, clinical record review and facility policy, the facility failed to ensure that a thorough investigation was conducted for resident #21. Findings include: Resident #21 was admitted [DATE] with diagnoses of mild cognative impairment and major depressive disorder. An annual Minimum Data Set, dated dated dated [DATE] included that this resident was cognitively intact and required extensive assistance with bed mobility, transfers, dressing and personal hygiene. A review of the SA complaint tracking system received October 23, 2023 by Long Term Care Licensing included that a family member is misappropriating the resident's finances and is not paying for bills nor equipment repairs. However, a five day report was not received for this incident. A request was made for the five day report on January 24, 2025 at 9:40 A.M. An interview was conducted with the Assistant Administrator (staff #35) on January 24, 2025 shortly after this request. This staff stated that they did not have a 5 day report for this incident. A follow up interview was conducted with this staff member (staff #35) on January 24, 2025 at 1:36 P.M. which included this staff saying that a 5 day report is part of a complete investigation and that she did not know what this incident was about but that it could be financial. This staff said that since our survey, we have put into place only herself or one other staff are the only ones to do the reporting, and that they are to do the 5 days and that was in their plan of correction. A policy titled Abuse Neglect and Exploitation implemented 2003 and updated April, 2024 included that It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. This policy included that the Administrator will follow up with government agencies, during business hours, to confirm the initial report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that abuse policies were implemented for two resident to resident abuse incidents, one involving resident (#222) and(#169); and the other involving residents (#223) and (#49). This deficient practice could result in further instances of resident to resident abuse. -Regarding Residents #222 and #169 -Resident #222 was initially admitted to the facility on [DATE] with diagnoses that included unspecified dementia, bipolar disorder, major depressive disorder, paroxysmal atrial fibrillation, and chronic obstructive pulmonary disease. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that resident #222 had a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognitive impairment. The assessment also revealed that the resident was exhibiting behavioral symptoms including physical, verbal, and behaviors not directed towards others on one to three days, and utilized a wheelchair for mobility. -Resident #169 was initially admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbance, psychotic disorder with hallucinations, generalized anxiety disorder, and major depressive disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a BIMS score of 03, which indicated severe cognitive impairment. The assessment also revealed that the resident was exhibiting behavioral symptoms including physical and verbal on four to six days, and needed staff assistance to move from sitting to standing. Progress notes dated April 7, 2022 revealed that the resident was in another resident's face and would not step back. The note indicated that the other resident asked Resident #169 to step back several times but she kept repeating no. The resident told Resident #169 get out of my face now and both residents were getting angry. The note relayed that Resident #169 would not leave the other resident alone and almost hit her. The progress notes also revealed that the resident was wandering the whole shift, picking plates and cups out of the garbage, wandering into others rooms and taking their stuff, and was easily upset when trying to redirect her. A progress note for dated April 9, 2022 at 9:37 a.m. revealed an altercation between Resident's #222 and #169 that was reported to a Registered Nurse (RN/Staff#158) while she passed medications. Resident #222 reported to the RN that she was hit several times in the stomach area earlier that day by Resident #169. The progress note revealed that Resident #222 did not have any obvious injuries and that they would continue to monitor the resident's skin for changes. Progress notes dated April 9, 2022 at 7:44 a.m. revealed that the resident almost turned a table over onto three other residents and she was screaming I am going to kill you and I am going to kill myself, and was repeatedly threatened staff and residents.The progress notes also revealed that Resident #169 was in the faces of several residents screaming they are going to kill you while drawing back her fist to hit another resident but was stopped by staff. The progress notes also revealed that Resident #169 was found in another resident ' s room screaming in her face. A progress note dated April 11, 2022 at 2:30 p.m. revealed that Resident #169 was sent out on April 9, 2022 as a result of the incident that took place in which Resident #169 punched Resident #222 and a police report was filed. Review of the SA complaint system form revealed the facility reported the incident on April 9, 2022 at 12:29 p.m. The report relayed that Resident #222 reported to Staff #158 at 11 a.m. that Resident #169 hit her in the stomach multiple times. The report revealed that Resident #169 had been very aggressive and threatening to staff and residents between the hours of 7:45-9 a.m. and that Resident #169 was sent to the emergency room . Review of the facility incident investigation revealed a statement from the previous DON indicating that the RN (Staff #158) was in the room when the event occurred and saw Resident #169 standing close to the resident, but was unaware that Resident #222 had been hit. The facility incident investigation also revealed a statement from the RN (Staff #158) who relayed that the resident who was found in Resident #222 ' s room earlier that day had been screaming and hitting her several times in the stomach. The RN pulled back the blanket and examined her stomach to find no injuries. An interview was conducted on October 22, 2024 at 1:10 p.m. with the RN, Staff #158, who stated that she remembered Resident #169. The RN stated that on April 9, 2022, the staff were shutting all the resident doors with residents inside to keep them safe from Resident #169 and that the resident had turned a table over with patients' food on it and when they called the Assistant Director of Nursing (ADON) she could hear the screaming over the phone and directed them to call the police. The RN stated that Resident #222 reported early in the morning that the resident had hit her. An interview was conducted on October 22, 2024 at 2:11 p.m. with the Director of Nursing (DON/Staff#49). Staff #49 recalled Resident #222 and an investigation from a couple years ago, but she did not recall the details. Staff #49 stated that the facility expects that staff follow the abuse policies and if the facility ' s abuse policies were not followed, there is potential for continued abuse, it could be detrimental to residents mental and physical wellbeing, and could cause harm. An interview was conducted on October 22, 2024 at 2:48 p.m. with the Administrator (Admin/Staff#205) who stated that the facility ' s expectation for handling resident to resident altercations was whatever the regulation requires, and if that expectation was not followed, residents could be injured. Behaviors would continue, other residents could get involved, and any number of things could happen. The administrator stated that the facilities expectation would be to follow their abuse policies and if they are not, there could be negative outcomes to residents. Review of the facility policy titled, Abuse, Neglect, and Exploitation, revealed that the facility should have developed and implemented written policies that prohibited and prevented abuse. The policy also revealed that abuse should have been reported to the state agency within two hours. The policy defines abuse as the willful infliction of injury, physical harm, pain or mental anguish, and it includes verbal abuse, physical abuse, and mental abuse. The policy defines physical abuse as including but not limiting hitting, slapping, punching, biting, and kicking. The policy also revealed that the facility should have identified, corrected, and intervened in situations in which abuse was more likely to occur. 51006 regarding resident #223 and resident #49 -Resident #223 was admitted on [DATE] with diagnosis of Atherosclerosis of Aorta, Schizophrenia, Unspecified, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety, Essential (Primary) Hypertension, And History of Falling. Resident #272 was discharged on [DATE]. A review of a admission Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12 out of 15, which indicated intact cognition. A review of a progress note dated February 26, 2023 and timed at 5:10 PM revealed Resident #223's involvement in the incident, indicating that the incident occurred. A review of the intake information for AZ00191964 revealed that the Facility Reported Incident (FRI) was submitted on February 26, 2023 at 5:59 PM. This review revealed that a Certified Nursing Assistant (CNA) observed Resident #49 hit Resident #223. A review of a progress note dated February 26,2023 and timed at 9:55 PM revealed that Resident #49 was coughing at the dining table when Resident #223 came over and told Resident #223 to stop coughing. Resident #49 hit Resident #223 and staff separated them. Resident #223 reported they were not hurt. A record request was submitted on October 22, 2024 and timed at 1:03 PM to request their 5-day report and additional investigation notes for the incident that occurred on February 26, 2023. At 1:22 PM, progress notes related to an incident on February 26, 2023 were provided. During this exchange of documents, point of contact/marketing coordinator/assistant administrator (Staff #18) reported and provided a signed 807 stating that the facility does not have any additional information regarding a 5-day report or an internal investigation. in regards to the incident that occurred on February 26, 2023. -Resident #49 was admitted on [DATE] with the diagnoses of Syncope And Collapse, Difficulty In Walking, Not Elsewhere Classified, Muscle Weakness (Generalized), Need For Assistance With Personal Care, Anxiety Disorder, Unspecified And Essential (Primary) Hypertension. Review of a quarterly Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated no cognitive impairement. A review of the SA complaint system revealed that the facility reported the incident and was submitted on February 26, 2023 at 5:59 PM. This review revealed that a Certified Nursing Assistant (CNA) observed Resident #49 hit Resident #223. A review of a progress note dated February 26, 2023 and timed at 9:55 PM revealed that Resident #49 was coughing at the dining table when Resident #223 came over and told Resident #223 to stop coughing. Resident #49 hit Resident #223 and staff separated them. Resident #223 reported they were not hurt. A review of a progress note dated February 26, 2023 and timed at 5:10 PM revealed Resident #49's involvement in the incident, indicating that the incident occurred. A record request was submitted on October 22, 2024 and timed at 1:03 PM to request their 5-day report and additional investigation notes for the incident that occurred on February 26, 2023. At 1:22 PM, progress notes related to an incident on February 26, 2023 were provided. During this exchange of documents, point of contact/marketing coordinator/assistant administrator (Staff #18) reported and provided a signed 807 stating that the facility does not have any additional information regarding a 5-day report or an internal investigation, in regards to the incident that occurred on February 26, 2023. Review of the facility policy titled, Abuse, Neglect, and Exploitation, revealed that the facility should have followed their developed and implemented written policies that prohibit, prevent, and investigate abuse, neglect and exploitation. The policy defines abuse as the willful infliction of injury, physical harm, pain or mental anguish, and it includes verbal abuse, physical abuse, and mental abuse. The policy defines physical abuse as including but not limiting hitting, slapping, punching, biting, and kicking. The policy also revealed that abuse should have been reported to the state agency within two hours. The policy also revealed that the facility should have identified, corrected, and intervened in situations in which abuse was more likely to occur. The policy also revealed that the the administrator is to follow up with government agencies to confirm the initial report is received, and again within 5 working days of the incident to report the investigation of the incident. The policy also revealed that the facility should have provided a completed and thorough documentation of the investigation of an incident.

Based on clinical record review, staff interviews, and review of facility policies and procedures, the facilty failed to ensure that one resident (#1) was transferred appropriately to prevent a fracture to her humerus. The sample size was three. Findings include: Resident #1 was admitted to the facility on (MONTH) 19, 2012 with [DIAGNOSES REDACTED]. Review of an ADL (activities of daily living) care plan dated (MONTH) 13, (YEAR) revealed Resident requires extensive assist with ADLs with two staff members for transfers .due to debility, due [MEDICAL CONDITION] and right sided sensory impairment. A goal documented was Resident will .have daily needs met by staff. Approaches documented were Two staff members for all transfers. Patient and her daughters refuse gait belt use. They have been educated but continue to state their refusal . Review of the quarterly MDS (Minimum Data Set) assessment dated (MONTH) 4, (YEAR), section G Functional Status revealed the resident required the extensive assistance of 2 for transfers and support. Nursing Note dated (MONTH) 23, (YEAR) documented Resident was being transferred by CNA (certified nursing assistant) from bed to wheelchair. When resident's legs touched the front wheel of the wheelchair and CNA was unable to complete transfer safely that's when CNA lowered resident gently to the floor and called for help. Nursing Note dated (MONTH) 23, (YEAR) documented Resident x-rays came back abnormal for RUE (right upper extremity). Orders were received and transcribed. Family is aware of transportation to (name of hospital) emergency room for further evaluation . An Accident/Incident Report dated (MONTH) 23, (YEAR) by the CNA who transferred the resident when she fell , staff #91, documented We were pivoting to sit in chair. Then she said oh. I looked down and seen her left foot slide behind her small front wheel. I could not hold her up and get her right foot in the right place so I slowly slid down my leg to a soft sit then held her up till nurse came and helped. I only held her under her arms. Got her feet in right place. I lifted her up and nurse had her legs. We sat her in the chair. Have never had a transfer go this way . A hospital History and Physical dated (MONTH) 23, (YEAR) documented .she had a fall while she was being lifted from the bed on her right side, complaining or right hip pain, right arm pain, about 7 out of 10 .Humerus fracture . Review of a nurse practitioner progress note dated (MONTH) 29, (YEAR) documented .Her right side is her weak side affected [MEDICAL CONDITION] when purposely moved with transfers or care, the area remains painful for patient .[MEDICATION NAME] increased to BID (twice a day) . An interview was conducted with a CNA, staff #41 on (MONTH) 28, (YEAR) at 9:02 a.m. The CNA stated that if she is unsure how a resident should be transferred she asks the nurse or physical therapist prior to transferring the resident. The CNA stated that the licensed nurse documents on the Report Sheet how a resident should be transferred. The CNA stated that if a new staff person or agency staff is working we always tell them how a resident should be transferred. An interview was conducted with a CNA, staff #21 on (MONTH) 28, (YEAR) at 9:10 a.m. The CNA stated that when a new resident is admitted we get report on how to care for them. The CNA stated that he always checks with the nurse first to see how a resident should be transferred. The CNA further stated that he would never transfer a resident without checking with the nurse first because you could do more harm than good. An interview was conducted with the DON (director of nursing), staff #64 on (MONTH) 28, (YEAR) at 9:15 a.m. The DON stated that the CNA who transferred the resident when she fell was an agency CNA but that she had been familiar with the residents. The DON stated that she thought the resident required the assistance of one person for transfers. When the resident's care plan was reviewed with the DON, the DON acknowledged that it was the assistance of two for transfers but stated that the facility usually used a mechanical lift if the resident required the assistance of two for transfers. The DON further stated that the MDS coordinator develops the care plan and then refers the information to the licensed nurse on the unit. An interview was conducted with the MDS coordinator, staff #15 on (MONTH) 28, (YEAR) at 9:30 a.m. The MDS coordinator stated that she completed the MDS and the care plan prior to the resident's fall and the resident was assessed to require two staff for transfers because of her [MEDICAL CONDITION]. The MDS coordinator further stated as far as I know she should have had two CNA's to transfer her at the time of the fall. An interview was conducted with the CNA, staff #91, who transferred the resident at the time of the fall on (MONTH) 28, (YEAR) at 10:50 a.m. The CNA stated that she worked at the facility as an agency CNA quite a few times. The CNA stated that she asked and was told that the resident was weight bearing and a one person transfer. The CNA stated that she always checked with facility staff first before she transferred a resident. The CNA stated that she did not want the resident to fall so she lowered her to the floor. The CNA stated she found out later that the resident was not feeling good that day. The CNA further stated the resident did not fall, she was an assist to sit. Another interview was conducted with the DON, staff #64 on (MONTH) 28, (YEAR) at 1:00 p.m. The DON stated that the facility did not have a specific policy regarding safe transfers but that she would expect staff to transfer residents safely and follow the care plan. A review of the facilty's policy Managing Falls and Fall Risk documented Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling .