Every finding on record at Rehab At Scottsdale Village Square

Based on observations, staff interviews, and a review of facility documentation and policies, the facility failed to properly label and store food items and maintain appropriate cleaning and sanitation practices. The universe was 103. The deficient practice increases the risk of cross-contamination and foodborne illness. Findings Include: -Regarding food storage: A kitchen observation was conducted with the Cook, staff #20, on August 11,2026 at 5:51 AM. Observation of the refrigerator revealed the following food items that were not labeled with an open date and/or use-by date and/or were not properly sealed: Waffles - No open or use-by date and the waffles were placed in a transparent plastic cover, which was left wide open and exposed to the air. Fresh cut fruit - Not properly sealed.Glenview farms white cheese slice - Not properly sealed. Hot dog bread - No use-by date.Two bags of Sweet potato - No open or use-by date and not properly sealed.Bag of French Fries - Big hole in the bag - Not properly sealed.Chicken Tenders - No open or use-by date and not properly sealed.Three Bags of onion rings - No open or use-by date and not properly sealed.Bag of hash browns - No open or use-by date and not properly sealed.Several Hamburger patties - Not properly sealed.Bag of Chicken Breasts -No open or use-by date and not properly sealed. Additionally, Staff members' personal food and beverages, including [NAME] Donut coffee, [NAME] donut strawberry & Blueberry yogurt, lemon water and plastic water bottles, were stored in the kitchen small refrigerator with resident food items, including butter, medication-pass shake and juice. - Regarding Ice Machine: During the kitchen observation with the Dietary Manager, Staff # 193, on August 14, 2026 at 8:28 AM, the interior frame of the ice machine was observed with dirt/dust buildup within the crevices, in close proximity to the ice. The exterior of the ice machine was also observed to have dirt/dust buildup. -Regarding Puree Preparation: A puree preparation observation was conducted with Dietary Cook, Staff # 218, on August 14 at 8:13 AM. Staff # 218 failed to sanitize the thermometer probe before obtaining the temperatures of the fish puree and the vegetable puree. Staff # 218 also used a measuring cup that had been placed on the preparation table without being sanitized before using the measuring cup to scoop flour from the flour container. -Regarding Tray line Observation: A tray line observation was conducted with the Lead Dietary Aide, Staff # 72, on August 12, 2026 at 10:25 AM. The Staff # 72 used the same alcohol swab to clean the thermometer probe while testing the temperatures from five food items. Staff # 72 then used another alcohol swab to clean the thermometer probe while testing the temperatures for eight additional food items rather than using a new alcohol swab to sanitize the probe between each food item.to clean the thermometer probe while testing the temperatures for 8 food items. An interview was conducted with the Director of Nursing (DON/ Staff #133) on August 11, 2026, at 7:02 AM. Staff #133 stated that, per facility policy, opened food packages must be properly sealed and labeled with a use-by date. Staff #133 further stated that staff members should not store personal food or beverages in the kitchen refrigerator, as a separate refrigerator is provided in the staff break room for this purpose. Staff #133 stated that improper food storage and the use of the kitchen refrigerator for staff food and beverages could increase the risk of foodborne illness and cross-contamination among residents. Potential effects of foodborne illness may include nausea and vomiting. Staff #133 further acknowledged that these practices did not meet her expectations and that the facility failed to follow its established policies and protocols. An interview was conducted with the Dietary Manager, Staff #193, on August 11, 2026, at 8:27 AM. Staff #193 stated that he and his assistants are responsible for monitoring food temperatures, labeling food items, and maintaining the cleanliness of the kitchen. He stated that all opened food items should be labeled with the date opened and the use-by date and should be properly sealed. He further stated that food items that are not stored properly should be discarded due to the potential risks of foodborne illness and cross-contamination. Staff #193 acknowledged that these practices were not acceptable and did not meet the facility's policies or his expectations. He further stated that staff members' personal food items should not be stored in the kitchen refrigerator, as doing so may increase the risk of cross-contamination. An interview was conducted with the Licensed Practical Nurse (LPN/ Staff #201) on August 11, 2026, at 11:54 AM. Staff #201 stated that staff members have a designated day room where they can store their personal food and beverages. She stated that it was not acceptable for staff to store personal food items in the kitchen refrigerator where residents' food items were stored, as this practice would increase the risk of cross-contamination and compromise infection control practices. Staff #201 further stated that food items that were not properly dated or sealed may pose a risk to residents and could result in gastrointestinal symptoms, including vomiting and diarrhea, as well as an increased risk of foodborne illness. An interview was conducted with the Director of Nursing, Staff #133, on August 14, 2026, at 8:40 AM. Staff #133 stated that a new alcohol swab should be used to sanitize the thermometer probe each time before obtaining food temperatures. She stated that the same alcohol swab should not be reused when checking the temperatures of multiple food items. Staff #133 further stated that using the same alcohol swab to clean the thermometer probe when taking temperatures of five to eight food items could result in cross-contamination, particularly for residents with special dietary needs or food allergies. Staff #133 further stated that a measuring cup that has not been properly sanitized should not be used to scoop flour from the flour container. She stated that if flour is handled with an unsanitized measuring cup and subsequently used to prepare puree, the puree should be discarded immediately and should not be served to the residents. Regarding the ice machine, Staff #133 stated that it should be properly cleaned and maintained. She stated that if dust or debris is observed in the crevices of the ice machine, the affected ice should be discarded. Staff #133 acknowledged that failure to properly clean and sanitize the ice machine did not meet the facility's infection control requirements and may increase the risk of cross-contamination and foodborne illness, with potential symptoms including nausea, vomiting, stomach upset, and dehydration. An interview was conducted with the Administrator, Staff #89, on August 14, 2026, at 8:58 AM. Staff #89 stated that staff members should not store personal food items in the kitchen refrigerator and should use the designated area provided for staff food storage. Staff #89 stated that storing staff members' personal food in the kitchen refrigerator could increase the risk of cross-contamination and did not meet the facility's expectations. Staff #89 further stated that all food items should be stored properly and labeled with the date opened and the use-by date. Failure to properly date and store food items could increase the risk of foodborne illness and residents becoming ill and does not meet facility policy or expectations. Regarding thermometer probes, Staff #89 stated that the probe should be properly cleaned and sanitized after each use. Staff #89 stated that using the same alcohol swab to clean the thermometer probe while obtaining temperatures from five to eight food items is not an acceptable practice, as it could result in cross-contamination and increase the risk of residents becoming ill. Staff #89 acknowledged that this practice does not meet facility policy or expectations. Staff #89 also stated that the ice machine should be cleaned in a timely and appropriate manner. Staff #89 stated that serving ice contaminated with dust or debris could cause gastrointestinal upset among residents. Regarding puree preparation, Staff #89 stated that the measuring cup should be properly sanitized before being used to scoop flour from the flour container. Staff #89 stated that failure to sanitize the measuring cup could increase the risk of foodborne illness and residents becoming ill, with potential symptoms including diarrhea, vomiting, and nausea. Staff #89 acknowledged that these practices did not meet facility policy or expectations.An interview was conducted with the Assistant Director of Nursing/Infection Preventionist, Staff #121, on August 14, 2026, at 9:58 AM. Staff #121 stated that failure to properly clean and sanitize the thermometer before and after each use could result in infection and bacterial growth. Staff #121 confirmed that an improperly cleaned thermometer could transfer bacteria, viruses, allergens, or other contaminants from one food item to another. Staff #121 stated that the thermometer should be cleaned and sanitized before obtaining the temperature of each food item and that using the same alcohol swab for five to eight different food items was not an acceptable practice. Staff #121 further stated that reusing a container that had been placed on a preparation table without being properly sanitized to scoop flour creates a significant risk of cross-contamination. Serving cross-contaminated food to residents could expose them to bacteria, allergens, or other contaminants and potentially result in illness or an allergic reaction. Staff #121 acknowledged that these practices were not acceptable and did not meet the facility's expectations or policies. Staff #121 further stated that an in-service would be provided to address these concerns. Regarding the ice machine, Staff #121 stated that dust or debris present in the ice machine or its crevices could contaminate the ice and increase the risk of illness or gastrointestinal upset if the ice were served to residents. Review of the facility's policy titled General Food Preparation & Handling revealed that food must be properly covered during storage and cooked as soon as possible after thawing. The policy further required food contained in broken packages, swollen or dented cans, cans with compromised seals, or food exhibiting an abnormal appearance or odor to be discarded. Additionally, all food service equipment must be properly cleaned, sanitized, air-dried, and reassembled after each use to ensure appropriate food safety and sanitation practices are maintained. Review of the facility's policy titled Food Temperatures revealed that a dial-face, metal probe-type thermometer must be washed, rinsed, and sanitized using an alcohol wipe. The policy further required that the thermometer be re-sanitized after each use. Review of the facility's policy titled Food safety & storage revealed that opened or repackaged food must be labelled with contents and use-by-date.

Based on clinical record review, staff interviews, and review of the facility policy and procedures, the facility failed to ensure that 1 out of 23 sampled residents (Resident # 64)'s blood pressure medication was administered per physician's orders. The universe was 103 residents. The deficient practice could result in uncontrolled blood pressure. Findings include: -Regarding administering midodrine outside of parameters.Resident #64 was admitted on [DATE], with diagnoses that include vascular dementia with other behavioral disturbances, schizoaffective disorder bipolar type, and age-related osteoporosis without current pathological fracture.A physician's order initiated on April 22, 2026, revealed an order for Midodrine Hydrochloride (HCL) Tablet, a medication used to treat low blood pressure (hypotension), 2.5 milligrams (MG), one tablet by mouth 2 times a day for dizziness with instructions to administer the medication for systolic blood pressure less than 100 and to hold the medication for systolic blood pressure greater than 130. The order was discontinued on June 8, 2026. A physician's order initiated on June 8, 2026, revealed an order for Midodrine HCL Tablet 2.5 MG, one tablet by mouth two times a day for hypotension with instructions to hold for systolic blood pressure of 130 and greater. The June 2026 Medical Administration Record (MAR) revealed that the Midodrine was marked as administered on following dates:June 5, 2026 at 8:00 p.m., with a blood pressure of 139/77June 18, 2026 at 8:00 p.m., with a blood pressure of 130/76The July 2026 MAR revealed that Midodrine was marked administered on July 16, 2026 at 8:00 p.m. with a blood pressure of 135/88.-Regarding not administering Midodrine within parameters.A physician's order initiated on June 8, 2026 at 11:45 a.m. revealed an order for Midodrine HCL Tablet 5 MG one tablet by mouth every 12 hours as needed for dizziness given for systolic blood pressure below 110 and hold for systolic blood pressure greater than 130. Further review of the order revealed it was discontinued on June 8, 2026 at 12:07 p.m. An order initiated on June 8, 2026 at 12:15 p.m. for Midodrine HCL Tablet 5 mg one tablet by mouth every 12 hours as needed for hypotension, give for systolic blood pressure less than 110.The June 2026 Blood Pressure Summary revealed the resident had the following blood pressure readings below 110: June 9, 2026 at 6:54 a.m. 96/69June 10, 2026 at 8:15 a.m. 102/58June 11, 2026 at 7:46 a.m. 104/60, 7:09 p.m. 106/71June 12, 2026 at 7:43 a.m. 102/72, 7:55 a.m. 109/72June 13, 2026 at 8:01 a.m. 106/78, 8:47 a.m. 106/78June 14, 2026 at 7:29 a.m. 108/61, 8:17 a.m. 103/61June 16, 2026 at 7:38 a.m. 106/58June 19, 2026 at 6:51 p.m. 106/60June 20, 2026 at 8:32 a.m. 108/60,6:13 p.m. 102/64June 21, 2026 at 7:33 a.m. 106/63, 1:07 p.m. 106/63June 22, 2026 at 8:13 a.m. 104/64, 10:34 a.m. 104/64, 6:39 p.m. 102/75June 24, 2026 at 7:51 a.m. 96/58, 8:37 a.m. 96/58, 8:12 p.m. 108/90 June 25, 2026 at 8:27 a.m. 108/78, 8:46 a.m. 108/78June 26, 2026 at 8:21 a.m. 98/62, 6:22 p.m. 103/66June 27, 2026 at 9:15 a.m. 104/66June 28, 2026 at 7:15 a.m. 100/60, 8:33 a.m. 100/60, 7:05 p.m. 96/57June 29, 2026 at 7:55 a.m. 105/58 June 30, 2026 at 6:49 p.m. 99/59 Review of the June 2026 MAR revealed that the Midodrine HCL 5 MG tablet was not administered in the month of June despite several systolic blood pressure readings below 110 over several days. Review of the July 2026 Blood Pressure Summary revealed the following blood pressures readings below 110:July 1, 2026 at 6:49 a.m. 103/61, 9:59 p.m. 96/55July 3, 2026 at 8:03 a.m. 108/64July 5, 2026 at 9:04 a.m. 106/62, 10:14 a.m. 98/56, 2:08 p.m. 109/62, 5:26 p.m. 103/68July 6, 2026 at 7:15 p.m. 108/65July 7, 2026 at 6:52 a.m. 102/71 July 8, 2026 at 6:34 a.m. 102/74, 7:19 p.m. 105/64July 9, 2026 at 8:09 a.m. 96/64, 9:46 a.m. 96/64July 10, 2026 at 7:48 a.m. 108/64, 8:34 a.m. 108/64, 5:58 p.m. 102/78, 5:59 p.m. 104/63July 11, 2026 at 8:07 a.m. 102/64, 9:16 a.m. 102/64July 12, 2026 at 8:16 a.m. 101/59, 1:59 p.m. 101/59, 7:04 p.m. 108/75July 13, 2026 at 1:15 p.m. 109/69July 14, 2026 at 7:36 a.m. 100/60, 6:48 p.m. 101/59July 15, 2026 at 9:01 a.m. 106/66, 9:39 a.m. 106/66 July 17, 2026 at 8:07 a.m. 90/60, 7:28 p.m. 104/71July 19, 2026 at 7:36 a.m. 105/88, 9:14 a.m. 105/68July 20, 2026 at 12:25 p.m. 107/57, 3:23 p.m. 107/70, 6:44 p.m. 107/66July 22, 2026 at 6:47 a.m. 102/76July 25, 2026 at 8:58 a.m. 107/66July 26, 2026 at 7:55 a.m. 106/65, 8:39 a.m. 106/65, 6:41 p.m. 106/75July 27, 2026 at 7:11 a.m. 106/65, 7:06 p.m. 106/76July 28, 2026 at 6:28 p.m. 109/70July 30, 2026 at 8:11 a.m. 102/67, 10:00 a.m. 104/68, 6:47 p.m. 95/63Review of the July 2026 Medical Administration Record (MAR) revealed that the Midodrine 5 mg was marked administered only on July 10, 2026 at 5:59 p.m. for blood pressure listed at 104/63. The MAR revealed that the PRN administration was effective even though the follow up blood pressures taken on July 11, 2026 at 8:07 a.m. revealed a blood pressure of 102/64, below the indicated 110 systolic blood pressure. The August 2026 Blood Pressure Summary revealed the following blood pressures readings below 110: August 1, 2026 at 8:40 a.m.- 101/68, 9:10 a.m.- 101/58, 6:11 p.m. 95/63 August 2, 2026 at 6:09 a.m.- 99/62, 7:18 p.m.- 91/54 August 3, 2026 at 7:11 a.m.- 92/53, 6:27 p.m.- 90/60August 4, 2026 at 6:42 a.m.- 96/66August 5, 2026 at 7:27 p.m.- 108/60August 7, 2026 at 8:26 a.m.- 96/58August 9, 2026 at 8:31 a.m. - 105/69, 1:54 p.m.- 105/69, 7:02 p.m.- 78/44, 8:00 p.m.- 97/56August 10, 2026 at 5:33 a.m.- 102/63, 6:54 a.m.- 100/59, 6:09 p.m.- 109/68August 11, 2026 at 6:35 a.m.- 100/64 August 12, 2026 at 6:28 a.m.- 100/60, 6:41 a.m.- 107/65The August 2026 Medical Administration Record (MAR) revealed that the Midodrine 5 mg was marked administered only on August 9, 2026 at 10:34 p.m. for blood pressure 102/63. The MAR revealed that the PRN administration was effective even though the follow up blood pressures taken on August 10, 2026 revealed a blood pressure of 102/63 at 5:33 a.m. and 100/69 at 1:54 p.m., below the indicated 110 systolic blood pressure. Further review of the medical administration record, progress notes, and vitals for June through August 2026 revealed no other administration of the Midodrine 5 mg despite several systolic blood pressure readings were below 110. The clinical record revealed no indication the physician had been contacted with the low systolic blood pressure readings or the medication was every put-on hold. An interview was conducted with Licensed Practical Nurse (LPN\Staff #81) on August 14, 2026 at 8:43 a.m. Staff #81 reviewed the scheduled order for Midodrine 2.5 mg and stated that the Midodrine was used for low blood pressure. Staff #81 stated that if the systolic blood pressure was at or over 130, the medication was not to be administered and the physician would be notified. Staff #81 further stated that giving Midodrine for systolic blood pressure above 130 could raise resident's blood pressure too high. Staff #81 reviewed the order for 5 mg of Midodrine every 12 hours as needed for hypotension, administer if systolic is below 110. Staff #81 stated that she would only give that medication if the resident was not feeling well and if the vitals show the systolic blood pressure below 110 then she would administer the 5 MG. Staff #81 then stated that if the Resident's systolic blood pressure was below 110 during the scheduled administration of the 2.5 MG, she would wait an hour or so retake if still below 110 then would administer the 5 mg of Midodrine.An interview was conducted on August 14, 2026 at 10:18 a.m. with the Medical Director (MD\Staff # 85) who stated that the midodrine was used for low blood pressure and the goal of the medication was to raise the systolic blood pressure and prevent the resident from becoming dizzy and falling. Staff #85 stated that the scheduled midodrine should not be administered when the resident's systolic blood pressure was at or above 130 because the medication could raise the resident's blood pressure too much. Staff #85 stated that his expectation was for staff to hold the medication and notify him if the systolic blood pressure was above 130. Staff # 85 stated that the PRN Midodrine 5 mg was ordered to be administered if the systolic blood pressure is below 110. Staff #85 stated that if the systolic blood pressure was below 110 at the time of the scheduled 2.5 mg dose, then staff should administer the 2.5 mg first, wait an hour or so and retake blood pressure to see if it was elevated above 110, if not then his expectation was to be notified and the 5 mg would be administered. Review of the PRN 5 MG midodrine order revealed that the medication was to be administered when systolic is below 110 for hypotension. Further review revealed no instruction to call physician prior to administration. An interview was conducted with the Director of Nursing (DON\Staff # 133) on August 14, 2026 at 11:57 a.m. who stated that medications, including midodrine, were expected to be administered within the parameters established by the physician. Staff #133 stated that is a blood pressure reading was outside of the ordered parameters, the nurse should recheck the blood pressure and, if available, have another nurse verify the reading. Staff #133 reviewed the MAR for the scheduled Midodrine 2.5 mg and stated that the medication should be administered as long as the resident's systolic blood pressure was below 130. Staff # 133 reviewed the dates when the resident's systolic blood pressure was at or above 130 and was asked whether additional blood pressure readings were available to support administration of the medication. Staff # 133 was unable to provide documentation of additional blood pressure readings that supported the identified medication administrations.Staff #133 then reviewed the PRN 5 MG order and stated that medication was to be administered when the Resident's systolic blood pressure was below 110. Staff #133 reviewed the July MAR for the administration of the 2.5 MG scheduled Midodrine and the listed blood pressures where the systolic blood pressure was below 110. Staff #133 stated that the PRN order was not to be administered when the 2.5 MG Midodrine was administered. Staff #133 could not show that in the PRN order for the Midodrine but stated that was the MD's wishes. Staff # 85 was contacted by Staff #133 and it was stated by the MD (staff #85) that his expectation for Midodrine orders was if the systolic blood pressure was below 110 while administering the scheduled 2.5 Midodrine medication staff should wait an hour retake the medication if still below 110 then contact the MD to decide on the administration of the 5 mg of Midodrine. Staff #133 reviewed the blood pressures and stated that the staff did not do 1 hour follow up blood pressure checks because the MD did not write that in the order to be completed. A Policy and Procedure, titled Medication Utilization and Prescribing, revised April 2108, revealed that the physician and staff will evaluate the rationale for existing medications that lack a clear indication or are being used intermittently on a PRN basis. A Policy and Procedure, titled Medication and Treatment Orders, revised July 2016, revealed that orders for medications and treatments will be consistent with principles of safe and effective order writing. The policy revealed that medications shall be administered only up the written order of a person duly licensed and authorized to prescribe such medications in the state. Orders for medications must include and interim follow-up requirements.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure wound was monitored and treated for 1 of 3 residents sampled for wound care (Resident #1). The deficient practice resulted in the development of maggots in the wound bed. Findings include: Resident #1 was admitted on [DATE], with diagnoses that included unspecified dementia, type 2 diabetes mellitus, essential hypertension, peripheral vascular disease, and diabetic neuropathy. A comprehensive care plan dated February 12, 2025, revealed that Resident #1 has peripheral vascular disease (PVD) related to diabetes mellitus. Interventions included monitoring, documenting, and reporting as needed any signs or symptoms of skin problems related to PVD including redness, edema, blistering, cuts, and other skin lesions. Further review of the interventions for the diabetes mellitus documented to monitoring, documenting, reporting as needed any signs or symptoms of infection to any open areas, including redness, pain, heat, swelling, or pus formation. A physician's order dated January 15, 2026 revealed that staff were to monitor a corn on right foot pinky toe and to report any signs or symptoms of infection to MD. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 3, indicating that the resident had sever cognitive impairment. The MDS assessment revealed no indication of wounds including foot problems such as infection of the foot, diabetic foot ulcers, and other open lesions on the foot. The CNA (certified nurse assistant) skin inspection reports dated April 24 and 28, 2026 included skin was good. The documentation did not include any skin issues. The nursing note dated April 29, 2026 included resident will be monitored for skin irritation, redness, or adverse reaction. Review of skin assessment dated [DATE] documented no new skin issues and feet were dry. A physician order dated May 3, 2026 included for a wound consult and treatment with skilled wound care surgical group until wounds are resolved. An alert note dated May 5, 2026, documented a new physician order to cleanse and apply xeroform and secure with dry sterile dressing. A alert note dated May 5, 2026, documented by Licensed Practical Nurse (LPN/Staff #143) revealed that a CNA notified the LPN (Staff #143) of an old saturated dressing on the right foot; and that, the bandage was removed and noted an open area with serosanguinous drainage to the right outer foot. The nurse documented that it was painful to the touch and the skin surrounding the wound was peeling. The note also documented that the dressing was changed and power of attorney, doctor, Assistant Director of Nursing were notified. However, there was no documentation found in the clinical record that the resident had physician orders for or was receiving treatment to the right foot wound prior to or on May 5, 2026. The IDT (interdisciplinary team) note dated May 5, 2025 included a plan to continue with wound treatments and wound team consult. A skin assessment dated [DATE] revealed a new skin finding to the right outer foot. The skin assessment documented that the right outer foot was noted with an old saturated dressing, indicating the wound was not new. A nurses noted dated May 6, 2026, by LPN/Staff #141, who documented that during cares a CNA notified the writer that the wound dressing to right foot was saturated form the drainage. The nurse documented that upon removing the dressing from the right foot, 5-10 white active larvae were observed in the wound bed. The nurses note revealed that larvae were removed via irrigation with normal saline, wound bed was cleansed and area around wound was cleaned. A physician orders dated May 6, 2026 included the following:Cleanse the right foot wound with normal Saline or Wound cleanser, pat dry, apply calcium alginate and cover with dry dressing and change daily and PRN (as needed) for dislodged or saturated dressing; and,Cleanse wound with betadine, apply xeroform and DSD (dry sterile dressing) and change daily and PRN every day shift for wound care. The order did not include the location of the wound to which this treatment was to be applied.These orders was transcribed onto the TAR (treatment administration record) for May 2026 and revealed the following:The PRN order for calcium alginate to right foot was not marked as administered as ordered on May 6 and the order was documented as discontinued on May 7, 2026; and,The order for xeroform and DSD was documented as administered and discontinued on May 6. The CNA skin inspection report dated May 8, 2026 revealed wound on the lower front and back of right foot. A wound care surgical note dated May 8, 2026 revealed that the would was located on the small toe, lateral area of right foot with an open area measuring 4.5 cm (centimeters) x 3 cm x 0.1 cm. A CNA skin inspection report with eligible date of May 8 or 18, 2026 included corn wrapped. Review of the TAR (treatment administration record) for May 2026 included that the physician order to monitor corn on the right foot pinky toe was transcribed and was documented as administered from May 1 through 17, 2026. A telephonic interview was conducted on May 18, 2026 at 3:52 p.m. with LPN (Staff #141) who stated that on the night of May 6 he was notified by a CNA that the resident's (#1) bandages were soaked and needed to be changed. Staff #141 stated upon removing the bandages he noted some abnormal findings including larvae in the wound bed and on the bandage. Staff #141 stated that they had been monitoring the corn on the right foot but not sure how the wound on the right foot started or when it started. Staff # 141 stated he cleaned out the wound with saline and rewrapped the wound and notified his manager and doctor. An interview was conducted on May 19, 2026 at 9:41 a.m. with LPN (Staff #143), who stated that when she arrived to work on May 5, 2026 and she was surprised and upset to see a bandage on Resident #1's right lateral foot. Staff #143 stated she was upset seeing the bandage on the right foot because there was no documentation regarding what happened to the foot and what treatment had been done besides just the bandage. Staff #143 stated that she knew the bandage was not there on May 1, 2026 during her shift because she had done a skin assessment and there was no bandage or wound on the right foot. Staff #143 stated that when she removed the bandage she saw the circular wound but not maggots. Staff #143 stated the the concern for not reporting wounds initially is they don't get properly monitored and infection could occur. An interview was conducted on May 19, 2026 with CNA (Staff #99), who stated that she was off of work for a while and when she came back to work about 2-3 weeks ago, she could not remember the exact date, she noticed blood on Resident #1's right lateral foot. Staff #99 reported there was a fair amount of blood and she had notified Registered Nurse (RN/Staff #205) who bandaged the foot. A request for information regarding Staff #205 revealed that staff #205 was terminated on May 2, 2026 for not completing a two week notice. An interview was conducted on May 19, 2026 with Director of Nursing (DON/Staff #159) stated that it is her expectation that any new wounds should be documented into PCC and a skin assessment done along with contacting the DON as well as the physician. The DON stated that Resident #1 had a corn on her right lateral foot in which they were monitoring and at some point it fell off causing the bleeding. She stated once that she was made aware of the wound the wound doctor was notified and Resident #1 was seen by the wound doctor on May 8, 2026. DON reviewed nursing note from Staff #141 and stated that Staff #141 is not a wound nurse and is unable to diagnosis larvae in a wound. The DON stated the concern that a new wound not documented when discovered could lead to improper or delayed treatment and infections. A policy titled, Wound Care revised October 2010, included a purpose to provide guidelines for the care of wounds to promote healing; and, to verify that there is a physician order for wound care. It also revealed that any wound care should be documented in the resident's medical record, with information that includes the type of wound care given, the date and time the wound care was given, the name and title of the individual providing wound care, any changes in the resident condition, all assessment data obtained when inspecting the wound and the signature and title of the person recording the data. The policy revealed that reporting of any changes to wounds must be done in accordance with facility policy and professional standards of practice.

Based on staff interviews, review of clinical record and policy review, the facility failed to protect the rights of 2 of 6 residents sampled (#2, #3) to be free from physical and verbal abuse between residents. The deficient practice could result in resident injury, psychological, or behavioral harm as well as continued resident to resident abuse. Findings include: Regarding Resident #2: -Resident # 2, the alleged victim, was admitted [DATE] with diagnoses that included paraplegia, schizoaffective disorder, and major depressive disorder. Review of physician orders dated May 4, 2026 revealed behavioral tracking to monitor behaviors including threatening others, screaming, yelling, cursing, name calling, sexually inappropriate comments, racial slurs, and abrasive tone. A nurses note dated May 6, 2026 documented that Resident #2 received physical aggression by another resident. The note revealed that nursing staff observed Resident #2 and Resident #3 having a verbal altercation. The nurses noted revealed that Resident #2 claimed he was punched in the chest by Resident #3. The note documented that he claimed there was a little 'sting' from the punch but denied any serious pain. Regarding Resident #3: -Resident # 3, the alleged perpetrator, was admitted [DATE] with diagnoses that included adjustment disorder, major depressive disorder, mood disorder, and anxiety disorder. A comprehensive care plan dated March 24, 2025 revealed that during discharge planning at times Resident #3 expresses that he does not need to be placed in a secured facility and denies history of behaviors. Further review of the care plan revealed that Resident #3 has a long history of documented behaviors and placement in behavioral facilities. A behavioral care plan dated April 15, 2026 documented that Resident #3's triggers included assistance from staff and cigarettes. The behavioral care plan revealed the current behaviors for Resident #3 as medication seeking behavior, obtaining contraband, cheeking medications, refusal of care and treatments, and agitation if does not get to smoke. Interventions include staff responding with calm understanding, acknowledging frustrations and avoid arguing about rules; instead redirect and support coping strategies. A quarterly MDS assessment dated [DATE] revealed a BIMS score of 15 indicating he is cognitively intact. The MDS assessment revealed that Resident # 3 has a history of rejecting cares. A Nurses Note dated May 6, 2026 reveal that Resident #3 initiated physical aggression towards resident #2. The nurses note documented that Resident #3 was observed having a verbal altercation with Resident #2 by nursing staff. The nurse's note revealed that Resident #3 stated there were no problems and residents were separated with 15 minute checks.6 A Social Services note dated May 6, 2026 revealed that Resident #3 was moved from room [ROOM NUMBER]A to room [ROOM NUMBER]. An IDT Note dated May 6, 2026, documented that Resident #3 claimed he did not touch Resident #2 and no injuries were noted. The IDT note documented that Resident #3 was moved off from Arbor unit and changed to a more secured unit as an intervention. A nursing note dated May 7, 2026 revealed that Resident #3 was having verbal behaviors toward floor nurse requesting pain medications prior to scheduled administration time. The nurse note also revealed that upon being informed medications would be administered only as a ordered, the resident became verbally agitated and argumentative with nursing staff. A facility investigation report, undated, revealed a witness statement dated May 6, 2026 from Certified Nursing Assistant (CNA, Staff #25) who documented that Staff # 25 was working on the unit around 9:20 p.m. when she saw Resident #3 and Resident #2 arguing with each other and cursing at each other. The witness revealed that Resident #3 was the one who started the verbal altercation using the 'N' word at Resident #2. The facility report did not provide any conclusions to their investigation, however they did provide interventions including Resident #3 being moved to a different unit to prevent further altercations. An interview was conducted with Resident #2 on May 18, 2026 at 3:13 p.m. who stated that Resident #3 was his roommate and during the day while they were in the room together, before smoke break, Resident #3 hits Resident #2 in the chest for not giving Resident #3 money. Resident #2 stated that Resident #3 kept calling me 'nigger' and 'punk'. Resident #3 stated that the physical punch did not hurt him but he was hurt and angry by the racial slurs. An interview was conducted with Resident #3 on May 18, 2026 at 3:31 p.m. who stated that he never had any problems with any residents. Resident #3 stated he has never fought or swore at any other residents while here at the facility. An interview was conducted with Assistant Director of Nursing (ADON/Staff # 155) who stated that a verbal altercation was witnessed by staff between Resident #2 and Resident #3. Staff #155 stated that she heard Resident #2 tell a nurse that Resident #3 had hit him in the chest and if Resident #3 is not moved Resident #2 will break Resident #3's neck. Staff #155 stated that Resident #3 was known for verbally antagonizing and saying degrading things to staff and residents. Staff #155 stated it was determined to move Resident #3 to the 600 hall where he could be monitored more closely. Staff #155 stated abuse can be physical and verbal and verbal abuse can be anything that is demeaning, derogatory, or threatening to another person. Staff #155 stated racial slurs at another resident would be considered abuse. An interview was conducted with Director of Nursing (DON/Staff #159) on May 19, 2026 at 11:28 p.m. stated that Resident #2 was in the same room as Resident #3 and they were not able to determine if the punch was thrown or who started what but placed interventions on Resident #3 by moving him into the 600 because we had the room in there. The DON stated that racial slurs and putting someone down is considered verbal abuse and the concern would be verbal usually leads to physical harm. A policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Revised April 2021, revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy also revealed that it includes physical and verbal abuse.

Based on staff interviews, review of clinical record and policy review, the facility failed to protect the rights of 10 of 11 residents sampled (#1, #2, #3, #4, #6, #7, #8, #9, #10, and #11) to be free from physical and verbal abuse between residents. The deficient practice could result in resident injury, psychological, or behavioral harm as well as continued resident to resident abuse.Findings include:Regarding Resident #1 and Resident #2:-Resident # 1, the alleged victim, was admitted [DATE], with diagnoses that included unspecified dementia, mood disorder due to known physiological condition with manic features, and alcohol dependence. The care plan initiated on October 8, 2025 revealed the resident had behaviors of yelling, exit seeking, wandering and delusional thinking, a history of going into other resident's rooms and wandering about the unit. Interventions included redirection and to avoid reacting to Resident if she engages in yelling or any signs of verbal aggression. A behavioral care plan dated April 2, 2026 revealed that Resident #1's known behaviors are mood swings, yelling, refusing care, anxiety, and worry. The Behavioral care plan also revealed that her triggers are missing family when she thinks she is alone on the unit. Interventions included approaching resident with patience and reassurance, using a calm voice and gentle tones, avoid confrontation or insisting on compliance when resident refuses care, and acknowledge resident's feelings.A Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 3, indicating that the resident had severe cognitive impairment. A nurse's note dated April 13, 2026, revealed that a Certified Nursing Assistant (CNA) notified the Nurse that Resident #1's face was grabbed at the lip by Resident #2 when Resident # 1 was getting up to move away. The note revealed the residents were placed on 15-minute safety checks and closely monitored. A skin assessment dated [DATE] revealed no new wounds since last documented skin check.-Resident # 2, the alleged perpetrator, was admitted on [DATE], with diagnosis that included personality disorder, anxiety disorder, adjustment disorder, and depression.The care plan revised on August 13, 2025, revealed the resident had behaviors consisting of placing herself on the floor, refusing care and medications, making false accusations, fabricating stories, going into other resident's rooms and breaking personal item. Interventions included allowing the resident time, encouragement to verbalize concerns, administering medications, education, explanation of why behavior is inappropriate, and checking for safety and comfort.Review of the quarterly MDS dated [DATE], revealed the resident had a BIMS score of 13, indicating the resident was cognitively intact. The quarterly MDS also revealed behaviors including rejection of care and other behavioral symptoms not directed towards others.A behavioral care plan dated February 13, 2026, revealed current behaviors as verbal aggression, nicotine impulsivity, and refusing cares. Further review of the behavioral care plan revealed triggers of being easily agitated with staff. Interventions included staff setting firm boundaries, providing a written schedule for smoke times, and educating the resident about taking medications as a scheduled for full, positive effect.A behavior note dated March 15, 2026, revealed that the resident became upset because staff have to continuously check her blood sugar. The behavior note documented the resident threw her whole meal out of her room causing the plates to break.A nurse's note dated April 13, 2026 revealed that a CNA reported to the nurse that Resident #2 grabbed Resident #1's face by her mouth while Resident # 1 was trying to move away from her. The nurses note documented that Resident #2 stated 'Yeah I grabbed her by the face. I don't like her!' A Psychiatry follow up note dated April 14, 2026 revealed that Resident # 2 provided a coherent account of the event. The psychiatry note revealed that Resident #2 claimed Resident #1 called her a 'filthy name' and Resident #2 reacted by grabbing Resident #1 because Resident #2 felt threatened when Resident #1 stood up. The facility investigation report, undated, documented an eyewitness statement from Certified Nursing Assistant (CNA/Staff # 81) dated April 13, 2026, revealed that Staff # 81 witnessed a verbal altercation between Resident # 1 and Resident # 2 over a pitcher of water. The statement documented that Resident # 1 angrily got up yelling obscenities at Resident #2, as Resident # 1 was getting up Resident # 2 grabbed Resident #1 by her mouth. The statement revealed that Staff #81 got in between both Residents before Resident # 1 retaliated. The facility investigation documented that the facility substantiated the allegation and found that Resident # 2 gets highly agitated when asked questions and if someone gets close to her. The facility investigation also revealed that Resident # 2 is verbally aggressive, which normally results in physical altercations.An interview with CNA (Staff # 67) was conducted on May 1, 2026 at 9:43 a.m. who stated that Resident #1 is very confused and forgetful but can easily be redirected while Resident #2 keeps to herself. Staff # 67 stated that Resident # 2 gets mad easily especially when Resident # 2 does not get her way. Staff #67 stated that Resident #2 gets possessive with belongings and food and gets mad if other residents touch them. Staff # 67 stated that after the incident between Resident # 1 and Resident # 2, the staff has to keep eyes on Resident # 1 when she is out in the courtyard to try and prevent her from getting close to Resident # 2. Staff # 67 stated that they do get training almost monthly on abuse training.An interview with CNA (Staff # 115) was conducted on May 1, 2026 at 9:45 a.m. Staff # 115 stated that Resident # 2 exhibits behaviors when other residents or staff make her mad. Staff # 115 revealed that Staff # 1 wanders around a lot especially into other resident's rooms. Staff # 115 stated that Resident # 1 likes to go into Resident # 2's room because there used to be another Resident who lived in that room who was sick and Resident # 1 would check on that resident when she wandered the courtyard. CNA # 115 revealed that since this last incident between Resident #1 and Resident #2 the staff now have to keep eyes on Resident #1 to prevent her wandering to Resident #2's room. Staff #115 stated that they usually get information regarding resident's care plan and changes of care during shift change. Staff # 115 also stated that they have access to the care plans in a binder that the CNA's can now access.An interview with Director of Nursing (DON/Staff # 199) on May 1, 2026 at 10:10 a.m. who stated that during her investigation she found out that Resident # 1 and Resident # 2 had an argument and as Resident #1 was trying to get up to leave, Resident # 2 grabbed Resident # 1 by the face. Staff # 199 stated that this is the second altercation between these two residents and she they added the 1:1 for Resident # 1 when in the courtyard to help prevent further altercations. Staff # 199 stated that her expectation is staff be proactive and identify potential aggression before it happens. Staff # 199 stated that the risk for not being proactive is that residents abuse other residents.Regarding Resident #3 and Resident #4: -Resident #3, the alleged victim, was admitted on [DATE], with diagnoses Schizophrenia, bipolar disorder, borderline personality disorder, and suicidal ideations.The behavior care plan dated March 13, 2026 revealed current behaviors which included mood swings, abusive tone, intrusive behaviors and manipulative medication seeking. Interventions included approaching resident with warm patience and reassurance, acknowledging her need for attention or interaction while kindly redirecting her to an appropriate activity, and responding to resident consistently, professionally, and with clear boundaries when resident manipulatively seeks medication.The quarterly MDS assessment dated [DATE] revealed the resident had a BIMS score of 15, indicating the Resident was cognitively intact. The quarterly MDS also revealed mood of feeling down, depressed, and sometimes isolated. The quarterly MDS revealed behaviors other behavioral symptoms not directed towards others.A nurse's note dated April 13, 2026 revealed that Resident # 3 was yelling and screaming for CNA # 27. The note also revealed that the staff in the 500 unit were alerted by her screams and sent CNA # 76 to the 600 wing to investigate. The nurse's note revealed that CNA # 76 entered and saw Resident # 3 in her wheelchair at the entrance of her room while Resident # 4 was striking Resident # 3 on the left side of her face. The nurse's note revealed that Resident # 3 stated to CNA # 76 that Resident # 4 entered her room and began hitting her on the left side of the face and ear while Resident #3 was trying to block the hits. A skin assessment dated [DATE] revealed no new skin issues observed.The care plan revised on April 14, 2026, revealed that Resident #3 had behavioral problems related to false allegations and attempts to 'split' staff. Interventions included anticipating and meeting the resident's needs, monitoring behavior episodes and attempt to determine underlying cause, and administering medications. -Resident # 4, the alleged perpetrator, was admitted on [DATE], with diagnoses that included Huntington's disease, schizoaffective disorder, and personal history of traumatic brain disorder. The care plan initiated on March 23, 2026, revealed that Resident # 4 had a potential to be physically aggressive related to poor impulse control and a history of aggressive behaviors toward others. Interventions included intervening when resident becomes agitated, asses and anticipate resident's needs, and administration of medication.The admission MDS assessment dated [DATE], revealed a BIMS score of 7, indicating that the resident had severe cognitive impairment. The admission MDS also revealed behaviors other behavioral symptoms not directed towards others. The behavioral care plan dated March 27, 2026, revealed current behaviors such as impulsive, poor safety awareness and unsafe transfers, physical aggression which include combative striking out at staff. Interventions included maintaining a structural routine, provide close supervision and anticipated needs, and approach resident calmly and give him space pausing care if aggression gets worse.A nurse's note dated April 13, 2026, revealed that CNA # 76 reported that Resident # 4 was in another Resident's room and was hitting Resident #3.A Psychiatry note dated April 14, 2026 revealed that Resident #4 was seen following the altercation with Resident #3. The note revealed that Resident #4 was put on 1:1 supervision for safety. The note also revealed that Resident #4's behavior was consistent with known history of significant aggression and inability to comprehend or reason through social interactions. The facility investigation, undated, documented that their investigation found that it was the first altercation for Resident #4 but would place him on a 1:1 to prevent future altercations with this resident. The facility did not substantiate allegation of abuse due to Resident #4's cognition. An interview was conducted on April 30, 2026 at 2:27 p.m. with Staff # 76 who stated that she was in another unit when she heard Resident #3 yelling through the walls. Staff # 76 stated she waited a minute because it is not uncommon for Resident # 3 to yell but since it continued, she was sent over to the 600 unit to see what was going on. Staff # 76 stated that when she got into the 600 hall Staff # 27 was not in the unit but giving a smoke break to another resident. Staff # 76 stated that when she entered Resident # 3's room, Resident # 3 was yelling at Resident # 4 while blocking her face and Resident # 4 was swinging at her, while she was trying to remove Resident # 4 from the situation. Staff # 27 arrived and helped deescalate the situation while Staff#76 got Resident # 4 to his room. An interview was conducted on May 1, 2026 at 9:10 a.m. with Licensed Practical Nurse (LPN/Staff # 161) who stated that Resident # 3's behaviors included being verbally manipulative, and narcissistic. Staff # 161 stated that Resident # 4 is very physical with his aggression and anything can trigger him. Staff # 161 stated that Resident # 4 had been physical with staff since his admission and that anything can trigger the aggression. Staff # 161 stated that the sitter that had been assigned to him had helped keep him under control, but since she has to cover both 500 and 600 wings, she can't be in both places at once. An interview with Director of Nursing (DON/Staff # 199) on May 1, 2026 at 10:10 a.m. who stated that their investigation determined that Resident # 4 was witnessed by staff in Resident # 3's room swinging at Resident # 3. Staff # 199 stated that due to history of Resident # 4's aggression they have placed him on a 1:1 to help avoid further altercations with other residents. Staff # 199 stated that her expectation is staff be proactive and identify potential aggression before it happens. Staff # 199 stated that the risk for not being proactive is that residents abuse other residents. Regarding Resident # 6 and Resident # 7:-Resident # 6, the alleged victim, was admitted on [DATE] with diagnoses of bipolar disorder, anxiety disorder, major depressive disorder, and post-traumatic stress disorder. The admission MDS dated [DATE], revealed the resident had a BIMS score of 4, indicating that the resident had severe cognitive impairment. The admission MDS revealed mood of feeling down and depressed and sometimes isolated. The admission MDS also revealed behaviors including rejection of evaluation of care and other behavioral symptoms not directed towards others.The Behavioral care plan dated April 15, 2026 revealed current behaviors such as adjusting to skilled nursing facility and blocking entrances to doorways. The behavioral care plan did not indicate any known triggers. Interventions included providing consistent reassurance, orient resident to his surroundings, and providing an alternative place resident can stand as to not block doorways.A nursing note dated April 18, 2026 revealed that Resident # 6 was hit on his left calf by Resident # 7. The nursing note further revealed that the residents were separated and Resident # 6 was assessed for any injuries. The nurses not revealed no injuries were discovered.A skin assessment dated [DATE] revealed two old skin tears to bilateral forearms which were present prior to the incident. The skin assessment revealed no new skin wounds.A care plan dated April 19, 2026, revealed the resident had a psychosocial well-being problem related to a resident-to-resident altercation. Interventions included 72-hour observation, consultation with pastoral care, social services, and psychiatric services, monitor and document resident's response to problems, and when conflict arises, remove resident to calm, safe environment and allow them to vent/share feelings. -Resident # 7, the alleged perpetrator, was admitted on [DATE] with diagnoses that included quadriplegia, major depressive disorder, and Schizophrenia.A behavioral care plan dated February 4, 2026, revealed the resident's current behavior is adjusting to the skilled nursing facility. The behavioral care plan also revealed his triggers as anxiety. Interventions include staff approaching resident with patience, empathy, and consistency.The quarterly MDS dated [DATE], revealed a BIMS score of 10, indicating that the resident had moderate cognitive impairment. The quarterly MDS revealed mood of feeling down and depressed and sometimes isolated. Further review of the quarterly MDS documented no behaviors.A nursing note dated March 6, 2026, documented that Resident # 7 was extremely upset about not having cigarettes and was told by staff that they were getting them today. The nursing note revealed that Resident # 7 started acting out by ramming his side table and door with his wheelchair knocking everything over. The nursing note also documented that he threw his cell phone and ran over it with his wheelchair yelling 'I hate this place'. The nurses note revealed that he continued to ram his wheelchair into a gate and breaking it. A care plan initiated on April 12, 2026, revealed that Resident # 7 had behavior problems of restlessness related to anxiety. Interventions included intervening as necessary to protect the rights and safety of others, diverting attention, and removing resident from situations and take to alternate locations. A nursing note dated April 18, 2026 at 9:44 a.m., revealed that Registered Nurse (RN/ Staff # 177) was alerted that Resident # 7 went over to Resident # 6 with his motorized wheelchair and intentionally hit Resident # 6 in the right calf. The nursing note documented that the residents were separated.A nursing note dated April 18, 2026 at 10:30 a.m. stated that Resident # 7 came to Staff # 177 upset that he was not alerted to the smoking session at 10:00 a.m. The nursing note further revealed that Resident # 7 began screaming at another resident at the nurses station. The nurses note documented that Staff # 177 separated Resident # 7 from the situation outside where Resident # 7 continued to be verbally abusive to Staff # 177.A nursing note dated April 18, 2026 at 3:52 p.m. revealed that Resident # 7 was throwing all his belongings on the floor breaking his nebulizer machine. The facility investigation, undated, documented that the altercation did occur. Resident # 7 was placed on 15-minute supervisory checks until resident could be seen by Behavioral Health.An interview was conducted with RN (Staff #177) on April 30, 2026 at 1:54 p.m. who stated that the day prior to the incident Resident #7 had a hard day because he was getting mail with contraband such as vapes with Tetrahydrocannabinol (THC) in them without a doctor's order so it was confiscated which aggravated Resident # 7. Staff # 177 stated the next day, April 18, 2026, he was still upset and focusing on the removed contraband. Staff # 144 stated that Resident # 6 was outside wandering when he saw a food tray being delivered and grabbed it thinking it was his, but it was for Resident # 7. Staff # 177 stated that Resident # 7 got further upset and 'went after' Resident # 6 with his wheelchair hitting him in the right calf. Staff # 177 said Resident # 7 was upset throughout the day throwing his belongings on the floor and ramming his wheelchair into doors and gates. Staff # 177 stated that finally Resident # 7's medical doctor came in to talk to him address the contraband and he started to calm down.An interview was conducted with CNA (Staff # 79) on April 30, 2026 at 2:01 p.m. who stated that he was in front of Resident # 7's door along with 2 other CNAs when he sees Resident # 7 move his electric wheelchair ramming it into Resident # 6's leg. Staff # 79 stated they had to separate them because Resident # 7 kept pushing his wheelchair into Resident #6. Staff # 79 stated that Resident # 6 likes to wander into residents' rooms and needed redirection. Staff # 79 stated that Resident # 7 was upset because Resident # 6 had his food tray by mistake.An interview with Director of Nursing (DON/Staff # 199) on May 1, 2026 at 10:10 a.m. who stated that it was determined through the investigation that Resident # 7 ran his motorized wheelchair into Resident # 6 because Resident # 7 thought Resident # 6 was stealing his food tray. Staff # 199 stated that she has had conversations with Resident # 7 regarding his behavior and Therapy has evaluated his ability to drive a wheelchair. Staff # 199 stated that her expectation is staff be proactive and identify potential aggression before it happens. Staff # 199 stated that the risk for not being proactive is that residents abuse other residents.Regarding Resident # 8 and Resident # 9:-Resident #8, the alleged victim, was admitted on [DATE] with diagnoses that included dementia, major depressive disorder, personal history of other mental and behavioral disorders. The care plan dated March 2, 2026 revealed the resident had the potential to be physically aggressive related to dementia with a history of hitting staff. Interventions included anticipating resident's needs, intervening before agitation escalates, and administration of medication. The admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 14, indicating the resident was cognitively intact. The admission MDS also revealed other behavioral symptoms not directed towards others.The behavioral care plan dated March 7, 2026 revealed the resident's current behaviors as anxiety, agitation, and cursing at staff. The behavioral care plan also revealed no known triggers. Interventions include by responding with a calm steady tone and avoid reacting emotionally.The care plan dated March 12, 2026 revealed the resident had a potential to be verbally aggressive related to dementia. Interventions included anticipating resident's needs, intervening before agitation escalates, and administration of medication. A nurse's note dated April 20, 2026 documented that Licensed Practical Nurse (LPN/Staff #146) was notified that Resident # 9 physically engaged Resident # 8 by placing arms around Resident # 8's neck initiating a chokehold while Resident # 9 positioned himself behind Resident # 8. The nurses note further revealed that residents were separated and assessments were completed on the residents.A skin assessment dated [DATE] revealed that skin was intact an no new wounds were observed since previous assessment.-Resident #9, the alleged perpetrator, was admitted on [DATE] with diagnoses that included dementia with agitation, bipolar disorder, unspecified mood disorder, and major depressive disorder.The care plan dated August 6, 2025, revealed that Resident # 9 had the potential to be verbally aggressive yelling or cursing at others related to dementia. Interventions included assessing resident's coping skills, intervening before agitation escalates and guiding the resident away from source of distress. A quarterly MDS assessment dated [DATE], revealed a BIMS score of 6 indicating that the resident had severe cognitive impairment. The quarterly MDS also revealed other behavioral symptoms not directed towards others.A behavioral care plan effective February 12, 2026 revealed that Resident #9's current behaviors included refusing and combative with cares, severe agitation, cursing, striking out and threats to others. Interventions included, to approach resident calmly and respectfully using a soft reassuring tone when he is combative, and when resident becomes agitated by striking out, staff are to ensure safety by maintaining a safe distance and removing other residents for the area if needed.The care plan dated April 2, 2026 revealed that Resident # 9 had the potential to be physically aggressive related to dementia. The care plan also documented that Resident #9 hit another resident with a tray table on April 2, 2026. Interventions included providing physical and verbal cues to alleviate anxiety, and intervening before the resident's agitation escalates. A nursing note dated April 21, 2026 revealed that Staff #146 was notified that Resident # 9 was engaged in an activity with building blocks at the communal table area. Resident # 9 left the table and upon his return Resident # 9 observed Resident # 8 occupying the same table and the arrangement of the blocks had been disrupted by Resident # 8. The nurses note further documented that Resident # 9 walked behind Resident # 8 and proceeded to physically engage Resident # 8 by placing his arms around Resident # 8's neck, initiating a choke hold. The facility investigation, undated, documented that the resident to resident altercation did occur.An interview was conducted with CNA (Staff # 85) on April 30, 2026 at 2:11 p.m. who stated that Resident # 9 was at the table playing with blocks and stacking them. Staff # 85 stated that Resident # 9 got up and walked away while Resident # 8 came in the room and sat down across from the blocks. Staff # 85 stated that Resident # 9 told Resident # 8 not to touch his block but Resident # 8 took his arm and knocked the blocks all over. Staff # 85 stated that Resident # 9 got upset and walked behind Resident # 8 and put him in a headlock. Staff #85 stated that she had to bribe Resident # 9 with ice cream in order for him to let go of Resident # 8 and follow her. An interview was conducted with CNA (Staff #88) on April 20, 2026 at 2:19 p.m. who stated that Resident # 9 was playing with his blocks when he got up and walked away from the table distracted. Staff # 88 stated that Resident # 8 came in sat down and knocked all the blocks across the table which angered Staff # 9. Staff # 88 stated that Resident # 9 came up behind Resident # 8 and grabbed Resident # 8's neck with his arms. Staff # 88 stated they had to offer Resident # 9 snacks in order to let him go and out of the room. An interview with LPN (Staff # 146) on May 1, 2026 at 8:30 a.m. who stated that it was reported to her that Resident # 9 was building blocks on the table and got up to talk with another resident and Resident # 8 sat down by the blocks. Staff # 146 stated that Resident # 8 knocked the blocks down and Resident # 9 approached Resident # 8 from behind and put Resident # 8 in a headlock. Staff # 146 stated that she did an assessment on Staff # 8 after they were separated and found no injuries.An interview with Director of Nursing (DON/Staff # 199) on May 1, 2026 at 10:10 a.m. who stated that the incident between Resident # 8 and Resident # 9 should have never happened. Staff # 199 stated that the staff were all over in the day room and saw the incident building to the moment Resident # 8 knocked the blocks over and allowed Resident # 9 to get close enough to Resident # 8 did not meet her expectations. The DON stated that the concern for not anticipating is that residents could abuse other residents. Regarding Resident #10 and Resident # 11:-Resident # 10, the alleged victim, was admitted [DATE] with diagnoses that included dementia with agitation, major depressive disorder, and post-traumatic stress disorder. The behavioral care plan dated February 16, 2026 revealed current behaviors of anxiety and agitation. The behavioral care plan further revealed triggers which included feeling confused. The annual MDS assessment dated [DATE], revealed a BIMS score of 11, indicating that the resident had moderate cognitive impairment. The annual MDS revealed no behaviors for the resident.An alert note dated April 24, 2026 documented that Staff # 146 was at the nursing station when Resident # 10 was seen exiting his room towards the hallway, Staff # 146 noticed that Resident # 10 was getting too close to Resident # 11. The alert note revealed that Resident # 11 got agitated when another Resident yelled 'call 911' repeatedly. The note documented that Resident # 11 was observed holding Resident # 10 by the throat and slammed Resident # 10 against the wall.A skin assessment dated [DATE] revealed a new skin tear on Resident #10's left upper arm. -Resident # 11, the alleged perpetrator, was admitted [DATE] with diagnoses that included senile degeneration of the brain, early onset Alzheimer's disease, and alcohol abuse. The discharge MDS assessment dated [DATE], revealed that resident # 11 had a BIMS score of 3, indicating that the resident had severe cognitive impairment. The discharge MDS also revealed other behavioral symptoms not directed towards others.An alert note dated April 24, 2026, revealed that Resident # 11 was mostly wandering during the overnight shift. At approximately 4:40 a.m. Resident # 11 tried to charge at a nurse and grab the nurse's arm. The alert note documented that Resident # 11 seemed angry for no reason trying to fight staff and wandering. note documented that Resident # 11 seemed angry for no reason trying to fight staff and wandering. An alert note dated April 24, 2026, revealed that attempts were made to contact Resident's hospice nurse to see what could be done with Resident # 11's aggression. The alert note documented that Resident # 11 had tried to hit two nurses and a CNA. An alert note dated April 24, 2026 at 12:50 p.m. revealed that Staff # 146 was sitting at the nursing station when Resident # 11 was walking with CNA # 131 in the hallway. The alert note documented that Resident # 10 was seen exiting from his room toward the hallway when another Resident started yelling 'call 911' over and over again. The nursing note revealed that Staff # 11 got agitated and angry and Staff # 146 observed Resident # 11 holding Resident # 10's throat and slammed Resident # 10 against the wall. The facility investigation, undated, documented that the altercation did occur.An interview was conducted on April 30, 2026 at 2:37 p.m. with CNA (Staff # 131) who stated that when she started her shift Resident # 11 was brand new to her and that Staff # 131 was told by the previous shift that Resident #11 was aggressive and strong. Staff # 131 stated that she started walking with him as he wandered up and down the hall as it seemed to ease some of his aggression. Staff # 131 stated that as she was coming off her lunch break to go back and walk with Resident #11 when she runs into Resident # 10 who asked where the exits were. Staff # 131 stated that she noticed how close Resident # 11 and Resident # 10 were getting while another resident was sitting on a bench. Staff # 131 stated that while she was redirecting Staff # 10 away from Staff # 11 the resident sitting on the bench stands up and yells 'call 911' several times. Staff # 131 stated that she noticed Resident #11 get angry and upset at which point she tried to push Resident #10 away from Resident # 11 but Staff # 131 was the only one there at the moment and Resident # 11 grabbed Resident # 10 by the neck and started choking him. Staff #131 stated other staff came to help and separate the residents. Staff # 131 ended up taking Resident # 10 away into his room closing the door. An interview was conducted on May 1, 2026 at 8:21 p.m. with CNA (Staff # 84) who stated that she was in the day room doing an activity when she heard a resident yelling call 911. Staff # 81 stated she left the day room and saw Resident # 11 choking Resident # 10 and the staff helped separate the residents.An interview was conducted on May 1, 2026 at 8:30 a.m. with Staff # 146 who stated that she was at the nurses' station doing documentation while Staff # 131 was walking Resident # 11 back and forth in the hall way. Staff # 146 stated that she noticed Resident # 10 come out of his room and speak with Staff # 131. Staff # 146 stated that she noticed how close Resident # 10 was to Resident # 11 and that another Resident was sitting on a bench talking which was making Resident # 11 upset. Staff # 146 stated that she told Staff # 131 to move Resident # 10 but as she was trying to do that, the resident sitting on the bench stood up and yelled 'call 911' several times. Staff # 146 stated that this made Resident # 11 extremely mad. She stated that he started cussing and moved quickly towards Resident # 10, grabbing Resident # 10 by the neck. Staff # 146 stated that all staff got up and separated the Residents and that they called the police, who eventually took him out of the facility. During an interview with Director of Nursing (DON/Staff # 199) on May 1, 2026 at 10:10 a.m., staff #199 stated that Resident # 11 was a hospice respite stay, because his wife needed a break. Staff # 199 stated that Resident # 11 was agitated from the start and staff had a difficult time administering medications. Staff # 199 stated that Resident # 11 had started choking Resident # 10 and slamming him against the wall. The DON revealed the Crisis team was called and Resident # 11 was removed from the facility. Staff # 199 stated that her expectation is staff be proactive and identify potential aggression before it hap

Based on interviews, clinical record and policy review, the facility failed to update comprehensive care plans related to repeat resident to resident abuse and update individualized resident interventions for three of eleven residents sampled (#1, #2, and #4). The deficient practice could result in a plan of care that did not meet the resident's needs and lead to continued resident to resident abuse. Findings include:-Regarding Resident #1:Resident # 1, was admitted [DATE], with diagnoses that included dementia, mood disorder due to known physiological condition with manic features, and alcohol dependence. A nurse's note dated February 20, 2026, revealed that Resident #1 approached the nurse's station crying and reported Resident #2 hit her in the nose. The note revealed both residents were placed on 15-minute safety checks and closely monitored. A nurse's note dated April 13, 2026, revealed that a Certified Nursing Assistant (CNA) notified the nursing staff that Resident #2 grabbed Resident #1 by face/lip area during an altercation. The note indicated both residents were placed on15-minute safety checks and closely monitored. The care plan initiated on April 14, 2026, revealed that Resident #1 has psychosocial well-being problem related to a resident-to-resident altercation with interventions that included, 72-hour observation, consulting with pastoral care, social services, psychiatry services, monitoring resident's usual responses, and when conflict arises remove residents to calm safe environments. Further review of the care plan revealed no indication that Resident #1 and Resident # 2 were in a previous altercation on February 20, 2026. The care plan also failed to indicate previous interventions that were in place as a result of the first altercation. Review of an undated facility investigation report revealed interventions that were implemented after the April 13, 2026 incident included a staff member present in the pavilion as long as Resident # 1 or Resident #2 are present at all times. Further review of the care plan revealed no intervention of staff members needing to be in the pavilion when either Resident #1 or Resident #2 are present. -Regarding Resident #2:Resident # 2, was admitted on [DATE], with diagnosis that included personality disorder, anxiety disorder, adjustment disorder, and depression.A nurses note dated February 20, 2026, revealed the resident stated she was tired of resident #1 opening her door which led her to hit Resident #1.A nurses note dated April 13, 2026 revealed that a CNA reported to the nurse that Resident #2 grabbed Resident #1's face by her mouth while Resident # 1 was trying to move away from her. The nurses note documented that Resident #2 stated 'Yeah I grabbed her by the face. I don't like her!' The care plan initiated on April 14, 2026, revealed that Resident #2 has psychosocial well-being problem related to a resident-to-resident altercation with interventions that included, 72-hour observation, consulting with pastoral care, social services, psychiatry services, monitoring resident's usual responses, and when conflict arises remove residents to calm safe environments. Further review of the care plan revealed no indication that Resident #1 and Resident # 2 were in a previous altercation on February 20, 2026. The care plan also failed to indicate previous interventions that were in place as a result of the first altercation. A undated facility investigation report revealed interventions that were implemented after the April 13, 2026 incident which included a staff member present in the pavilion as long as Resident # 1 or Resident #2 are present at all times. Further review of the care plan revealed no intervention of staff members needing to be in the pavilion when either Resident #1 or Resident #2 are present. An interview was conducted with CNA (Staff # 67) on May 1, 2026 at 9:43 a.m. who stated that Resident #1 is very confused and forgetful but can easily be redirected. She stated that Resident #2 keeps to herself. Staff #67 stated that Resident #2 gets possessive with belongings and food and gets mad if other residents touch them. Staff # 67 stated that after the incident between both staff members the staff has to keep eyes on Resident # 1 when she is out in the courtyard to try and prevent her from getting close to Resident # 2. An interview with CNA (Staff # 115) on May 1, 2026 at 9:45 a.m. stated that Resident # 2 exhibits behaviors when other residents or staff make her mad. Staff # 115 revealed that Staff # 1 wanders around a lot especially into other resident's rooms. Staff # 115 stated that Resident # 1 likes to go into Resident # 2's room because there used to be another resident who lived in that room who was sick and Resident # 1 would check on that resident when she wandered the courtyard. CNA # 115 revealed that since this last incident between Resident #1 and Resident #2 the staff now have to keep eyes on Resident #1 to prevent her wandering to Resident #2's room. An interview was conducted with the Minimum Data Set Licensed Practical Nurse (MDS LPN/Staff # 152) on May 1, 2026 at 8:47 a.m., who stated the Interdisciplinary Team (IDT) meets following resident-to-resident altercations to determine interventions which are then added to the care plan. Staff # 152 stated that in the IDT meeting it was determined that staff needed to be present in the pavilion when Resident # 1 or Resident # 2 are present. Staff #152 reviewed the current care plan and stated this intervention was not in the care plan and probably should be. Staff # 152 stated the concern for this intervention not being in the care plan is that staff would not know this intervention was in place and the Residents could get in another altercation.An interview was conducted with the Director of Nursing (DON/Staff # 199) on May 1, 2026 at 10:10 a.m. who stated that during her investigation she found out that Resident # 1 and Resident # 2 had an argument and as Resident #1 was trying to get up to leave when Resident # 2 grabbed Resident # 1 by the face. Staff # 199 stated that this is the second altercation between the two residents. She stated they added the 1:1 for Resident # 1 and Resident # 2 when in the courtyard to help prevent further altercations. Staff # 199 stated that this intervention should be in the care plan, but when Staff # 199 reviewed the care plan for this intervention she stated that she could not find it. She stated the concern is, if it is not in the care plan, that staff could be unaware of the intervention and the residents could have another altercation. -Regarding Resident # 4Resident # 4 was admitted on [DATE], with diagnoses that included Huntington's disease, schizoaffective disorder, and personal history of traumatic brain disorder. The care plan initiated on March 23, 2026, revealed that Resident # 4 had a potential to be physically aggressive related to poor impulse control and a history of aggressive behaviors toward others. Interventions included intervening when resident becomes agitated, asses and anticipate resident's needs, and administration of medication.A nurse's note dated April 13, 2026, revealed that the nurse was informed by CNA # 76 that this resident was in Resident #3's room and was hitting Resident #3.The care plan initiated on April 14, 2026, revealed that Resident #4 has a psychosocial well-being problem related to a resident-to-resident altercation with interventions that included, 72-hour observation, consulting with pastoral care, social services, psychiatry services, monitoring resident's usual responses, and when conflict arises remove residents to calm safe environments.A Psychiatry note dated April 14, 2026 revealed that Resident #4 was seen following the altercation with Resident #3. The note revealed that Resident #4 was put on 1:1 supervision for safety. A facility investigation report, undated, revealed interventions that were implemented after the April 13, 2026 incident included placing the Resident on a 1:1 to prevent future altercations.Further review of the care plan revealed no intervention of Resident #4 on being placed on a 1:1.An interview was conducted on May 1, 2026 at 9:10 a.m. with Licensed Practical Nurse (LPN/Staff # 161) who stated that Resident # 3's behaviors included being verbal, manipulative, and narcissistic. Staff # 161 stated that Resident # 4 is very physical with his aggression and anything can trigger him. Staff # 161 stated that Resident # 4 had been physical with staff since his admission and that anything can trigger the aggression. Staff # 161 stated that the sitter that was assigned to him has helped keeping him under control especially since she has to cover both 500 and 600 wings and can't be in both places at once. An interview was conducted with Minimum Data Set Licensed Practical Nurse (MDS LPN/Staff # 152) on May 1, 2026 at 8:47 a.m., who stated that after all resident-to-resident altercations the Interdisciplinary Team would meet to discuss the incident and interventions that need to be put into place. Staff # 152 further stated that once the interventions were decided, they are placed in the care plan. Staff # 152 stated that Resident # 4 had some medication adjustments after the altercation and the IDT team had placed Resident # 4 on a 1:1. Staff # 152 reviewed the care plan and stated that the 1:1 was not in the care plan interventions. Resident # 152 stated that the concern for not documenting the 1:1 in the care plan, is staff not being aware that a one on one is needed and he could attack another resident. An interview with Director of Nursing (DON/Staff # 199) was conducted on May 1, 2026 at 10:10 a.m. who stated that their investigation determined that Resident # 4 was witnessed by staff in Resident # 3's room swinging at Resident # 3. Staff # 199 stated that due to history of Resident # 4's aggression they had placed him on a 1:1 to help avoid further altercations with other residents. Staff # 199 reviewed the care plan and stated that the intervention of the 1:1 was not in the care plan, She stated that it needed to be in the care plan for documentation purposes and to let staff know what interventions were in place. A Policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also revealed that care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant decision making. The policy revealed that the ITD team reviews and updates the care plan: when there has been a significant change in the resident's condition, and when a desired outcome is not met.

Based on clinical record review, staff interviews, review of facility documentation and policies, the facility failed to protect the rights of 3 residents (#3, #4, #7) to be free from physical abuse by other residents (#2, #5, #6). The deficient practice could result in further abuse of residents and appropriate action not taken.Findings Include:Regarding Resident #3 and Resident #2 incident:Resident #3 was admitted on to the facility on 2/20/2025 with diagnoses that included Dementia and Major Depressive Disorder.The Resident's care plan dated 5/21/2025, revealed that the resident had an impaired cognitive function or impaired thought processes related to Dementia.The Resident's Behavioral Care Plan progress notes with an effective of 2/17/2026, revealed that the Resident's current behavior included an adjustment to living in a skilled nursing facility. The interventions included for the staff to provide supportive and compassionate care to help ease the transition; establish a consistent daily routine to provide structure and reduce uncertainty; and introduce him gradually to staff, peers, and activities focusing on building familiarity and comfort at his pace.The Resident's Alert Note in the progress notes dated 3/29/2026, at 8:50 AM, revealed that Resident #2 with a closed fist hit Resident #3's right shoulder. It was documented that a Certified Nursing Assistant (CNA) saw Resident #2 punch Resident #3 and that Resident #3 denied pain. Resident #3 was assessed and there were no red marks and bruising. Resident #3's doctor was notified and there were no new orders received. The Resident's Power of Attorney (POA), the Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were notified.The revised care plan dated 3/30/2026 included a psychosocial well-being problem related to resident to resident altercation. The interventions included to follow the behavioral care plan; cue, reorient and supervise as needed; and when conflict arises, remove the resident to a calm safe environment and allow to vent and share his feelings.Another review of the Resident's Alert Note in the progress notes dated 3/30/2026, at 5:11 AM, revealed that Resident #3 was on an alert charting following the incident with Resident #2. Resident #3's skin assessment, per document, had no redness, bruising, swelling, or open areas. Resident #3 complained of soreness on his right shoulder and rated the pain 2 out of 10.A Psych Follow Up progress note dated 3/31/2026, was reviewed. Resident #3 was seen for psychiatric follow-up after an altercation in which Resident #2 struck Resident #3's right shoulder with a closed fist. Per document, the staff witnessed the contact and immediately intervened. It was documented that Resident #3 denied pain, and there were no redness, bruising, or visible injury noted. Further, per documentation, Resident #3 reported that he was sitting in the day room when Resident #2 approached him from the corner of his eye and Resident #2 struck his arm without prior interaction or verbal exchange. Resident #3 only had mild soreness to the right shoulder. Resident #3's well being remained consistent with baseline following the incident.-Resident #2 was admitted to the facility on [DATE], with a primary diagnosis of Schizoaffective Disorder.A review of the Resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating that the resident's cognition was intact. The Resident did not exhibit behavioral symptoms. The Resident's active diagnosis included Schizophrenia. The MDS further revealed that the Resident was taking Antianxiety and Antipsychotic medications on a routine basis.A Behavioral Care Plan progress note, effective 3/11/2026, was reviewed. The Resident's current behaviors included a verbal and physical aggression (posturing, threats) and exit- seeking. The interventions included that the Resident may display verbal or physical aggression when he feels frustrated, overwhelmed, or perceives a loss of control, and that these behaviors may be his way of expressing distress or attempting to regain a sense of power. It was documented that the staff should remain calm, maintain a safe distance, avoid arguing or escalating the interaction, use steady, respectful tone, offer space for the Resident to de-escalate while redirecting the Resident to a quieter area if possible. Once the Resident begins to settle, offer the Resident simple choices and supportive guidance while maintaining clear boundaries and prioritizing safety.The Alert Note in the progress note dated 3/29/2026, at 2:11 AM, revealed that Resident #2 asked to smoke every 10 minutes or so and kept trying to negotiate good behavior for a cigarette. The staff nurse informed Resident #2 that he can not have a cigarette but he may go back to his room and behave. Per document, Resident #2 was told many times that he may not have a cigarette until 8:00 AM during the designated smoking time. Resident #2 started threatening the staff. It was documented that Resident #2 called 911. Resident #2 chased and went after the staff while on the phone with the 911 dispatcher. The police came and were able to calm Resident #2, and informed Resident #2 that smoking time is at 8:00 AM.Another review of the Alert Note in the progress note dated 3/29/2026, at 9:25 AM, revealed that at the start of the AM shift, Resident #2 was agitated with anxiety, getting up, walking around, and making inappropriate gestures to female staffs, along with showing verbal aggression then escalated to physical. Resident #2 was not happy that he was not allowed to smoke as he wanted, due to set times for smoke breaks. Resident #2 saw a housekeeper coming and Resident #2 grabbed the housekeeper's hand with the keys and yanked it out of her arm. The housekeeper staff reported an injury to her right shoulder. After the housekeeper staff incident with Resident #2, Resident #2 became aggressive and punched a male CNA's abdomen. Resident #2 became verbally aggressive when he was asked to sit down. The ADON, DON, and the administrator were notified of Resident #2's physical aggressive behavior. The staff called 911 at 8:01 AM. Further, per document, during the time that the police officers were in the facility campus, Resident #2 randomly hit Resident #3's right shoulder in passing prior to being approached by the police officer. Upon being approached by the officers, Resident #2 reached for the police officer's hand gun.A review of the Resident's comprehensive care plan which was revised on 3/30/2026, revealed that the Resident had the potential to be verbally aggressive related to mental, emotional illness, poor impulse control, and will threaten staff when he did not get what he wants. The care plan revealed that on 3/29/2026, Resident #2 punched another resident in the arm. The interventions included immediate separation, the staff to follow the Behavioral Care Plan for any possible triggers. The plan also included for the Resident to be relocated to another facility.The Interdisciplinary Team (IDT) progress note dated 3/30/2026, revealed, per document, that Resident #2 hit Resident #3's shoulder. Resident #3 and Resident #2 were separated. The administrator, DON, and the police were notified. The police took Resident #2 to a hospital and, Resident #2 would be transferred to another facility once he was released from the hospital. The document revealed that the facility was unable to meet the needs of Resident #2.A review of the facility's 5-day report investigation revealed an undated report. The report included statements from the staff members. On the left upper top corner of the statement document, Incident #1 was written. Per the document, it revealed that early morning on 3/29/2026, Resident #2 had been up all night, was very agitated, was not listening, was very adamant about having a cig, and was asking several times. The CNA (Staff #10) informed Resident #2 that it was not time yet. Resident #2 was told to step out. Then, Resident #2 walked very slowly, then turned around and struck the CNA (Staff #10) in the stomach. The CNA (Staff #10) reported the incident to the nurse. In the middle part of the statement document, Incident #2 was written. Per the document, it revealed that after the police was called, the CNA (Staff #10) went to the gate and spoke with the police to give his statement. After giving his statement to the police, the CNA (Staff #10) returned in the day room and saw that Resident #2 struck Resident #3's right shoulder. The CNA (Staff #10) separated Resident #2 and Resident #3, and then the CNA (Staff #10) informed the nurse. The police came and took Resident #2 out of the facility. In addition, the 5 -day report investigation revealed that the IDT team determined that it might be in the best interest of the facility not to re-admit Resident #2 back to the facility as the facility was unable to meet his needs.Regarding Resident #6 and Resident #7 incident:-Resident #6 was admitted to the facility on [DATE], with diagnoses that included dementia, Bipolar Disorder, Major depressive Disorder, and Anxiety Disorder.The Resident's care plan initiated on 8/6/2025, revealed that the Resident was at risk for not meeting emotional, intellectual, physical, and social needs related to Dementia. The interventions included that all staff were to converse with the Resident while providing care; introduce the Resident to other residents with similar background, interests; and encourage and facilitate the interaction.A review of the Resident's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 6.0, indicating that the Resident's cognition was severely impaired. The assessment revealed that physical behavioral symptoms directed towards others and verbal behavioral symptoms directed towards others were not exhibited, but other behavioral symptoms not directed towards others had occurred. Further, the assessment revealed that the Resident was receiving Antipsychotic and Antidepressant medications.The Resident's Behavioral Care Plan progress note with an effective date of 2/12/2026, revealed a current behavior that included refusing and combative with care, severe agitation, cursing, striking out, and threats. The interventions included when Resident #6 becomes combative or refuses care, approach him calmly and respectfully; avoid rushing or overwhelming him by explaining each step clearly; and allow extra time for processing to help Resident #6 feel a sense of control. Further, per Behavioral Care Plan, if Resident #6 becomes agitated, pause and attempt care later when he is calmer; redirect his attention to a preferred topic or activity; and use familiar routines to ease anxiety; and when Resident #6 becomes severely agitated such as striking out, cursing, or making threats, ensure safety by maintaining a safe distance and removing other residents from the area if needed.An Alert Note progress note dated 4/2/2026, revealed that Resident #6 hit Resident #7 with a tray table. Resident #6 and Resident #7 were immediately separated and the tray table was removed from Resident #6. Resident #6 was assessed and no injury found.An IDT Note progress note dated 4/3/2026, revealed that Resident #6 was the aggressor towards Resident #7.Further review of the Resident's comprehensive care plan revealed an updated care plan dated 4/3/2026. The care plan revealed that Resident #6 was at risk for psychosocial well-being problem related to Resident to Resident altercation and, another revised care plan dated 4/6/2026, revealed that the resident had the potential to be physically aggressive related to Dementia. Resident #6 hit another resident with a tray table on 4/2/2026. The interventions included to follow the updated Behavioral Care Plan; when the Resident becomes agitated, intervene before agitation escalates, guide away from the source of distress, engage calmly in conversation; and when conflict arises to remove the residents to a calm safe environment.A review of the Psych Follow Up progress notes dated 4/7/2026, revealed that Resident #6 was evaluated following a report of aggression toward Resident #7 on the evening of 4/2/2026, during which Resident #6 struck Resident #7 with a tray table. Resident #6 and Resident #7 were immediately separated and there were no injuries identified per nursing documentation.-Resident #7 was readmitted on [DATE], with diagnoses that included Dementia, Type 2 Diabetes Mellitus, and cognitive communication deficit.The Quarterly MDS assessment dated [DATE], revealed that a BIMS was not conducted due to the resident was rarely and never understood. The Resident did not exhibit physical and verbal behavioral symptoms directed towards others, but, other behavioral symptoms not directed towards others such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds, occurred. The Resident's Behavioral Care Plan progress note effective 2/13/2026, revealed a wandering/exit seeking current behavior.A review of the Alert Note in the progress note dated 4/2/2026, at 9:41 PM, revealed that the nurse was notified by staff that Resident #7 was hit by Resident #6 with a tray table. Resident #7 and Resident #6 were immediately separated, and the tray table was removed. Resident #7 was assessed for injury and there was no injury found. The provider was contacted and there were no new orders received.On 4/3/2026, at 1:08 AM, per Alert Note progress note review, the document revealed that Resident #7 had been asleep, but got up once to the bathroom, and the neuro checks were within normal limits (WNL).On 4/3/2026, at 1:16 AM, per Alert Note progress note review, the document revealed that Resident #7 was not cooperative with vital signs and neuro checks. Resident #7 was agitated.Another review of the Alert Note in the progress note dated 4/3/2026, at 4:49 AM, revealed that Resident #7 had a new skin tear to his right arm. The skin tear was covered with a dressing.An IDT Note progress note dated 4/3/2026, revealed that Resident #7 received a physical aggression from Resident #6. Resident #7 and Resident #6 were separated immediately.A review of the Resident's revised care plan dated 4/3/2026, revealed that Resident #7 had a psychosocial well-being problem related to a resident to resident. The intervention included when conflict arises to remove the resident to a calm and safe environment.A review of the facility's 5-day report investigation revealed that the investigation did not have a date. The investigation included multiple staff interview statements related to the incident. A statement interview from an LPN (Staff #13) revealed that she was not present during the resident to resident altercation on 4/2/2026. An interview statement from a CNA (Staff #15) revealed that he was in the dining room and he did not witness the incident. An interview statement from a CNA (Staff #21) revealed that she did not see nor witness the incident. An interview statement from another CNA (Staff #17) revealed that she did not see the incident happen but that she called for help and the other CNAs came to help. Another interview statement from a fourth CNA (Staff #25) revealed that she did not see the incident happen. Further, an interview statement from 3-individuals (Staff #22, Staff #33, and Staff #41) revealed that Resident #6 was folding linens while Resident #7 was sitting in front of Resident #6. Resident #6 and Resident #7 were engaging in a civil conversation when all of a sudden Resident #6 said why are you talking shit and then Resident #6 grabbed a wooden folded table, yelled f**k you, and launched it at Resident #7's head. Resident #7 remained non-verbal and did not retaliate. Resident #7 was removed from the common area and the nurse was informed.A review of the 4/2/2026, PM shift schedule revealed that the following CNAs, Staff #21, Staff #25, Staff #15, and Staff #17; and 1-LPN (Staff #13) were scheduled to work at the unit where Resident #6 and Resident #7 resided. Despite having 4-scheduled CNAs and 1-nurse for the unit where Resident #6 and Resident #7 resided, based on the facility's 5-day report investigation, Resident #6 and Resident #7 were not supervised by the scheduled staff members while Resident #6 and Resident #7 were in the common area.An interview was conducted on 4/16/2026, at 10:38 AM with Resident #6 in the common area. Resident #6 stated that he gets along with everybody, he gets along well, he is happy at the facility, and he had no disagreement except maybe 20 years ago.An interview was conducted on 4/16/2026, at 10:44 AM with Resident #7. Resident #7 was observed sitting in a couch in his room, and when asked a question, he just nodded his head.On 4/16/2026, at 11:21 AM, a request was made to the administrator to identify 3- individuals that were included in the Resident #6 and Resident #7 altercation interview statement. The 3-individuals were not included in the employee list provided. The administrator stated that the individuals were students.On 4/16/2026, at 11:44 AM, CNA (Staff #25) called back. Staff #25 stated that she was aware of the incident involving Resident #6 and Resident #7. She stated that there were individuals in training on the day of the incident. She said that she was on the other side of the unit and she heard screaming. She said that the trainees were yelling about 2-residents who were fighting. She said that once she got to the location of the incident, she said that CNA (Staff # [NAME]), and she saw Resident #6 and Resident #7 going back and forth holding on a folded side table, and she was trying to get Resident #6 to let go of the folded side table. She also stated that she saw Resident #7's left arm was bleeding, she noticed 2-small skin tears, one was in the lower arm and the other was located higher in the arm. She said that she reported the bleeding on Resident #7's arm to the LPN (Staff #13). Further, she asked the individuals in training and CNA (Staff #17) what had happened, and the individuals in training stated that they saw Resident #6 holding on the folded table over his head aiming at Resident #7. She said that one of the individuals in training inform her that Resident #6 hit Resident #7's head. She said that the whole time of the incident, Resident #7 was just sitting on the chair while Resident #6 was the one standing.A phone interview was conducted on 4/16/2026, at 12:10 PM with Staff #100. Staff #100 stated that after she spoke with the DON, she was just made aware of the incident involving Resident #6 and Resident #7, to which the students witnessed a resident to resident incident. Staff #100 stated that the students made a written statement on what had happened and their instructor was informed. Regarding Resident #4 and #5:-Resident #4 was readmitted to the facility on [DATE], with diagnoses that included bone infection (osteomyelitis), mild cognitive impairment, and Type 2 Diabetes Mellitus. The Resident's Behavioral Care Plan progress note, effective 3/16/2026, revealed a current behavior for isolation. The intervention included for the staff to approach Resident #4 with warmth and gentle encouragement to help him engage with others; invite him to join the activities without pressure; and respecting his needs for personal space.The Quarterly MDS assessment dated [DATE], revealed a BIMS score of 9.0, indicating that the Resident's cognition was moderately impaired. And, the assessment revealed that the Resident did not exhibited behavioral symptoms.An Incident Note progress note dated 3/29/2026, revealed per document, that a housekeeping staff notified a nurse that Resident #4 was on the floor. It was documented that Resident #4 was trying to get by and was pushed by Resident #5 because Resident #5 was not letting Resident #4 get through. Resident #4's vital signs were checked and the vital signs were WNL. The staff performed neuro checks. Resident #4 was sent out for a non-emergent per the provider's order. Resident #4's POA, the DON and the administrator were notified.A review of the Resident's care plan revealed that Resident #4 had an actual fall while in his wheelchair on 3/29/2026, due to another resident pushing his wheelchair back. The interventions included to immediately separate Resident #4 from the other resident, perform a skin and body check, and Resident #4 was sent out to the emergency room to rule out injury from falling back while in the wheelchair.The hospital discharge record dated 3/29/2026, was reviewed. Per the document, Resident #4 was sent to the emergency room after falling backwards in his wheelchair and hitting his head. Per the document, Resident #4 was going up a ramp when there may have been an altercation with another person. During the emergency room visit, a CT Scan was performed, and the result was negative for acute traumatic injury.On 3/29/2026, at 5:33 PM, per Incident Note progress note, Resident #4 returned to the facility, and his provider was notified.Further, another revised care plan, initiated on 3/30/2026, for Resident #4 included a psychosocial well-being problem related to a resident to resident altercation. The interventions included a 72-hour observation and when conflict arises, remove the residents to a calm and safe environment. A review of the IDT Note progress note dated 3/30/2026, revealed that Resident #4 was sent out to the emergency room to check for head injury and to rule out bleeding since Resident #4 was on aspirin daily. And, per the document, to apply anti-tippers to the wheelchair, and the physical therapist to evaluate the wheelchair.-Resident #5 was admitted to the facility on [DATE], with diagnoses that included Dementia, Anxiety Disorder, and violent behavior.Review of the Resident's Behavioral Care Plan progress notes effective 1/10/2026, revealed that the Resident's current behaviors included anxiety, screaming, and agitation. The intervention for this current behavior included for the staff to approach Resident #5 with calm, reassuring demeanor to help his anxiety; minimize environmental stressors and create a quiet and supportive space; avoid rushing him; and avoid arguing, raising voices, or rushing interactions as this may escalate his agitation.The Resident's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 6.0, indicating that the Resident's cognition was severely impaired.A review of the Incident Note progress note dated 3/29/2026, revealed that Resident #5 was the aggressor, and had pushed Resident #4 down outside the dayroom. Resident #5 stated that Resident #4 was in his way. Resident #4 and Resident #5 were separated. The DON, ADON, provider, and the administrator were notified of the situation.An IDT Note progress note dated 3/30/2026, revealed, per documentation, that Resident #5 was separated immediately from Resident #4. The administrator and the DON were notified of the incident. It was documented that the police came and that Resident #4 was sent out to the hospital to get his head checked out. Resident #5 was placed on a change of condition for a 72 hours behavior check. Resident #5 was moved to another unit.A review of Psych Follow Up progress notes dated 3/31/2026, revealed that Resident #5 was evaluated following a reported altercation in which Resident #5 pushed Resident #4 from a wheelchair outside the dayroom. Per the documentation, Resident #5 stated that Resident #4 was in his way. The staff immediately separated Resident #4 and Resident #5. The DON, ADON, provider and the administrator were notified. The police responded to the facility and completed a report. Resident #4 was sent out to the hospital for an evaluation. Resident #5 was placed on close observation checks for 72 hours and was relocated to another unit. An interview was conducted with Resident #4 on 4/16/2026, at 2:10 PM. Resident #4 was sitting in his wheelchair in the dining room common area. He said that he gets along with everybody, and that they do not hurt him, do not punch or push him.The facility's 5-day report investigation revealed an investigation without a date. The investigation included an interview statement from Staff #40. Staff #40 stated that she witnessed Resident #4 trying to go up the ramp, Resident #5 was at the top of the ramp, and Resident #5 said to Resident #4 no you can't come up. Staff #40 said that Resident #4 tried to move up but was pushed down to the floor by Resident #5. Staff #40 notified the nurses.A phone call was placed to interview LPN (Staff #13) on 4/16/2026, at 10:57 AM, a voice mail message was left.A phone call was placed to interview CNA (Staff #25) on 4/16/2026, at 11:38 AM, left a voice mail message.A phone call was placed to interview CNA (Staff #21) on 4/16/2026, at 11:40 AM, left a voice mail message.An interview was conducted on 4/16/2026, at 2:06 PM with a CNA (Staff #19). Staff #19 stated that Resident #4 is independent, and Resident #5 was moved to the other unit last month due to an incident that happened last month. Staff #19 said that he was not working that day so he was unable to give details of the incident.An interview was conducted on 4/16/2026, at 2:24 PM, with a CNA (Staff #11). Staff #11 stated that his abuse training was completed during his orientation. He said that abuse is neglect or mistreating a resident. He said that if he witnesses an abuse, he will report it because he would not want to see anyone with bruises or unusual markings, and it is the right thing to do. He also said that if he observed a resident to resident altercation, he would separate the residents, create a distance between the 2 residents so the residents could cool off a little bit, and he would report the incident to the nurse. He said that regarding Resident #5, the Resident was moved to his unit 2 weeks ago. He said that Resident #5 was in his wheelchair and there was an incline ramp outside. The ramp is steep for Resident #5. He said that at that moment, Resident #5 was being taken to have a shower, and Resident #5 can be combative. Staff #11 also said that at least one CNA has to be in the dining room/day room when residents are in the room just in case an altercation happens, and that staff should be available to watch the nursing station because some residents could open the door and wander in the nurses' station.An interview was conducted on 4/16/2026 after 3:00 PM with Staff #40 (Mostly Spanish-speaking only) and present during the interview was the Maintenance Director (Staff #66) who served as the Spanish language interpreter. Staff 40 stated that she remembered an incident between Resident #4 and Resident #5 that happened on March 2026. Staff #40 said that Resident #5 was coming from the dining room and the other resident, Resident #4 was going to the dining room. She said that Resident #4 and Resident #5 were both in their wheelchairs. She said that Resident #5 asked if he can excuse him so he can come out but Resident #4 did not want to, so Resident #5 pushed Resident #4's shoulder with his hand and used his feet to kick Resident #4's wheelchair. Resident #4's wheelchair flipped over and fell to the ground. Staff #40 said that she had clothes in her hand, so she put the clothes down, and went over to the day room, and called for help. After Staff #40 called for help, the staff members came over to help Resident #5 and Resident #4.A phone interview was conducted on 4/16/2026, at 3:28 PM with a Registered Nurse (RN/Staff #43). Staff #43 stated that an end incident was witnessed at the end of March 2026, by a laundry staff member. Staff #43 stated that Resident #4 was at the bottom of the ramp, on his backside, and his wheelchair tipped over. Resident #5 was at the top of the ramp to the day room. Staff #43 stated that he was the nurse for Resident #4 and Resident #5 on the day of the incident, but did not witness the incident between Resident #4 and Resident #5. Staff #43 said that he noticed Resident #4 on the floor and he called another nurse. They separated Resident #4 and Resident #5. Resident #5 went back to his room while Resident #4 was taken to the day room. Resident #4 was assessed and Resident #4 was sent out to the emergency room because he was on aspirin. Resident #4 returned back to the facility that same evening, and Resident #4 did not have injury. An interview was conducted on 4/17/2026, at 11:33 AM with the DON (Staff # 80). The DON stated that her responsibilities included assessing the department to make sure that the staff are following the policies and procedures; auditing to make sure all care required were being completed, and if not followed, she would do an in-service to the staff as to why the polices and procedures are put in place; and assisting nurses. Regarding abuse, the DON stated that abuse could be physical, verbal, and when residents receive inappropriate care. She said that physical abuse such as an altercation between residents include laying a hand and or using an object to hit another resident. She said that a verbal abuse is when a resident is calling a resident bad name. The DON said that her plan was to educate her staff before an abuse happens by being proactive not reactive. Her plan also included tracking and trending abuse, on what unit, and tracking and trending the time and day when an abuse happens. The DON also stated that she had created a behavioral care book with a behavioral care plan, which specifies specific triggers per resident. Regarding the incident involving Resident #6 and Resident #7, the DON stated that the training CNAs reported the incident because they were standing at the doorway while Resident #6 and Resident #7 were yelling at each other, Resident #6 picked up the folded table and swung at Resident #7, and Resident #6 and Resident #7 were immediately separated. The DON stated that the it was the training CNAs first night in the facility, and they were just there to observe. The DON said that there were no CNA staff members in the incident room when the incident between Resident #6 and Resident #7 happened because the CNAs were assisting other residents. The DON said that the nurse was supposed to be looking at the window while preparing the medications. Further, the DON stated that when residents are in the common area, there should always be a staff member observing them. The DON said that the nurse did not provide full attention because she was preparing the medications. The DON said that her expectation was that there should be a CNA staff member at the area at all times to try to eliminate a resident to resident altercation from happening. The DON said that if she had a CNA physically sitting at the area, and 2 residents are arguing, the CNA could have pulled and redirected the residents. The DON stated that the incident between Resident #6 and Resident #7 did not have a CNA who was physically in the common area and there was no CNA supervision. She did not expect the training CNAs to approach the residents and to deescalate because the training CNAs do not have the experience yet, and it would be more of a risk if the training CNAs do not know what to do. Regarding the incident between Resident #2 and Resident #3, the DON stated that the police officer witnessed Resident #2 hit the shoulder of Resident #3. The DON stated that Resident #2 made physical contact with Resident #3. Further, the DON said that Resident #2 was getting more agitated because Resident #2 wanted more smoking time and the staff informed Resident #2 that it was not time to smoke yet. The DON said that she expected her staff to redirect the Resident and to keep the smoking schedule. The DON said that if she was the nurse on duty, she would have taken Resident #2 to have a cigarette to try to calm him down. Regarding Resident #4 and Resident #5 incident, the DON stated that the incident happened outside, the ramp was narrow, one person at a time can only come up and down, and the incident involved one resident was coming up the ramp while the other resident was going down the ramp. The DON said that the CNAs do their rounding outside every 15-minutes. The DON said that she does not want her CNAs just inside the common area. The DON said that she was glad that the housekeeper staff saw what happened between Resident #4 and Resident #5, and that the houseke

Based on the review of the clinical records, staff interviews, and review of facility's policy and procedure, the facility failed to ensure a PASRR Level 2 (pre-admission screening and resident review) was submitted for one residents (#2) to the appropriate state-designated authority . The deficient practice could result in residents' medically related social and emotional needs not being met.Findings include:Resident #2 was admitted to the facility on [DATE], with a primary diagnosis of Schizoaffective Disorder.Resident #2's Pre-admission Screening and Resident Review (PASRR) Level 1 was completed on 2/26/2026. Per document, the Resident has a serious mental illness, Schizophrenia, and a Level 2 referral for mental illness was necessary.A review of the Resident's Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating that the resident's cognition was intact. The Resident did not exhibit behavioral symptoms. The Resident's active diagnosis included Schizophrenia. The Resident was taking Antianxiety and Antipsychotic medications on a routine basis.A Behavioral Care Plan progress note with an effective of 3/11/2026, was reviewed. The document revealed that the Resident's current behaviors included verbal and physical aggression (posturing, threats) and exit- seeking. The interventions included that the Resident may display verbal or physical aggression when he feels frustrated, overwhelmed, or perceives a loss of control, and that these behaviors may be his way of expressing distress or attempting to regain a sense of power. The staff should remain calm, maintain a safe distance, avoid arguing or escalating the interaction, use steady, respectful tone, offer space for the Resident to de-escalate while redirecting the Resident to a quieter area if possible. Once the Resident begins to settle, offer the Resident simple choices and supportive guidance while maintaining clear boundaries and prioritizing safety.On April 16, 2026, at 3:29 PM, the Administrator (Staff #88) provided a document revealing that the facility did not have Level 2 PASRR for Resident #2.An interview was conducted on 4/17/2026 at 10:11 AM with the Social Service Director (Staff #50) and present during the interview was another Social Service staff member (Staff #55). Regarding PASRR, the Social Service Director stated that when a resident is admitted to their facility and the resident did not come in with a PASRR, she would complete a Level 1 PASRR for the resident. She said that if the resident had a diagnosis of Schizophrenia, she would send a Level 2 referral by submitting the document electronically to Arizona Health Care Cost Containment System (AHCCCS). Regarding Resident #2's PASRR, the Social Service Director stated that Resident #2 was admitted for a long term stay at the facility, and that she completed Resident #2's Level 1 PASRR. She further stated that Resident #2 did not have a Level 2 because she did not submit the document to AHCCCS for a referral. The Social Service Director stated that the reason for submitting a referral for determination for Level 2 for a resident was to make sure that the resident was appropriate for the facility and the environment to meet the resident's needs. The Social Service Director stated that Resident #2 was taken by the police to the hospital for an evaluation because Resident #2 became violent with his behaviors.An interview was conducted on 4/17/2026, at 11:33 AM with the DON (Staff # 80). Regarding PASRR for Resident #2, the DON stated that Resident #2 was admitted with a Schizoaffective Disorder as his main diagnosis. The DON stated that Resident #2 was in a secured unit, and Resident #2 was being followed by their facility psychiatric provider. The DON said that she does not know a lot about PASRR. The DON said that she was informed that Resident #2 did not have a Level 2 PASRR referral submitted to AHCCCS.According to AHCCCS, Preadmission Screening and Resident Review (PASRR) is guided by federal regulations that require all individuals being considered for admission to a Medicaid-certified nursing facility (NF) be screened prior to admission, to determine if the person has, or is suspected of having, a mental illness, intellectual disability, or related condition. The PASRR helps to ensure that individuals are not inappropriately placed in nursing homes for long term care. The PASRR requires that: 1) all applicants to a Medicaid-certified nursing facility be evaluated for mental illness (MI) and/or intellectual disability (ID);2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care settings); and3) receive the services they need in those settings including specialized services.

Based on staff interviews, review of clinical record and policy review, the facility failed to protect the rights of twelve of twelve residents sampled (#1, #3, #5, #7, #9, #2, #4, #6, #8, #10, #13, and #16) to be free from physical abuse from each other. The deficient practice could result in continued resident to resident abuse. Findings include: Regarding Resident #4 on Resident #6 abuse: Resident #6 was admitted on [DATE], with diagnoses of dementia, mood disorder, anxiety disorder, and psychotic disorder. The care plan initiated on October 8, 2025, revealed the resident had behaviors of yelling, wandering, delusional thinking, and a history of making false allegations against residents and staff. Interventions included redirection, administering medications, and assistance developing appropriate methods of coping and interacting. The quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 04, indicating severe cognitive impairment. The Behavior Charting dated February 20, 2026, indicated the resident was yelling, screaming, cursing, and had an abrasive tone. A nurse's note dated February 20, 2026, revealed that Resident #6 approached the nurse's station crying and reported she was hit by Resident #4 in the nose. The note stated the residents were placed on 15-minute safety checks and closely monitored. -Resident #4 was admitted on [DATE], with diagnoses that included personality disorder, anxiety disorder, adjustment disorder, and depression. The care plan initiated on August 12, 2025, revealed the resident had behaviors consisting of placing herself on the floor, refusing care and medications, making false accusations, fabricating stories, and going into other resident's rooms and breaking their personal items. Interventions included allowing the resident time, encouragement to verbalize concerns, administering medications, education, explanation of why behavior is inappropriate, and checking for safety and comfort. Review of the quarterly MDS dated [DATE], revealed the resident had a BIMS score of 13, indicating the resident was cognitively intact. A nurses note dated February 20, 2026, revealed the resident stated she was tired of resident #6 opening her door. The facility incident report received on March 12, 2026, revealed that Resident #6 entered into Resident #4's room un-invited and Resident #4 punched Resident #6 in the nose. The facility report also revealed that staff separated the residents and Resident #6 was redirected out of Resident #4's room and placed on 15-minute supervisory checks. An interview was conducted on March 11. 2026, at 3:18 PM with Licensed Practical Nurse (LPN, Staff #182). She stated Resident #4 likes to stay in her room or sit just outside her door so she can enjoy the sunshine. The resident does not like anyone getting too close to her and prefers to be left alone. Resident #6 enjoys walking around and has a behavior of going into other resident rooms. She stated on February 19, 2026, Resident #6 was very agitated, pacing, cursing, and argumentative and Resident #4 was sitting outside of her room. The LPN said both residents appeared to be irritated with each other. Resident #6 began crying and yelling that Resident #4 hit her in the face. She stated both residents were separated and there had not been any more incidents. She stated the staff have implemented having an aide sit in the common area with the residents, where they can observe everyone and deescalate any situations quickly. Staff #182 stated all behaviors should be documented in the care plan; however, the nursing staff do not have access to the care plan to update. The LPN stated the MDS nurse updates the care plan. An interview was conducted on March 11, 2026, at 3:45 PM with Certified Nursing Assistant (CNA, Staff #178). She stated if a resident to resident altercation occurs she will intervene and stop the conflict, ensure the safety of both residents, assess for injuries, obtain vitals, report the incident and keep the residents separated. She stated communication regarding resident to resident altercations are communicated to staff through means of report and documentation in the clinical record. She stated staff receive training for abuse quarterly which is usually completed via computer course or an in-service, however the facility does not have a designated staff member to conduct continued education. She stated she is confident the residents are safe with the training staff receive. Regarding Resident #8 on Resident #10: Resident #10 was readmitted to the facility on [DATE], with diagnoses of parkinsonism and Alzheimer's Disease. The care plan initiated on December 13, 2025, revealed the resident had a psychosocial well-being problem related to a resident to resident altercation. Interventions included 72-hour observation, consultation with pastoral care, social services, and psychiatric services, and allow the resident to vent/share feelings. The comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 07, indicating severe cognitive impairment. An Alert Nursing Note dated February 12, 2026, revealed the resident was moved away from his roommate (#8) because resident #10 stated he hit me. A skin assessment revealed Resident #10 had a purple/blue bruise under his left eye. Resident #8 was admitted on [DATE], with diagnoses of parkinsonism, major depressive disorder, psychotic disorder, and anxiety disorder. The care plan initiated on November 13, 2025, revealed the resident had behaviors of putting himself on the floor trying to hide from people, including hiding in the closet or under his bed, refusing care and telling his family no one is offering him anything. Interventions included administering medications, providing positive interaction, explaining why behavior is inappropriate, intervening to protect the rights and safety of others, divert attention, and removing the resident from the situation. A Behavior Inter-Disciplinary Team (IDT) Review Care Plan dated February 13, 2026 included when Resident #8 showed signs of agitation, anxiety, or restlessness, approach should be completed in a calm and soothing manner, guidance to a quiet safe space, encourage slow deep breathing or offer a calming activity. The comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 03, indicating severe cognitive impairment. An IDT note dated February 13, 2026, revealed Resident #8 accused Resident #10 of stealing millions of dollars from him and punched Resident #10 in the eye. The facility investigation report received on February 17, 2026, completed by the Administrator, stated a comprehensive investigation was completed using resident interviews and staff interviews and was found that the incident did not happen, however after further review it was determined to be an accident. An interview was conducted on March 12, 2026, at 11:30 AM with LPN (staff #58). She stated Resident #8 has many behaviors and delusions/hallucinations, however, the resident was easily redirected. She stated when the resident becomes agitated escalation occurs quickly. A behavior often exhibited was accusing someone of stealing his four million dollars. An interview with DON (Staff # 167) on March 12, 2026 at 12:51 p.m., revealed that the facility is a behavioral facility and you never know what the behaviors will be or when they manifest. The DON revealed that when she started working here 5 weeks ago there were a lot of resident to resident altercations and when a resident hits another resident that is abuse which is required to be reported. The DON identified one area that staff needed to work on was identifying when residents get into the personal space of other residents and be proactive before the abuse happens. An interview was conducted on March 12, 2026, at 2:55 PM with CNA (Staff #209). He stated staff frequently attempted to keep Resident #8 busy in the dayroom with activities. The CNA said when the Resident becomes agitated he will start to curse and sometimes just sitting with him 1:1 can deescalate him. An interview was conducted on March 12, 2026, at 3:41 PM with CNA (Staff #57). She stated on February 12, 2026, between 3:00 and 4:00 PM, she was in the dayroom when she heard Resident #10 yell help. She saw Resident #8 standing over Resident #10, who was in bed, with his feet up toward Resident #8. The CNA stated she assisted Resident #8 back to bed and asked Resident #10 what happened. Resident #10 stated Resident #8 accused him of stealing four million dollars and then hit him in the eye. The CNA stated she saw purple and blue discoloration under his left eye. The CNA stated she reported the incident to the nurse and then removed Resident #8 from the room. She then got vitals on Resident #10. The CNA stated Resident #10 becomes agitated and escalates quickly. One of his behaviors included accusing residents of stealing his four million dollars. She stated this is the first time she had observed Resident #8 hitting another resident. She said Resident #8's current behavior was stealing food and drinking his roommate's beverages. Staff will intervene and redirect often. Regarding Resident #13 on Resident #16: Resident #16 was admitted on [DATE], with diagnoses of bipolar, anxiety disorder, major depressive disorder, and post-traumatic stress disorder (PTSD). The comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 04 indicating severe cognitive impairment. A nursing note dated March 7, 2026, documented the resident's right wrist was grabbed and squeezed hard by another resident. The care plan dated March 8, 2026, revealed the resident had a psychosocial well-being problem related to a resident to resident altercation. Interventions included 72-hour observation, consultation with pastoral care, social services, and psychiatric services, monitor and document resident's response to problems, and when conflict arises, remove resident to calm, safe environment and allow them to vent/share feelings. Resident #13 was admitted on [DATE], with diagnoses of dementia, and major depressive disorder. The care plan initiated on October 28, 2025, revealed the resident had potential to be physically aggressive related to dementia. Interventions included 1:1 as indicated, administer medications as ordered, assess and address contributing sensory deficits, and monitoring, documenting, and reporting signs or symptoms of the resident posing a danger to himself or others. The quarterly MDS dated [DATE], revealed a BIMS score of 06, indicating severe cognitive impairment. The nurse's note dated March 7, 2026, revealed the resident grabbed another resident and they were both separated and removed from the situation. An interview was conducted on March 12, 2026, at 3:18 PM with Registered Nurse (RN, Staff #103). She stated Resident #16 was drawn to automatic doors. He appeared to be fascinated by them and was usually standing close to them which required redirection. The RN stated Resident #13's behavior is trying to be helpful. If he saw another resident trying to do something they should not be doing he intervened. She stated that is why Resident #13 grabbed Resident #16's wrist to try to pull him away from the automatic doors. She stated she receives in-services and computer-based classes for abuse training. She said the residents are safe due to the extensive abuse training received. Regarding Resident # 1 and Resident # 3: Resident # 3 was admitted on [DATE], with diagnoses that included senile degeneration of brain, alcohol cirrhosis, anxiety disorder, major depressive disorder, and unspecified dementia. The Resident's care plan initiated on June 6, 2025, revealed that the Resident is a fall risk with multiple falls due to gat balance problems. Further review of the care plan revealed an intervention that included anticipating and meet the resident's needs. The Resident's care plan initiated on June 6. 2025, revealed that Resident #3 has the potential to be verbally aggressive due to dementia and poor impulse control. The Interventions included analyzing key times, places and circumstances, triggers, and what de-escalates behavior and document. Further review of interventions revealed that when Resident #3 becomes agitated, intervene before agitation escalates and Guide away from source of distress. A Change of Condition Minimum Data Set (MDS) assessment dated [DATE], revealed a BIMS score of 6 indicating severe cognitive impairment. Further review of the MDS revealed that the Resident was taking Antipsychotic, Antidepressant medications. A nurses note dated February 7, 2026, revealed that Resident # 3 had punched a CNA while providing care. The nurses note also revealed that the Resident had been physically abusive and growling and making threatening faces and putting his hands up to fight anyone who would walk by him regardless if it was a patient or another resident. An incident note dated February 11, 2026, revealed that Licensed Practical Nurse (LPN/Staff # 182), witnessed Resident # 1 kicking Resident # 3, three times on the left thigh before Staff # 182 could reach Resident # 3 and redirect both residents. A care plan initiated February, 11, 2026, revealed that Resident # 3 had a psychosocial well-being problem related to a resident to resident altercation. Interventions included monitor and document resident's unusual response to problems and 72-hour observations. An Interdisciplinary Team (IDT) meeting note dated February 12, 2026, revealed that Resident #3 was kicked by Resident # 1, The IDT note also revealed that both residents were separated, placed on 15 minute checks for 72 hours. IDT interventions included monitoring and documenting resident's unusual response to problems and if conflict arises remove residents to a calm safe environment. Resident # 1 was admitted on [DATE], with diagnoses schizoaffective disorder, bipolar type, unspecified dementia with agitation, and other psychoactive substance abuse. A resolved care plan focus initiated on August 8, 2024 revealed that Resident # 1 was at risk for psychosocial emotional distress related to a resident-to-resident altercation. Interventions included monitoring for psychosocial emotional distress for 72 hours. Further review of the care plan revealed that this focus was resolved on January 31, 2025 and removed from the active care plan. A behavior note dated August 8, 2024 revealed that Resident # 1 was observed assaulting another resident after being told to shut up by the resident. The behavioral note also revealed that while the nurse was trying to break up the fight Resident #1 turned his anger on the nurse, threatening to hit the nurse. A care plan initiated on October 27, 2025 revealed problems related to dementia, schizoaffective bipolar disorder exhibiting verbal aggression, being demanding and psychotic thinking. Interventions include attempt to determine cause if aggression and promptly address needs. Further review of the active care plan revealed no history of physical aggression. An annual MDS assessment dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment. Further review of MDS assessment revealed no behaviors indicated. An incident note dated February 11, 2026, revealed that Licensed Practical Nurse (LPN/Staff # 182), witnessed Resident # 1 kicking Resident # 3, three times on the left thigh before Staff # 182 could reach Resident # 3 and redirect both residents. A care plan initiated February, 11, 2026, revealed that Resident # 1 had a psychosocial well-being problem related to a resident to resident altercation. Interventions included monitor and document resident's unusual response to problems and 72-hour observations. A Social Services note dated February 13, 2026, revealed that a care plan meeting was held on February 11, 2026 revealed that the resident to resident was discussed including interventions of a room change and follow up with psychiatry services. The facility investigation report received February 13, 2026, revealed that Resident # 1 made contact with Resident # 3 during an altercation. The facility report also revealed that staff reacted after the incident started but did not indicate what preemptive interventions were utilized despite the history of physical behaviors for both residents. An Interview with LPN (Staff # 182) on March 11, 2026, at 2:59 p.m., revealed that while she was working on the computer at the nurses' station she looked up and saw Resident # 1 kick Resident # 3 several times in the thigh. Staff # 182 also revealed that other aides arrived and they separated the residents to other sides of the building. Staff # 182 revealed that is was her first day on that floor and stated the advice she was given about Resident # 1's behaviors was not to get on his bad side. An interview with Certified Nursing Assistant (CNA/Staff # 79) on March 12, 2026 at 2:11 p.m., revealed that Resident # 3 was walking by Resident # 1 and witnessed Resident # 1 kick Resident # 3. Staff # 79 also revealed that Resident # 1 gets upset when he does not get his cigarettes or a Coke when he wants one. Staff # 79 stated he will get verbally abusive and physically lash out when he gets frustrated. Staff # 79 also stated that he has seen Resident # 1 get frustrated when residents or staff walk Infront of the television. He revealed that Resident # 3 had been wandering a lot and probably got Infront of the television causing Resident # 1 to kick him. An interview with Director of Nursing (DON/Staff # 167) on March 12, 2026 at 12:51 p.m., revealed that the facility is a behavioral facility and behaviors are unpredictable. The DON revealed that when she started working at the facility 5 weeks ago there were a lot of resident-to-resident altercations and when a resident hits another resident that is abuse which is required to be reported. Regarding Resident # 5 and Resident # 7: Resident # 7 was admitted on [DATE], with diagnoses that included post traumatic stress disorder, major depressive disorder, and mood affective disorder. A care plan focus initiated on July 22, 2025, revealed that Resident # 7 had impaired cognitive function or impaired thought process related to Alzheimer's disease. Interventions included cueing, reorienting, and supervising as needed. Further review of the active care plan did not reveal any concern of physical aggression. An Incident Note on August 3, 2025, revealed that Resident # 7 was involved in a resident-to-resident altercation and hit another resident in the face. An Incident Note on December 24, 2025, revealed that Resident # 7 was involved in a resident-to-resident altercation with physical aggression. Resident # 7 was observed leaning over other resident hitting him repeatedly. A nurses note dated February 14, 2026, revealed that at 7:20 p.m. CNA (Staff # 178) who was assigned to Resident # 7 reported to the nurse that Resident # 7 had a personal altercation outside. When Resident # 7 came into the dining room he had a witnessed fall. An incident note dated February 14, 2026, revealed that Resident # 5 hit Resident # 7 in the stomach while the other resident was wandering in the dining room. Regarding Resident # 5 Resident # 5, the perpetrator, was admitted on [DATE], with diagnoses that included vascular dementia, cognitive communication deficit, anxiety disorder, and violent behavior. A care plan focus initiated on October 13, 2025, revealed that Resident # 5 displayed behaviors at prior placement, of refusal of medications and activities. The care plan also revealed that Resident # 5 urinated in inappropriate places and exhibited intrusive wandering. Interventions included intervening as necessary to protect the rights and safety of others and approach or speak in a calm manner. A Behavior Note dated December 20, 2025, revealed Resident # 5 started arguing with another resident and they started swinging at each other. A Behavioral Care Plan dated January 10, 2026, revealed Resident # 5's current behaviors are anxiety and screaming/agitation with a known trigger of feeling anxious. Further review of the behavioral care plan revealed no past behaviors of physical aggression even though Resident # 5 was involved in a resident-to-resident altercation 20 days prior. A nurses note dated February 14, 2026, revealed that CNA (Staff # 178) reported that Resident # 5 was involved in a resident-to-resident altercation punching Resident # 7 in the stomach. A facility investigation received February 19, 2026, revealed that the facility determined the incident had occurred. An interview conducted with CNA (Staff # 178) on March 11, 2026 at 3:29 p.m., revealed that Resident # 5 was very agitated that day and he was ranting about something he saw outside. Staff # 178 stated that Resident # 7 inserted himself into the conversation and wanted to help. Resident # 7 started helping Staff # 178 push Resident # 5's wheelchair. Staff # 178 revealed that Resident # 5 does not like anyone touching him including staff and when Resident # 5 realized Resident # 7 had placed his hands on Resident # 5's wheelchair, Resident # 5 stood up and punched Resident # 7 in the stomach. An interview conducted on March 12, 2026 at 2:22 p.m. with Registered Nurse (RN/Staff # 160) revealed that Resident #5's biggest trigger for agitation is taking a shower and being touched. Staff # 160 revealed that they usually leave him alone and try to approach him again. Staff # 160 revealed that from time to time Resident # 7 likes to help and push other residents around in a wheelchair even though there are residents that do not like being touched or other residents in their space. An interview with DON (Staff # 167) on March 12, 2026 at 12:51 p.m., revealed that the facility is a behavioral facility and you never know what the behaviors will be or when they will manifest. The DON revealed that when she started working here 5 weeks ago there were a lot of resident-to-resident altercations and when a resident hits another resident that is abuse which is required to be reported. The DON identified one area that staff needed to work on was identifying when residents get into the personal space of other residents and be proactive before the abuse happens. Regarding Resident # 9 and Resident # 2: Resident # 2 was admitted on [DATE], with diagnoses that included cerebrovascular disease, and anxiety disorder. An admission MDS dated [DATE], revealed a BIMS score of 8, indicating moderate cognitive impairment. A nurses note dated February 19, 2026, revealed Resident # 2 was sitting in the day room and told staff that he was hit in the head by his roommate Resident # 9. The nurses revealed that Resident # 9 hit Resident # 2 on left side of the head because Resident # 9 wanted Resident # 2's blanket. Resident # 9 took Resident # 2's blanket and Resident # 9 went back to bed. A social services note dated February 19, 2026 revealed that Resident # 2 was moved to a different room. Resident # 9 was admitted on [DATE], with diagnoses that included Alzheimer's disease, dementia with agitation, personality change, major depressive disorder, and anxiety disorder. A behavior note dated July 15, 2024, revealed that Resident #9 was stealing other resident's food off the counter and becoming combative during redirection back to room after finishing breakfast. A behavior note dated July 23, 2024, revealed that Resident # 9 was taking other residents food after finishing his. A behavior note dated November 23, 2024, revealed that during lunch Resident # 9 reached over and took another resident's cake. A behavioral treatment plan dated December 19, 2025, revealed Resident # 9's current behaviors are sexually inappropriate and isolative behavior with known triggers of female staff assisting in cares. Further review of the behavioral treatment plan revealed past behaviors including elopement and exposing himself. There was no indication that Resident # 9 had a history of taking other Resident's food. A care plan focus initiated on December 24, 2025, revealed that Resident # 9 had a behavior problem related to sexual inappropriateness, history of delusions, elopement risk, and self-isolation. Further review of the care plan revealed interventions which included cares in pairs, and following a behavior plan. A quarterly MDS assessment dated [DATE], revealed a BIMS score of 7, indicating severe cognitive impairment. The MDS assessment also revealed that Resident # 9 also experienced other behaviors for 1 to 3 days which include sexual acts. A nurses note dated February 19, 2026, revealed Resident # 9's roommate, Resident # 2, claimed he was struck by Resident # 9 on the side of the head and Resident # 9 took Resident # 2's blanket. The nurses note revealed that Resident # 9 admitted to hitting Resident # 2 in the head because he wanted Resident # 2's blanket. A facility investigation report received, February 24, 2026, revealed that the facility confirmed the incident happened based on resident interviews and review of the recorded incident which indicated that the incident occurred. During an interview with Resident # 2 on March 11, 2026 at 10:34 a.m., Resident # 2 said that he did not like his roommate, calling him an ass. Resident # 2 stated that Resident # 9 hit him in the head. Resident # 2 took his hat off and pointed to the left side of his head. Resident # 2 revealed that his room was moved away from him but wanted to leave the facility. An observation with Resident # 9 on March 11, 2026 at 10:46 p.m. revealed the resident lying in his bed with a blanket wrapped around him covering his head. Resident # 9 did not speak; his response was to nod his head. A review of the room revealed no other resident currently occupying the other bed. An interview with CNA (Staff # 79) on March 12, 2026 at 2:11 p.m. revealed that he had never known Resident # 9 to be physically aggressive or to take belongings from other residents. Staff # 79 revealed that Resident # 9 can be handsy with female staff and that's one of the reasons why he primarily works on that unit. Staff # 79 revealed that he did not see the incident with Resident # 2 but heard from Resident # 2 that Resident # 9 hit Resident # 2 and took his blanket because Resident # 9 was cold. An interview with RN (Staff # 103) on March 12, 2026 at 3:18 p.m., revealed that one of Resident # 9's behaviors was to be sexually inappropriate. The RN stated that care staff always does cares in pairs. Staff # 103 said that Resident # 9 grabs female staff and is inappropriate with them. Staff # 103 further stated that Resident # 9 was not known as physical and can be redirectable. An interview with CNA (Staff # 107) on March 13, 2026 at 10:12 a.m., revealed that Resident # 9 is an easy-going guy who likes to stay in his bedroom. Staff # 107 revealed that if Resident # 9 wants something he is going to try and take it. Staff # 107 stated that they try to redirect him before he takes something that does not belong to him. Staff #107 said most residents in their rooms are checked on hourly unless they are on 15 min checks. An interview with Director of Nursing (DON/Staff # 167) on March 12, 2026 at 12:51 p.m., revealed that the facility is a behavioral facility and you never know what the behaviors will be or when they will manifest. The DON stated that when she started working here 5 weeks ago there were a lot of resident-to-resident altercations and when a resident hits another resident that is abuse which is required to be reported. An interview with Administrator (Staff # 60) on March 13, 2026 at 11:34 a.m., revealed that he conducted the investigation and determined that it was a cold night and Resident # 9 was cold and decided he wanted Resident # 2's blanket. Staff # 60 stated that it was determined that the incident occurred because Resident # 2 was consistent in his recollection of the incident and his BIMs score was high enough to believe him. A policy and procedure titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Revised April 2021, revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The policy also revealed that it includes physical abuse.

Based on interviews, clinical record and policy review, the facility failed to update comprehensive care plans related to individualized resident triggers so residents may attain the highest practical physical, mental, and psychosocial well-being for twelve of twelve residents sampled (#1, #3, #5, #7, #9, #2, #4, #6, #8, #10, #13, and #16) to be free from abuse from each other. The deficient practice could result in a plan of care that did not meet the resident's needs and lead to continued resident to resident abuse. Findings include: Regarding Resident #6 and resident #4: Resident #6, the victim, was admitted on [DATE], with diagnosis of dementia, mood disorder, anxiety disorder, and psychotic disorder. The care plan initiated on October 8, 2025, revealed the resident had behaviors of yelling, wandering, delusional thinking, and a history of making false allegations against residents and staff. Interventions included redirection, administering medications, and assistance developing appropriate methods of coping and interacting. The quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) of 04, indicating severe cognitive impairment. The Behavior Charting dated February 20, 2026, indicated the resident was yelling, screaming, cursing, and had an abrasive tone. Staff knowledge of behaviors and interventions are not reflected in the resident care plan. A nurse's note dated February 20, 2026, revealed that Resident #6 approached the nurse's station crying and reported she was hit by Resident #4 in the nose. The note stated the residents were placed on 15-minute safety checks and closely monitored. Resident #4, the perpetrator, was admitted on [DATE], with diagnoses that included personality disorder, anxiety disorder, adjustment disorder, and depression. The care plan initiated on August 12, 2025, revealed the resident had behaviors consisting of placing herself on the floor, refusing care and medications, making false accusations, fabricating stories, and going into other resident's rooms and breaking their personal items. Interventions included allowing the resident time, encouragement to verbalize concerns, administering medications, education, explanation of why behavior is inappropriate, and checking for safety and comfort. The quarterly MDS dated [DATE], revealed the resident had a BIMS score of 13, indicating the resident was cognitively intact. A nurses note dated February 20, 2026, revealed the resident stated she was tired of resident #6 opening her door. The facility incident report received on March 12, 2026, revealed that Resident #6 entered into Resident #4's room un-invited and Resident #4 punched Resident #6 in the nose. The facility report also revealed that staff separated the residents and Resident #6 was redirected out of Resident #4's room and placed on 15-minute supervisory checks. An interview was conducted on March 11. 2026, at 3:18 PM with Licensed Practical Nurse (LPN, Staff #182). She stated Resident #4 likes to stay in her room or sit just outside her door so she can enjoy the sunshine. The resident does not like anyone getting too close to her and prefers to be left alone. Resident #6 enjoys walking around and has a behavior of going into other resident rooms. She stated on February 19, 2026, Resident #6 was very agitated, pacing, cursing, and argumentative and Resident #4 was sitting outside of her room. The LPN said both residents appeared to be irritated with each other. Resident #6 began crying and yelling that Resident #4 hit her in the face. She stated both residents were separated and there have not been any more incidents. She stated the staff have implemented having an aide sit in the common area with the residents, where they can observe everyone and deescalate any situations quickly. Staff #182 stated all behaviors should be documented in the care plan; however, the nursing staff do not have access to the care plan to update. The LPN stated the MDS nurse updates the care plan. Staff knowledge of behaviors and interventions are not reflected in the resident care plan. Regarding Resident #10 and resident #8: Resident #10, the victim, was readmitted on [DATE], with diagnosis of parkinsonism and Alzheimer's Disease. The care plan initiated on December 13, 2025, revealed the resident had a psychosocial well-being problem related to a resident to resident altercation. Interventions included 72-hour observation, consultation with pastoral care, social services, and psychiatric services, and allow the resident to vent/share feelings. The comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 07, indicating severe cognitive impairment. An Alert Nursing Note dated February 12, 2026, revealed the resident was moved away from his roommate (#8) because he stated he hit me. A skin assessment revealed Resident #10 had a purple/blue bruise under his left eye. There is no updated care plan. Resident #8, the perpetrator, was admitted on [DATE], with diagnosis of parkinsonism, major depressive disorder, psychotic disorder, and anxiety disorder. The care plan initiated on November 13, 2025, revealed the resident had behaviors of putting himself on the floor trying to hide from people, including hiding in the closet or under his bed, refusing care and telling his family no one is offering him anything. Interventions included administering medications, providing positive interaction, explaining why behavior is inappropriate, intervening to protect the rights and safety of others, divert attention, and removing the resident from the situation. A Behavior Inter-Disciplinary Team (IDT) Review Care Plan dated February 13, 2026 included when Resident #8 showed signs of agitation, anxiety, or restlessness, approach should be completed in a calm and soothing manner, guidance to a quiet safe space, encourage slow deep breathing or offer a calming activity. The comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 03, indicating severe cognitive impairment. An IDT note dated February 13, 2026, revealed Resident #8 accused Resident #10 of stealing millions of dollars from him and punched Resident #10 in the eye. The facility investigation report received on February 17, 2026, completed by the Administrator, stated a comprehensive investigation was completed using resident interviews and staff interviews and was found that the incident did not happen, however after further review was determined to be an accident. An interview was conducted on March 12, 2026, at 11:30 AM with LPN (staff #58). She stated Resident #8 has many behaviors and delusions/hallucinations, however, the resident was easily redirected. She stated when the resident becomes agitated escalation occurs quickly. A behavior often exhibited was accusing someone of stealing his four million dollars. The LPN stated twice a month abuse training is conducted by the Director of Nursing (DON), the Administrator, and one of the Unit Managers. She said completed computer-based courses on abuse and protocols for abuse are posted at the nurse's station. An interview with DON (Staff # 167) on March 12, 2026 at 12:51 p.m., revealed that the facility is a behavioral facility and you never know what the behaviors will be or when they manifest. The DON revealed that when she started working here 5 weeks ago there were a lot of resident to resident altercations and when a resident hits another resident that is abuse which is required to be reported. The DON identified one area that staff needed to work on was identifying when residents get into the personal space of other residents and be proactive before the abuse happens. An interview was conducted on March 12, 2026, at 2:55 PM with CNA (Staff #209). He stated staff frequently attempted to keep Resident #8 busy in the dayroom with activities. The CNA said when the Resident becomes agitated he will start to curse and sometimes just sitting with him 1:1 can deescalate him. An interview was conducted on March 12, 2026, at 3:41 PM with CNA (Staff #57). She stated on February 12, 2026, between 3:00 and 4:00 PM, she was in the dayroom when she heard Resident #10 yell help. She saw Resident #8 standing over Resident #10, who was in bed, with his feet up toward Resident #8. The CNA stated she assisted Resident #8 back to bed and asked Resident #10 what happened. Resident #10 stated Resident #8 accused him of stealing four million dollars and then hit him in the eye. The CNA stated she saw purple and blue discoloration under his left eye. The CNA stated she reported the incident to the nurse and then removed Resident #8 from the room. She then got vitals on Resident #10. The CNA stated Resident #10 becomes agitated and escalates quickly. One of his behaviors included accusing residents of stealing his four million dollars. She stated this is the first time she had observed Resident #8 hitting another resident. She said Resident #8's current behavior was stealing food and drinking his roommate's beverages. Staff will intervene and redirect often. Staff knowledge of behaviors and interventions are not reflected in the resident care plan. Regarding Resident #16 and resident #13: Resident #16, the victim, was admitted on [DATE], with diagnoses of bipolar, anxiety disorder, major depressive disorder, and post-traumatic stress disorder (PTSD). Review of the comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 04 indicating severe cognitive impairment. Review of a nursing note dated March 7, 2026, documented the resident's right wrist was grabbed and squeezed hard by another resident. Review of the care plan dated March 8, 2026, revealed the resident had a psychosocial well-being problem related to a resident to resident altercation. Interventions included 72-hour observation, consultation with pastoral care, social services, and psychiatric services, monitor and document resident's response to problems, and when conflict arises, remove resident to calm, safe environment and allow them to vent/share feelings. Resident #13, the perpetrator, was admitted on [DATE], with diagnosis of dementia, and major depressive disorder. Review of the care plan initiated on October 28, 2025, revealed the resident had potential to be physically aggressive related to dementia. Interventions included 1:1 as indicated, administer medications as ordered, assess and address contributing sensory deficits, and monitoring, documenting, and reporting signs or symptoms of the resident posing a danger to himself or others. Review of the quarterly MDS dated [DATE]. 2026, revealed a BIMS score of 06, indicating severe cognitive impairment. Review of nurse's note dated March 7, 2026, revealed the resident grabbed another resident and they were both separated and removed from the situation. An interview was conducted on March 12, 2026, at 3:18 PM with Registered Nurse (RN, Staff #103). She stated Resident #16 was drawn to automatic doors. He appeared to be fascinated by them and was usually standing close to them which required redirection. The RN stated Resident #13's behavior is trying to be helpful. If he saw another resident trying to do something they should not be doing he intervened. She stated that is why Resident #13 grabbed Resident #16's wrist to try to pull him away from the automatic doors. She stated she receives in-services and computer-based classes for abuse training. She said the residents are safe due to the extensive abuse training received. Staff knowledge of behaviors and interventions are not reflected in the resident care plan. Regarding Resident #3 and resident #1: Resident # 3, the alleged victim, was admitted on [DATE], with diagnoses that included senile degeneration of brain, alcohol cirrhosis, anxiety disorder, major depressive disorder, and unspecified dementia. A nurses note dated February 7, 2026, revealed that Resident # 3 had punched a CNA while providing care. The nurses note also revealed that the Resident had been physically abusive and growling and making threatening faces and putting his hands up to fight anyone who would walk by him regardless if it was a patient or another resident. An incident note dated February 11, 2026, revealed that Licensed Practical Nurse (LPN/Staff # 182), witnessed Resident # 1 kicking Resident # 3, three times on the left thigh before Staff # 182 could reach Resident # 3 and redirect both residents. A care plan focus initiated February, 11, 2026, revealed that Resident # 7 had a psychosocial well-being problem related to a resident to resident altercation. Interventions included 72 hour observations, consultation with pastoral care, social services, and psych services, monitor and document resident's unusual response to problems and when conflict arises, remove residents to calm safe environment. Resident # 1, the alleged perpetrator, was admitted on [DATE], with diagnoses schizoaffective disorder, bipolar type, unspecified dementia with agitation, and other psychoactive substance. A resolved care plan focus initiated on August 8, 2024 revealed that Resident # 1 was at risk for psychosocial emotional distress related to a resident-to-resident altercation. Interventions included monitoring for psychosocial emotional distress for 72 hours. Further review of the care plan revealed that this focus was resolved on January 31, 2025 and removed from the active care plan. A behavior note dated August 8, 2024 revealed that Resident # 1 was observed assaulting another resident after being told to shut up by that resident. The behavioral note also revealed that while the nurse was trying to break up the fight Resident #1 turned his anger on the nurse, threatening to hit the nurse. A care plan initiated on October 27, 2025 revealed problems related to dementia, schizoaffective bipolar disorder exhibiting verbal aggression, being demanding and psychotic thinking. Interventions include attempt to determine cause if aggression and promptly address needs. Further review of the active care plan revealed no history of physical aggression. An annual MDS assessment dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment. Further review of MDS assessment revealed no behaviors indicated. An incident note dated February 11, 2026, revealed that Licensed Practical Nurse (LPN/Staff # 182), witnessed Resident # 1 kicking Resident # 3, three times on the left thigh before Staff # 182 could reach Resident # 3 and redirect both residents. A care plan focus initiated February, 11, 2026, revealed that Resident # 1 had a psychosocial well-being problem related to a resident to resident altercation. Interventions included 72-hour observations, consultation with pastoral care, social services, and psych services, monitor and document resident's unusual response to problems and when conflict arises, remove residents to calm safe environment. It was noted that Resident # 1's care plan focus was identical to Resident # 3's care plan focus and interventions. Regarding Resident #7 and resident #5: Resident # 7, the alleged victim, was admitted on [DATE], with diagnoses that included post traumatic stress disorder, major depressive disorder, and mood affective disorder. A care plan focus initiated on July 22, 2025, revealed that Resident # 7 had impaired cognitive function or impaired thought process related to Alzheimer's disease. Interventions include cueing, and reorienting and supervising as needed. Further review of the active care plan did not reveal any concern of physical aggression. Review of Incident Note on August 3, 2025, revealed that Resident # 7 was involved in a resident-to-resident altercation and hit another resident in the face. Review of Incident Note on December 24, 2025, revealed that Resident # 7 was involved in a resident-to-resident altercation with physical aggression. Resident # 7 was observed leaning over the other resident hitting him repeatedly. A nurses note dated February 14, 2026, revealed that at 7:20 p.m. CNA (Staff # 178) was assigned to Resident # 7 had reported to the nurse that Resident # 7 had a personal altercation outside. When Resident # 7 came into the dining room he had a witnessed fall. An incident note dated February 14, 2026, revealed that Resident # 5 hit Resident # 7 in the stomach while the other resident was wandering in the dining room. A care plan focus initiated February, 16, 2026, revealed that Resident # 7 had a psychosocial well-being problem related to a resident to resident altercation. Interventions included 72-hour observations, consultation with pastoral care, social services, and psych services, monitor and document resident's unusual response to problems and when conflict arises, remove residents to calm safe environment. Resident # 5, the alleged perpetrator, was admitted on [DATE], with diagnoses that included vascular dementia, cognitive communication deficit, anxiety disorder, and violent behavior. A Behavior Note dated December 20, 2025, revealed Resident # 5 started arguing with another resident and started swinging at each other. Review of a Behavioral Care Plan dated January 10, 2026, revealed Resident # 5's current behaviors are anxiety and screaming/agitation with a known trigger of feeling anxious. Further review of the behavioral care plan reveals past behaviors of physical aggression even though Resident # 5 was involved in a resident-to-resident altercation 20 days prior. A nurses note dated February 14, 2026, revealed that CNA (Staff # 178) reported that Resident # 5 was involved in a resident-to-resident altercation punching Resident # 7 in the stomach. A care plan focus initiated February, 16, 2026, revealed that Resident # 5 had a psychosocial well-being problem related to a resident to resident altercation. Interventions included 72-hour observations, consult with pastoral care, social services, and psych services, monitor and document resident's unusual response to problems and when conflict arises, remove residents to calm safe environment. Regarding Resident #2 and resident #9: Resident # 2, the victim, was admitted on [DATE], with diagnosis that included cerebrovascular disease, and anxiety disorder. A nurses note dated February 19, 2026, revealed Resident # 2 was sitting in the day room and told staff that he was hit in the head by his roommate Resident # 9. The nurses revealed that Resident # 9 hit Resident # 2 on left side of the head because Resident # 9 wanted Resident # 2's blanket. Resident # 9 took Resident # 2's blanket and Resident # 9 went back to bed. A care plan focus initiated February, 19, 2026, revealed that Resident # 2 had a psychosocial well-being problem related to a resident to resident altercation. Interventions included 72-hour observations, consultation with pastoral care, social services, and psych services, monitor and document resident's unusual response to problems and when conflict arises, remove residents to calm safe environment. Resident # 9, the alleged perpetrator, was admitted on [DATE], with diagnoses that included Alzheimer's disease, dementia with agitation, personality change, major depressive disorder, and anxiety disorder. A behavior note dated July 15, 2024, revealed that Resident #9 was stealing other residents' food off the counter and becoming combative during redirection back to room after finishing breakfast. A behavior note dated July 23, 2024, revealed that Resident # 9 was taking other residents food after finishing his. A behavior note dated November 23, 2024, revealed that during lunch Resident # 9 reached over and took another resident's cake. A behavioral treatment plan dated December 19, 2025, revealed Resident # 9's current behaviors are sexually inappropriate and isolative behavior with known triggers of female staff assisting in cares. Further review of the behavioral treatment plan revealed past behaviors including elopement and exposing himself. There was no indication that Resident # 9 had a history of taking other Resident's food. A nurses note dated February 19, 2026, revealed Resident # 9's roommate, Resident # 2 claimed he was struck by Resident # 9 on the side of the head and took Resident # 2's blanket. The nurses note revealed that Resident # 9 admitted to hitting Resident # 2 in the head because he wanted his blanket. A care plan focus initiated February, 19, 2026, revealed that Resident # 2 had a psychosocial well-being problem related to a resident to resident altercation. Interventions included 72-hour observations, consultation with pastoral care, social services, and psych services, and remove residents to calm safe environment. Further review of the affected residents' care plans revealed that all residents involved in a resident-to-resident altercation received the same care plan focus and the same interventions no matter if they were the victim or the perpetrator. Further review of the care plans revealed that previous history of resident-to-resident aggression was not on the active care plan. An interview was conducted with LPN (Staff # 182) on March 11, 2026 at 2:59 p.m. She revealed that most of her information on residents' behaviors was received during shift change or during shift reports. Staff # 182 revealed that she does not have access or does not know how to access the care plan and cannot make changes to the care plan. An interview was conducted with CNA (Staff # 178) on March 11, 2026 at 3:29 p.m. who revealed that if there is a resident-to-resident altercation she would communicate to her nurse and document in the charting system. Staff # 178 stated that she cannot update care plans as she does not have access to care plans but the nurses have access to the care plans. An interview was conducted with Corporate Resource RN (Staff # 220) on March 12, 2026 at 1:27 p.m. revealed that after a resident-to-resident altercation they separate the residents and provide redirection. If the residents involved are roommates, we separate the two parties typically moving the aggressor to a single room. Staff # 220 also revealed the MDS nurse is responsible for updating the care plan when there is a resident-to-resident altercation. An interview was conducted with MDS LPN (Staff # 165) on March 13, 2026 at 8:52 a.m. who revealed that he is responsible for updating the care plans after a resident-to-resident altercation once he is made aware of the incident. Staff #165 revealed that all residents involved in resident-to-resident altercations get the same interventions including 72-hour observation, consulting with social services and removing the resident. He said the care plans are vague and are general and not specific to the resident. Staff # 165 also revealed that if someone needed more information regarding the resident-to-resident altercation they can get it from Risk Management, however Staff # 165 revealed not everyone has access to Risk Management. Another interview was conducted with Corporate Resource (Staff # 220) on March 13, 2026 at 12:37 p.m. revealed that it is her expectation that resident care plans are customized to the resident and anyone in the building can update the care plan to get an accurate account of the resident. A Policy titled, Care Plans, Comprehensive Person-Centered, revised March 2022, revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy also revealed that care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant decision making. When possible, interventions address the underlying sources of the problem areas, not just symptoms or triggers.

Based on staff interviews, facility documentation, and policy review, the facility failed to track, trend, and analyze the cause of resident-to-resident abuse and implement a measurable preventative action plan. The deficient practice could result in continued resident-to-resident abuse.Findings include:Review of a quality assessment and assurance committee (QAA) meeting dated December 11. 2025, revealed that the meeting review period was for November 2025. Review of the meeting minutes revealed that the number of reportable incidents for November was blank. Further review of the meeting minutes revealed there were 1 pending report for November, however, trends listed for November 2025 revealed 1 incident in Kiva and 3 incidents in Vista East. Review of the Clinical systems review conducted by the Director of Nursing does not specifically review resident to resident Abuse. Further review of meeting minutes revealed ongoing action plans which include, avoiding resident to resident by educating on behaviors, memory care, and how to prevent resident-to-resident by keeping the residents arms distance from one another.Review of QAA meeting dated February 24, 2026, revealed that the meeting review period was for December 2025 and January 2026. Review of the meeting minutes revealed that the number of reportable incidents for December 2025 were 6 while the number for reportable incidents for January 2026 were 2 for a total of 8 incidents. There were no listed pending reports, however documentation of the trends across units revealed 2 incidents in Kiva, 2 in Vista East, and 3 in [NAME] totaling 7 incidents. Further review of meeting minutes revealed the same action plan avoiding resident to resident with the same plan to educate on behaviors, memory care, and how to prevent resident by keeping residents arms distance from one another. Review of the resolved action plans was left blank and there is no measurable progress on the action plan of avoiding resident-to-resident abuse. An interview with the Director of Nursing (DON/Staff # 167) revealed that she audits the resident-to-resident altercations examining such things as what time of day, who is working and what kind of medications the resident is taking. She stated that her main focus is educating staff on abuse including how to be cognizant of residents invading other residents' space. The DON also revealed that the facility does not know what triggers the resident's and that is why they involve psych services especially after a resident-to-resident altercation. An interview with the Administrator (Staff # 60) on March 13, 2026 at 11:34 a.m. revealed that during QAA meetings they discuss falls, staffing issues, and go over quality measures. The Administrator revealed that resident-on-resident altercations are kept track under reportable events along with anything that is self-reported to the state agency. The administrator stated that they talk about the incidents but the only tracking of trends that they do is with regards to where the incident took place. The administrator revealed that he does not go far enough in tracking the trends of resident-to-resident abuse. The Administrator also revealed that the DON Staff # 167 is working on analyzing the data and coming up with a plan for the resident-to-resident abuse. A policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, revealed that the resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support objective such as establishing and implementing a quality assurance and performance improvement (QAPI) review and analysis of reports, allegations or findings of abuse, neglect mistreatment or misappropriation of property. A policy titled Abuse, Neglect, Exploitation and Misappropriation, QAPI Review of, revised September 2022, revealed that all occurrences of abuse, neglect, and mistreatment, injuries of unknown source, and theft or misappropriation of resident property are reviewed by the QAPI committee. The policy further revealed that the QAPI committee reviews any allegations of abuse during their regularly scheduled meetings. If an allegation confirms that abuse has occurred the QAPI committee is responsible for integrating the findings into a performance improvement initiative. The performance improvement projects related to abuse are considered a priority and are supported by the administration and governing body.

Based on interviews, clinical record and policy review, the facility failed to update behavioral health care plans related to individualized resident triggers so residents may attain the highest practical physical, mental, and psychosocial well-being for two residents (#8 and #9). The deficient practice could result in a plan of care that did not meet the resident's needs. Findings include: Resident #8, the perpetrator, was admitted on [DATE], with diagnosis of parkinsonism, major depressive disorder, psychotic disorder, and anxiety disorder. Review of the care plan initiated on November 13, 2025, revealed the resident had behaviors of putting himself on the floor trying to hide from people, including hiding in the closet or under his bed, refusing care and telling his family no one is offering him anything. Interventions included administering medications, providing positive interaction, explaining why behavior is inappropriate, intervening to protect the rights and safety of others, divert attention, and removing the resident from the situation. A Behavior Inter-Disciplinary Team (IDT) Review Care Plan dated February 13, 2026 included when Resident #8 showed signs of agitation, anxiety, or restlessness, approach should be completed in a calm and soothing manner, guidance to a quiet safe space, encourage slow deep breathing or offer a calming activity. Review of the comprehensive MDS dated [DATE], revealed the resident had a BIMS score of 03, indicating severe cognitive impairment. An IDT note dated February 13, 2026, revealed Resident #8 accused Resident #10 of stealing millions of dollars from him and punched Resident #10 in the eye. The facility investigation report received on February 17, 2026, completed by the Administrator, documented that a comprehensive investigation was completed using resident interviews and staff interviews and it was determined that the incident did not happen, however after further review the incident was determined to be an accident. An interview was conducted on March 12, 2026, at 11:30 AM with LPN (staff #58). She stated Resident #8 has many behaviors and delusions/hallucinations, however, the resident was easily redirected. She stated when the resident becomes agitated escalation occurs quickly. She said a behavior often exhibited was accusing someone of stealing his four million dollars. The LPN stated twice a month abuse training is conducted by the Director of Nursing (DON), the Administrator, and one of the Unit Managers. She said completed computer-based courses on abuse and protocols for abuse are posted at the nurse's station. An interview with DON (Staff # 167) on March 12, 2026 at 12:51 p.m., revealed that the facility is a behavioral facility and you never know what the behaviors will be or when they manifest. The DON revealed that when she started working here 5 weeks ago there were a lot of resident to resident altercations and when a resident hits another resident that is abuse which is required to be reported. The DON identified one area that staff needed to work on was identifying when residents get into the personal space of other residents and be proactive before the abuse happens. An interview was conducted on March 12, 2026, at 2:55 PM with CNA (Staff #209). He stated staff frequently attempted to keep Resident #8 busy in the dayroom with activities. The CNA said when the Resident becomes agitated he will start to curse and sometimes just sitting with him 1:1 can deescalate him. An interview was conducted on March 12, 2026, at 3:41 PM with CNA (Staff #57). She stated on February 12, 2026, between 3:00 and 4:00 PM, she was in the dayroom when she heard Resident #10 yell help. She saw Resident #8 standing over Resident #10, who was in bed, with his feet up toward Resident #8. The CNA stated she assisted Resident #8 back to bed and asked Resident #10 what happened. Resident #10 stated Resident #8 accused him of stealing four million dollars and then hit him in the eye. The CNA stated she saw purple and blue discoloration under his left eye. The CNA stated she reported the incident to the nurse and then removed Resident #8 from the room. She then got vitals on Resident #10. The CNA stated Resident #10 becomes agitated and escalates quickly. One of his behaviors included accusing residents of stealing his four million dollars. She stated this is the first time she had observed Resident #8 hitting another resident. She said Resident #8's current behavior was stealing food and drinking his roommate's beverages. Staff will intervene and redirect often. Regarding Resident #9 Resident # 9 was admitted on [DATE], with diagnoses that included Alzheimer's disease, dementia with agitation, personality change, major depressive disorder, and anxiety disorder. A behavior note dated July 15, 2024, revealed that Resident #9 was stealing other residents' food off the counter becoming combative during redirection back to room after finishing breakfast. A behavior note dated July 17, 2024, revealed that Resident # 9 continues to eat other residents' food from the counter while staff try unsuccessfully to redirect him. A behavior note dated July 23, 2024, revealed that Resident # 9 was taking other residents food after finishing his. A behavior note dated November 23, 2024, revealed that during lunch Resident # 9 reached over and took another resident's cake. A behavioral treatment plan dated December 19, 2025, revealed Resident # 9's current behaviors are sexually inappropriate and isolative behavior with known triggers of female staff assisting in cares. Further review of the behavioral treatment plan revealed past behaviors including elopement and exposing himself. There was no indication that Resident # 9 had a history of taking other Resident's food. A care plan focus initiated on December 24, 2025, revealed that Resident # 9 had a behavior problem related to sexual inappropriateness, history of delusions, elopement risk, and self-isolation. Further review of the care plan revealed interventions which included cares in pairs, and following behavior plan. Review of the current care plan does not indicate a history of taking resident food or belongings. A quarterly MDS assessment dated [DATE], revealed a BIMS score of 7, indicating severe cognitive impairment. The MDS assessment also revealed that Resident # 9 also experienced other behaviors for 1 to 3 days which include sexual acts. An interview with CNA (Staff # 79) on March 12, 2026 at 2:11 p.m. revealed that he had never known Resident # 9 to be physically aggressive or to take belongings from other residents. Staff # 79 revealed that Resident # 9 can be handsy with female staff and that's one of the reasons why he primarily works on that unit. Staff # 79 revealed that he did not see the incident with Resident # 2 but heard from Resident # 2 that Resident # 9 hit Resident # 2 and took his blanket because Resident # 9 was cold. An interview with RN (Staff # 103) on March 12, 2026 at 3:18 p.m., revealed that one of Resident # 9's behaviors was to be sexually inappropriate. The RN stated that care staff always does cares in pairs. Staff # 103 said that Resident # 9 grabs female staff and is inappropriate with them. Staff # 103 further stated that Resident # 9 was not known as physical and can be redirectable. An interview with a CNA (Staff # 107) on March 13, 2026 at 10:12 a.m., revealed that Resident # 9 is an easy-going guy who likes to stay in his bedroom. Staff # 107 revealed that if Resident # 9 wants something he is going to try and take it. Staff # 107 stated that they try and redirect before he takes something that does not belong to him. Staff #107 revealed most residents if they are in their room are checked on hourly unless they are on 15 min checks. A policy titled Dementia-Clinical Protocol revised November 2018, revealed that for treatment and management of dementia the IDT will identify and document the resident's condition and level of support needed during care planning and review changes as they arise. The policy also revealed that the physician will help define potential benefits and risks of medical interventions based on individual risk factors, current conditions, history and details of current symptoms.

Based on clinical record review, staff and resident interviews, and facility policy, the facility failed to protect the rights of one Resident (#6) out of the three sampled residents to be free from abuse by staff. The deficient practice could result in other residents being abused.Findings include--Regarding Resident (#6)Resident #6 was admitted to the facility on [DATE], with diagnoses that included depression, schizophrenia, quadriplegic, and hypertension. A care plan revised on August 9, 2025, revealed that the Resident #6 was at risk for not meeting emotional, intellectual, physical, and social needs related to Schizophrenia. The interventions revealed that all staff to converse with resident while providing care.Orders dated August 26, 2025, revealed an order for fluoxetine HCl oral tablet 20 mg, one time a day for depression.A quarterly MDS (minimum data set) dated November 12, 2025, revealed that the resident was a BIMS (brief interview for mental status) score of 10 which indicated moderately impaired cognition.A behavior charting assessment dated [DATE], revealed that Resident #6 was very upset and started to get physically and verbally aggressive with staff.Review of the clinical record revealed no evidence of a skin assessment after the altercation between staff and resident on January 26, 2026.Orders dated January 30, 2026, revealed an order for diazepam oral tablet 5 mg (milligram), given 1 tablet by mouth, every 12 hours as needed for anxiety.A progress note, dated August 6, 2025 to February 3, 2026, did not reveal any documentation of risk pertaining to the incident nor did it reveal any issues that would put Resident #6 at risk for staff to resident altercation.A facility document titled, suspected abuse investigation report, dated January 26, 2026, the Director of Nursing (DON, staff #168), per document, revealed that Resident #6 was trying to run into staff and other residents with his electric wheelchair on January 26, 2026, in the common area/day room. Certified nursing assistant (CNA staff #34) got in front of Resident #6's wheelchair. Resident #6 then kicked the CNA (staff #34). The CNA then placed the Resident's #6 into the recliner but also the CNA was yelling loudly. The CNA was suspended and educated related to not using a loud voice towards residents and safe transferring of residents. The investigation conclusion revealed that the CNA was complaining loudly and the loud voice was not appropriate in a behavior setting. However, the suspected abuse that occurred on January 26, 2026, was not reported to the State Agency (SA).The CNA (staff #34) employment record titled, counseling/disciplinary notice, dated January 26, 2026, revealed that the CNA (staff #34) witnessed Resident #6 had gotten to the nurse's station in electronic wheelchair and threw over the medication cart spilling everything on the floor. Resident #6 used his electronic wheelchair as a weapon and headed towards other residents. While the CNA had the right to transfer Resident #6 from electric wheelchair for safety, Resident #6 then kicked the CNA which made CNA (staff #34) upset and he verbalized in a loud way. The CNA was suspended until he completed education from the director of nursing (DON, staff #168) on resident transfers and behavioral response.An interview was conducted on February 4, 2026, at 11:06 a.m., with a CNA (staff # 34) who worked at the facility for about 7 months and assisted residents with activities of daily living (ADLs) including transferring, bathing, dressing, and oral care. Regarding abuse, the CNA stated that there are different types of abuse, including physical, verbal, financial and staff get abuse training once a month. The CNA then stated that he is familiar with resident #6, who is mostly independent and CNA assists the resident with toileting, dressing, and getting ready for meals. The CNA then stated that on January 26, 2026, during dayshift, Resident #6 came to day room naked in the morning, in his electric wheel chair and was upset with a licensed practical nurse (LPN, staff #140) for not getting his medications. While LPN was doing her medication count at medication cart for medication pass close to nurse station at day room, the Resident #6 started to get extremely upset with the LPN and using his electric wheelchair (EWC) as a weapon to go all over the day room, that is when CNA intervened and tried to calm down the resident. Resident #6 became upset, cursed and kicked the CNA, causing bruising to CNA's leg and side. CNA further stated that he tried to control the situation by physically grabbing the resident's leg from his electric wheelchair and sat him on a recliner couch. Resident #6 then put himself to the floor and tried to crawl towards the wheelchair. That is when the CNA called the DON and notified of the incident. CNA was then sent home pending investigation, provided education and training on abuse.An interview was conducted on February 4, 2026, at 2:26 p.m., with the DON (staff #168) who stated that abuse means hurting another person verbally, physically, emotionally, and financially. The DON further stated that all staff receive abuse training during new hire orientation, monthly, and annually. The DON stated when there is an altercation between a resident and a staff member, then both were separated and head to toe assessment were done of resident for any injuries. The DON stated that the incident is then reported to the State Agency (department of health services, AZDHS) within 2 hours (hrs.) and start the investigation if it is deemed abuse. The DON then stated that the abuse investigations will start immediately which included interviewing resident, staff, visitor and other residents. If the alleged perpetrator is a staff member then staff will be immediately sent home pending investigation. The DON recalled the incident between CNA (staff #34) and Resident #6, she stated that the incident happened in the day room on January 26, 2026. She also stated that Resident #6 was in his electric wheelchair and ran into the medication cart, causing the cart to be dumped to the floor containing the laptop, medications, and water pitcher. She further stated that the resident backed up his wheelchair, to hit another resident, that is when CNA (staff#34) intervened and tried to get Resident #6 out of his wheelchair to the recliner couch. The DON stated that during the transfer to the recliner, Resident #6 started kicking the CNA with his leg and the CNA then notified the DON regarding the incident in a loud and angry tone. The DON further stated that the CNA was suspended immediately because he was not supposed to be talking in a loud tone in a behavior unit. The DON then stated that the CNA (staff #34) was also provided in-service training the next day regarding abuse, neglect, and resident rights. The DON further stated that she would not consider the incident as abuse because it was not intentional and the CNA was trying to protect other residents and therefore, the incident was not notified to the SA.An interview was conducted on February 4, 2026, at 3:04 p.m., with an administrator (staff #7) who stated that there are all kinds of abuse including physical, verbal, sexual, and financial. The administrator then stated that the facility process for staff to resident abuse is to identify if the incident was intentional, then separate the resident, making sure resident is safe, notify state agency within 2 hrs., suspend staff pending investigation, and then submitting investigation report to state agency within 5 working day along with staff in-service training regarding abuse, neglect, and resident rights. The administrator further stated that if abuse was not reported to the state agency then the residents would also be at risk. The administrator then stated that the incident between CNA (staff #34) and Resident #6, was not intentional and therefore the SA was not notified. However, the CNA (staff #34) was suspended on the day of investigation January 26, 2026, was reeducated the next day on resident rights, abuse, and neglect.Review of the facility policy titled Resident Rights, revised in February 2021, revealed that the resident would be treated with respect, kindness, and dignity. The policy further revealed that resident would be free from abuse, neglect, misappropriation of property, and exploitation.Review of the facility policy titled Identification and investigation of Abuse, Neglect, Misappropriation, and injuries of unknown origin, revised on August 1, 2023, revealed that if a staff member is implicated in an abuse/neglect situation, regardless of discipline, the facility will protect the resident, which may include but not limited to, immediately removed from any resident contact, interviewed with their version of the incident documented, suspended pending investigation results. The policy further revealed that document results of the resident assessment, notification of the physician and resident advocate, and any treatment provided.

Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure an allegation of abuse was reported timely to required entities for one resident (#6). The deficient practice could lead to ongoing abuse leading to harm of a resident.Findings include--Regarding Resident (#6)Resident #6 was admitted to the facility on [DATE], with diagnoses that included depression, schizophrenia, quadriplegic, depression, and hypertension.A quarterly MDS (minimum data set) dated November 12, 2025, revealed that the resident was a BIMS (brief interview for mental status) score of 10 which indicated moderately impaired cognition.A behavior charting assessment dated [DATE], revealed that Resident #6 was very upset and started to get physically and verbally aggressive with staff.Review of the clinical record revealed no evidence of a skin assessment after the altercation between staff and resident on January 26, 2026.The clinical record revealed no evidence that the incident was reported to the State Agency (SA) within 24 hrs. (hours).A request was made on February 4, 2026, at 3:20 p.m. for document regarding reporting to SSA for abuse allegation between CNA (staff #34) and Resident #6. The facility failed to provide the requested documentation during the survey.A facility document titled, suspected abuse investigation report, dated January 26, 2026, the Director of Nursing (DON, staff #168), per document, revealed that Resident #6 was trying to run into staff and other residents with his electric wheelchair on January 26, 2026, in the common area/day room. Certified nursing assistant (CNA staff #34) got in front of Resident #6's wheelchair. Resident #6 then kicked the CNA (staff #34). The CNA then placed the Resident's #6 into the recliner but also the CNA was yelling loudly. The CNA was suspended and educated related to not using a loud voice towards residents and safe transferring of residents. The investigation conclusion revealed that the CNA was complaining loudly and the loud voice was not appropriate in a behavior setting. However, there was no evidence that the suspected abuse investigation dated January 26, 2026, was reported to the SA.An interview was conducted on February 4, 2026, at 10:52 a.m. with CNA (staff #67) who stated that in cases of alleged abuse, the facility's policy is to first examine the picture for the safety of the resident, then report it to the nurse or abuse coordinator right away.An interview was conducted on February 4, 2026, at 2:26 p.m., with a DON (staff #168) who stated that abuse means hurting another person verbally, physically, emotionally, and financially. The DON further stated that all staff receive abuse training during new hire orientation, monthly, and annually. The DON then stated when there is an altercation between a resident and a staff member, both were separated and head to toe assessment were done on resident for any injuries and reporting to the SA within 2 hrs. The DON then stated that the risk of not reporting abuse allegations to the SA could result in further abuse. The DON further stated that abuse allegation between CNA (staff #34) and the Resident #6 was not reported to the SA because it was not an intentional abuse and CNA was trying to protect the other residents from Resident #6.An interview was conducted on February 4, 2026, at 3:04 p.m., with an administrator (staff #7) who stated that there are all kinds of abuse including physical, verbal, sexual, and financial. The administrator then stated that the facility process for staff to resident abuse is to identify if the incident was intentional, then separate the resident, and making sure the resident is safe, then notify SA within 2 hrs. The administrator further stated that the risk of not reporting abuse to the state agency could result in further risk to the resident. Then regarding the incident between CNA (staff #34) and the Resident #6, the administrator stated that he did not think that the incident was intentional and therefore the state agency was not notified.An interview was conducted on February 4, 2026, at 3:20 p.m. with an administrator (staff #7) who stated that facility did not have any document regarding reporting to SA for an abuse allegation between CNA (staff #34) and Resident #6.Review of the facility policy titled Identification and investigation of Abuse, Neglect, Misappropriation, and injuries of unknown origin, revised on August 1, 2023, revealed if any form of abuse is alleged (physical, verbal) or serious bodily injury is identified related to any other reportable incident (injury of unknown source or allegation of neglect involving serious bodily injury), the Chief Executive Officer (CEO) will notify the State Agency immediately, but not later than 2 hours after the allegation is made. The policy further revealed that all other allegations involving neglect, exploitation, mistreatment, misappropriation of resident property and injuries of unknown source will be reported to State Agency immediately, but not later than 24 hours from the time the incident/allegation was made to the staff member.

Based on interviews, review of records, and review of facility policy and procedure, the facility failed to ensure an allegation of abuse investigation report was submitted within 5 working days to the State Survey Agency for one resident (#6). The deficient practice could lead to ongoing abuse leading to harm of a resident.Findings include--Regarding Resident (#6)Resident #6 was admitted to the facility on [DATE], with diagnoses that included depression, schizophrenia, quadriplegic, depression, and hypertension. A quarterly MDS (minimum data set) dated November 12, 2025, revealed that the resident was a BIMS (brief interview for mental status) score of 10 which indicated moderately impaired cognition.A behavior charting assessment dated [DATE], revealed that Resident #6 was very upset and started to get physically and verbally aggressive with staff.A request was made on February 4, 2026, at 3:20 p.m. for facility's 5-day investigation report for abuse allegation between CNA (Staff #34) and Resident #6. The facility failed to provide the requested documentation during the survey.The clinical record revealed no evidence that the incident investigation report was submitted to the State Agency (SA) within 5 working days.A facility document titled, suspected abuse investigation report, dated January 26, 2026, the Director of Nursing (DON, staff #168), per document, revealed that Resident #6 was trying to run into staff and other residents with his electric wheelchair on January 26, 2026, in the common area/day room. Certified nursing assistant (CNA staff #34) got in front of Resident #6's wheelchair. Resident #6 then kicked the CNA (staff #34). The CNA then placed the Resident's #6 into the recliner but also the CNA was yelling loudly. The CNA was suspended and educated related to not using a loud voice towards residents and safe transferring of residents. The investigation conclusion revealed that the CNA was complaining loudly and the loud voice was not appropriate in a behavior setting. However, there was no evidence that the abuse investigation dated January 26, 2026, was submitted to the State Survey Agency within 5 working days.An interview was conducted on February 4, 2026, at 2:26 p.m., with a DON (Staff #168) who stated that abuse means hurting another person verbally, physically, emotionally, and financially. The DON further stated that all staff receive abuse training during new hire orientation, monthly, and annually. The DON then stated when there is an altercation between a resident and a staff member, both were separated and head to toe assessment were done on resident for any injuries and reporting to the SA within 2 hrs. The DON then stated that the abuse investigations will start immediately which included interviewing resident, staff, visitor and other residents. If the alleged perpetrator is a staff member then staff will be immediately sent home pending investigation. The DON also stated that a detailed investigation report will be sent to the SA within 5 working days. The DON further stated that If the abuse incident was not investigated then it could happen again.An interview was conducted on February 4, 2026, at 3:04 p.m., with an administrator (Staff #7) who stated that there are all kinds of abuse including physical, verbal, sexual, and financial. The administrator then stated that the facility process for staff to resident abuse is to identify if the incident was intentional, then separate the resident, and make sure the resident is safe, notify SA within 2 hrs., suspend staff pending investigation, and then submitting the detailed investigation report to the SA within 5 working days along with staff in-service training regarding abuse, neglect, and resident rights. The administrator further stated that If the risk of abuse was intentional and was not investigated then all the residents would be at risk for further abuse.An interview was conducted on February 4, 2026, at 3:20 p.m. with an administrator (Staff #7) who stated that facility did not have any 5-day investigation report for abuse allegation between CNA (Staff #34) and the Resident #6.Review of the facility policy titled Identification and investigation of Abuse, Neglect, Misappropriation, and injuries of unknown origin, revised on August 1, 2023, revealed that the investigation must be completed within five working days, unless there are special circumstances causing the investigation to continue beyond 5 working days (holiday, account review of funds).

Based on clinical record reviews, staff and resident interviews, and policy, the facility failed to protect the rights of 3 of 3 residents (#1, #2, #3) to be free from physical abuse by other residents and family members. The deficient practice could result in further abuse.Regarding a resident-to-resident altercation that involved Resident #1 and Resident #2. -Regarding Resident #1 Resident #1 was initially admitted to the facility on [DATE], and re-admitted on [DATE], with diagnoses of dementia, major depressive disorder, anxiety disorder, epilepsy, and bipolar disorder. The care plan dated November 06, 2025, had a focused care area for Resident #1, having a behavior problem related to taking things and flushing them down the toilet. Interventions included administering medication as ordered, monitoring/documenting for side effects and effectiveness, anticipating and meeting the resident's needs, and, if reasonable discuss the resident's behavior. explain/reinforce why the behavior is inappropriate and/or unacceptable to the resident, and intervene as necessary to protect the rights and safety of others. Approach/speak in calm manner. Divert attention. Remove from the situation and take to an alternate location as needed. A Significant Change MDS (Minimum Data Set) assessment dated [DATE], revealed Resident #1 had a BIMS (Brief Interview for Mental Status) score of 07, which indicated severe cognitive impairment. A behavior note dated December 24, 2025, at 3:09 PM revealed that the nurse observed Resident #1 being hit by another resident in the dining room. The nurse ran over to the residents to separate the two men. A skin assessment was performed, no noted injuries were observed at the time. A change in condition evaluation dated December 24, 2025, revealed Resident #1 had an injury on the left side of the forehead. The care plan dated December 24, 2025, had a focused care area for Resident #1, having a psychosocial well-being problem related to a resident-to-resident altercation. Interventions included:72 HRS observation, Consult with: Pastoral care, social services, psych services, Other: monitor/document resident's usual response to problems: Internal - how individualmakes own changes, external - expects others to control problems or leaves to fate,or luck, and when conflict arises, remove residents to a calm, safe environment and allow them to vent/share feelings-Regarding Resident #2 Resident #2 was admitted to the facility on [DATE], with diagnoses of Alzheimer's disease, post-traumatic stress disorder, anxiety disorder, major depressive disorder, mood disorder, and dementia. A quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed Resident #2 had a BIMS (Brief Interview for Mental Status) score of 05, which indicated severe cognitive impairment. An incident note dated December 24, 2025, at 03:01 PM revealed a resident to resident altercation with physical aggression. Resident #2 was observed leaning over Resident #1, hitting him repeatedly. The writer observed Resident #2 after the incident; he was alert, upset, and shaky, stating, someone was trying to get into his backside. Resident #2 has discoloration to the right knuckle of the 2nd finger and a right knuckle hematoma between the 3rd finger hematoma. Administrator and DON (Director of Nursing) notified. The medical doctor was notified. Left voicemail with daughter. Resident #2 was placed on 15-minute checks. A skin check note dated December 24, 2025, at 03:11 PM revealed that the skin was warm and dry, with skin color within normal limits (WNL), and turgor is normal, resident does not have an external device. The skin issue was that the right-hand knuckle had a hematoma and discoloration. A care plan dated December 24, 2025, revealed Resident #2 is at risk for psychosocial well-being problems related to Resident-to-Resident altercations.Regarding a visitor-to-resident altercation that involved Resident #3 and the husband. Regarding Resident #3 Resident #3 was admitted on [DATE], with a diagnosis that included dementia, Parkinsonism, hypertension, postconcussional syndrome, and a history of falling. An admissions MDS assessment dated [DATE], revealed Resident #3 had no BIMS score, and cognitive skills for daily decision making indicated that Resident #3 was severely cognitively impaired. A behavior note dated January 2, 2026, at 7:44 PM, revealed that Resident #3 had multiple verbal and physical outbursts after her husband left this morning. The nurse was informed by a CNA (Certified Nursing Assistant) that the husband had physically abused the resident in the day room. The CNA stated he heard what appeared to be the husband of Resident #3 arguing in the resident's room as he was coming back to the station. The nurse could not decipher what was said as both were shouting at each other in a language other than English. CNA stated the incident just happened prior to them going back to Resident #3's room. The nurse then stated he was going back to the room to make sure the husband would leave the patient/facility and contact the DON to inform her of what had occurred. The husband was already gone once the nurse went back to the room. The DON stated she was already on her way and would take a statement from the CNA once she got to the facility. After receiving the statement from the CNA, the DON stated she would then report it. Police would then come in later about the situation. The nurse was under the impression that the husband was not allowed back into the facility. The patient was visibly upset after the incident, but mellowed out throughout the day with activities.A care plan dated January 02, 2026, revealed a focused care area for Resident #3, stating that Resident #3 has a psychosocial well-being problem related to Dementia. Husband becomes frustrated with her when trying to help her with medication, eating, and adl's (activities of daily living). Husband has yelled and physically touched her when this occurs. Resident #3 does better when her husband is present and can assist her, as she cares more when just the staff is one-on-one with Resident #1. Interventions included: Consult with: Pastoral care, Social services, Psych services, Encourage participation from the resident who depends on others tomake own decisions, Monitor/document resident's usual response to problems: Internal -how an individual makes their own changes, External - expects others to control problems orleaves to fate, or luck, supervised visits in public places only, and when conflict arises, remove residents to a calm, safe environment and allow them to vent/share feelings. A change of condition evaluation dated January 2, 2026, revealed that there was no change in the skin status evaluation. An interview was conducted on January 20, 2026, at 11:06 AM with the Licensed Practical Nurse (LPN/ staff #1), who stated that if she hears of abuse, she contacts the administrator, DON, or the administration team. Further stated that if she witnesses any abuse, she will separate the abuser and do all necessary documentation related to the incident, notify the administrator, doctor, and family member if they have any. Staff #1 stated that there was a physical altercation between Resident #1 and Resident #2. She stated she saw that both of the Residents #1 and #2 were in the dining room. Resident #1 was in a wheelchair when Resident #2 was hitting Resident #1 while he was standing up, and Resident #1 was trying to fight back, but Resident #2 had the advantage of hitting him more since he was standing up. She stated she does not know what led to the hitting, but she and another staff member broke up the fight. She stated both Resident #1 and Resident #2 were assessed and separated. She stated that Resident #2 had bruising on his fingers and his knuckles. Furthermore, staff #1 initially stated that Resident #1 did not have any injuries after the incident. When she went back to Resident #1 to check up on the resident, she observed that Resident #1 had a knot on his forehead, which might be from the tight hat he wears all the time, she then revised the skin assessment report. She further stated that Resident #2 relayed that Resident #1 was trying to touch his butt, and that Resident #1 stated that he did not do anything. Also, Staff #1 stated that several staff members had witnessed the altercation between Resident #1 and Resident #2. An interview was conducted on January 20, 2026, at 11:13 AM and 11:46 AM with the alleged perpetrator, who was the visitor for Resident #3. He stated that he is unable to talk to the surveyor because the surveyor does not know how to speak Korean. Therefore, the interview was not successful. An interview was conducted on January 20, 2026, at 12:50 PM with Resident #2; however, Resident #2 was not consistent in his reporting, stating initially that he did have an altercation and later he did not. A call attempt was made on January 20, 2026, at 10:25 AM for LPN (Staff #4), the other nurse on the East unit for Residents #1 and #2 altercation, but Staff #4 was unreachable because the call was not answered, nor was the surveyor able to leave the voicemail because the call ended before giving the option to leave voicemail. An interview was conducted on January 20, 2026, at 12:48 PM with Resident #1, who stated that he does not know Resident #2 and that he had no altercation with the resident. He stated that no one has hit him and feels safe in the facility. An interview was conducted on January 20, 2026, at 1:20 PM with CNA (Staff #3), who stated that there are different types of abuse, such as physical, emotional, verbal, sexual, and financial. She stated that if she witnesses abuse, she would first ensure that the resident is safe, report to the nurse, and take the necessary vitals for the resident. She stated she did not witness abuse between residents, but stated that she did see the staff members rush to help the residents in an altercation last month on the East unit. She further stated that if she witnesses resident-to-visitor abuse, she would make sure the resident is safe, report it right away, and stop the altercation. She stated that she does not remember working with Resident #3. An interview was conducted on January 20, 2026, at 1:34 PM with the Activities Assistant (Staff #2), who stated that there are different types of abuse: physical, mental, financial, verbal, and sexual. She stated that if she witnessed to resident-to-resident abuse, she would yell to get nearby staff for help and stop the abuse. She stated that she would report the unit nurse and tell the executive director about the abuse immediately. She further stated that she saw the altercation between Resident #1 and Resident #2 when other residents were playing bingo. She saw Resident #2 walk up to Resident #1 and put his hand on him, then she yelled, and two nurses came to break up the fight, before she was able to intervene, since she was sitting behind the table. Staff #2 stated that they were first having a normal conversation, next thing you know, the incident happened. She does not know what caused Resident #2 to hit Resident #1. She further stated that with the altercation between the Resident and Visitor, she would not intervene since it is family, but she would report it. She stated that she does not have the right to restrain a family member, and she stated that she did not see the resident-to-visitor altercation and does not know Resident #3. Multiple calls were made on January 20, 2026, at 09:07 AM, 11:04 AM, and 1:52 PM to LPN (Staff #5), who wrote the progress note for Resident #3, but the LPN was unreachable. Voice messages were left, but no return call was received. Multiple calls were made on January 20, 2026, at 12:31 PM and 1:30 PM to CNA (Staff #6), who witnessed the incident with Resident #3 and her Visitor, and had told other staff members, but she was unreachable, because the call was not answered. An interview was conducted on January 20, 2026, at 2:17 PM with CNA (Staff #7), who stated that there are different types of abuse, which include hitting, stealing, being mean to them, leaving the resident dirty, and restraining them. She stated that if she sees abuse, she would report it to the nurse and call the DON. She stated that she has not witnessed abuse, but heard of abuse between resident to family. She stated that her coworker, CNA #6, told her that she witnessed Resident #3's husband kicking her very hard and notified the nurse and the DON. Staff #7 stated that Resident #3 was crying after the incident and was unable to express herself since she spoke Korean. The husband was sent home after the incident and returned because of the begging to talk to the wife, but he would have a supervised visit with Resident #3. He was not allowed to be alone with his wife. An interview was conducted on January 20, 2026, at 3:25 PM with CNA (Staff #8), who stated that the facility's process for abuse is to report abuse right away to the charge nurse or the administrator. He stated that there are different types of abuse, such as physical, financial, sexual, and verbal. Staff #8 stated that if he witnessed resident-to-resident abuse, he would first separate the two, then get help from another CNA, and report it. He stated that if he witnessed resident-to-visitor abuse, he would report it right away to ensure the resident's safety. Then stated that there was an incident that occurred between a resident and a visitor, when he was not present, where the husband got mad at his wife, the patient, for not taking the medication, when she refused to take them, and he kicked her. Staff #8 stated that cops were called, and the husband was only allowed supervised visits by CNA's. An interview was conducted on January 20, 2026, at 3:33 PM with an LPN (Staff #9), who stated that the facility's process for abuse is to separate the two individuals who are involved in the abuse and immediately notify the administrator or the DON. After notifications, the incident would be documented in the resident's chart, so the Administrator can start the investigation. He stated that the different types of abuse are financial, physical, mental, and sexual. He stated that if he witnessed abuse of a resident by another resident, he would separate the parties involved and notify the DON, so they can start their investigation. He further stated that if he witnessed resident-to-visitor abuse, he would intervene, do an assessment, and let the administrator know. He stated that if a visitor who is combative is allowed back to the facility, it places the resident in harm's way. He then stated that if the visitor is allowed back, the visit should be supervised by a staff member. He stated that he has not worked with Resident #1. An interview was conducted on January 20, 2026, at 3:43 PM with the DON (Staff #10), who stated that she expects staff members to report abuse to the administrator, because staff members are aware they have two hours to report. She stated if there is a resident-to-resident altercation, she would expect the staff members to immediately separate the individuals right away, put them on 1-on-1 supervision, be assessed by the nurse; at the same time, they would call the abuse coordinator and report the abuse. The abuse coordinator would then conduct the investigation. She stated that if there is a visitor abusing a resident, the staff member should immediately separate the parties involved and call her, and she would respond immediately. She stated that Resident #3's husband pushed medication into the resident's mouth after she spat out the medication, since she was refusing, he panicked and started to kick her. The DON stated that he was banned from coming in for a couple of days, but the wife was not cooperating with staff or was taking medication, and she would only listen to the husband and understood, so with supervision, he was brought back after a couple of days. She would be sad, crying, wanting to see her husband. DON stated Resident #3's husband's visits were monitored; he was not left alone after the incident. Further stated that a visitor kicking a resident is considered physical abuse. Staff #8 stated that regarding Resident #2 and Resident #1, that Resident #2 hit Resident #1 without warning in the dining area with full force. She further stated that both residents were immediately separated by the staff member. The DON stated that this would be considered abuse. A policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program was revised April 2021 revealed that Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

Based on interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of four of eight sampled residents (#24, 15, 20, and 9) to be free from abuse by other residents (#20, 22, 11, 18). The deficient practice could lead to ongoing abuse, leading to harm to other residents.-Findings include:Regarding Resident #24Resident #24 (alleged victim) was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, post-traumatic stress disorder, anxiety disorder, and insomnia.A review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 9, which indicated the resident had moderate cognitive impairment. The MDS further revealed that Resident #24 had exhibited no verbal or physical behavioral symptoms directed towards others during the assessment period.Review of Resident #24's care plan, which was initiated on October 10, 2025, revealed a risk for psychosocial well-being problem potentially related to a resident-to-resident altercation. Interventions included: when conflicts arise, remove residents to a calm, safe environment, allowing them to vent and share feelings.Resident #20 (alleged perpetrator) was admitted to the facility on [DATE], with diagnoses including dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, anxiety disorder, post-traumatic stress disorder, vascular dementia, with other behavioral disturbance, and major depressive disorder.A review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 00, which indicated the resident #20 could not complete the assessment. The MDS further revealed that Resident #20 had exhibited no verbal or physical behavioral symptoms directed towards others during the assessment period.Review of Resident #20's care plan that was initiated September 4, 2025, revealed a risk for a behavioral problem, intrusive and combative with care at times. Interventions included an attempt to redirect behaviors.-Regarding the December 5, 2025, incident On December 5, 2025, a nursing progress note was entered into the clinical record for Resident #24. It stated that Resident #24 was observed getting hit in the face with a room door. Resident #24 had an abrasion to the right lower eyebrow. Head-to-toe skin assessment was completed with no other injuries noted.Review of a skin assessment for Resident #24, dated December 5, 2025, revealed that Resident #24 had an abrasion on his right upper eyelid and no other skin injuries or wounds were noted.On December 5, 2025, a nursing progress note was entered into the clinical record for resident #20. It stated that Resident #20 was observed abruptly closing the door to a resident's room on the resident's face, causing injury. Resident #20 was then taken to the day room for checks every 15 minutes. Review of a skin assessment dated [DATE], revealed no areas of concern for resident #20. Review of the facility's undated 5-day investigation report regarding the altercation that occurred on December 5, 2025, revealed that a laundry aid (staff #234) was delivering clothing to resident #24's room and witnessed the altercation. Following the alteration, Resident #20 was placed on 15-minute supervisory checks. The report further stated that resident #24 was seen by the facility's behavior nurse practitioner. Resident #20 could not recall the events, and no changes were ordered to his medications. An interview was conducted by telephone on December 23, 2025, at 2:22 p.m. with staff #234. Staff #234 stated that on December 5, 2025, she was delivering clean clothing to the room of resident #24. As she was hanging clothes in his closet, she heard a verbal argument between Resident #24 and Resident #20. She then observed resident #20 attempting to enter resident #24's room. Resident #24 was attempting to close the door while resident #20 was trying to enter. Staff #234 stated that she called out for help and witnessed Resident #20 forcefully push the door into the face of Resident #24. An interview was conducted with Director of Nursing (DON/staff #31) on December 23, 2025, at 3:23 p.m. Staff #31 stated that the altercation between Resident #20 and Resident #24 on December 5, 2025, in which a resident used a door to strike another resident, would meet the definition of abuse and fail to meet the facility's expectation. Regarding Resident #15Resident #15 (alleged victim) was admitted to the facility on [DATE], with diagnoses including unspecified dementia, with agitation, metabolic encephalopathy, major depressive disorder, generalized anxiety disorder, and a personal history of benign neoplasm of the brain.A review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 2, which indicated the resident had severe cognitive impairment. The MDS further revealed that Resident #15 had exhibited other behavioral symptoms not directed towards others one to three days during the assessment period.Review of resident #15's care plan that was initiated on April 19, 2024, revealed a risk for the potential to be physically aggressive regarding dementia. Interventions included analyzing times of day, places, circumstances, triggers, and what de-escalates behavior and document. Resident #22 (alleged perpetrator) was admitted to the facility on [DATE], with diagnoses including unspecified dementia with agitation, bipolar disorder, mood affective disorder, major depressive disorder, anxiety disorder, and insomnia.A review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 5, which indicated the resident had severe cognitive impairment. The MDS further revealed that Resident #22 had exhibited other behavioral symptoms not directed towards others one to three days during the assessment period.A care plan that was initiated on August 6, 2025, revealed that resident #22 was at risk for the potential to be verbally aggressive, yelling or cursing at others. Interventions included when Resident #22 becomes agitated, intervention before escalating, and guiding away from distress. - Regarding the December 10, 2025, incident On December 10, 2025, a nursing progress note was entered into the clinical record for resident #15. It stated that Resident #15 was in an altercation with another resident and ended up with a hematoma around the left eye. Resident #15 then calmed down and is no longer in pain. Review of a change in condition form for Resident #15 dated December 10, 2025, revealed that Resident #15 had a documented contusion and discoloration and reported to be in pain. Further review revealed that Resident #15 expressed non-verbal signs of pain, including tension, distressed pacing, and fidgeting. On December 10, 2025, a nursing progress note was entered into the clinical record of Resident #22. It stated that Resident #22 was in an altercation with another resident at 9:25 p.m., and the resident was assessed with no injuries noted and was currently sleeping. Review of a change in condition form for Resident #22, dated December 10, 2025, revealed no pain or physical injuries to Resident #22. Review of the facility's undated 5-day investigation report regarding the altercation that occurred on December 10, 2025, revealed that at approximately 9:30 p.m., both resident #15 and resident #22 were in the dayroom. A licensed practical nurse (LPN/staff #6) was in the room, but had his back turned towards the residents when the altercation happened. The report further stated that Resident #22 tried to put a blanket over Resident #15's head, and Resident #15 said words to Resident #22, and Resident #22 slapped Resident #15 across the face several times. Resident #22 was placed on 15-minute supervisory checks until he could be seen by the behavioral nurse practitioner. Attempts to interview Staff #6 by phone took place on December 23, 2025, at 12:12 p.m., 1:11 p.m., and 1 :56 p.m. Voicemail messages were left, but no return call was received. An interview was conducted with staff #31 on December 23, 2025, at 3:23 p.m. Staff #31 stated that the altercation between Resident #15 and Resident #22 on December 10, 2025, in which a resident hit or slaps another resident, would meet the definition of abuse and fail to meet the facility's expectation.Regarding Resident #20Review of the care plan for resident #20 (alleged victim) revealed a focus initiated on December 5, 2025, that Resident #20 was at risk for psychosocial well-being problem regarding a resident-to-resident altercation. Interventions included when a conflict arises, remove resident to a calm safe environment and allow Resident #20 to vent and share feelings. Resident #11 (alleged perpetrator) was admitted to the facility on [DATE], with unspecified dementia, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, personal history of traumatic brain injury, and generalized anxiety disorder.A review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated the resident had severe cognitive impairment. The MDS further revealed that Resident #11 had exhibited other behavioral symptoms not directed towards others, one to three days during the assessment period.A care plan that was initiated on April 24, 2025, revealed that Resident #11 was at risk for potential to be physically aggressive. Interventions included monitoring, documenting, and reporting any signs or symptoms of Resident #11 posing a danger to self or others. - Regarding the December 12, 2025, incidentOn December 12, 2025, a nursing progress note was entered into the clinical record for Resident #20. It stated that Resident #20 was pushed onto the ground. Resident #20 only had minor pain and injuries and was doing fine now and resting. Review of a change in condition form for Resident #20, dated December 12, 2025, revealed that Resident #20's skin was noted to have a contusion and an abrasion. The evaluation further stated that resident #20 was experiencing new pain symptoms.On December 13, 2025, a nursing progress note was entered into the clinical record for resident #20. It stated that resident #20's x-ray results indicated that he had an acute olecranon avulsion fracture of the right elbow and an acute olecranon avulsion fracture of the right forearm. The medical doctor said Resident #20 may need surgery, but doesn't know if the resident is a candidate for surgery. The note further stated that the initiator (Resident #11), who pushed Resident #20 to the ground, is still going after Resident #20, and staff are keeping a close eye on them with checks every 15 minutes. On December 12, 2025, a nursing progress note was entered into the clinical record for Resident #11. It stated that resident #11 was irritated with another resident and pushed him down to the ground. Both residents were calm and resting after the incident, and no injuries occurred. Review of a change in condition form for Resident #11, dated December 12, 2025, revealed that Resident #11 had no physical injuries noted and was not in any pain. On December 13, 2025, a nursing progress note was entered into the clinical record for resident #11. It stated that Resident #11 was still showing signs of aggression towards Resident #20, and the staff was still watching both residents closely. Review of the facility's undated 5-day investigation report regarding the altercation that occurred on December 12, 2025, revealed that at approximately 7:30 p.m., the staff witness, Certified Nursing Assistant (CNA/staff #250), observed Resident #20 and Resident #11 arguing. Staff #250 ran to separate the residents and witnessed resident #11 push resident #20 to the floor. Staff #250 then took resident #11 to the day room. The report further stated that resident #20 was assessed to have a bruise on his right elbow and his right scapula. Resident #11 told staff that he felt like Resident #20 was causing trouble by going into rooms and stealing things. An interview was conducted with Staff #31 on December 23, 2025, at 3:23 p.m. Staff #31 stated that the altercation between Resident #20 and Resident #11 on December 12, 2025, in which one resident pushed another resident to the ground, causing injuries, would meet the definition of abuse and fail to meet the facility's expectations.- Regarding the December 22, 2025, incident On December 22, 2025, a nursing progress note was entered into the clinical record for Resident #20. It stated that Resident #20 was walking around the unit and stopped at another resident's table and grabbed the other resident's banana. The resident got upset, got up, and punched resident #20 in the stomach. The two residents were separated and assessed for injuries. Management and the family were notified. Review of a change in condition form for Resident #20, dated December 2, 2025, revealed that Resident #20's skin had no changes observed, and Resident #20 was not in pain. On December 22, 2025, a nursing progress note was entered into the clinical record for Resident #11. It stated that Resident #11 was eating breakfast when another resident wandering in the unit came up to him and took his banana. Resident #11 got upset and got up and punched the other resident in the stomach. Resident #11 was placed on one-on-one supervision. Review of a skin assessment and weekly skin check for Resident #11, both dated December 22, 2025, revealed no skin injuries or areas of concern for Resident #11. An interview was conducted by telephone on December 23, 2025, at 2:34 p.m. with CNA (staff #58). Staff #58 stated that on December 22, 2025, during breakfast, he witnessed resident #20 walking around. Resident #20 walked up to the table occupied by Resident #11 and took Resident #11's banana. Staff #58 went over to intervene and witnessed Resident #11 accuse Resident #20 of stealing, and Resident #11 punched Resident #20 in the stomach. Staff #58 then separated the residents, and Resident #11 denied hitting Resident #20. Review of the facility's undated 5-day investigation report regarding the altercation that occurred on December 12, 2025, revealed that resident #11 and resident #20 were assessed, and no physical injuries were noted to either resident; psycho-social support was provided to both residents. An interview was conducted with Staff #31 on December 23, 2025, at 3:23 p.m. Staff #31 stated that the altercation between resident #20 and Resident #11 on December 22, 2025, in which one resident hit another resident in the stomach, would meet the definition of abuse and fail to meet the facility's expectation. Regarding Resident #9 Resident #9 (alleged victim) was admitted to the facility on [DATE], with diagnoses including dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder.A review of the admission MDS assessment dated [DATE], revealed a BIMS score of 11, which indicated the resident had moderate cognitive impairment. The MDS further revealed that Resident #9 had exhibited no verbal or physical behavioral symptoms during the assessment period.Review of Resident #9's care plan that was initiated on December 19, 2025, revealed a risk for impaired cognitive function or impaired thought related to his diagnosis of dementia. Interventions included monitoring, documenting, and reporting changes in condition and cue, reorienting and supervising Resident #9, as needed. Resident #18 (alleged perpetrator) was admitted to the facility on [DATE], with diagnoses including vascular dementia, with other behavioral disturbance, insomnia, anxiety disorder, metabolic encephalopathy, anemia, and violent behavior.A review of the annual MDS assessment dated [DATE], revealed a BIMS score of 6, which indicated the resident had moderate cognitive impairment. The MDS further revealed that Resident #18 had exhibited no verbal or physical behavioral symptoms directed towards others, but was observed to reject care one to three times during the assessment period. Review of Resident #18's care plan that was initiated on October 29, 2025, revealed a risk for psychosocial well-being related to a resident-to-resident altercation. Interventions included removing Resident #18 to a calm, safe environment when conflicts arise, and allowing him to share his feelings. - Regarding the December 20, 2025, incidentOn December 20, 2025, a behavior progress note was entered into the clinical record for Resident #9. It stated that Resident #9 started arguing with another resident. A nurse walked over to get between the men when they started to swing and hit each other a few times. The two residents were separated, no injuries were noted, and the nurse would continue to monitor. Review of a change in condition form for Resident #9, dated December 20, 2025, revealed that Resident #9's skin had no changes and was not in pain. The document noted the resident's physical aggression. On December 20, 2025, a behavior progress note was entered into the clinical record for resident #18 (identical note as Resident #9). It stated that Resident #18 started arguing with another resident. A nurse walked over to get between the men when they started to swing and hit each other a few times. The two residents were separated, no injuries were noted, and the nurse would continue to monitor.Review of a change in condition form for Resident #9, dated December 20, 2025, revealed that Resident #18's skin had no changes and was not in pain. The document noted the resident's physical aggression. An interview was conducted by telephone on December 23, 2025, at 12:14 p.m. with LPN/staff #212. Staff #212 stated that on December 20, 2025, she was passing medications and observed Residents #9 and #18 both seated at the dinner table. She overheard Resident #18 verbally threaten Resident #9 and immediately reacted to separate the residents. As she approached, she saw Resident #18 hit Resident #9 with his hand. Resident #9 then hit back at resident #18 until staff could separate the residents. Staff #212 assessed both residents, and no physical injuries were noted to either resident. Review of the facility's undated 5-day investigation report regarding the altercation that occurred on December 20, 2025, revealed that residents #9 and #18 were arguing over a female resident, and Resident #18 believed he was protecting her. An interview was conducted with Staff #31 on December 23, 2025, at 3:23 p.m. Staff #31 stated that the altercation between Resident #9 and Resident #18 on December 20, 2025, would meet the definition of abuse and fail to meet the facility's expectations.Review of a facility policy titled, Abuse and Neglect - Clinical Protocol, revised in March of 2018, revealed that abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Review of a policy revised in September of 2022, titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and investigating, revealed a definition of abuse being the willful infliction of injury withresulting physical harm, pain or mental anguish. The policy further revealed a definition for willful being that an individual acted deliberately.Review of a policy revised in April of 2021, titled, Abuse, Neglect, Exploitation or Misappropriation -Prevention Program, revealed that residents have a right to be free from abuse, and the facility was committed to ensuring residents were protected from abuse by anyone, including other residents.

Based on clinical record review, staff interviews, review of facility documentation and policies, the facility failed to protect the rights of four residents (#1, #2, #10, and #20) to be free from abuse from each other. The deficient practice could result in further abuse of residents and appropriate action not taken.Findings include:Regarding incident involving Resident #20 and Resident #2:-Regarding Resident #20 (alleged perpetrator):Resident #20 was initially admitted at the facility on August 20, 2021, with diagnoses of dementia, chronic obstructive pulmonary disease (COPD), and generalized anxiety disorder.A review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6.0, severely impaired, and no behavioral symptoms exhibited.A review of the care plan dated August 19, 2025, revealed the resident has a cognitive deficit related to dementia with behavioral disturbance. The intervention included for the staff to attempt to keep her away from close proximity to one particular resident at all times.Review of the Nurse Note progress note dated September 29, 2025, at 2:55 PM revealed that Resident #20, identified as Resident A in the progress note, was observed self-transferring in a wheelchair in the day room. Another resident, identified as Resident B, attempted to grab the handle of the wheelchair. Resident #20 turned and struck the other resident with a closed fist. The other resident proceeded to strike Resident #20 with a closed fist. The nurse separated the residents, redirecting Resident #20. A head-to-toe assessment was completed, and no injuries. Resident #20 was placed on every 15-minute check until reevaluated by psych.Another care plan, revised on September 30, 2025, revealed the resident is at risk for a psychosocial well-being problem related to a resident-to-resident altercation.-Regarding Resident #2:Resident #2 was initially admitted at the facility on December 22, 2022, with diagnoses of senile degeneration of the brain, Type 2 Diabetes Mellitus, and dementia.Review of the care plan dated June 23, 2025, revealed the resident has a cognitive deficit related to dementia and Parkinson's disease.Review of the Significant Change in Status MDS dated [DATE], revealed a BIMS score of 6.0, severely impaired, and behavioral symptoms not directed to others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred.A review of the eINTERACT SBAR Summary for Providers progress note dated September 29, 2025, at 2:10 PM revealed, a change in condition situation, per nursing observations, evaluation, and recommendations: Resident #2 was observed in the dayroom grabbing the handle of another resident, identified as the aggressor, wheelchair. Resident #2 turned and struck the other resident with a closed fist. The other resident proceeded to strike Resident #2 with a closed fist. The nurse separated both residents. A head-to-toe assessment was completed for both residents, and there were no injuries.Review of another care plan dated September 30, 2025, revealed that the resident was at risk for a psychosocial well-being problem related to a resident-to-resident altercation. The intervention included removing residents to a calm, safe environment and allowing them to vent/share feelings.Per the facility's investigation report, after a comprehensive internal investigation was completed, per the report, it was found that Resident #20 was highly agitated and disoriented for the past several days. She did not like anyone to touch her and her belongings, and when Resident #2 touched her, Resident #20 responded by slapping at Resident #2.Regarding incident involving Resident #10 and Resident #1:-Regarding Resident #10 (alleged perpetrator):Resident #10 was initially admitted at the facility on September 17, 2024, with diagnoses of Alzheimer's disease, Dementia, and Type 2 Diabetes Mellitus.A review of the annual MDS assessment dated [DATE], revealed a BIMS score of 9.0, moderately impaired, and no behavioral symptoms exhibited.An eINTERACT SBAR Summary for Providers progress note dated October 10, 2025, at 12:15 PM revealed a change of condition for behavioral symptoms. Per the progress note's nursing observations, evaluation, and recommendation, a verbal and physical altercation between the roommate and Resident #10 was the aggressor. Resident #10 slapped, pushed his roommate, and fell on the floor. The residents were separated and monitored. The administrator, director of nursing, the providers, and the family were notified.A review of the care plan dated October 10, 2025, and revised on October 13, 2025, revealed the resident has a potential psychosocial well-being problem related to a resident-to-resident.-Regarding Resident #1 (alleged victim):Resident #1 was admitted at the facility on February 6, 2025, with Parkinsonism, Major Depressive Disorder, epilepsy, traumatic brain injury, and anxiety disorder.A review of the MDS assessment dated [DATE], revealed a BIMS score of 10.0, moderately impaired; and per assessment, his mood included feeling down, depressed, or hopeless.A review of the eINTERACT SBAR Summary for Providers progress note dated October 10, 2025, at 12:39 PM revealed a change of condition for trauma; and per nursing observations, evaluation, and recommendations, the resident was in a verbal/physical altercation with another resident. The progress note revealed that Resident #1 ran into his roommate with his wheelchair, then Resident #1 was slapped on the back of his head, pushed out of his wheelchair, and fell onto the floor, hitting the back of his head. A golf ball-sized reddened/swollen bump was noted on the top back of his head. There were no other injuries. The residents were separated. The provider was notified.A review of the physician progress note dated October 11, 2025, revealed that the resident was involved in an altercation yesterday, in which he was pushed. The resident did not recall the incident, who the incident was with, or what happened. Per the progress note, Resident #1 reported pain in the back of the head, but has no evidence of trauma.Per the Skin Only progress note dated October 10, 2025, at 5:16 PM, revealed per skin issue, a traumatic wound was located at the top/back of the head, 10.0 centimeters (cm) in length by 10 cm in width. The resident sustained an injury to the top/back of the head after a fall, reddened, swollen bump was noted. The provider and the resident's family member were notified.During an observation conducted on October 20, 2025, at 11:42 PM, in Resident #1's room, Resident #1 was in his bed, lying down with a blanket covering all the way to his face. A certified nursing assistant (CNA/Staff #40) was in the resident's room. Staff #40 stated that he was in the room for a one-on-one with the resident in the other bed. Staff #40 stated that the Resident #1 was in the same room for 4 months.An interview was conducted on October 20, 2025, at 12:27 PM with a CNA/Staff #45. Staff #45 stated that her abuse training includes reporting to the nurse and providing a statement on what had happened. She stated that abuse is sexual, stealing, hitting, such as hitting someone's head and arm, and touching someone inappropriately. She stated that she will report the abuse because it could harm residents and staff. She stated that if she witnessed two residents having an altercation, she would separate them, take one resident outside, because the residents might get overstimulated. She stated that Resident #10 gets frustrated, demanding cigarettes and coffee, is independent, ambulatory, continent, and Resident #10 came to her unit two days ago. During an observation on October 20, 2025, at 12:38 PM, Resident #10 was standing in his room, and he was talking about his past, and stated that he arrived in his room two or three days ago.An interview was conducted on October 20, 2025, with a Licensed Practical Nurse (LPN/Staff #50). Staff #50 stated that abuse types include physical, exploitation, financial, neglect, and mental. She stated that she reports the abuse to her director of nursing (DON) or the administrator. She stated that physical abuse is punching, hitting, and kicking another person. She stated that if a resident with dementia or the resident is mentally sick, and kicking another person, she considers it abuse. She will separate the residents to make sure the abuse does not continue. She stated that Resident #10 is pleasant, alert, and oriented, and she does not know the reason why Resident #10 was moved to her unit. She stated that Resident #2 has dementia and can be active. She stated that regarding Resident #20, she is not aware or was not made aware during the report of any altercation between Resident #2 and Resident #20.On October 20, 2025, at 1:21 PM, Resident #2 was observed in her room, lying in her bed, and she did not want to have a conversation.On October 20, 2025, at 1:22 PM, Resident #20 was observed in her room, and she stated that she gets along with the other residents.Another interview was conducted on October 20, 2025, with CNA/Staff #36. Staff #36 stated that abuse is physical, verbal, mental, emotional, and financial. She stated that she gets dementia care training provided by her night supervisor. She stated that physical abuse could be two residents having a physical altercation, like hitting. She stated that verbal abuse includes cursing someone, calling them names, and being verbally aggressive. She said that she works in the locked unit, and if she witnessed an altercation in the behavioral dementia unit, she would separate both residents, place the aggressor on a one-on-one, and if the residents are roommates, she would switch the resident to another room. Staff stated that Resident #1 has been involved in an incident. She stated that Resident #1's roommate was moved out of the room. She stated that Resident #10 pushed Resident #1 from his wheelchair about a week ago. Resident #1 fell on the floor and hit his head, then Resident #10 was moved out to another unit. The residents were separated because they could get hurt. If she witnessed abuse, she would notify the nurse and the administrator.Another interview was conducted on October 20, 2025, with a Registered Nurse (RN/Staff #47). Staff #47 stated that her abuse training included reporting the abuse immediately to the administrator, so the abuse can be investigated. If the abuse is not reported, the abuse can cause injury if repeated, and the resident will live in fear and depression. She stated that abuse is not right and it is a violation of the resident's rights. She stated that abuse can also be physical, sexual, emotional, and financial. She stated that physical abuse involved physical contact, like punching, hitting the head, or arms. She stated that Resident #1 uses his wheelchair; she was not aware of any altercation involving Resident #1, except that his roommate, Resident #10, was moved out of their room.Several phone calls were attempted on October 20, 2025. A call was placed to Staff #38, and a voice message was left.A phone interview was conducted on October 20, 2025, at 2:15 PM with a CNA/Staff #18. Staff #18 stated that her abuse training is through computer and in-service. She stated that abuse can be physical and emotional, and to report the abuse to her supervisor because if it is not reported, it can be considered as neglect. A call was placed to CNA/Staff #32, left a voice mail message.A phone interview was conducted on October 20, 2025, at 2:39 PM with CNA/Staff #49. Staff #49 stated that her responsibility when she witnesses abuse is to report. Staff #49 stated that there was an incident in one of the rooms in her unit. The residents were both going out to smoke, and Staff #49 was going to take the residents to smoke. Staff #49 stated that Resident #1 was in a wheelchair, Resident #1 might have backed his wheelchair, and Resident #10 grabbed Resident #1 by the back of his neck. Staff #49 separated the residents and notified the nurse.A phone interview was conducted on October 20, 2025, at 2:44 PM with Staff #52. Staff #52 stated that she received her abuse training during her orientation, monthly staff meeting, and in-services. She stated that abuse is restraining, confinement, taking things, verbal assault, and physical assault, such as intentional hitting, and residents hitting each other. Staff #52 stated that between Resident #2 and Resident #20 incident, she was on duty that day, and the incident happened in the dayroom about 1:30 PM. She stated that Resident #20 was attempting to self-ambulate, she was pushing her wheelchair with her feet, passed by Resident #2, then Resident #2 grabbed the handle of the wheelchair, then Resident #20 turned around and hit Resident #2, and then Resident #2 hit Resident #20 on her back. Staff #52 stated that she separated both residents and escorted Resident #20 to her room. Staff #52 stated that she spoke with Resident #20, and Resident #20 stated that she was aware that she hit Resident #2, but not aware of the reason why she did it. Staff #52 stated that there was physical contact made, and she considers it an abuse.A phone interview was conducted on October 21, 2025, at 8:57 AM with Staff #38. Staff #38 stated that two weeks ago, there was an incident involving Resident #10 and Resident #1, which she did not witness. The residents were roommates. She stated that a CNA came to her about the incident, describing that Resident #1 was under his bed, the staff picked him up from the floor, and both residents reported what had happened. She stated that Resident #10 smacked Resident #1 on the back of his head and then pushed his wheelchair. Resident #1 became frustrated, so he backed his wheelchair into Resident #10's leg by accident. She stated that the residents were separated. She stated that Resident #1 had muscle spasm and his feet pushed the bottom of the floor, and then his wheelchair went backwards. She stated that Resident #10 told her that Resident #1 backed into him. Staff #38 stated that she took Resident #1 to the dayroom, assessed him, saw a goose egg bump on the back of his head, applied ice, performed neuro checks, and notified the provider, his family, and the administrator to report the incident. Staff #38 stated that Resident #10 has a history of being verbally aggressive, walks independently, and has dementia. She stated that Resident #1 is impaired physically because he cannot swing, has spastic movement, and is weak. Staff #38 stated that her abuse training involved doing it through the online module, having continuing education training (CEU), and a skills lab. She stated that abuse is verbal, physical, and intimidation. She stated examples of physical abuse, such as assaulting, hitting, kicking, and neglect by staff. She considered the incident between Resident #10 and Resident #1 to be physical abuse, with the smack on the head. She also stated that Resident #10 can easily get agitated and has a short fuse, and Resident #1 accidentally backed into Resident #10.An interview was conducted on October 20, 2025, at 3:55 PM with the administrator/Staff #15. The administrator stated that abuse is anything with physical, sexual, misappropriation of property, abandonment, or neglect. Physical abuse is hitting somebody or being forceful, like grabbing, hitting on the head, pushing somebody down, and punching someone. Regarding Resident #1 and Resident #10, the administrator stated that the incident was not witnessed by staff, but the residents concurred that the incident had occurred. The administrator said that Resident #10 hit Resident #1 on the back of his head because Resident #1 was blocking the doorway. Regarding Resident #2 and Resident #20, the administrator stated that both residents were in their wheelchairs. Resident #20 was passing by Resident #2; Resident #2 grabbed the wheelchair, and Resident #20 got upset, so Resident #20 turned back and hit Resident #2's head.Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised in April 2021, revealed that residents have the right to be free from abuse.Review of the facility's policy titled, Resident Rights, revised in February 2021, revealed that the federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to: b. be treated with respect, kindness, and dignity; and c. be free from abuse.

Based on interviews, review of records, and review of facility policy and procedure, the facility failed to protect the rights of three of seven sampled residents (#10, #8, and #20) to be free from abuse by other residents (#22, 16, and 6). The deficient practice could lead to ongoing abuse, leading to harm of other residents.-Findings include:Regarding Resident #10Resident #10 (alleged victim) was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, major depressive disorder, anxiety disorder, encounter for palliative care, benign prostatic hyperplasia with lower urinary tract symptoms, and senile degeneration of brain.A review of the admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 3, which indicated the resident was severely cognitively impaired. The MDS further revealed that resident #10 had exhibited no verbal or physical behavioral symptoms directed towards others during the assessment period. Review of resident #10's care plan that was initiated September 23, 2025, revealed a risk for psychosocial well-being related to a resident-to-resident altercation. Interventions included increased communication and monitoring of his usual response to problems.Resident #22 (alleged perpetrator) was admitted to the facility on [DATE] with diagnoses including unspecified moderate dementia- with agitation, anxiety disorder, anemia, chronic obstructive pulmonary disease, generalized muscle weakness, hypothyroidism, acute respiratory failure with hypoxia, metabolic encephalopathy, and unsteadiness on feet.Review of resident #22's quarterly MDS dated [DATE] revealed a BIMS score of 8, which indicated moderate cognitive impairment. The MDS further stated that resident #22 exhibited no verbal or physical behavioral symptoms directed towards others. A care plan that was initiated September 23, 2025 that revealed that resident #22 was at risk for a psychosocial wellbeing problem related to a resident-to-resident altercation. Interventions included 72-hour observation, consult with pastoral, social services, and psych services, and monitor/document resident #22's unusual response to problems. -Regarding October 20, 2025 incidentOn October 20, 2025, at 12:24 p.m. an incident progress note was entered into the clinical record for resident #10. It stated that at approximately 12:24 p.m. resident #10 was observed having being struck in the abdomen by another resident. Per the note, resident #10 was at baseline very confused and only muttered something about a radio. Both residents were immediately separated for safety. Resident #10 was assessed head to toe with no redness or bruising noted. Resident #10 denied any pain.Review of resident #10's skin assessment, dated October 20, 2025, revealed that resident #10's skin was clean dry and intact. No skin issues or injuries were noted.Review of a psych follow up progress note dated October 21, 2025, documented that per the assessment, resident #10's deemed that his safety risk was low and a safety plan was not required.On October 20, 2025, at 12:43 p.m. an incident progress note was entered into the clinical record for resident #22. It stated that at approximately 12:24 p.m. resident #22 was observed punching another resident in the abdomen. Resident #22 kept saying he's a f^cking rat. Both residents were separated for safety.Review of a psych follow up progress note dated October 21, 2025, revealed that resident #22 had been seen by Behavior Nurse Practitioner (NP/staff #174). The note documented that the NP had adjusted the orders for medications and resident #22 was monitored and remained under observation.Review of the facility's undated 5-day investigation report regarding the altercation which occurred on October 20, 2025 revealed that resident #10 entered the day room at approximately 12:30 p.m. and was observed greeting other residents around the room. Per the report, resident #10 approached resident #22, resident #22 said something to resident #10 and then resident #22 punched resident #10 in the stomach. The report documented that neither resident had physical injuries noted. Further review of the 5-day investigation report revealed a written staff witness statement by a Registered Nurse (RN/staff #130). The statement indicated that staff #130 was giving another resident medication in the shower room and upon exiting observed the resident-to-resident altercation. Attempts to contact the RN (staff #130) for a telephonic interview were made on November 6, 2025 at 11:29 a.m., 12:42 p.m., and 3:24 p.m. No return call was received. -Regarding resident #10 and resident #22 on October 21, 2025 incidentReview of a clinical records for residents #10 revealed an incident progress note at on October 21, 2025, at 4:43 p.m. The notes stated that resident #22 had been observed verbally assaulting resident #10 in the dayroom. Resident #10 was sitting at the table, and not provoking resident #22. Resident #22, moved his wheelchair near resident #10 and resident #22 punched resident #10 in the upper body. Resident #10 was transported outside to diffuse and separate the residents and no physical injuries were noted to either resident. Review of a skin assessments for residents #10, dated October 21, 2025 revealed that no physical injuries were noted to resident #10. Review of a clinical records for residents #22 revealed an incident progress note at on October 21, 2025, at 4:37 p.m. The notes stated that resident #22 had been observed verbally assaulting resident #10 in the dayroom. Resident #10 was sitting at the table, and not provoking resident #22. Resident #22, moved his wheelchair near resident #10 and resident #22 punched resident #10 in the upper body. Resident #10 was transported outside to diffuse and separate the residents and no physical injuries were noted to either resident. Review of a skin assessments for residents #22, dated October 21, 2025, revealed that no physical injuries were noted to resident #22. Review of facility census records for resident #22 reveal that resident #22 was moved from the Vista East unit to the Vista [NAME] unit on October 21, 2025.Review of the facility's undated 5-day investigation report for the altercation which occurred on October 21, 2025 revealed that resident #10 was sitting at a table when he had a verbal altercation with resident #22. Resident #22 then punched resident #10 in the upper body. The report further stated that resident #22 had just been seen by the NP (staff #174) and had been placed on 15-minute supervisory checks. The facility determined it was best to move resident #22 to a different secure unit and continued one-on-one staff monitoring until the change in medication took effect. Further review of the undated 5-day investigation revealed that no witness statements were included in the report for the altercation on October 21, 2025.Attempts were made to interview Licensed Practical Nurse (LPN/staff #163) on November 6, 2025, at 11:32 a.m., 12:46 p.m. and 3:25 p.m. No return call was received.An updated quarterly MDS for resident #22 was entered into the clinical record on October 22, 2025. Resident #22's BIMS score was assessed to be 7, indicating severe cognitive impairment. The MDS documented that the resident did not exhibit physical behavioral symptoms directed towards others. However, the MDS indicated that the resident exhibited verbal and other behavioral symptoms directed towards others during the assessment period. An interview was conducted with the Director of Nursing (DON/staff #56) on November 6, 2025 at 3:05 p.m. Staff #56 stated that her expectation is that when a resident-to-resident altercation occurs, the residents with a history of behaviors directed towards others would be placed on one-on-one supervision until they can be seen by the facility's psych provider. If the resident has no history of behaviors directed towards others, the perpetrator would be placed on behavioral checks every 15 minutes until the resident could be seen by the psych provider. The DON said that incidents between residents #22 and #10 which occurred on October 20, 2025 and October 21, 2025 both met the definition of abuse and failed to meet her expectations for the residents and the facility. Regarding resident #8 -Resident #8 (alleged victim) was admitted to the facility on [DATE], with diagnoses including vascular dementia with other behavioral disturbance, dysphagia, oral phase, anxiety disorder, hypokalemia, metabolic encephalopathy, violent behavior, and anemia.Review of resident #8's care plan initiated October 13, 2025 revealed that resident #8's behaviors included intrusive wandering and refusal of care. Interventions included indicated for staff to intervene as necessary to protect the rights and safety of others. Review of the quarterly MDS assessment for resident #8 dated October 14, 2025, revealed a BIMS score of 6, which indicated severe cognitive impairment. The MDS further documented that resident #8 did not exhibit verbal or physical behavioral symptoms directed towards others during the assessment period.An incident progress note dated October 29, 2025documented that the RN (staff #130) heard a commotion in the dayroom while charting at the station. Per the note, staff #130 looked up and saw resident #8 being hit on the arm by another resident. Resident #8 informed the RN that the other resident was yelling at him and then hit him. According to the note, both residents were separated and no physical injuries were noted to either resident. -Resident #16 (alleged perpetrator) was admitted to the facility on [DATE] with diagnoses including unspecified dementia with agitation, generalized anxiety disorder, chronic obstructive pulmonary disease, chronic pain syndrome, unspecified severe protein-calorie malnutrition, recurrent major depressive disorder, and hyperlipidemia.Review of resident #16's care plan initiated November 20, 2024 and revised September 30, 2025 addressed psychosocial wellbeing related to a resident to resident altercation. Interventions directed to monitor and document resident #16's usual response to problem and consult with pastoral care, social services and psych services. Review of resident #16's annual MDS assessment dated [DATE] revealed a BIMS score of 6, which indicated severe cognitive impairment. The MDS indicated that resident #16 did not exhibit verbal or physical behavioral symptoms directed towards others during the assessment period.An incident progress note dated October 29, 2025 documented that a RN (staff #130) heard a commotion while charting at the nurse's station. Per the note, the RN looked up and saw resident #16 hitting another resident on the arm. The note indicated that resident #16 was baseline dementia and laughed about the situation. According to the note the residents were separated for safety and no physical injuries were noted to either resident. Review of the facility's undated 5-day investigation report for the altercation which occurred on October 29, 2025 revealed that at approximately 4:11 p.m., resident #16 was witnessed shouting at resident #8 while in the dayroom. The report indicated that resident #8 was heard telling resident #16 to shut up. Per the report resident #16 hit resident #8 on the arm then resident #8 struck back at resident #16. The report documented that staff separated and assessed both residents. No injuries were observed to either resident. Both resident #8 and resident #16 could not recall the incident 30 minutes after the altercation. Resident #16 was placed on 15-minute supervisory checks until she could be seen by the NP (staff #174). Further review of the undated 5-day report revealed a written staff witness statement by RN (staff #130). The statement revealed that at approximately 4:07 p.m. on October 29, 2025, staff #130 heard a commotion in the dayroom while charting., The RN stood up and witnessed resident #16 hit resident #8 on his arm. Attempts to contact staff witness, RN #130, were made on November 6, 2025 at 11:29 a.m., 12:42 p.m., and 3:24 p.m. No return call was received.On November 6, 2025 at 3:05 p.m., an interview was conducted with Director of Nursing (DON/staff #56). Staff #56 stated that her expectation regarding resident-to-resident altercation is that the residents with a history of behaviors directed towards others be placed on one-on-one supervision until they can be seen by the facility's psych provider. If the resident has no history of behaviors directed towards others, she expects the perpetrator to be placed on behavioral checks every 15 minutes until the resident could be seen by the psych provider. The DON said that the incident between residents #16 and #8 on October 29, 2025 met the definition of abuse and failed to meet her expectations for the residents and the facility.-Regarding Resident #20-Resident #20 (alleged victim) was admitted to the facility on [DATE] , with diagnoses including: major depressive disorder, type 2 diabetes mellitus without complications, obstructive sleep apnea, polyneuropathy, fibromyalgia, chronic obstructive pulmonary disease, atherosclerotic heart disease of native coronary artery without angina pectoris, narcissistic personality disorder, adjustment disorder with mixed anxiety and depressed mood, mild cognitive impairment of uncertain or unknown etiology, malignant neoplasm of bladder, rheumatoid arthritis, and encounter for antineoplastic chemotherapy.Review of the quarterly MDS assessment for resident #20 dated August 1, 2025, revealed a BIMS score of 12, which indicated moderate cognitive impairment. The MDS further stated that resident #20 exhibited no verbal or physical behavioral symptoms directed towards others during the assessment period.Further review of resident #20's MDS assessment dated [DATE] revealed that he was assessed to be independent for sit to stand, and walking 50 feet with two turns, once standing. Furthermore, the assessment indicated that resident #20 required assistance prior to or after walking 150 feet after standing. The MDS assessment noted that resident #20 had no falls noted prior to admission and indicated one fall with injury since admission to the facility. Review of resident #20's care plan focus initiated May 6, 2024, revealed a risk for falls related to psychoactive drug use. Interventions included anticipating and meeting the resident's needs.A care plan focus for resident #20 initiated August 12, 2024, revealed that resident #20 was at risk for elopement. Interventions included assessment for fall risk and distract resident from wandering by offering pleasant diversions and conversations. Another care plan for resident #20 revealed a focus initiated October 29, 2025, revealed that resident #20 was at risk for not meeting social needs. Interventions included indicated to introducing introduce resident #20 to other residents with a similar background and encouraging encourage and facilitating facilitate their interactions.A skin assessment dated [DATE] documented that the resident had no skin issues/injuries. An SBAR (Situation, Background, Assessment and Recommendation) Summary note dated November 3, 2025 documented that documented that at approximately 7:00 p.m., another resident was joking around with peers in the dayroom and appeared to have said something to this resident which upset him and caused him to push the other resident to the floor. A Nurses note dated November 3, 2025 documented that resident #20 was involved in an incident with another resident. Per the note resident #20 wanted to make sure the other resident was okay before he left. The incident was categorized as unexpected due to the residents usually joking with each other. The note indicated that neuro and vital check were accomplished and provider was notified of the findings. According to the note, new orders were received to send the resident to the ER (emergency room) for scans.Review of the Weekly Skin Check form dated November 4, 2025 revealed that resident #20 did not have documented skin issues/injuries or new skin condition.A change of condition evaluation for resident #20 dated November 3, 2025, at 7:03 p.m. revealed that Resident #6 had developed a bump on the back of his head and was noted to be in acute pain. A review of the census information for resident #20 revealed that resident #20 was discharged for a hospital leave on November 3, 2025. The resident had not returned to the facility. Resident #6 (alleged perpetrator) was admitted to the facility on [DATE] , with diagnoses including: unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, atrial fibrillation, depression, personal history of transient ischemic attack (tia), and cerebral infarction without residual deficits, and essential (primary) hypertension.Review of the quarterly MDS for resident #6, dated September 2, 2025, revealed a BIMS of 6, which indicated severe cognitive impairment. The MDS further stated that resident #6 exhibited no verbal or physical behavioral symptoms directed towards others during the assessment period.Review of the care plan for resident #6 revealed a focus revised on December 1, 2024 for not meeting resident #6's emotional, intellectual, physical and social needs, in regards to resident #6's diagnoses of dementia. Interventions included assistance and escort to activity functions and introducing resident #6 to other residents with similar background and interests and encourage and facilitate interaction. Another care plan focus initiated June 2, 2025, revealed that resident #6 had an impaired cognitive function regarding his diagnosis of dementia. Interventions included cueing, reorienting and supervision of resident #6 as needed. Review of resident #6's progress notes revealed a provider summary note dated November 3, 2025, at 8:37 p.m. for resident #6's change in condition related to behavioral symptoms. It stated that at approximately 7:00 p.m. resident #20 was joking with peers in the dayroom and appeared to say something to resident #6 as resident #20 was walking by resident #6's table. Resident #6 appeared to get upset and pushed resident #20 to the floor. Resident #20 stated that He pushed me and I fell, but I'm okay. The residents were separated, assessed for neuros, vitals and assessed head to toe. The provider's recommendations were to place resident #6 on checks every 15 minutes and monitor. A nursing progress note on November 3, 2025, at 9:41 p.m. revealed that after the altercation, resident #6 stated that he wanted to make sure that resident #20 was okay before leaving the day room. The note further stated that the incident was unexpected because both residents joke with each other daily. An interview was conducted by telephone on November 6, 2025, at 2:10 p.m. with Licensed Practical Nurse (LPN/staff #111). LPN #111 stated that on November 3, 2025, at approximately 7:00 p.m., resident #6 was seated at a table in the day room and resident #20 came into the room to get a snack from a nurse. Resident #20 stopped by the table occupied by resident #6 and resident #20 said something to resident #6, quietly. LPN #111 then witnessed resident #6 stand up aggressively. Staff then attempted to intervene but resident #20 pushed resident #6 to the floor. The residents were separated and assessed. LPN #111 stated that resident #20 had immediately told staff that he was not injured and resident #6 could not recall the incident 10 minutes later. resident #6 likes to joke with other residents and staff, so this behavior was unlike him. An interview was conducted by telephone on November 6, 2025, at 2:18 p.m. with Certified Nursing Assistant (CNA/staff #120). CNA #120 stated that on November 3, 2025 at approximately 7:00 p.m., she was working on the computer and overheard resident #6 tell resident #20 You don't talk to me like that. She then witnessed resident #6 push resident #20 to the ground. CNA #120 stated she ran towards the residents to assist in separating them and that resident #6, could not recall the events that took place, soon after the incident. An interview was conducted on November 6, 2025, at 3:05 p.m. with DON #56. DON #56 stated that on November 3, 2025, resident #20 had been out of the facility on a bus trip attending a program for military veterans. Upon his return, resident was assessed to have a sprained ankle that could have altered his stability on his feet. DON #56 stated that resident #20 is still at the hospital recovering from a broken hip due to the incident, and they expect him to return to the facility in the near future. DON #56 then stated that the incident on November 3, 2025, between residents #20 and #6 would be considered abuse and would fail to meet her expectations. Review of the facility's 5-day investigation revealed that after staff witnessed resident #6 push resident #20 to the ground, resident #20 was initially assed to only have a bump on his head. Later in the evening, resident was taken to the emergency room and at the hospital it was reported that resident #20 had fracture of his right hip. Resident #6 expressed remorse to staff, but could not recall the incident soon after. Resident #6 was moved to a different unit of the facility but became irate and aggressive and the facility moved him back to his previous room. Review of a facility policy titled, Abuse and Neglect - Clinical Protocol, revised in March of 2018, revealed that abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Review of a policy revised in September of 2022, titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and investigating, revealed a definition of abuse being the willful infliction of injury withresulting physical harm, pain or mental anguish. The policy further revealed a definition for willful being that an individual acted deliberately.Review of a policy revised in April of 2021, titled, Abuse, Neglect, Exploitation or Misappropriation -Prevention Program, revealed that residents have a right to be free from abuse, and the facility was committed to ensuring residents were protected from abuse by anyone, including other residents.

Based on clinical record review, staff interviews, review of facility documentation and policies, the facility failed to protect the rights of four residents (#1, #2, #10, and #20) to be free from abuse from each other. The deficient practice could result in further abuse of residents and appropriate action not taken.Findings include:Regarding incident involving Resident #20 and Resident #2:-Regarding Resident #20 (alleged perpetrator):Resident #20 was initially admitted at the facility on August 20, 2021, with diagnoses of dementia, chronic obstructive pulmonary disease (COPD), and generalized anxiety disorder.A review of the annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 6.0, severely impaired, and no behavioral symptoms exhibited.A review of the care plan dated August 19, 2025, revealed the resident has a cognitive deficit related to dementia with behavioral disturbance. The intervention included for the staff to attempt to keep her away from close proximity to one particular resident at all times.Review of the Nurse Note progress note dated September 29, 2025, at 2:55 PM revealed that Resident #20, identified as Resident A in the progress note, was observed self-transferring in a wheelchair in the day room. Another resident, identified as Resident B, attempted to grab the handle of the wheelchair. Resident #20 turned and struck the other resident with a closed fist. The other resident proceeded to strike Resident #20 with a closed fist. The nurse separated the residents, redirecting Resident #20. A head-to-toe assessment was completed, and no injuries. Resident #20 was placed on every 15-minute check until reevaluated by psych.Another care plan, revised on September 30, 2025, revealed the resident is at risk for a psychosocial well-being problem related to a resident-to-resident altercation.-Regarding Resident #2:Resident #2 was initially admitted at the facility on December 22, 2022, with diagnoses of senile degeneration of the brain, Type 2 Diabetes Mellitus, and dementia.Review of the care plan dated June 23, 2025, revealed the resident has a cognitive deficit related to dementia and Parkinson's disease.Review of the Significant Change in Status MDS dated [DATE], revealed a BIMS score of 6.0, severely impaired, and behavioral symptoms not directed to others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred.A review of the eINTERACT SBAR Summary for Providers progress note dated September 29, 2025, at 2:10 PM revealed, a change in condition situation, per nursing observations, evaluation, and recommendations: Resident #2 was observed in the dayroom grabbing the handle of another resident, identified as the aggressor, wheelchair. Resident #2 turned and struck the other resident with a closed fist. The other resident proceeded to strike Resident #2 with a closed fist. The nurse separated both residents. A head-to-toe assessment was completed for both residents, and there were no injuries.Review of another care plan dated September 30, 2025, revealed that the resident was at risk for a psychosocial well-being problem related to a resident-to-resident altercation. The intervention included removing residents to a calm, safe environment and allowing them to vent/share feelings.Per the facility's investigation report, after a comprehensive internal investigation was completed, per the report, it was found that Resident #20 was highly agitated and disoriented for the past several days. She did not like anyone to touch her and her belongings, and when Resident #2 touched her, Resident #20 responded by slapping at Resident #2.Regarding incident involving Resident #10 and Resident #1:-Regarding Resident #10 (alleged perpetrator):Resident #10 was initially admitted at the facility on September 17, 2024, with diagnoses of Alzheimer's disease, Dementia, and Type 2 Diabetes Mellitus.A review of the annual MDS assessment dated [DATE], revealed a BIMS score of 9.0, moderately impaired, and no behavioral symptoms exhibited.An eINTERACT SBAR Summary for Providers progress note dated October 10, 2025, at 12:15 PM revealed a change of condition for behavioral symptoms. Per the progress note's nursing observations, evaluation, and recommendation, a verbal and physical altercation between the roommate and Resident #10 was the aggressor. Resident #10 slapped, pushed his roommate, and fell on the floor. The residents were separated and monitored. The administrator, director of nursing, the providers, and the family were notified.A review of the care plan dated October 10, 2025, and revised on October 13, 2025, revealed the resident has a potential psychosocial well-being problem related to a resident-to-resident.-Regarding Resident #1 (alleged victim):Resident #1 was admitted at the facility on February 6, 2025, with Parkinsonism, Major Depressive Disorder, epilepsy, traumatic brain injury, and anxiety disorder.A review of the MDS assessment dated [DATE], revealed a BIMS score of 10.0, moderately impaired; and per assessment, his mood included feeling down, depressed, or hopeless.A review of the eINTERACT SBAR Summary for Providers progress note dated October 10, 2025, at 12:39 PM revealed a change of condition for trauma; and per nursing observations, evaluation, and recommendations, the resident was in a verbal/physical altercation with another resident. The progress note revealed that Resident #1 ran into his roommate with his wheelchair, then Resident #1 was slapped on the back of his head, pushed out of his wheelchair, and fell onto the floor, hitting the back of his head. A golf ball-sized reddened/swollen bump was noted on the top back of his head. There were no other injuries. The residents were separated. The provider was notified.A review of the physician progress note dated October 11, 2025, revealed that the resident was involved in an altercation yesterday, in which he was pushed. The resident did not recall the incident, who the incident was with, or what happened. Per the progress note, Resident #1 reported pain in the back of the head, but has no evidence of trauma.Per the Skin Only progress note dated October 10, 2025, at 5:16 PM, revealed per skin issue, a traumatic wound was located at the top/back of the head, 10.0 centimeters (cm) in length by 10 cm in width. The resident sustained an injury to the top/back of the head after a fall, reddened, swollen bump was noted. The provider and the resident's family member were notified.During an observation conducted on October 20, 2025, at 11:42 PM, in Resident #1's room, Resident #1 was in his bed, lying down with a blanket covering all the way to his face. A certified nursing assistant (CNA/Staff #40) was in the resident's room. Staff #40 stated that he was in the room for a one-on-one with the resident in the other bed. Staff #40 stated that the Resident #1 was in the same room for 4 months.An interview was conducted on October 20, 2025, at 12:27 PM with a CNA/Staff #45. Staff #45 stated that her abuse training includes reporting to the nurse and providing a statement on what had happened. She stated that abuse is sexual, stealing, hitting, such as hitting someone's head and arm, and touching someone inappropriately. She stated that she will report the abuse because it could harm residents and staff. She stated that if she witnessed two residents having an altercation, she would separate them, take one resident outside, because the residents might get overstimulated. She stated that Resident #10 gets frustrated, demanding cigarettes and coffee, is independent, ambulatory, continent, and Resident #10 came to her unit two days ago. During an observation on October 20, 2025, at 12:38 PM, Resident #10 was standing in his room, and he was talking about his past, and stated that he arrived in his room two or three days ago.An interview was conducted on October 20, 2025, with a Licensed Practical Nurse (LPN/Staff #50). Staff #50 stated that abuse types include physical, exploitation, financial, neglect, and mental. She stated that she reports the abuse to her director of nursing (DON) or the administrator. She stated that physical abuse is punching, hitting, and kicking another person. She stated that if a resident with dementia or the resident is mentally sick, and kicking another person, she considers it abuse. She will separate the residents to make sure the abuse does not continue. She stated that Resident #10 is pleasant, alert, and oriented, and she does not know the reason why Resident #10 was moved to her unit. She stated that Resident #2 has dementia and can be active. She stated that regarding Resident #20, she is not aware or was not made aware during the report of any altercation between Resident #2 and Resident #20.On October 20, 2025, at 1:21 PM, Resident #2 was observed in her room, lying in her bed, and she did not want to have a conversation.On October 20, 2025, at 1:22 PM, Resident #20 was observed in her room, and she stated that she gets along with the other residents.Another interview was conducted on October 20, 2025, with CNA/Staff #36. Staff #36 stated that abuse is physical, verbal, mental, emotional, and financial. She stated that she gets dementia care training provided by her night supervisor. She stated that physical abuse could be two residents having a physical altercation, like hitting. She stated that verbal abuse includes cursing someone, calling them names, and being verbally aggressive. She said that she works in the locked unit, and if she witnessed an altercation in the behavioral dementia unit, she would separate both residents, place the aggressor on a one-on-one, and if the residents are roommates, she would switch the resident to another room. Staff stated that Resident #1 has been involved in an incident. She stated that Resident #1's roommate was moved out of the room. She stated that Resident #10 pushed Resident #1 from his wheelchair about a week ago. Resident #1 fell on the floor and hit his head, then Resident #10 was moved out to another unit. The residents were separated because they could get hurt. If she witnessed abuse, she would notify the nurse and the administrator.Another interview was conducted on October 20, 2025, with a Registered Nurse (RN/Staff #47). Staff #47 stated that her abuse training included reporting the abuse immediately to the administrator, so the abuse can be investigated. If the abuse is not reported, the abuse can cause injury if repeated, and the resident will live in fear and depression. She stated that abuse is not right and it is a violation of the resident's rights. She stated that abuse can also be physical, sexual, emotional, and financial. She stated that physical abuse involved physical contact, like punching, hitting the head, or arms. She stated that Resident #1 uses his wheelchair; she was not aware of any altercation involving Resident #1, except that his roommate, Resident #10, was moved out of their room.Several phone calls were attempted on October 20, 2025. A call was placed to Staff #38, and a voice message was left.A phone interview was conducted on October 20, 2025, at 2:15 PM with a CNA/Staff #18. Staff #18 stated that her abuse training is through computer and in-service. She stated that abuse can be physical and emotional, and to report the abuse to her supervisor because if it is not reported, it can be considered as neglect. A call was placed to CNA/Staff #32, left a voice mail message.A phone interview was conducted on October 20, 2025, at 2:39 PM with CNA/Staff #49. Staff #49 stated that her responsibility when she witnesses abuse is to report. Staff #49 stated that there was an incident in one of the rooms in her unit. The residents were both going out to smoke, and Staff #49 was going to take the residents to smoke. Staff #49 stated that Resident #1 was in a wheelchair, Resident #1 might have backed his wheelchair, and Resident #10 grabbed Resident #1 by the back of his neck. Staff #49 separated the residents and notified the nurse.A phone interview was conducted on October 20, 2025, at 2:44 PM with Staff #52. Staff #52 stated that she received her abuse training during her orientation, monthly staff meeting, and in-services. She stated that abuse is restraining, confinement, taking things, verbal assault, and physical assault, such as intentional hitting, and residents hitting each other. Staff #52 stated that between Resident #2 and Resident #20 incident, she was on duty that day, and the incident happened in the dayroom about 1:30 PM. She stated that Resident #20 was attempting to self-ambulate, she was pushing her wheelchair with her feet, passed by Resident #2, then Resident #2 grabbed the handle of the wheelchair, then Resident #20 turned around and hit Resident #2, and then Resident #2 hit Resident #20 on her back. Staff #52 stated that she separated both residents and escorted Resident #20 to her room. Staff #52 stated that she spoke with Resident #20, and Resident #20 stated that she was aware that she hit Resident #2, but not aware of the reason why she did it. Staff #52 stated that there was physical contact made, and she considers it an abuse.A phone interview was conducted on October 21, 2025, at 8:57 AM with Staff #38. Staff #38 stated that two weeks ago, there was an incident involving Resident #10 and Resident #1, which she did not witness. The residents were roommates. She stated that a CNA came to her about the incident, describing that Resident #1 was under his bed, the staff picked him up from the floor, and both residents reported what had happened. She stated that Resident #10 smacked Resident #1 on the back of his head and then pushed his wheelchair. Resident #1 became frustrated, so he backed his wheelchair into Resident #10's leg by accident. She stated that the residents were separated. She stated that Resident #1 had muscle spasm and his feet pushed the bottom of the floor, and then his wheelchair went backwards. She stated that Resident #10 told her that Resident #1 backed into him. Staff #38 stated that she took Resident #1 to the dayroom, assessed him, saw a goose egg bump on the back of his head, applied ice, performed neuro checks, and notified the provider, his family, and the administrator to report the incident. Staff #38 stated that Resident #10 has a history of being verbally aggressive, walks independently, and has dementia. She stated that Resident #1 is impaired physically because he cannot swing, has spastic movement, and is weak. Staff #38 stated that her abuse training involved doing it through the online module, having continuing education training (CEU), and a skills lab. She stated that abuse is verbal, physical, and intimidation. She stated examples of physical abuse, such as assaulting, hitting, kicking, and neglect by staff. She considered the incident between Resident #10 and Resident #1 to be physical abuse, with the smack on the head. She also stated that Resident #10 can easily get agitated and has a short fuse, and Resident #1 accidentally backed into Resident #10.An interview was conducted on October 20, 2025, at 3:55 PM with the administrator/Staff #15. The administrator stated that abuse is anything with physical, sexual, misappropriation of property, abandonment, or neglect. Physical abuse is hitting somebody or being forceful, like grabbing, hitting on the head, pushing somebody down, and punching someone. Regarding Resident #1 and Resident #10, the administrator stated that the incident was not witnessed by staff, but the residents concurred that the incident had occurred. The administrator said that Resident #10 hit Resident #1 on the back of his head because Resident #1 was blocking the doorway. Regarding Resident #2 and Resident #20, the administrator stated that both residents were in their wheelchairs. Resident #20 was passing by Resident #2; Resident #2 grabbed the wheelchair, and Resident #20 got upset, so Resident #20 turned back and hit Resident #2's head.Review of the facility's policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised in April 2021, revealed that residents have the right to be free from abuse.Review of the facility's policy titled, Resident Rights, revised in February 2021, revealed that the federal and state laws guarantee certain basic rights to all residents of this facility. The rights include the resident's right to: b. be treated with respect, kindness, and dignity; and c. be free from abuse.

Based on staff interviews, clinical record review, facility's documentation review, and facility policy review, the facility failed to ensure adequate supervision was provided for one resident (#200). The deficient practice resulted in resident wandering away and becoming lost in the community. Findings include: Resident #200 was admitted to the facility on [DATE] with diagnoses of amyotrophic lateral sclerosis, dementia with psychosis, and depressive disorder. The behavior monitoring & interventions note dated August 22, 2024 revealed that on the evening shift the resident exhibited behaviors of wandering and elopement. Review of the elopement risk evaluation dated August 23, 2024 revealed a score of 0 indicating the resident had no risk for elopement. The behavior monitoring & interventions notes from August 26, 27 and 28, 2024 included the resident exhibited wandering and elopement behaviors. A review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating the resident was cognitively intact. The assessment coded the resident for wandering behavior that occurred 1 to 3 days of the assessment; and that, the wandering does not place the resident at risk of getting to a potentially dangerous place nor intrude on the privacy or activities of others. The behavior monitoring & interventions on August 30, 2024 included that the resident exhibited wandering and elopement behaviors. A review the behavior monitoring & interventions notes dated September 2 and 3, 2024 revealed the resident exhibited behaviors of wandering and elopement. The behavior note dated September 3, 2024 included that the resident refused evening medication, was restless, pacing back and forth from his room to the hallway and stated that he was leaving because someone was coming to pick him up. Per the documentation, the resident looked tired but did not want to go to bed; and that, the resident was redirected with negative impact. The behavior monitoring & interventions on September 4, 2024 revealed the resident exhibited wandering and elopement behaviors. The psych evaluation note dated September 4, 2024 revealed that the resident reported that he was leaving and was frustrated about being at the facility. Per the documentation, the resident reported that he was depressed and anxious because he wanted to be home. A review of the Care Area Assessment (CAA) Triggers Summary for behavioral symptoms dated September 4, 2024 revealed that the resident had wandered that occurred 1 to 3 days of the assessment. The summary also included that this was addressed in the care plan. However, a review of the care plan revealed no documentation of a care plan addressing resident's wandering and elopement behavior. The behavior monitoring & interventions on September 5, 2024 revealed the resident exhibited wandering and elopement behaviors. The behavior note dated September 5, 2024 included that the resident had been awake most of the night, seated on his chair and sometimes walked to the hallway just pacing back and forth. The behavior monitoring & intervention notes dated September 7 and 8, 2024 revealed the resident exhibited wandering and elopement behaviors. Despite documentation that the resident exhibited wandering and elopement behaviors, there was no evidence found of any interventions implemented to address this behavior. An alert note dated September 9, 2024 revealed the resident's room window was popped opened and the resident is no resident in the room. Per the documentation, the resident was missing; and that, the front desk staff reported that the police officers were with the resident about a block from the facility. It also included that the resident was taken to a hospital by the officers for checkup because he obtained minor injuries from a fall, as resident was dragged by a vehicle trying to get in to it while the vehicle was moving. In an interview nursing assistant (NA/staff #30) conducted on September 12, 2024 at 10:53 a.m., the NA stated that her role was to take care of the day room, deliver room trays, give resident water and snacks. The NA said that she cannot help a resident like changing and she calls a certified nursing assistant (CNA) for that. The NA said that for residents who have wandering behaviors, she will distract the resident, find something for them to do and ensure that they do not go into other resident rooms. She also said that she was on shift when resident #200 left the faciity on Monday, September 9. She stated that she was in the day room caring for other residents and there were two CNAs scheduled to help with breakfast. She stated that another staff then came in and reported that resident #200 was nowhere to be found. She said that everyone started looking for resident #200; and that, the resident left using the window in his room. She stated the window in the resident's room had a latch and a screen; but, there was no alarm. She stated that she heard from another staff about resident #200 wanting to leave. An interview with another CNA (staff #14) was conducted on September 12, 2024 at 11:11 a.m. The CNA stated that resident #200 was calm, liked to keep self in his room, and did not have a roommate. She stated that she was surprised about the resident leaving by opening the window in his room. The CNA also said that she had not checked if it was easy to open the window in the room of resident #200. An interview was conducted on September 12, 2024 at 12:16 pm with the MDS nurse (staff #58) and the director of nursing (DON/staff #68). The MDS nurse stated her role for resident's care plan included reviewing medications, diagnoses, listening to their behaviors and other staff such as social services by attending behavioral meeting twice a week; then, she can readjust the resident's care plan to be more appropriate for the resident. The MDS nurse said that the care plan is completed within their 14-day period. During the interview, a review of the clinical record was conducted by the DON who stated that the resident was not care planned for wandering behaviors. The DON stated that the facility completed an elopement assessment at admission which showed that the resident had no risk. He stated that the resident had a BIMS score of 13 which indicated the resident had no cognitive impairment. Further, the DON stated that based on the assessment/tool used, the facility believes the resident had no risk for elopement. Review of facility policy on Wandering and Elopements revised March 2019 revealed that the facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. (1) If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain resident's safety.

Based on clinical record review, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to protect the rights of one resident (#23) to be free from sexual abuse and one resident (#3) to be free from physical abuse by a staff; and failed to ensure one resident (#45) by another resident (#9). The deficient practice resulted in psychosocial harm to resident #23 and had placed resident #3 and other residents at increased risk for further abuse, serious injury, harm and psychosocial harm. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care (SQC) were identified. The census was 100. Findings include: On July 31, 2024 at 3:23 p.m., the condition of IJ was identified. The administrator was informed of the facility's failure to ensure residents were free from sexual and physical abuse by staff was found. The administrator presented the removal plan on July 31, 2024 at 6:33 p.m. The administrator was informed that the removal plan was not acceptable and failed to include when an assessment will be completed for the affected residents (#23 and #3); what the plan was with the alleged certified nurse assistant (CNA/#66) to prevent further abuse; when the in-service training for staff would begin and expected to be complete; identify the staff that would complete the in-service training; and, actions the facility will take if a staff did not complete the required in-service/training. A revised removal plan was received on July 31, 2024 at 7:22 p.m. The administrator was informed that the removal plan was accepted at 7:30 p.m. The accepted removal plan included the following: -When an assessment will be completed for the affected residents (#23 and #3); -What the plan was with the alleged certified nurse assistant (CNA/#66) to prevent further abuse; -When the in-service training for staff would begin and expected to be complete; identify the staff that would complete the in-service training; -Actions the facility will take if a staff did not complete the required in-service/training; - Inservice training on abuse for all staff to include contract and volunteers will be completed; -Medical and Psych evaluation for the affected residents (#23 and #3); -Provision of emotional support sitters for the affected residents (#23 and #3); -Interviews with all residents to ensure any unreported abuse is reported and investigated; -A new administrator was hired; and, -The alleged perpetrator was terminated. -All findings and results of audits will be reported to QAPI. On August 1, 2024 at 1:22 p.m., the condition of IJ was removed after multiple observations were conducted of the facility implementing their removal plan which included resident and staff interviews, personnel record review, in-service training of staff and review of documentation provided by the facility. Regarding Resident #23 Resident #23 admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar type, dementia and anxiety disorder. The ADL (activities of daily living) care plan dated December 21, 2023 revealed that the resident had an ADL self-care performance deficit related to schizophrenia and bipolar disorder that cause her to display resistive to care behaviors. Interventions included to encourage resident to participate to the fullest extent possible with each interaction; provide supportive care, assistance with mobility as needed and document assistance as needed. The care plan dated January 8, 2024 included the resident had a behavior problem related to yelling, crying, resistive to medications and care, inciting peers and delusional statements. Interventions included to anticipate and meet the resident needs, intervene as necessary to protect the rights and safety of others, divert attention, and monitor behavior episodes and attempt to determine underlying cause. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 12 indicating that the resident had moderate cognitive impairment. The assessment included that resident was coded for delusions and verbal behavioral symptoms directed towards others. The behavior note dated June 16, 2024 included the resident refused to get up from bed; and that, when she needed assistance, she would yell at the top of her lungs for attention. The behavior notes dated June 19, 2024 included that resident was alert and oriented, refused to wake up from bed and reported that she was not feeling well; and that, the resident was heard yelling and screaming that her back hurts. A psych follow-up note dated June 26, 2024 revealed that the resident was yelling and screaming during ADLs and hygiene care. A behavior note dated July 9, 2024 included the resident stayed in bed the rest of the afternoon and evening; and that, the resident was yelling and screaming for no reason at all and was redirected with positive impact. The behavior note dated July 11, 2024 revealed resident yelled and screamed with no reason and was redirected with positive impact. The psych follow-up note dated July 17, 2024 revealed that the resident was demanding and had false accusation behaviors on July 12, 2024; was screaming during care and continued to ask to be changed and moved then did not want the care on July 13, 2024; was screaming in her room for no reason on July 14, 2024; was demanding and refused to get up for breakfast and had false accusation behaviors on July 16, 2024; and, was crying and screaming during care, cries when lifted or touched and complained of pain during shift on July 17, 2024. A behavior note dated July 23, 2024 included that the resident was yelling and screaming with no reason and was redirected with positive impact. The psych follow-up note dated July 24, 2024 revealed that the resident was crying and panic during care and had complaints of pain all over her body when touched on July 20, 2024; was yelling on and off through the night and was very agitated on July 23, 2024; and, was screaming during cares even when no contact was made to her and made false allegations on July 24, 2024. The order-administration noted dated July 26, 2024 included that the resident was complaining of being anxious and reported that she had heart pain during the night shift; and was unable to be redirected with 1:1 attention or snack. The eINTERACT note dated July 31, 2024 revealed that the resident reported allegations of sexual abuse by staff. Intervention included 1:1 and 72-hour psychosocial emotional distress monitoring. The social services note dated July 31, 2024 included that resident reported feeling anxiety and uneasiness that had increased recently. Review of the SA complaint tracking system revealed an anonymous report that a resident reported an allegation of sexual abuse by a certified nurse assistant (CNA) and none of it was reported to State or even addressed by management. An interview conducted with the social services director (SSD/staff #44) and social service staff (#12) conducted on July 31, 2024 at 10:15 a.m., both staffs stated that typically in an abuse situation they would make scheduled visits to the resident to make sure they feel safe and ask if they have any concerns. Both staffs said that they might file a grievance about the incident and the interdisciplinary team will brainstorm what was happening and develop new interventions. In an interview with social services (SS/staff #12) conducted on July 31, 2024 the SS stated that she did not receive any reports of abuse for resident #23 or Resident #3 and were not tracking them or completing any follow up. An interview was conducted on August 1, 2024 at 11:00 a.m. with the alleged CNA (staff #66), who stated that he had never provided any care, nor had been assigned to resident #23; but, he worked on the unit the resident was for the past 4 to 5 months. Later in the interview, the alleged CNA said that he assisted another CNA in using the Hoyer lift to transfer resident #23; and that, he often interacted with the resident in the dayroom if she needed a small item brought to her. Further, the alleged CNA said that resident #23 often calls male staff sexy; and that, sometimes the resident was rude and sometimes was very nice. In an interview with resident #23 conducted on July 31, 2024 at 11:07 a.m., the resident stated that the alleged CNA (staff #66) rubbed on her breasts, and inserted his finger in her vagina during a brief change; and that it had happened up to 10 times in the past several months. The resident stated that she told the DON a week and a half ago, but she never received any updates about her allegations. Further, the resident stated that she had to see the alleged CNA often because the alleged CNA continued to provide care to her roommate after she reported the incident. In an interview with a behavior health staff (BHS/staff #88) conducted on July 31, 2024 at 11:53 a.m. staff #88 stated that resident #23 made a lot of false accusations such as staff was leaving her unattended, and that, the resident felt that the staff go too fast, and were also hurting her during care. Staff #88 stated that the resident did not make any allegations of physical or sexual abuse; and that, the resident's allegation of sexual abuse against the alleged CNA was false accusation because the alleged CNA denied hurting the resident when the alleged CNA was asked. An interview was conducted on July 30, 2024 at 12:35 p.m. with the complainant who stated that she spoke with resident #23 who reported that the alleged CNA was staff #66; and that, the incident happened on July 21, 2024 and it was reported to her by 3 CNAs. Further, the complainant stated that the alleged CNA was allowed to work with residents after the allegation of sexual abuse was reported to the DON and the unit manager. In an interview conducted on July 31, 2024 at 1:04 p.m., the unit manager (staff #55) stated that on July 22, 2024, the charge nurse had come and reported to her the allegation of sexual abuse made by resident #23. The unit manager stated that she went to talk to the resident; but that, the resident was very behavioral. The unit manager said that there was lot of false allegations from the resident who was in cares in pairs as a result of this. Further, the nurse manager stated that she reported the allegations of sexual abuse to the DON; and that, according to the CNAs, the resident reported that the alleged CNA (staff #66) had groped her breasts and fingered her. The unit manager stated she had never heard anything negative about the alleged CNA. In a later interview with the unit manager conducted on July 31, 2024 the unit manager stated that there was an incident with another CNA who felt harassed by the alleged CNA; and that, human resources (HR) and administration had to reprimand the alleged CNA. During an interview with the DON conducted on July 31, 2024 at 1:25 p.m., the DON stated that if there was report of a staff sexually abusing someone she would report it within two hours to the SA. She also said that the protocol post incident for a suspected sexual abuse allegation was to monitor vitals, check to make sure resident was okay and see if they have any changes, social services will follow up with the resident. Regarding resident #23, the DON said that she was not aware of any staff complaints or reports; and that, she did not report anything regarding resident #23 to SA or the police. An interview with another CNA (staff #99) conducted on July 31, 2024 at 2:04 p.m. Staff #99 stated that resident #23 reported to another CNA that the alleged CNA (staff #66) would touch her inappropriately. Staff #99 stated that she went back to resident #23 to verify the information because many residents on the unit tend to get very confused. Staff #99 stated that resident #23 repeated the allegations to her and she then reported the allegations made to the nurse and unit manager. Further, staff #99 said that the DON ultimately had everyone write statements regarding the incident. In an interview with the DON conducted on July 31, 2024 at 4:16 p.m., the DON stated she had investigated the allegation of sexual abuse of resident #23; and that, the alleged CNA (staff #66) was sent home early on July 21, 2024 and returned on July 23, 2024 when he brought in his statement regarding resident #23. She stated that the alleged CNA was allowed to return because she had completed her investigation. The DON further stated that her investigation included an interview with the alleged CNA (staff #66), interview with staff who witnessed the incident, interview the resident, her roommate, and one person in the room to the left of them. Regarding Resident #3 -Resident #3 was admitted on [DATE] with diagnoses of generalized anxiety disorder, major depressive disorder, and Parkinson's disease. The quarterly MDS assessment dated [DATE] included a BIMS score 5 indicating that the resident had severe cognitive impairment. The MDS also included that the resident had physical and verbal behavioral symptoms directed towards others. The weekly skin check dated July 10, 2024 revealed skin was intact, warm and had a turgor within normal limits The weekly skin check dated July 17, 2024 included that the resident had a healing old small skin tear on the right forearm. The nurse progress note dated July 21, 2024 revealed that the certified nursing assistants (CNA) reported to the nurse that the resident had a bruise to his left wrist, scratches to his right arm, and a blister or pressure injury on his right shoulder. A weekly skin check dated July 23, 2024 included an abrasion to right shoulder, a scratch to right arm, and had a bruise to the left arm. Review of the SA complaint tracking system revealed an anonymous report that on July 21, 2024 the CNAs reported that the CNA the night before had been seen being so rough with a resident that resulted in left bruises and scratches on his arm and wrist. Per the report, the incident reported the incident to management who did not do anything about it. An interview on July 31, 2024 at 9:57 a.m. was conducted with a CNA (staff #22) who stated that she and another CNA (staff #33) walked into the day room on July 21, 2024 when they saw the alleged CNA (staff #66) pushed a table against resident #3. Staff #22 stated that the resident was found to have a bruise on his back and his arm; and that she reported the incident to the DON the following morning. Staff #22 further stated that the DON had her write a statement regarding the details of the incident. In an interview with the alleged CNA (staff #66) conducted on July 31, 2024 at 11:00 a.m., the alleged CNA stated that he recalled that resident #3 was sitting in a wheelchair at the dining table; and that the resident was out of control and was kicking, punching, and grabbing. The alleged CNA stated that the resident stood up which resulted in his wheelchair to flip backwards so the alleged CNA pushed the table into the resident, and then placed a chair beside the resident because the resident was aggressive. The alleged CNA stated that resident was boxed in the wall with the table in front, on the side and a chair on the other side, while the resident sat in his wheelchair. He stated the nurse told him to do this and he did not note any bruises or scratches on the resident. The alleged CNA said that he was never suspended after the incident, but he was told to go home 30 minutes before his shift ended. He stated that he met with Human Resources (HR) and the DON who told him to write a statement regarding the incident. During an interview with the DON on July 31, 2024 at 4:16 p.m., the DON stated that resident #3 had an abrasion on his back and right side and bruising on his hands which were likely resulted from the resident swinging his arms and being agitated. She stated she had an incident report for the incident; however, she was not able to provide a copy of the incident report. The DON also stated that she did not consider the event reportable because of the resident's history of agitation and swinging of his arms and sitting up in his wheelchair repeatedly. Regarding Residents #45 and #9 -Resident #45 was admitted on [DATE] with diagnoses of dementia without behavioral/psychotic and mood disturbance and anxiety. The care plan initiated on November 29. 2023 revealed the resident had impaired cognitive function/dementia or impaired thought processes related to dementia. The quarterly MDS assessment dated [DATE] included a BIMS score 7 indicating the resident had severe cognitive impairment. The care plan with revision date of July 4, 2024 included the resident had behavior problems such as intrusive with peers, had sexually inappropriate behaviors such as alluring men to her room and wandered at night into other resident rooms. The goal was that the resident will have fewer episodes of behavior. Interventions included 1:1, to monitor behavior episodes and attempt to determine underlying cause. A late entry health status note dated July 14, 2024 included that on July 13, 2024 there was physical touching between two residents. The documentation did not include description of the incident. The behavior note dated July 14, 2024 included that the resident had exit seeking behavior throughout the shift, going to each gate and attempted to open them. The documentation included that redirection was effective. A physician order dated July 14, 2024 included for every 15 minutes checks for 3 days. A health status note dated July 15, 2024 included that on July 13, 2024 physical touching between two residents were noted. However, the documentation did not include description of the incident The physician order dated July 15, 2024 revealed that the resident was on alert charting two times a day for 3 days for sexually inappropriate behaviors. The behavior note dated July 15, 2024 included the resident was on 1:1 care. The physician order dated July 16, 2024 included for 1:1 every shift for every 15 minutes checks for 3 days. The orders-administration note dated July 16, 2024 revealed that the resident had a room change and was on alert charting to include any concerns, issues and interventions for sexually inappropriate behaviors. The alert note dated July 16, 2024 included that the resident was on 1:1 due to sexually inappropriate behaviors. The alert note dated July 17, 2024 revealed that the resident continued on alert charting for room change; and that. The resident was extremely agitated throughout the entire shift. The documentation included that the resident argued with staff that she needed to go over the fence back to her home and she had things she needed to do. The discharge summary note dated July 23, 2024 included that the resident was discharged from the facility at 12:00 p.m. There was no documentation found in the clinical record that the resident was assessed for any consensual relationship with resident #9. -Resident #9 was admitted on [DATE] with diagnosis of mild vascular dementia with other behavioral disturbance. The admission MDS assessment dated [DATE] revealed a BIMS score of 7 indicating the resident had severe cognitive impairment. The MDS also coded for hallucinations, delusion, physical and verbal behaviors towards others. The care plan with revision date of June 5, 2024 included the resident had impaired cognitive function or dementia or impaired though processes related to vascular dementia. Interventions included to administer medication as ordered and to monitor and document for side effects and effectiveness. The orders-administration note dated July 9, 2024 included that the resident had verbal behaviors towards others such as threatening comments, screaming, yelling, cursing, name calling, racial slurs/comments and sexually inappropriate comments. The physician orders dated July 10, 2024 for an anticonvulsant to treat his verbal and physical aggression related to dementia. The psych follow-up note dated July 10, 2024 included that the resident was alert and oriented to person, uncooperative, disruptive, showed impulsivity, had impaired judgment and insight. A behavior note dated July 10, 2024 included that the resident started yelling at another resident because the other resident sat in the recliner close to the table. Another behavior note dated July 10, 2024 included that the resident was upset and became verbally aggressive and began posturing toward the other resident. Per the documentation, staff intervened and redirected the other resident from the table. A nursing note dated July 11, 2024 included that the resident continued to be on alert charting for new medication. Per the documentation, the resident was pacing the unit and yelled at staff regarding locked doors; and that, the resident was redirected back to the table in the dayroom. The physician progress note dated July 11, 2024 revealed that the resident was alert and oriented x 1; and, had a diagnosis of dementia with behaviors. The order-administration notes dated July 11, 2024 included that the resident had behaviors directed at others such as public sexual acts, disrobing in public and throwing or smearing bodily waste. The documentation also included that the resident had been intrusive with a female peer (resident #45), and had been separated 10 times; and, the resident believed that resident #45 was his girlfriend. However, review of the clinical record revealed no documentation that resident #9 was assessed for consensual relationship with the other resident (#45). A late entry health status note dated July 14, 2024 included that on July 13, 2024, physical touching between two residents were noted. The documentation did not include description of the details of the incident. The behavior note dated July 14, 2024 included that the resident was found in the room of resident #45 and he was laying in the bed of resident #45 by a CNA. Per the documentation, the resident did not answer when the CNA asked him what he was doing in the room and bed of resident #45. The care plan with revision date of July 24, 2024 included that the resident had a behavior problem. Interventions included to discuss the resident's behavior, explain/reinforce why behavior was inappropriate and/or unacceptable to the resident, minimize behavior episodes and attempt to determine underlying cause, and to anticipate and meet the resident's needs. The behavior note dated July 15, 2024 included that the resident was wandering the unit asking different residents and staff where fell ow resident was located. The orders-administration note dated July 15, 2024 revealed that the resident was on alert charting for 72 hours for sexually inappropriate behavior. Per the documentation resident stayed in his room all morning, came out for lunch and went looking for the resident (#45). The psych follow-up note dated July 17, 2024 included that the resident was found to be sexually inappropriate with another resident; and that, the resident was moved to another unit. His care plan initiated on June 2, 2024 did not address his sexually inappropriate behaviors. An interview with resident #45 was attempted on July 31, 2024 but was not successful because the resident was not able to answer questions. In an interview with the power of attorney/ responsible party for resident #45 conducted on July 31, 2024 at 8:20 a.m. she stated that the facility had never done an evaluation, informal or otherwise, to assess whether or not resident #45 was able to consent into a sexual relationship with anyone. She stated resident #45 has dementia and intellectual ability to pick sexual partners; and, was not able to independently pick her clothing each day; and that, she had made all treatment decisions for resident #45 in the last 2 years. Regarding the incident, the POA stated that she spoke with resident #45 about the incident and the resident was shocked and was not able to recall the events. An interview was conducted on July 31, 2024 at 10:15 a.m. with the Social Services SS/staff #12) and the social services director (SSD/staff #44) who both stated that social services did not determine or complete any assessments whether or not residents #45 and #9 were capable of giving consent to engage in a consensual sexual relationship. The SS also said that the assessment and determination would also be up to the DON, the administrator as well as the psychiatric provider. The SS stated that in her personal opinion cognitive function would be the criteria to disqualify a resident from being able to have a consensual relationship. In an interview with the psychiatric provider conducted on July 31, 2024 at 10:38 a.m., the psychiatric provider said that both residents (#45 and #9) had no cognitive capacity to make a medical decision including a sexual or intimate relationship decision. An interview with Licensed Practical Nurse (LPN/staff #10) was conducted on July 31, 2024 at 10:52 a.m. The LPN stated that if she saw any two residents engaged in sexual intercourse she would immediately separate two residents ensure both residents were safe and then report the incident immediately to the Director of Nursing (DON) and family if applicable. She stated staff may start 15-minute checks on the involved residents; and, she would consider this incident as an abuse allegation until she got more information or completed an investigation on the incident. An interview was conducted on July 31, 2024 at 1:02 p.m. with resident #9 who stated that he had a consensual relationship and had sexual intercourse one or two times with resident #45. He stated there had been no conversation about the relationship with the doctor before or after the relationship. During an interview with the DON (staff #90) conducted on July 31, 2024, the DON stated that per regulations residents can have a sexual relationship with other residents; and it depends on the resident's cognitive ability to consent. She stated that the resident's POA can consent to it as well. The DON said a resident would be disqualified from being able to consent if the resident was are not able to give consent and/or the resident was not okay with it. She stated that the assessment of resident's ability to give consent to consensual sexual relationship would be done by a nurse and the DON; and, this would be documented in resident's clinical record. She stated if two residents were found engaging in sexual intercourse, it would not be initially assumed to as sexual abuse. The DON said that there would be an investigation and that was how the facility would make sure both residents were safe; and, it would not be reported to the State Agency (SA) or police. Regarding the incident between resident #45 and #9, the DON stated that she recalled an incident between both residents (#45 and #9) but she cannot recall if the incident was about the sexual intercourse. She stated that a CNA reported to her on the night of July 13, 2024 that when the CNA went into room of resident #45, she found resident #45 performing oral sex on resident #9. The DON said that both residents were assessed at that time regarding whether both residents could consent. However, the DON said that both residents were not assessed prior to this incident. She stated the assessment for the ability of both residents to consent should be found in the progress note in the clinical record. During the interview, a review of the clinical record for both residents was conducted with the DON who stated that there was no documentation found in the clinical record of both resident #45 and #9 of the assessment to consent to consensual sexual relationship. The facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with revision date of April 2021, it stated that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The facility policy on Abuse, Neglect, Misappropriation- Reporting and investigating with last revision date of September 2022 revealed that any employee who has been accused of resident abuse is placed on leave with no resident contact until the investigation is complete.

Based on clinical record reviews, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to report allegations of abuse to the State Agency, Adult Protective Services (APS) and local law enforcement for three residents (#23, #3 and #45). The sample was 3. The deficient practice could result in abuse not identified and investigated and place all residents at risk for further abuse. Findings include: Regarding Resident #23 Resident #23 admitted to the facility on [DATE] with diagnoses of schizoaffective disorder, bipolar type, dementia and anxiety disorder. The quarterly Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 12 indicating that the resident had moderate cognitive impairment. The assessment included that resident was coded for delusions and verbal behavioral symptoms directed towards others. A psych follow-up note dated June 26, 2024 revealed that the resident was yelling and screaming during ADLs and hygiene care. The psych follow-up note dated July 17, 2024 revealed that the resident was demanding and had false accusation behaviors on July 12, 2024; was screaming during care and continued to ask to be changed and moved then did not want the care on July 13, 2024; was screaming in her room for no reason on July 14, 2024; was demanding and refused to get up for breakfast and had false accusation behaviors on July 16, 2024; and, was crying and screaming during care, cries when lifted or touched and complained of pain during shift on July 17, 2024. The psych follow-up note dated July 24, 2024 revealed that the resident was crying and panic during care and had complaints of pain all over her body when touched on July 20, 2024; was yelling on and off through the night and was very agitated on July 23, 2024; and, was screaming during cares even when no contact was made to her and made false allegations on July 24, 2024. The order-administration noted dated July 26, 2024 included that the resident was complaining of being anxious and reported that she had heart pain during the night shift; and was unable to be redirected with 1:1 attention or snack. The eINTERACT note dated July 31, 2024 revealed that the resident reported allegations of sexual abuse by staff. Intervention included 1:1 and 72-hour psychosocial emotional distress monitoring. Review of the SA complaint tracking system revealed an anonymous report that a resident reported an allegation of sexual abuse by a certified nurse assistant (CNA) and none of it was reported to State or even addressed by management. The documentation included that the alleged date of incident was July 13, 2024. However, there was no evidence found that an allegation of sexual abuse for resident #23 was reported to appropriate local agencies such as the SA, police, Adult Protective Services (APS), Ombudsman and the police. In an interview with social services (SS/staff #12) conducted on July 31, 2024 the SS stated that she did not receive any reports of abuse for resident #23 or Resident #3 and were not tracking them or completing any follow up. An interview was conducted on August 1, 2024 at 11:00 a.m. with the alleged CNA (staff #66), who stated that he had never provided any care, nor had been assigned to resident #23; but, he worked on the unit the resident was for the past 4 to 5 months. Later in the interview, the alleged CNA said that he assisted another CNA in using the Hoyer lift to transfer resident #23; and that, he often interacted with the resident in the dayroom if she needed a small item brought to her. Further, the alleged CNA said that resident #23 often calls male staff sexy; and that, sometimes the resident was rude and sometimes was very nice. In an interview with resident #23 conducted on July 31, 2024 at 11:07 a.m., the resident stated that the alleged CNA (staff #66) rubbed on her breasts, and inserted his finger in her vagina during a brief change; and that it had happened up to 10 times in the past several months. The resident stated that she told the DON a week and a half ago, but she never received any updates about her allegations. Further, the resident stated that she had to see the alleged CNA often because the alleged CNA continued to provide care to her roommate after she reported the incident. In an interview with a behavior health staff (BHS/staff #88) conducted on July 31, 2024 at 11:53 a.m. staff #88 stated that resident #23 made a lot of false accusations such as staff was leaving her unattended, and that, the resident felt that the staff go too fast, and were also hurting her during care. Staff #88 stated that the resident did not make any allegations of physical or sexual abuse; and that, the resident's allegation of sexual abuse against the alleged CNA was false accusation because the alleged CNA denied hurting the resident when the alleged CNA was asked. Staff #88 said that he was a mandatory reported but he did not report this incident to anyone. An interview was conducted on July 30, 2024 at 12:35 p.m. with the complainant who stated that she spoke with resident #23 who reported that the alleged CNA was staff #66; and that, the incident happened on July 21, 2024 and it was reported to her by 3 CNAs. Further, the complainant stated that the alleged CNA was allowed to work with residents after the allegation of sexual abuse was reported to the DON and the unit manager. In an interview conducted on July 31, 2024 at 1:04 p.m., the unit manager (staff #55) stated that on July 22, 2024, the charge nurse had come and reported to her the allegation of sexual abuse made by resident #23. The unit manager stated that she went to talk to the resident; but that, the resident was very behavioral. The unit manager said that there was lot of false allegations from the resident who was in cares in pairs as a result of this. Further, the nurse manager stated that she reported the allegations of sexual abuse to the DON; and that, according to the CNAs, the resident reported that the alleged CNA (staff #66) had groped her breasts and fingered her. The unit manager stated she had never heard anything negative about the alleged CNA. During an interview with the DON conducted on July 31, 2024 at 1:25 p.m., the DON stated that if there was report of a staff sexually abusing someone she would report it within two hours to the SA. She also said that the protocol post incident for a suspected sexual abuse allegation was to monitor vitals, check to make sure resident was okay and see if they have any changes, social services will follow up with the resident. Regarding resident #23, the DON said that she was not aware of any staff complaints or reports; and that, she did not report anything regarding resident #23 to SA or the police. An interview with another CNA (staff #99) conducted on July 31, 2024 at 2:04 p.m. Staff #99 stated that resident #23 reported to another CNA that the alleged CNA (staff #66) would touch her inappropriately. Staff #99 stated that she went back to resident #23 to verify the information because many residents on the unit tend to get very confused. Staff #99 stated that resident #23 repeated the allegations to her and she then reported the allegations made to the nurse and unit manager. Further, staff #99 said that the DON ultimately had everyone write statements regarding the incident. During another interview with the DON (staff #90) conducted on July 31, 2024, the DON stated that per regulations residents can have a sexual relationship with other residents; and it depends on the resident's cognitive ability to consent. She stated that the resident's POA can consent to it as well. The DON said a resident would be disqualified from being able to consent if the resident was are not able to give consent and/or the resident was not okay with it. She stated that the assessment of resident's ability to give consent to consensual sexual relationship would be done by a nurse and the DON; and, this would be documented in resident's clinical record. She stated if two residents were found engaging in sexual intercourse, it would not be initially assumed to as sexual abuse. The DON said that there would be an investigation and that was how the facility would make sure both residents were safe; and, it would not be reported to the State Agency (SA) or police. Regarding Resident #3 -Resident #3 was admitted on [DATE] with diagnoses of generalized anxiety disorder, major depressive disorder, and Parkinson's disease. The quarterly MDS assessment dated [DATE] included a BIMS score 5 indicating that the resident had severe cognitive impairment. The MDS also included that the resident had physical and verbal behavioral symptoms directed towards others. The nurse progress note dated July 21, 2024 revealed that the certified nursing assistants (CNA) reported to the nurse that the resident had a bruise to his left wrist, scratches to his right arm, and a blister or pressure injury on his right shoulder. A weekly skin check dated July 23, 2024 included an abrasion to right shoulder, a scratch to right arm, and had a bruise to the left arm. Review of the SA complaint tracking system revealed an anonymous report that on July 21, 2024 the CNAs reported that the CNA the night before had been seen being so rough with a resident that resulted in left bruises and scratches on his arm and wrist. Per the report, the incident reported the incident to management who did not do anything about it. An interview on July 31, 2024 at 9:57 a.m. was conducted with a CNA (staff #22) who stated that she and another CNA (staff #33) walked into the day room on July 21, 2024 when they saw the alleged CNA (staff #66) pushed a table against resident #3. Staff #22 stated that the resident was found to have a bruise on his back and his arm; and that she reported the incident to the DON the following morning. Staff #22 further stated that the DON had her write a statement regarding the details of the incident. In an interview with the alleged CNA (staff #66) conducted on July 31, 2024 at 11:00 a.m., the alleged CNA stated that he recalled that resident #3 was sitting in a wheelchair at the dining table; and that the resident was out of control and was kicking, punching, and grabbing. The alleged CNA stated that the resident stood up which resulted in his wheelchair to flip backwards so the alleged CNA pushed the table into the resident, and then placed a chair beside the resident because the resident was aggressive. The alleged CNA stated that resident was boxed in the wall with the table in front, on the side and a chair on the other side, while the resident sat in his wheelchair. He stated the nurse told him to do this and he did not note any bruises or scratches on the resident. The alleged CNA said that he was never suspended after the incident, but he was told to go home 30 minutes before his shift ended. He stated that he met with Human Resources (HR) and the DON who told him to write a statement regarding the incident. There was no evidence found that this incident was reported to appropriate local agencies such as the SA, police, Adult Protective Services (APS), Ombudsman and the police. During an interview with the DON on July 31, 2024 at 4:16 p.m., the DON stated that resident #3 had an abrasion on his back and right side and bruising on his hands which were likely resulted from the resident swinging his arms and being agitated. She stated she had an incident report for the incident; however, she was not able to provide a copy of the incident report. The DON also stated that she did not consider the event reportable because of the resident's history of agitation and swinging of his arms and sitting up in his wheelchair repeatedly. Regarding Residents #45 and #9 -Resident #45 was admitted on [DATE] with diagnoses of dementia without behavioral/psychotic and mood disturbance and anxiety. The quarterly MDS assessment dated [DATE] included a BIMS score 7 indicating the resident had severe cognitive impairment. The care plan with revision date of July 4, 2024 included the resident had behavior problems such as intrusive with peers, had sexually inappropriate behaviors such as alluring men to her room and wandered at night into other resident rooms. The goal was that the resident will have fewer episodes of behavior. Interventions included 1:1, to monitor behavior episodes and attempt to determine underlying cause. A late entry health status note dated July 14, 2024 included that on July 13, 2024 there was physical touching between two residents. The documentation did not include description of the incident. A health status note dated July 15, 2024 included that on July 13, 2024 physical touching between two residents were noted. However, the documentation did not include description of the incident The physician order dated July 15, 2024 revealed that the resident was on alert charting two times a day for 3 days for sexually inappropriate behaviors. The orders-administration note dated July 16, 2024 revealed that the resident had a room change and was on alert charting to include any concerns, issues and interventions for sexually inappropriate behaviors. The alert note dated July 16, 2024 included that the resident was on 1:1 due to sexually inappropriate behaviors. -Resident #9 was admitted on [DATE] with diagnosis of mild vascular dementia with other behavioral disturbance. The admission MDS assessment dated [DATE] revealed a BIMS score of 7 indicating the resident had severe cognitive impairment. The MDS also coded for hallucinations, delusion, physical and verbal behaviors towards others. The orders-administration note dated July 9, 2024 included that the resident had verbal behaviors towards others such as threatening comments, screaming, yelling, cursing, name calling, racial slurs/comments and sexually inappropriate comments. The order-administration notes dated July 11, 2024 included that the resident had behaviors directed at others such as public sexual acts, disrobing in public and throwing or smearing bodily waste. The documentation also included that the resident had been intrusive with a female peer (resident #45), and had been separated 10 times; and, the resident believed that resident #45 was his girlfriend. A late entry health status note dated July 14, 2024 included that on July 13, 2024, physical touching between two residents were noted. The documentation did not include description of the details of the incident. The behavior note dated July 14, 2024 included that the resident was found in the room of resident #45 and he was laying in the bed of resident #45 by a CNA. Per the documentation, the resident did not answer when the CNA asked him what he was doing in the room and bed of resident #45. Despite documentation of the incident between resident #45 and #9, there was no evidence found that this incident was reported to appropriate local agencies such as the SA, police, Adult Protective Services (APS), Ombudsman and the police. In an interview with the psychiatric provider conducted on July 31, 2024 at 10:38 a.m., the psychiatric provider said that both residents (#45 and #9) had no cognitive capacity to make a medical decision including a sexual or intimate relationship decision. An interview with Licensed Practical Nurse (LPN/staff #10) was conducted on July 31, 2024 at 10:52 a.m. The LPN stated that if she saw any two residents engaged in sexual intercourse she would immediately separate two residents ensure both residents were safe and then report the incident immediately to the Director of Nursing (DON) and family if applicable. She stated staff may start 15-minute checks on the involved residents; and, she would consider this incident as an abuse allegation until she got more information or completed an investigation on the incident. An interview was conducted on July 31, 2024 at 1:02 p.m. with resident #9 who stated that he had a consensual relationship and had sexual intercourse one or two times with resident #45. He stated there had been no conversation about the relationship with the doctor before or after the relationship. During an interview with the DON (staff #90) conducted on July 31, 2024, the DON stated that if two residents were found engaging in sexual intercourse, it would not be initially assumed to as sexual abuse. The DON said that there would be an investigation and that was how the facility would make sure both residents were safe; and, it would not be reported to the State Agency (SA) or police. Regarding the incident between resident #45 and #9, the DON stated that she recalled an incident between both residents (#45 and #9) but she cannot recall if the incident was about the sexual intercourse. She stated that a CNA reported to her on the night of July 13, 2024 that when the CNA went into room of resident #45, she found resident #45 performing oral sex on resident #9. The DON said that both residents were assessed at that time regarding whether both residents could consent. However, the DON said that both residents were not assessed prior to this incident. She stated the assessment for the ability of both residents to consent should be found in the progress note in the clinical record. During the interview, a review of the clinical record for both residents was conducted with the DON who stated that there was no documentation found in the clinical record of both resident #45 and #9 of the assessment to consent to consensual sexual relationship. The facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, with revision date of April 2021, it stated that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy also included that they will establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problems; will implement measures to address factors that may lead to abusive situations, for example: instruct staff regarding appropriate ways to address interpersonal conflicts; and help staff understand how cultural, religious and ethnic differences can lead to misunderstanding and conflicts; will investigate and report any allegations within timeframes required by federal requirements; and, protect residents from any further harm during investigations.

Based on observation, closed clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure that one resident (#107) was provided adequate supervision and that additional safety measures were implemented to help prevent a fall with injury, and failed to ensure a resident room was free from an accident hazard. Findings include: -Resident #107 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the closed clinical record revealed the resident resided on the secured wandering dementia unit. A Fall Risk Care Plan dated June 23, 2014, identified that the resident was a fall risk due to impaired cognition, impaired mobility, poor balance, and had impulsive attempts to complete transfers. Interventions included to assist with mobility and ADLs, provide verbal cues and reminders for safety, low bed with floor mats, and a tab alarm to the resident's bed and wheelchair. Review of the fall investigative documentation revealed the resident sustained [REDACTED]. The resident was found on the floor next to his bed and was lying on his bed linens. No injuries were noted. The interventions in place to reduce fall risk at the time of the fall included a low bed and tab alarm to the bed. However, there was no documentation that the tab alarm sounded at the time of the fall. The documentation further included to continue with the low bed and bed alarm. Further review of the clinical record revealed there was no documentation that the resident was provided any increased supervision to help prevent further falls, nor any additional interventions that were implemented, despite having impulsive attempts to self transfer, impaired cognition with poor safety awareness, impaired mobility and an unsteady gait. The quarterly Minimum Data Set (MDS) assessment dated [DATE], assessed the resident to have had both short and long term memory problems. The resident was also assessed to need extensive assistance of two people for transfers from bed to chair/wheelchair and to a standing position. A Wandering Risk Evaluation dated October 7, 2014, was also completed and included that the resident was disoriented and forgetful, ambulates with one assist, was taking anti-anxiety medications, and was a known wanderer. The resident scored an 11, which was considered at high risk. A Fall Risk Evaluation was completed on October 7, 2014, due to recent falls and a change in the resident's functional ability. The evaluation included that the resident had a decline in his recall ability, had exhibited wandering behavior that occurred daily or more, and used short discontinuous steps. Per the evaluation, the resident had sustained 1-2 falls in the past six months and scored an 11, which indicated moderate risk. Despite the decline in the resident's condition, there was no documentation that any increased supervision or any other interventions were implemented to help prevent further falls. Nursing notes dated October 15, 2014, documented the resident was heard outside at 1:45 a.m., shouting for help. A certified nursing assistant (CNA) found the resident lying on his right side on the ground next to his wheelchair, outside of his room. The resident sustained [REDACTED]. The notes also included the physician was notified and gave an order to send the resident to the emergency room for evaluation. Review of the hospital documentation dated October 15, 2014, revealed the resident had sustained a fracture to his right hip. According to the facility's investigative documentation, the resident sustained [REDACTED]. Further documented was that the resident was found outside on the ground by his wheelchair and was calling out for help at 1:45 a.m. The interventions documented as being in place at the time of the fall included a low bed and a tab alarm to the bed and wheelchair. The resident was transferred to the hospital and was diagnosed with [REDACTED]. Further review of the clinical record and the investigative report revealed there was no documentation if the alarm had sounded. During the survey, an observation was conducted of the secured dementia unit, where the resident had resided. The secured unit contained two separate buildings, one included the nurse's station and dining/activity room, and the other included the resident rooms. This area was secured by a fence. The two buildings were connected by outside hallways. Each resident room door opened to the outside walkways. It was also observed that the resident room doors were usually kept closed. During an interview conducted on March 26, 2015 at 9:30 a.m., a CNA stated if a resident falls, the person that responds to the resident is required to document the circumstances surrounding the fall; how they were found, and what safety devices were in place at the time. The CNA was asked if documentation should include whether an alarm was sounding and she replied yes. She further stated if it isn't documented that the alarm was sounding, then it wasn't. The CNA stated that it is very difficult to hear the tab alarms, because the resident rooms are in a separate building away from the main building. The CNA further stated the doors to the residents' rooms are closed at night. During an interview conducted on March 26, 2015 at 10:15 a.m., the licensed practical nurse acknowledged that the nurse's station for the secured dementia unit was not equipped with a light or sound system that would alert the nurse that a resident's alarm was sounding in their room. An interview was conducted with the Director of Nursing (DON) on March 26, 2015 at 12:30 p.m., who stated if it is determined a resident is at risk for falls, a care plan is developed that includes interventions; such as the bed in low position, mats on the floor next to the bed and tab alarms on the wheelchairs and beds. The DON stated the rationale of tab alarms is to alert staff that the resident has moved their body and to respond as quickly as possible. She also stated that if a fall has occurred, staff need to document the circumstances of the fall, including possible causes of the fall and what interventions were in place. The DON further stated she knew hearing tab alarms in the residents' rooms presented a problem, since the rooms were in a separate building from the nurses station. Review of a policy regarding Safety and Supervision of Residents included that resident supervision is a core component of the systems approach to safety. The type and frequency of supervision is determined by the residents assessed needs and identified hazards in the environment. The policy stated that the type and frequency of supervision may vary over time and may need to be increased when there are temporary hazards in the environment or if there is a change in the resident's condition. The policy also included to strive to make the environment as free from accident hazards as possible and that resident safety and supervision and assistance to prevent accidents are priorities. The policy further noted to evaluate the effectiveness of interventions and to modify or replace interventions as needed. A policy on Falls and Fall Risk documented that 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 falls and to try to minimize complications from falling. Review of a facility policy titled Falls-Clinical Protocol included that the staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, and any observations of the events, etc. According to a policy on Assessing Falls and Their Causes, the purpose was to provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Under documentation, it included that when a resident falls, information should be recorded in the resident's medical record regarding appropriate interventions taken to prevent further falls. -An observation of resident room #316 was conducted on March 24, 2015. A coaxial cable which was approximately two feet long was observed on the floor of the room near the resident's door. The cable was disconnected from the source and was not secured to the wall and part of the cable was protruding out into the walkway. A second observation of the resident's room was conducted on March 26, 2015. It was observed that the cable had been reattached to the source, but had not been secured to the wall and remained near the door. Part of the cable was protruding out into the walkway. An interview was conducted with the maintenance director at 11:30 a.m. on March 26, 2015. He said that he was not aware of this cable and that if he had known about it, he would have fixed it so that it would not be a tripping hazard. He stated that the nursing staff alert him when something in a room needs to be repaired through a work order and the unit managers make a list of what needs to be fixed on the units and they repair all of the issues on the list quarterly. Review of a facility policy and procedure revealed that the director of operations and maintenance supervisor are responsible for a comprehensive, facility-wide program to identify and carry out necessary maintenance and repair of the facility. The department staff are to conduct periodic, detailed inspections to evaluate the maintenance condition of the building and to identify any necessary corrective work. The policy noted that the maintenance department will perform any necessary maintenance and repairs in a timely manner.

Based on clinical record review, observation, staff interview, and facility policy, the facility failed to prevent one resident (#175) from developing two pressure ulcers. The sample size was one of one. Findings include: Resident #175 was admitted [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the Nursing Admission Database assessment dated [DATE], that documented the resident had multiple bruises, fluid filled blister on the right heel, a surgical incision right hip/thigh, and reddened scrotum and coccyx. The Nurse's Notes dated October 29, 2012, included the skin was dry, warm, and intact with no open wounds. A Braden Scale used for predicting pressure sore risk scored the resident a 12. A total score of 12 or less represents a high risk for pressure ulcer. The Care Plan dated November 15, 2012, included approaches to prevent further skin breakdown that included to float heels/heel boots. It also included Prevalon Boots that was dated November 28, 2012. Review of the Treatment Sheet dated November 2012, revealed staff initials that weekly skin assessments were done on November 2, 9, 16, and 23, 2012. The Treatment Sheet for weekly skin assessment included (-) = no change from prior date; (+) = change in areas, see Nurses Notes for description. These symbols (-) and (+) were not documented. Continued review of the clinical record revealed the Weekly Skin Assessment form that included "This form should be completed weekly on all residents per facility policy. Any areas of skin requiring treatment should have a thorough record of documentation in addition to this form location elsewhere in the chart pre facility protocol. Check "Yes" or "No" if the item reflects the resident's assessment. Review the care plan to ensure skin care is included as necessary. "This Weekly Skin Assessment revealed documentation for October 29, 2012, November 2, 9, and 16, 2012. The question was there any open ulcers were checked "No" for October 29, 2012, November 2, and 9, 2012. November 16, 2012, documentation included there was an open ulcer on the right gluteal fold measuring 5.8 centimeters (cm) x 0.1 cm and scratches on the leg from wheelchair. No Weekly Skin Assessment documentation was found on this form for November 23, 2012. Review of the Wound/Skin Record revealed documentation dated November 20, 2012, that there was two pressure ulcers stage UTD (unable to determine) on the right posterior leg. The top right posterior leg pressure ulcer was documented as 5.0 cm x 2.3 cm, wound bed closed-light brown scab, and surrounding tissue pink in color. The bottom right posterior leg pressure ulcer was documented as 2.0 cm x 3.3 cm, wound bed closed-light brown scab, and surrounding tissue pink/red in color. It was also documented that the physician was notified November 21, 2012. A Temporary Problem List documented a right shin wound as a problem with a daily santyl dressing change as an approach on November 21, 2012. No documentation regarding these two pressure ulcers were found in the pressure ulcer care plan. Further review of the Wound/Skin Record revealed documentation dated November 23, 2012, that the top right posterior leg pressure ulcer measured 5.5 cm x 3.0 cm, stage UTD, scant amount yellow exudate, and wound bed described as 25% yellow slough and 75% eschar. This documentation also included the bottom right posterior leg pressure ulcer measured 4.3 cm x 3.0 cm, stage UTD, scant amount yellow exudate, and wound bed described as 75% yellow slough and 25% black eschar. No other documentation regarding these pressure ulcers was found in the clinical record. A wound dressing change observation conducted on November 28, 2012 at 9:20 a.m., revealed the top right posterior leg pressure ulcer measurements of 5.2 cm x 3.0 cm and the bottom right posterior leg pressure ulcer measurements of 3.2 cm x 4.0 cm. These areas were scabbed over and dry. During an interview conducted November 28, 2012 at 9:40 a.m., a Registered Nurse (RN) stated the resident's significant other was rolling blankets tight and securing the blankets with tape to the resident's right leg which this RN believed caused the pressure ulcers. This RN further stated the significant other was trying to help the resident since the resident did not like wearing the boots; that the resident tended to be non-compliant with wearing the boots. She also stated she had given education regarding this. However, documentation supporting this claim was unable to be found in the clinical record. During an interview conducted on November 29, 2012 at 9:50 a.m., the resident stated he acquired the two pressure ulcers on the leg while a resident at the facility. The resident further stated he did not know what caused the pressure ulcers. On November 28, 2012 at 9:50 a.m. a Certified Nursing Assistant (CNA) stated she would report any skin changes to the nurse. This same CNA on November 29, 2012 at 1:00 p.m., stated she would find blankets wrapped around the resident's leg and that she would remove the blankets. She stated they finally had to remove the blankets from the room. Interviews conducted with another CNA and a RNA on November 29, 2012, revealed they had not seen blankets wrapped around the resident's leg. During an interview conducted on November 29, 2012 at 2:20 p.m., another RN stated no redness or skin issues were noted on the right leg during the November 16, 2012 weekly skin assessment. This RN further stated the resident's significant other would use towel/blanket to wrap around the resident's leg because the resident did not like the boots. She stated she gave education regarding not applying the blankets to the resident's leg but may not have documented such. The RN also stated November 20, 2012, was when she received information that the resident had two pressure ulcers on the posterior right leg. Both RNs stated on November 29, 2012, that they had provided education regarding not using the blankets around the resident's leg. No documentation could be found in the clinical record regarding staff identifying blankets wrapped around the resident's leg or education to the resident regarding how this practice could potentially cause skin damage. During an interview conducted on November 30, 2012 at 9:40 a.m., the Director of Nursing stated the nurses were to document any new skin issues on the skin assessment sheet and document a narrative in the nurse's notes. The facility's policies documented, "...the physician and wound nurse will be promply notified of pressure ulcers...requiring treatment...Skin assessments may be done more frequently when indicated...Active/passive range of motion..."