Every finding on record at Winslow Campus of Care

Based on staff interviews, review of clinical record and review of facility policy and procedures, the facility failed to protect the rights of two of three sampled residents (#2 and #3) to be free from physical 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 on [DATE] with diagnoses that included pneumonia, antineutrophilic cytoplasmic antibody vasculitis, acute respiratory failure with hypoxia, and pain in right knee. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) of 6, indicating that the resident had severe cognitive impairment. The MDS revealed no behaviors exhibited. A progress note dated August 17, 2026 revealed that at approximately 5:05 p.m., the activities assistant reported that Resident #2 was kicked by Resident #3 in the main dining room during dinner time. The progress note further documented that the nurse went to the main dining room to assess residents and that Resident #2 reported being kicked in the right knee by Resident #3.-Regarding Resident #3:Resident #3, the alleged perpetrator, was admitted on [DATE] with diagnoses that included abnormal weight loss, personal history of other endocrine disease, impulse disorder, and attention-deficit hyperactivity disorder. An admission MDS assessment dated [DATE], revealed a BIMS score of 7, indicating that the resident had severe cognitive impairment. The MDS assessment documented that Resident #3 had feelings of being down and depressed but there was no indication of behaviors. A progress note dated August 17, 2026 revealed that at approximately 5:05 p.m., the activities assistant reported that Resident #3 kicked Resident #2 in the main dining room during dinner time. The note further documented that the nurse assessed Resident #3, who was crying, and Resident #3 reported that she kicked Resident #2 in the right leg. Resident #3 stated that she had been dancing and that Resident #2 told her she was crazy and to go to hell, which upset her and resulted in her kicking Resident #2. A comprehensive care plan dated August 17, 2026 revealed that Resident #3 may exhibit the behaviors of physical and or verbal aggression towards others. The care plan documented that Resident #3 may be quick to anger at times. Interventions included starting a behavior flowsheet every shift and if Resident #3 gets agitated with another resident staff are to remove her from the area to calm her down. Review of the Facility Reported Incident Form follow-up report dated August 23, 2026 documented that the facility reviewed video footage of the incident. The footage showed Resident #3 talking to Resident #2, after which Resident #3 kicked toward Resident #2 but did not make contact. Resident #3 then attempted to kick Resident #2 a second time and made contact with Resident #2's right leg. The facility's investigation verified the allegation of abuse. An interview was conducted on August 24, 2026 at 2:05 p.m. with Registered Nurse (RN/Staff #187) who stated that the activities assistant (Staff # 22) came up to her and told her that she saw Resident #3 kick Resident #2 in the right knee. Staff #187 stated that she immediately went to the main dining room and separated both residents. Staff #187 stated after talking with each resident she found out that Resident #3 was dancing and Resident #2 did not like the dancing and called Resident #3 crazy so Resident #3 kicked Resident #2 in the leg. Staff #187 stated she did skin assessments on Resident #2 and there were no injuries discovered. Staff #187 then contacted Assistant Director of Nursing and the police.A telephonic interview was conducted on August 24, 2026 at 2:33 p.m. with Activities Assistant (Staff #22) who stated that she was passing out coffee at the start of dinner service when she heard yelling behind her. Staff #22 stated when she turned around, she saw Resident #3 kicking Resident #2 on the right knee. Staff #22 stated that she immediately ran over to Resident #3 to stop her from hitting Resident #2. Staff #22 stated she told a CNA (Certified Nursing Assistant) and Staff #187 about the altercation. An interview was conducted on August 24, 2026 at 3:04 p.m. with the CNA (Staff# 154) who stated that she had interviewed both Resident #2 and Resident #3 regarding the incident because she spoke Navajo. Staff #154 stated that Resident #2 reported that Resident #3 kicked her in the right knee. Staff #154 stated that when she had asked Resident #2 why she thought Resident #3 kicked her, Resident #2 reported that she did not know and that she was not bothering Resident #3. Staff #154 stated that she also interviewed Resident #3, who was crying at the time. According to Staff #154, Resident #3 reported that she had been dancing in the main dining room with her hands in the air when Resident #2 called her crazy and told her she could go to hell. Staff #154 stated that Resident #3 reported becoming angry and kicking Resident #2.An interview was conducted on August 24, 2026 at 3:21 p.m. with Director of Nursing (DON/Staff #79), who stated that she was notified by the Assistant Director of Nursing (ADON) of the altercation between Resident #2 and Resident #3. Staff #79 stated that the residents were immediately separated in the dining room and Resident #3 was subsequently moved to a different hall for safety. Staff #79 stated that video footage of the incident was reviewed and showed Resident #3 attempt to kick Resident #2 in the right leg but miss, followed by a second kick that made contact with Resident #2's leg. Staff #79 stated that is when Staff #22 turned around and saw Resident #3 kick Resident #2's leg. Staff #79 stated that the concern when residents physically abuse other residents is it could cause mental anguish and physical harm to the residents. A policy and procedure titled Abuse Prevention Policy & Procedure, revised April 2025, revealed that it is the policy of the facility to take appropriate steps to prevent the occurrence of Abuse. The policy also revealed the definition of physical abuse as hitting, slapping, pinching, and kicking.

Based on staff interviews, clinical record review, and review of facility policy and procedure, the facility failed to ensure adequate assessment, monitoring, and supervision to prevent elopement for one (Resident #7) of the four sampled residents. The deficient practice could result in injury to residents.Findings Include:Resident #7 was readmitted to the facility on [DATE], with diagnoses including obstructive and reflux uropathy (primary admission diagnosis), vitamin D deficiency, dry eye syndrome, a history of influenza A with other respiratory manifestations, a history of pneumonia, a history of Escherichia coli urinary tract infection, benign prostatic hyperplasia with and without lower urinary tract symptoms, hypoxemia, altered mental status, hypo-osmolality and hyponatremia, fever, reduced mobility, long-term drug therapy, depression, dysphagia, alcohol abuse, chronic pain, and constipation.A Quarterly Minimum Data Set (MDS) assessment completed on June 25, 2026, indicated that Resident #7 had a Brief Interview for Mental Status (BIMS) score of 07, reflecting severe cognitive impairment.An Elopement Assessment performed on June 20, 2026 didn't indicate that the resident # 7 is at risk for wandering or elopement.According to a Progress Note July 4, 2026, At 6:45 AM, documented that the resident had eloped out to the front sidewalk all the way to the East side of the building close to the street. The notes documented that the resident stated he wanted to go for a stroll.A skin assessment for Resident # 7 completed after the incident, revealed no new injuries were noted related to the elopement incident.Nursing notes for the next couple dates after the incident did not reveal any significant change in the resident #7's behaviors.The Care plan related to wandering and exit-seeking behaviors following the elopement incident was updated. The care plan interventions included 1:1 approach, social service visits as needed, anticipate basic needs and provide care: i.e. pain, hunger, elimination, rest, follow familiar routines as much as possible, implement safety measures as needed, maintain calm environment and approach towards resident, make sure all staff are aware of elopement risk, provide simple tasks, activities, provide unit activities as diversions: redirect as needed, remind resident to use the gazebo space outside that is designated for residents and remind resident # 7 to use the common outdoor space.An interview was conducted on July 8, 2026, at 8:30 AM with the Certified Nursing Assistant (CNA / Staff # 40), who stated that she arrived at work at approximately 6:00 AM and did not observe anything unusual. Staff # 40 proceeded to her assigned area, Unit 200. Staff # 40 was wearing a facility-provided shirt, but it was too long, so Staff # 40 decided to change into a different shirt. At approximately 6:45-7:00 AM, after changing, the CNA (Staff # 40) was returning to the building when she observed resident # 7 sitting in a wheelchair in the lobby wearing a bright red shirt. Staff # 40 immediately informed the housekeeper, who was cleaning the lobby at the time, and asked her to notify the floor nurse. After informing the housekeeper, Staff # 40 went over to speak with Resident # 7 because he was familiar with staff #40. Resident # 7 smiled when Staff # 40 approached him. Staff # 40 asked, How did you end up here? Resident # 7 pointed toward the exit door and said that the door was open. Resident # 7 did not appear anxious or in distress. Resident #7 was laughing and seemed calm. The night nurse, Licensed Practical Nurse (LPN / Staff # 201) from Unit 100 arrived and asked resident #7 why he was there and whether he was okay. Staff # 40 & Staff # 201 then escorted resident # 7 back into the building through the front entrance, and staff # 40 returned to her assigned hall. Staff # 40 stated that she doesn't recall any previous incidents of this nature involving him. Resident # 7 has never made any comments about wanting to leave the facility. Staff # 40 further stated that all exit doors are equipped with alarms and Staff # 40 believe this incident would be considered an elopement.An interview was conducted with the Maintenance Director (Staff #5) on July 8, 2026, at 9:53 AM. Staff #5 stated that Staff #5 and Staff # 114 were responsible for ensuring that all exit doors were properly secured before the end of each shift. Staff #5 explained that the doors were designed to lock automatically and that all exit doors and alarm systems were inspected at least once a month. Staff #5 stated that the only issues Staff #5 was aware of the Unit 300 exit door and the laundry room door, both of which had been addressed and repaired promptly. Staff #5 stated that he was not aware of any open maintenance requests or work orders related to the Unit 100 exit door. Staff #5 stated that Staff # 114 had inspected the doors the night before the incident and that no concerns had been reported. Staff #5 acknowledged that if an exit door was not properly latched or secured, it created an unsafe condition for residents. Staff #5 agreed that the facility had failed to ensure the doors were properly secured before the end of the shift and acknowledged that the incident was considered an elopement.An interview was conducted with the Director of Nursing (DON/Staff #137) on July 8, 2026, at 11:16 am . The DON (Staff #137) stated that the facility's protocol for elopement began with an admission assessment to determine whether a resident was at risk for wandering or elopement. If a resident was identified as being at risk, an individualized care plan was developed. Residents identified as being at risk for elopement could have a WanderGuard device applied based on a physician's order, and the use of the device was documented in the resident's medical record for ongoing monitoring. The DON (Staff #137) stated that it was not acceptable for any resident, including one with a BIMS score of 6-8 or 99, to wander or elope from the facility. Staff #137 stated that residents who wandered or eloped were at risk for physical injury, mental injury, and other serious bodily harm. The DON (Staff #137) recalled the incident involving Resident #7. The DON (Staff #137) stated that Resident #7 exited through the therapy room door, which led to the sidewalk outside the building. A Certified Nursing Assistant (CNA / Staff # 40), who was returning from her vehicle to the main entrance, observed Resident #7 wheeling himself toward the main entrance. When the CNA asked where he was going, Resident #7 reportedly stated that it was hot outside and that he was coming back inside. Later, when Staff #31, the Behavioral Unit Manager, spoke with Resident #7, Resident #7 stated that he had gone out for a stroll. Staff #31 educated Resident #7 regarding the risks associated with leaving the facility unsupervised. The DON (Staff #137) stated that Staff #31 immediately checked the therapy room exit door and confirmed that it was properly latched and that the alarm system was activated. The DON (Staff #137) stated that the facility believed the door might not have been fully latched when Resident #7 exited. Staff #137 estimated that it had taken approximately two minutes for Resident #7 to exit through that door. The DON (Staff #137) further stated that the exit alarm did not sound when Resident #7 left the building, indicating that the door likely had not been secured as intended. The DON (Staff #137) stated that maintenance staff were responsible for routinely checking all exit doors to ensure they were functioning properly. Staff #137 acknowledged that maintenance staff had failed to perform their responsibilities as expected and that the incident did not meet the facility's standards. The DON (Staff #137) agreed that the facility had failed to ensure that Resident #7 did not elope from the facility. Following the incident, the facility updated Resident #7's care plan to address the resident's elopement risk.An interview was conducted with the MDS Director (Staff #6) on July 8, 2026, at 12:42 p.m. Staff #6 stated that a baseline care plan was initiated within 48 hours of a resident's admission. Staff #6 further stated that a comprehensive care plan was then developed within 21 days based on the findings of the Minimum Data Set (MDS) assessment and the resident's identified care needs. Staff #6 stated that, within the first 48 hours of admission, the facility completed assessments including fall risk, skin integrity, the Braden Scale, and elopement risk. Staff #6 further stated that any licensed nurse could initiate or revise a care plan following a change in a resident's condition or after an incident, such as wandering or elopement. Staff #6 stated that Staff #6 considered the incident involving Resident #7 to have been an elopement and acknowledged that the facility had failed to ensure that Resident #7 did not elope from the facility. Staff #6 stated that the facility's follow-up interventions after an elopement included notifying the physician, the resident's family, and the case manager; completing skin and neurological assessments as indicated; interviewing the resident regarding the incident; and implementing a WanderGuard device, if appropriate. Telephonic Interview with Licensed Practical Nurse (LPN/Staff #201) on July 8, 2026, at 5:26 PM. LPN (Staff #201) stated that the facility's protocol for an elopement included notifying the supervisor and the Director of Nursing (DON), reporting the incident to the state, notifying the resident's family and physician, and performing a skin assessment and neurological assessments, as indicated. The LPN (Staff #201) stated that residents who wandered or eloped from the facility were at risk for serious harm, including kidnapping, dehydration, and lack of food and nutrition. LPN (Staff #201) further stated that residents at risk for wandering or elopement were identified based on exit-seeking behaviors, repeated statements about wanting to leave the facility, the use of WanderGuard devices, and documentation in the resident's face sheet notes. LPN (Staff #201) stated that all facility exit doors were equipped with alarms. The LPN (Staff #201) stated that she remembered the incident involving Resident #7. The LPN stated that her understanding was that Resident #7 had wandered out through the therapy room. The LPN believed there had been a malfunction with the alarm and that it did not sound. Staff #201 stated that she was fairly certain of this because she had been working on the 100 Unit that day. Staff #201 further stated that at approximately 6:45 AM, she had been notified by another Staff Member # 40 about the incident. LPN (Staff #201) immediately went outside and found Resident #7 in his wheelchair. Staff #201 assessed Resident #7's condition and found him to be stable. Staff #201 stated that Staff #201 educated Resident #7 regarding the risks of leaving the facility without notifying staff, and Resident #7 smiled in response. LPN (Staff #201) agreed that the incident met the definition of an elopement and reflected the facility's failure to ensure that Resident #7 did not leave the premises unsupervised. A review of the facility policy regarding the Elopement Process indicated that the facility was responsible for assessing residents for wandering or elopement risk upon admission and implementing established procedures to prevent and respond to resident elopement, with resident safety and security as a primary priority.

Based on resident and staff interviews, facility documentation and policy review, the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week. The census was 100 residents. The deficient practice could result in residents not receiving appropriate care and treatment that they need.Findings include: The Payroll-Based Journal (PBJ) Staffing Data Report revealed that the facility consistently triggered for one star staffing rating for all four quarters of 2025. The PBJ also revealed that the facility triggered No RN Hours for quarters 1 and 2 of 2025. Per the report, No RN hours were submitted on the following dates:November 16 and 28, 2024December 14 and 15, 2024January 1, 4, and 5, 2025February 16, 2025 The facility assessment updated on November 2025, revealed that the facility was licensed for 119 residents, had an average daily census of 95-100 residents, and had an average number of 3 admissions per week and average number of 1 discharge per week. Staffing plan included the following: Licensed nurses providing direct care 92.5 hours per day and other nursing personnel including those with administrative duties at 112 hours per week. Further review of the assessment revealed that the scheduled hours for nursing did not delineate between RNs and Licensed Practical Nurses (LPN) hours. The facility plan documented that in the event of nurse call offs, the facility will shift responsibilities for coverage while we contact off duty personnel to come in if possible or have a nurse manager work the shift, or contacting contracted nursing agency to fill the vacancy.Review of the facility staff postings revealed no RN hours posted during the following dates:November 6, 8, 12,13,15, and 26th 2024.January 1, 15 and 29, 2025. Review of the facility payroll system revealed that no RN had worked on November 16, 2024. The facility payroll system confirmed an RN worked on November 6, 8, 12,13,15, 26, and 28 2024.Review of the facility payroll system for the month of December 2025 confirmed an RN had worked on December 14 and 15, 2024.Review of the facility payroll system revealed no evidence that an RN worked January 1, 4, and 5, 2025. The facility payroll system confirmed an RN worked on January 15 & 29, 2025. Review of the facility payroll system for February 16, 2025 revealed no evidence that an RN worked on that date.An interview with Activity Director (Staff # 12) on May 14, 2026 at 2:10 p.m. who stated that sometimes the facility is staff challenged but has improved since last year. Staff #12 stated that she works as manager on duties on some weekends and staffing can be really challenging as call offs happen. Staff # 12 stated when a call off happens she calls the manager of the department to notify and start reaching out their staff to cover, if they can not get someone to come in then they reach out to agency. Staff #12 stated that her activity department helps keep the residents occupied during the day to hep alleviate the effects of a call off giving nurses time to attend to all the residents.An interview as conducted with a Certified Nursing Assistant (CNA/Staff #36) on May 14, 2026 at 2:57 p.m. Staff #36 stated that most of the time it feels like they work short staffed and have to help cover other shifts and work overtime. CNA states that the nurses she works with on the floor are primarily Licensed Practical Nurses (LPNs) she does not work much or see RNs during her shift. Staff #36 stated that she does work a lot with agency staff but more with other CNAs and LPNs. An interview conducted on May 15, 2026 at 8:20 a.m. with Business Office Director (Staff # 174), who stated that her department is responsible for submitting the staffing hours for the PBJ. Staff # 174 stated that a third party payroll system tracks all hours and submits the worked hours for the PBJ. Staff # 174 stated that January 2025 they had switched payroll systems and during the switch had caused some time cards to be lost. Staff # 174 stated that they had to manually enter those dates by hand but some of the pay cards were lost and they do not have the information.An interview conducted on May 15, 2026 at 10:16 a.m. with Director of Nursing (DON/Staff #98), who stated that currently she staffs one RN to be charge nurse during the day Monday through Friday. Staff # 98 stated that she also can utilize her Assistant Director of Nursing (Staff #7) as well for coverage. Staff #98 stated that all of the RNs are the facilities staff and no agency is utilized for RN services. The DON stated that back in 2024 to 2025 the facility changed to a new payroll system that would document staffing hours better than the previous system. The DON stated that during the switch they had lost a lot of staffing hour data and had to manually go back and enter lost time into the payroll. The DON stated that included the ADON's (Staff #7) hours they had covered. The DON stated that is why the hours are not matching with postings and PBJ during this time period. The DON had reviewed the missing PBJ and staff posting RN hours and stated that an RN had worked on January 1, 4, and 5, 2025 but they did not have the payroll time sheet to prove those dates were worked. The DON could not supply the RN name or confirmation worked for February 16, 2025. The DON confirmed that no RN had worked on November 16, 2024. The DON explained that the concern when there is no RN working 8 consecutive hours in a day is that there is no clinical oversight and certain medications and procedures can not be performed unless it is by an RN which places the residents at risk for delay of treatment.A request was placed for the Facility Staffing Policy, on May 15, 2026 at 9:28 a.m. The DON documented that the facility had no staffing policy. Review of the Facility Assessment, updated November 2025, revealed that the facility resources needed to provide competent support and care for the resident population, every day and during emergencies, included Nursing services. The Facility assessment listed RNs, Charge Nurses, and wound nurses as part of the nursing services.

Number of residents sampled: Number of residents cited: Based on observations, staff interviews, and facility policy review, the facility failed to ensure proper hand hygiene was conducted during medication administration. The deficient practice could result in contaminated medications being administered to residents along with medication contamination, and potential infection . Findings:During the Medication Administration observation with the Licensed Practitioner Nurse (LPN / Staff #196) on May 14, 2026, at 9:00 AM in the 400 hallway, it was observed that the LPN (Staff #196) had nearly finished administering medications to Resident # 410. The LPN then returned to the medication cart without performing hand hygiene and proceeded to administer the medications to another resident # 499. No hand hygiene was performed during this time. The LPN crushed all medications, mixed them with yogurt, and administered them to Resident # 499.After administering medications to Resident #499, staff # 196 picked up trash from the floor and discarded it in the trash bin. Without performing hand hygiene, the LPN (Staff #196) then began preparing medications for another resident #550 by pouring them into a cup. The LPN (Staff #196) opened a Divalproex capsule with bare hands and emptied it into the cup. The LPN (Staff #196) then put on gloves, opened a Duloxetine 60 mg capsule into the same cup, crushed all medications, and administered them to Resident # 550. The LPN crushed all medications, mixed them with yogurt, and administered them to Resident # 550.An Interview was conducted on May 14, 2026 at 10:36 AM with a Registered Nurse (RN/Staff # 136) stated that all nurses typically clean the medication cart with disinfectant wipes before beginning their shift, and each patient's medications are prepared individually according to the medications due on the eMAR at that time. Hand sanitizer and gloves are kept on each cart to support proper infection control practices. Only one resident's medications are prepared at a time, and the nurse locates the resident to administer the medications directly. She further stated that staff ensure the resident has swallowed the medication before discarding the medication cup, performing hand hygiene, and preparing the next resident's medications. For eye drops, proper protocol includes sanitizing hands, wearing gloves, and providing the resident with a tissue to wipe away tears after administration. She stated gloves are then discarded, hand hygiene is performed, and the medication is returned to the cart before moving on to the next resident. Staff #136 stated that when administering capsule medications, the capsule is opened into a separate medication cup while wearing gloves, and the empty capsule shells are discarded appropriately. After administering the medication, gloves are removed and hands are sanitized. She stated that if a staff member touches a dirty surface, such as the floor, during medication pass, they should immediately stop and perform hand sanitization before continuing care with another resident. Staff #136 stated that failure to follow these infection control procedures places residents at risk of exposure to harmful organisms that could negatively impact their health. The RN stated that touching capsules or medications without proper hand hygiene or gloves significantly increases the risk of contamination and potential illness for the resident. Staff #136 stated that these practices are not acceptable and do not comply with facility protocols for hand sanitization, sanitary procedures, or established standards during medication administration. An Interview was conducted on May 15, 2026 at 09:15 AM with the Director Of Nursing (DON/Staff # 98) who stated that the expectation is that staff administering medications maintain proper hygiene practices between residents, including performing hand hygiene before and after each patient interaction. She stated while there may not be a specific policy for hand hygiene during medication administration, the general hand hygiene protocol still applies throughout the process. Staff #98 stated that if a staff member touches a dirty floor or picks up trash during medication pass, hand hygiene should be performed immediately to prevent cross-contamination, infection, and contamination of the workspace. She stated that picking up trash and then opening medications without proper hand hygiene or gloves can also contaminate the medication itself. The DON stated that staff are expected to wear gloves before opening capsules or handling medications. Staff #98 further stated that failure to follow these practices is not acceptable and indicates that the facility's infection control and hygiene policies were not followed properly. A facility policy and procedure titled Hand Hygiene states that staff must follow proper handwashing practices and may also use routine hand decontamination before direct contact with patients.

Based on observation, staff interviews, facility documents, and policy, the facility failed to ensure a call system was operational for 1 out of 20 residents sampled (# 5). The universe was 100 residents. The deficient practice could place residents' safety at risk.Findings include:Resident # 5 was admitted [DATE] with diagnoses that included unspecified heart failure, hypotension, type 2 diabetes mellitus, and major depressive disorder. A significant change in status Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) of 13 indicating the resident's cognitive function is intact. The MDS assessment revealed that Resident # 5 had a fall in the last 2-6 months prior to admission. A Work Order created on May 8, 2026 at 3:11 p.m. revealed that Resident # 5's call light does not work. Further review of the work order documented that the order remained open, no work had been logged on the order, and no alternative call systems were provided to the Resident. An interview was conducted with Resident # 5 on May 12, 2026 at 12:51 p.m. who stated that I can't call for staff when I need something because the button came off a while ago. Resident # 5 stated that the facility is aware that it is broke and they have not fixed the box yet. An observation was conducted in Resident #5's room on May 12, 2026 at 12:51 p.m. revealed the resident's call button hanging over the back the resident's wheelchair not in reach from the bed. Further observation revealed the box where the call light button is connected to was pulled out of the wall with wires connecting the box visible. The call box itself was dangling by the wires. A comprehensive care plan reviewed on May 13, 2026 revealed that Resident #5 was at risk for falling. Interventions included keeping call light within reach at all times and place a 'Call, Don't Fall' sign in room.An interview was conducted with Certified Medical Assistant (CMA/Staff #178) on May 14, 2026 at 8:52 a.m. who stated that she was not aware the resident's call light was not working. Staff #178 went into Resident #5's room and pressed Resident #'s button and walked out of the room to see the light did not come on. Staff #178 went to ask about the call light to maintenance and return stating that maintenance was aware and he had told administration about it. Staff # 178 stated that the resident typically uses he call light a lot when it was working. An interview was conducted with Environmental Services manager (Staff #3) on May 14, 2026 at 8:58 a.m. Staff #3 stated that he was alerted last week that the cord to the call light system had been pulled out and no longer working. Staff #3 stated that they have tried to get the system fixed but the call system is obsolete and parts are no longer available for it. Staff #3 stated that the facility is working on getting a contractor out to work on the whole system but is unsure when the work will be completed. Staff #3 stated that when a call light is not working, the Resident should receive a bell in order to call the facility. Staff #3 went into the room to look for the bell but stated he did not see one and does not know why a bell is not in the room.Another interview was conducted with Resident #5 on May 14, 2026 at 9:05 a.m. who stated he does not have a bell and never got a bell when the call light broke. Resident #5 stated that he usually hollers in the hallway to try and get attention to staff to get help. An interview was conducted on May 15, 2025 at 8:41 a.m. with Assistant Director of Nursing (ADON, Staff #7) who stated that she was made aware on May 14th by staff that the call light was not working in Resident #5's room. Staff #7 stated that as soon as she found out that it was not working they moved both Residents in the room to a different room with a working call light. The ADON stated the concern of not having a way for residents to call for staff is that the resident could not get the care they needed without the ability to notify staff. An interview was conducted on May 15, 2025 at 10:27 a.m. with Director of Nursing (DON, Staff # 98) who stated that it is her expectation that if resident's do not have an operational call light that another system such as a bell is supplied until the call light can be fixed or the resident can be relocated to a room with an operational call light. The DON stated the concern for a resident with out a working call light is patient does not receive the appropriate care. A policy and procedure titled Fall Prevention Policy, dated September 2024, revealed that a plan of care will be developed for a resident found to be a risk of falls on the comprehensive care plan that provides appropriate interventions. The fall prevention policy revealed suggested interventions which include assessing the environment and making the appropriate changes including call light is within in reach.

Number of residents sampled: Number of residents cited: Based on a review of clinical records, staff and resident interviews, and facility policies and procedures, the facility failed to ensure that pain medication for one (Resident # 111) of the five sampled residents was administered in accordance with physician orders. This deficient practice had the potential to result in either overmedication or undermedication of the resident. Findings include:Resident #111 was admitted to the facility on [DATE] with diagnoses that included senile degeneration of the brain, acute kidney failure, dementia, cellulitis of the right lower limb, gastro-esophageal reflux disease with esophagitis, H.pylori and chronic pain.Resident # 111's care plan dated February 19, 2026 revealed that the facility must anticipate the resident's need for pain relief and respond immediately to any complaint of pain. During every shift, the facility is expected to evaluate the effectiveness of pain interventions, review for compliance, alleviating of symptoms, dosing schedules and resident satisfaction with results, impact on functional ability and impact on cognition.Review of the physician's order dated February 19, 2026 revealed that Morphine concentrate 0.25 ml, should be administered orally or sublingually as needed, every two hours for pain levels of 4-10/10 or for shortness of breath.Review of the Medication Administration Record (MAR) dated February 2026 and March 2026 revealed that five times, Morphine concentrate was administered when the documented pain level was zero. Those dates and reported pain levels included:February 22, 2026 - Pain level 0 - Morphine administered at 8:34 PMFebruary 24, 2026 - Pain level 0 - Morphine administered at 8:56 PMMarch 6, 2026 - Pain level 0 - Morphine administered at 6:34 PMMarch 9, 2026 - Pain level 0 - Morphine administered at 7:02 PMMarch 16, 2026 - Pain level 0 - Morphine administered at 1:59 PMReview of the Medication Administration Record (MAR) dated February 2026, March 2026 and April 2026 revealed that four times, Morphine concentrate was not administered when pain levels of 4 or 5 were noted in the pain task. Those dates and reported pain levels included:February 19, 2026 - Pain level 4 - Morphine was not administered.February 26, 2026 - Pain level 4 - Morphine was not administered.March 12, 2026 - Pain level 4 - Morphine was not administered.April 21, 2026 - Pain level 5 - Morphine was not administered.An interview was conducted on May 14, 2026, at 10:36 AM with a Registered Nurse (RN/Staff #136), who stated that the facility administered both scheduled and PRN pain medications. The RN (Staff # 136) explained that PRN pain medications were administered by nurses in accordance with physician orders and pain scale parameters. Nurses assessed residents' pain levels daily to determine whether medication administration was appropriate. For example, if a resident reported a pain level of 4 or higher and the physician's order indicated that PRN medication should be administered at that level, the resident should have received the medication. If the resident reported no pain, pain medication should not have been administered unnecessarily.The RN (Staff # 136) further stated that failure to administer pain medication when a resident was experiencing pain could have resulted in unmanaged discomfort, behavioral changes, elevated blood pressure, and a decreased quality of life. Conversely, administering pain medication when a resident was not in pain could have negatively impacted the resident's quality of life and exposed the resident to unnecessary medication effects.The RN (Staff # 136) acknowledged that there was a documented discrepancy involving morphine administration for Resident #111 and confirmed the inconsistency in administration practices. The RN stated that this was not an acceptable practice and that improvements were needed to ensure consistent and accurate pain medication administration in accordance with facility policy and physician orders.An interview was conducted on May 15, 2026, at 9:15 AM with the Director of Nursing (DON/Staff #98), who stated that when a resident experienced pain that fell within the ordered pain parameters, the expectation was for staff to administer the medication if the resident permitted. If the resident refused, staff were expected to attempt alternative methods for pain relief. The DON (Staff #98) stated that failure to administer pain medication when indicated could have resulted in the resident continuing to experience pain without relief and emotional distress, and would have constituted a medication error.The DON (Staff #98) further stated that administering pain medication when it was not needed, particularly narcotic medication, could have resulted in oversedation, respiratory depression, altered mental status, and injury to the resident. The DON (Staff #98) acknowledged that an opioid medication had been administered in a manner that did not follow the physician's order and stated that this was not an acceptable practice.The DON (Staff #98) stated that staff required additional education on following physician orders and appropriately adhering to pain scale parameters.Regarding the consequences of the medication error for Resident #111, the DON (Staff #98) stated that the resident's needs were not met when pain medication was indicated, and the resident was overmedicated when it was not required. The DON (Staff #98)further stated that because the resident had dementia, the improper administration of Morphine could have negatively affected the resident's mental status and safety, impaired swallowing ability, decreased oral intake due to oversedation, and exacerbated the resident's Failure to Thrive.A facility policy and procedure titled Medication Management - Medication Administration states that nurses holding current licensure through the Arizona State Board of Nursing are authorized to administer medications pursuant to the order of a medical practitioner.

Based on clinical records, review of facility documentation, staff interviews and review of policy and procedure facility failed to ensure an allegation of abuse for 2 of 21 residents (#70, #37) was fully investigated. The universe was 100 residents. The deficient practice could result in allegations of abuse not being thoroughly investigated and abuse occurring in the facility.Findings include:Regarding Resident #70:Resident #70, the alleged victim, was admitted [DATE], with diagnoses that included unspecified dementia, maxillary fracture unspecified side, nausea with vomiting, urinary tract infection, and depression. A physician's order initiated on September 23, 2025 revealed that Resident #70 should be monitored for combative behavior and determine unmet needs as needed. The care plan initiated on September 24, 2025 revealed the resident is fearful of men she does not know and may strike out at men in her area. Interventions included documenting behaviors, female caregivers if possible, and making sure all basic needs are met. 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. The MDS documented that the Resident had disorganized thinking and inattentive. The MDS revealed no behaviors exhibited. A progress note dated April 23, 2026 at 2:19 a.m. documented that Resident #70 was in the hallway/tv room area watching TV at 7:25 p.m. when Resident # 37 appeared to punch Resident #70 on her left leg. The progress note further documented that the Assistant Director of Nursing (ADON/Staff #7) reviewed the video footage and determined there was not contact. The progress note revealed that the residents were separated from each other and assessed for injuries. Regarding Resident #37:Resident # 37, the alleged perpetrator, was admitted on [DATE] with diagnoses that included severe dementia in other diseases classified elsewhere with psychotic disturbance.An admission MDS assessment dated [DATE] revealed a BIMS score of 0 due to the inability to complete the exams. The MDS assessment documented Resident #37 had behaviors of delusions, verbal and other behavioral symptoms which put the resident at significant risk for physical illness or injury. The MDS assessment revealed that the resident is administered antipsychotic medication on a routine basis. A progress note dated April 22, 2026 at 7:25 p.m. written by Licensed Practical Nurse (LPN/Staff #84) which documented that Resident #37 was exit seeking at 7:10 pm and was moved to the TV room for the resident to watch TV. The progress note revealed that at 7:25 p.m. Staff #84 observed Resident #37 swat at Resident #70. The progress note documented that Resident #37 balled up his fist and appeared to punch Resident #70 on her left leg. The progress note revealed that Staff #84 asked Resident #37 if he meant to hurt Resident #70, he nodded his head yes. The progress noted documented that Resident #37 was aggressive and agitated after the incident with behaviors that included, balling up his fist at another female resident and telling staff to 'get the hell away from me'. Staff #84 documented that she contacted the Director of Nursing (DON/Staff# 98) and the police to file a report. The progress note revealed that the ADON (Staff #7) came to the facility and reviewed the camera footage and determine that no contact was made.Review of Resident #37's census report revealed that on April 23, 2026 Resident #37 was relocated from his room [ROOM NUMBER]-2 to the secured unit in room [ROOM NUMBER]-2. A physician's order dated April 27, 2026 revealed monitoring of Resident #37 for aggression every shift. The order further revealed if behavior is present, the staff are to document in the progress note.An interview was conducted on May 14, 2026 with the ADON/Behavioral Unit Director (Staff #19) who stated that she oversees the behavioral units (300 and 400) while ADON Staff # 7 and DON Staff #98 oversee the other units (100 and 200). Staff #19 revealed that any abuse allegations including resident to resident abuse that occur in the behavioral units she would report to her DON, police, state agency, Adult Protective Services and Ombudsman. Staff #19 stated that she would then conduct her investigation talking to staff and residents. Staff #19 stated then she would review the camera footage to see if there is visual evidence of the abuse. Staff #19 stated that she would complete her investigation within 5 days and send it over for the DON to review and the investigation gets sent to the state agency. An interview was conducted with LPN Staff #84 on April 14, 2026 at 2:36 p.m. via telephone. Staff #84 stated that on the night of April 22, 2026 Resident #37 was exit seeking so she moved him to the TV room near the 100 hall where she could keep eyes on him. Staff #84 stated that Resident #70 was sitting facing toward the bird cage while Resident #37 was next to her facing more toward the tv. Staff #84 stated that they were conversing and Resident #70 started laughing and giggling which made Resident #37 agitated. Staff #84 stated that Resident #37 pulled back and hit Resident #70 in the left leg. Staff #84 said she separated the residents and called the police to file a report and reported the alleged abuse to the DON. Staff #84 stated that the ADON Staff #7 came to the facility and reviewed the camera footage. Staff #84 stated that the ADON determined that no contact was made and sent the Police home without investigating. An interview was conducted with ADON Staff #7 on April 15, 2026 at 8:41 a.m. who stated that if there is a resident-to-resident altercation they first make sure the residents are safe then they investigate the incident while also reporting to the DON, adult protectives services, police and state agencies. Staff #7 stated that she takes witness statements and reviews the camera footage to see what happened during the incident. Staff # 7 stated that once the investigation is concluded then it is submitted to DON who then submits the 5-day investigation report to the state agency. Staff #7 said she was notified by the DON to come in on April 22, 2026 to review an altercation between Resident #70 and Resident #37. Staff # 7 stated that she reviewed that camera footage and it appeared to her that Resident # 37 never made contact with Resident #70 and Resident #37 was moving his hand like 'shooing her away'. The ADON stated that the police did arrive because Staff #84 had called them but Staff #7 stated that she told the police no contact was made and they left without investigating. Staff #7 stated no other agencies were contacted including the state agency and the investigation concluded without staff interviews or resident interviews. An interview was conducted with the DON Staff # 98 on May 15, 2026 at 10:27 a.m. who stated that her expectation if resident to resident abuse takes place that first the nurses need to get the residents to safety, then notify the DON or administrator. Staff #98 stated then she would start the investigation process getting witness statements from staff and if able residents, while that is being done notifications are made to police and state agency, APS, ombudsman. family and case managers. Staff #98 stated that once the investigation is complete it is sent to the state agency. Staff #98 stated that Staff #84 had contacted her about a potential altercation with Resident #37 and Resident #7. The DON stated that Staff #84 sounded unsure if the abuse took place so the DON sent Staff #7 to investigate. The DON stated that Staff #7 told her that no contact was made. Staff #98 reviewed the Progress note on Resident #37 regarding the altercation. Staff #98 stated that does not sound like Staff #84 was unsure what happened. Staff #98 stated that if residents hit each other than that is abuse with a concern of causing injury to other residents. Staff #98 stated that she thought that if they could confirm that no contact was made, they did not have to complete a full investigation. A policy and procedure titled Abuse Prevention Policy & Procedure, revised April 2025, revealed that it is the policy of the facility to take appropriate steps to prevent the occurrence of abuse. The policy documented that the Administrator or DON will designate the individual who is to conduct each investigation depending on the circumstances of the incident. The policy documented that the investigation may include interviews with employees, visitors, and residents who may have knowledge of the alleged incident. The abuse policy revealed that the results of the investigations are reported to the Administrator and to the appropriate State agency as required by State law, with a copy of the investigation report submitted to the Department of Health Services within five working days of the alleged violation.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to implement its policy to ensure that an allegation of abuse for 2 out of 21 residents (#70, #37) was reported to all applicable state agencies. The universe was 100 residents. The deficient practice could result in further allegations of neglect not being reported. Findings include:Regarding Resident #70:Resident #70, the alleged victim, was admitted [DATE], with diagnoses that included unspecified dementia, maxillary fracture unspecified side, nausea with vomiting, urinary tract infection, and depression. A physician's order initiated on September 23, 2025 revealed that Resident #70 should be monitored for combative behavior and determine unmet needs as needed. The care plan initiated on September 24, 2025 revealed the resident is fearful of men she does not know and may strike out at men in her area. Interventions included documenting behaviors, female caregivers if possible, and making sure all basic needs are met. 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. The MDS documented that the Resident had disorganized thinking and inattentive. The MDS revealed no behaviors exhibited. A progress note dated April 23, 2026 at 2:19 a.m. documented that Resident #70 was in the hallway/tv room area watching TV at 7:25 p.m. when Resident # 37 appeared to punch Resident #70 on her left leg. The progress note further documented that the Assistant Director of Nursing (ADON/Staff #7) reviewed the video footage and determined there was not contact. The progress note revealed that the residents were separated from each other and assessed for injuries. Regarding Resident #37:Resident # 37, the alleged perpetrator, was admitted on [DATE] with diagnoses that included severe dementia in other diseases classified elsewhere with psychotic disturbance.An admission MDS assessment dated [DATE] revealed a BIMS score of 0 due to the inability to complete the exams. The MDS assessment documented Resident #37 had behaviors of delusions, verbal and other behavioral symptoms which put the resident at significant risk for physical illness or injury. The MDS assessment revealed that the resident is administered antipsychotic medication on a routine basis. A progress note dated April 22, 2026 at 7:25 p.m. written by Licensed Practical Nurse (LPN/Staff # 84) which documented that Resident #37 was exit seeking at 7:10 pm and was moved to the TV room for the resident to watch TV. The progress note revealed that at 7:25 p.m. Staff # 84 observed Resident #37 swat at Resident #70. The progress note documented that Resident #37 balled up his fist and appeared to punch Resident #70 on her left leg. The progress note revealed that Staff # 84 asked Resident #37 if he meant to hurt Resident #70, he nodded his head yes. The progress noted documented that Resident #70 was aggressive and agitated after the incident with behaviors that included, balling up his fist at another female resident and telling staff to 'get the hell away from me'. Staff #84 documented that she contacted the Director of Nursing (DON/Staff# 98) and the police to file a report. The progress note revealed that the ADON (Staff #7) came to the facility and reviewed the camera footage and determine that no contact was made.An interview was conducted on May 14, 2026 with the ADON/Behavioral Unit Director (Staff #19) who stated that she oversees the behavioral units (300 and 400) while ADON Staff # 7 and DON Staff #98 oversee the other units (100 and 200). Staff #19 revealed that any abuse allegations including resident to resident abuse that occur in the behavioral units she would report to her DON, police, state agency, Adult Protective Services and Ombudsman. An interview was conducted with LPN Staff #84 on April 14, 2026 at 2:36 p.m. via telephone. Staff #84 stated that on the night of April 22, 2026 Resident #37 was exit seeking so she moved him to the TV room near the 100 hall where she could keep eyes on him. Staff #84 stated that Resident #70 was sitting facing toward the bird cage while Resident #37 was next to her facing more toward the tv. Staff #84 stated that they were conversing and Resident #70 started laughing and giggling which made Resident #37 agitated. Staff #84 stated that Resident #37 pulled back and hit Resident #70 in the left leg. Staff #84 said she separated the residents and called the police to file a report and the DON. An interview was conducted with ADON Staff #7 on April 15, 2026 at 8:41 a.m. who stated that if there is a resident-to-resident altercation they first make sure the residents are safe then they investigate the incident while also reporting to the DON, adult protectives services, police and state agencies. Staff #7 said she was notified by the DON to come in on April 22, 2026 to review an altercation between Resident #70 and Resident #37. Staff #7 stated that she reviewed that camera footage and it appeared to her that Resident #37 never made contact with Resident #70 and Resident #37 was moving his hand like 'shooing her away'. The ADON stated that the police did arrive because Staff #84 had called them but Staff #7 stated that she told the police no contact was made and they left without investigating. Staff #7 stated no other agencies were contacted including the state agency.An interview was conducted with the DON Staff # 98 on May 15, 2026 at 10:27 a.m. who stated that her expectation if resident to resident abuse takes place that first the nurses need to get the residents to safety, then notify the DON or administrator. Staff #98 stated then she would start the investigation process getting witness statements from staff and if able residents, while that is being done notifications are made to police and state agency, APS, ombudsman. The DON stated that Staff #7 told her that no contact was made while observing the video. Staff #98 stated that she thought that if they could confirm that no contact was made, they did not have to report to the appropriate state agencies. The DON stated that the concern if the appropriate agencies are not contacted is that alleged abuse may not get not fully investigated. A policy and procedure titled Abuse Prevention Policy & Procedure, revised April 2025, revealed that it is the responsibility of all employees to immediately report any suspected or alleged violation of abuse. The policy documented that the facility will take appropriate steps to ensure that all suspected or alleged violations of Federal or State laws which involve abuse are reported immediately, but no later than 2 hours after the allegation is made if the events that cause the allegation involved abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involved abuse and do not result in serious bodily injury, the the Administrator and to other officials including the State Survey Agency and Adult Protective Services where State law provides for jurisdiction.

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to implement their abuse policy involving an allegation of abuse with 2 of 21 residents (#70 and #37). The universe was 100 residents. The deficient practice could result in the appropriate State Agencies not being notified and allegations of abuse not being thoroughly investigated. Findings include:Regarding Resident #70:Resident #70, the alleged victim, was admitted [DATE], with diagnoses that included unspecified dementia, maxillary fracture unspecified side, nausea with vomiting, urinary tract infection, and depression. A physician's order initiated on September 23, 2025 revealed that Resident #70 should be monitored for combative behavior and determine unmet needs as needed. The care plan initiated on September 24, 2025 revealed the resident is fearful of men she does not know and may strike out at men in her area. Interventions included documenting behaviors, female caregivers if possible, and making sure all basic needs are met. 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. The MDS documented that the Resident had disorganized thinking and inattentive. The MDS revealed no behaviors exhibited. A progress note dated April 23, 2026 at 2:19 a.m. documented that Resident #70 was in the hallway/tv room area watching TV at 7:25 p.m. when Resident # 37 appeared to punch Resident #70 on her left leg. The progress note further documented that the Assistant Director of Nursing (ADON/Staff #7) reviewed the video footage and determined there was not contact. The progress note revealed that the residents were separated from each other and assessed for injuries. Regarding Resident #37:Resident # 37, the alleged perpetrator, was admitted on [DATE] with diagnoses that included severe dementia in other diseases classified elsewhere with psychotic disturbance.An admission MDS assessment dated [DATE] revealed a BIMS score of 0 due to the inability to complete the exams. The MDS assessment documented Resident #37 had behaviors of delusions, verbal and other behavioral symptoms which put the resident at significant risk for physical illness or injury. The MDS assessment revealed that the resident is administered antipsychotic medication on a routine basis. A progress note dated April 22, 2026 at 7:25 p.m. written by Licensed Practical Nurse (LPN/Staff # 84) which documented that Resident #37 was exit seeking at 7:10 pm and was moved to the TV room for the resident to watch TV. The progress note revealed that at 7:25 p.m. Staff #84 observed Resident #37 swat at Resident #70. The progress note documented that Resident #37 balled up his fist and appeared to punch Resident #70 on her left leg. The progress note revealed that Staff #84 asked Resident #37 if he meant to hurt Resident #70, he nodded his head yes. The progress noted documented that Resident #70 was aggressive and agitated after the incident with behaviors that included, balling up his fist at another female resident and telling staff to 'get the hell away from me'. Staff #84 documented that she contacted the Director of Nursing (DON/Staff# 98) and the police to file a report. The progress note revealed that the ADON (Staff #7) came to the facility and reviewed the camera footage and determine that no contact was made.Review of Resident #37's census report revealed that on April 23, 2026 Resident #37 was relocated from his room [ROOM NUMBER]-2 to the secured unit in room [ROOM NUMBER]-2. A physician's order dated April 27, 2026 revealed monitoring of Resident #37 for aggression every shift. The order further revealed that if behavior is present, staff are to document in the progress note.An interview was conducted on May 14, 2026 with the ADON/Behavioral Unit Director (Staff #19) who stated that she oversees the behavioral units (300 and 400) while ADON Staff #7 and DON Staff #98 oversee the other units (100 and 200). Staff #19 revealed that any abuse allegations including resident to resident abuse that occur in the behavioral units she would report to her DON, police, state agency, Adult Protective Services and Ombudsman. Staff #19 stated that she would then conduct her investigation talking to staff and residents. Staff #19 stated then she would review the camera footage to see if there is visual evidence of the abuse. Staff #19 stated that she would complete her investigation within 5 days and send it over for the DON to review and the investigation gets sent to the state agency. An interview was conducted with LPN Staff #84 on April 14, 2026 at 2:36 p.m. via telephone. Staff #84 stated that on the night of April 22, 2026 Resident #37 was exit seeking so she moved him to the TV room near the 100 hall where she could keep eyes on him. Staff #84 stated that Resident #70 was sitting facing toward the bird cage while Resident #37 was next to her facing more toward the tv. Staff #84 stated that they were conversing and Resident #70 started laughing and giggling which made Resident #37 agitated. Staff #84 stated that Resident #37 pulled back and hit Resident #70 in the left leg. Staff #84 said she separated the residents and called the police to file a report and reported the alleged abuse to the DON. Staff #84 stated that the ADON Staff #7 came to the facility and reviewed the camera footage. Staff #84 stated that the ADON determined that no contact was made and sent the Police home without investigating. An interview was conducted with ADON Staff #7 on April 15, 2026 at 8:41 a.m. who stated that if there is a resident-to-resident altercation they first make sure the residents are safe then they investigate the incident while also reporting to the DON, adult protectives services, police and state agencies. Staff #7 stated that she takes witness statements and reviews the camera footage to see what happened during the incident. Staff #7 stated that once the investigation is concluded then it is submitted to DON who then submits the 5-day investigation report to the state agency. Staff #7 said she was notified by the DON to come in on April 22, 2026 to review an altercation between Resident #70 and Resident #37. Staff #7 stated that she reviewed that camera footage and it appeared to her that Resident #37 never made contact with Resident #70 and Resident #37 was moving his hand like 'shooing her away'. The ADON stated that the police did arrive because Staff #84 had called them but Staff #7 stated that she told the police no contact was made and they left without investigating. Staff #7 stated no other agencies were contacted including the state agency and the investigation concluded without staff interviews or resident interviews. An interview was conducted with the DON Staff #98 on May 15, 2026 at 10:27 a.m. who stated that her expectation if resident to resident abuse takes place that first the nurses need to get the residents to safety, then notify the DON or administrator. Staff #98 stated then she would start the investigation process getting witness statements from staff and if able residents, while that is being done notifications are made to police and state agency, APS, ombudsman. family and case managers. Staff #98 stated that once the investigation is complete it is sent to the state agency. Staff #98 stated that Staff #84 had contacted her about a potential altercation with Resident #37 and Resident #70. The DON stated that Staff #84 sounded unsure if the abuse took place so the DON sent Staff #7 to investigate. The DON stated that Staff #7 told her that no contact was made. Staff #98 reviewed the Progress note on Resident #37 regarding the altercation. Staff #98 stated that does not sound like Staff #84 was unsure what happened. Staff #98 stated that if residents hit each other than that is abuse with a concern of causing injury to other residents. Staff #98 stated that she thought that if they could confirm that no contact was made, they did not have to complete a full investigation and report to the appropriate state agencies. A policy and procedure titled Abuse Prevention Policy & Procedure, revised April 2025, revealed that it is the policy of the facility to take appropriate steps to prevent the occurrence of abuse. The policy documented that such violations are also reported to State agencies in accordance with existing Stat law and the facility investigates each alleged violation thoroughly and reports the results of all investigations to the Administrator or designee, as well as to State agencies as required by State and Federal law.

Based on staff interviews, review of clinical record and policy review, the facility failed to protect the rights of 2 of 21 residents sampled (#70, #37) to be free from physical abuse between residents. The universe was 100 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 #70:Resident #70, the alleged victim, was admitted [DATE], with diagnoses that included unspecified dementia, maxillary fracture unspecified side, nausea with vomiting, urinary tract infection, and depression. A physician's order initiated September 23, 2025 revealed that Resident #70 should be monitored for combative behavior and determine unmet needs as needed. The care plan initiated on September 24, 2025 revealed the resident is fearful of men she does not know and may strike out at men in her area. Interventions included documenting behaviors, female caregivers if possible, and making sure all basic needs are met. 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. The MDS documented that the Resident had disorganized thinking and inattentive. The MDS revealed no behaviors exhibited. A progress note dated April 23, 2026 at 2:19 a.m. documented that Resident #70 was in the hallway/tv room area watching TV at 7:25 p.m. when Resident # 37 appeared to punch Resident #70 on her left leg. The progress note further documented that the Assistant Director of Nursing (ADON/Staff #7) reviewed the video footage and determined there was not contact. The progress note revealed that the residents were separated from each other and assessed for injuries. Regarding Resident #37:Resident # 37, the alleged perpetrator, was admitted on [DATE] with diagnoses that included severe dementia in other diseases classified elsewhere with psychotic disturbance.An admission MDS assessment dated [DATE] revealed a BIMS score of 0 due to the inability to complete the exams. The MDS assessment documented Resident #37 had behaviors of delusions, verbal and other behavioral symptoms which put the resident at significant risk for physical illness or injury. The MDS assessment revealed that the resident is administered antipsychotic medication on a routine basis. A progress note dated April 22, 2026 at 7:25 p.m. written by Licensed Practical Nurse (LPN/Staff # 84) which documented that Resident #37 was exit seeking at 7:10 pm and was moved to the TV room for the resident to watch TV. The progress note revealed that at 7:25 p.m. Staff # 84 observed Resident #37 swat at Resident #70. The progress note documented that Resident # 37 balled up his fist and appeared to punch Resident #70 on her left leg. The progress note revealed that Staff #84 asked Resident #37 if he meant to hurt Resident #70 he nodded his head yes. The progress noted documented that Resident #70 was aggressive and agitated after the incident with behaviors that included, balling up his fist at another female resident and telling staff to 'get the hell away from me'. Staff #84 documented that she contacted the Director of Nursing (DON/Staff#98) and the police to file a report. The progress note revealed that the ADON (Staff #7) came to the facility and reviewed the camera footage and determine that no contact was made.Review of Resident #37's census report revealed that on April 23, 2026 Resident #37 was relocated from his room [ROOM NUMBER]-2 to the secured unit in room [ROOM NUMBER]-2. A physician's order dated April 27, 2026 revealed monitoring of Resident #37 for aggression every shift. The order further revealed if behavior is present, document in the progress note.An interview was conducted on May 14, 2026 with the ADON/Behavioral Unit Director (Staff #19) who stated that she oversees the behavioral units (300 and 400) while ADON Staff #7 and DON Staff #98 oversee the other units (100 and 200). Staff #19 revealed that any abuse allegations including resident to resident abuse that occur in the behavioral units she would report to her DON, police, state agency, Adult Protective Services and Ombudsman. Staff #19 stated that she would then conduct her investigation talking to staff and residents. Staff #19 stated then she would review the camera footage to see if there is visual evidence of the abuse. Staff #19 stated that she would complete her investigation within 5 days and send it over for the DON to review and the investigation gets sent to the state agency. Staff #19 revealed that the video footage only saves for 14 days then is cleared from the system. Staff #19 revealed that if the alleged abuse takes place in the 100 or 200 units then ADON Staff #7 will do the same process. Staff #19 stated that Resident # 37 was moved into the behavioral unit because he was getting aggressive in the 100 hall so it was determined that he would be a better fit in the 300 hall. An interview was conducted with LPN Staff #84 on April 14, 2026 at 2:36 p.m. via telephone. Staff #84 stated that on the night of April 22, 2026 Resident #37 was exit seeking so she moved him to the TV room near the 100 hall where she could keep eyes on him. Staff #84 stated that Resident #70 was sitting facing toward the bird cage while Resident #37 was next to her facing more toward the tv. Staff #84 stated that they were conversing and Resident #70 started laughing and giggling which made Resident #37 agitated. Staff #84 stated that Resident #37 pulled back and hit Resident #70 in the left leg. Staff #84 said she separated the residents and called the police to file a report and the DON. Staff #84 stated that the ADON Staff #7 came to the facility and reviewed the camera footage. Staff #84 stated that the ADON determined that no contact was made and sent the Police home with out investigating. An interview was conducted with ADON Staff #7 on April 15, 2026 at 8:41 a.m. who stated that if there is a resident to resident altercation they first make sure the residents are safe then they investigate the incident while also making contact to DON, adult protectives services, police and state agencies. Staff #7 stated that she takes witness statements and reviews the camera footage to see if they can see what happened during the incident. Staff # 7 stated that once the investigation is concluded then it is submitted to DON who then submits the 5 day investigation report to the state agency. Staff #7 said she was notified by the DON to come in on April 22, 2026 to review an altercation between Resident #70 and Resident #37. Staff # 7 stated that she reviewed that camera footage and it appeared to her that Resident # 37 never made contact with Resident #70 and Resident #37 was moving his hand like 'shooing her away'. Staff #7 stated that the residents were separated. The ADON stated that the police did arrive because Staff #84 had called them but Staff #7 stated that she told the police no contact was made and they left without investigating. Staff #7 stated that the next day Resident #37 was transferred to the behavioral unit due to verbal outbursts towards staff. Staff #7 stated that the video footage of the incident was never saved because the video only saves for 14 days. An interview was conducted with the DON Staff #98 on May 15, 2026 at 10:27 a.m. who stated that her expectation if resident to resident abuse takes place that first the nurses need to get the residents to safety then notify the DON or administrator. Staff #98 stated then she would start the investigation process getting witness statements from staff and if able residents, while that is being done notifications are made to police and state agency, APS, ombudsman. family and case managers. Staff #98 stated that once the investigation is complete it is sent to the the state agency. Staff #98 stated that Staff #84 had contacted her about a potential altercation with Resident #37 and Resident #70. The DON stated that Staff #84 sounded unsure if the abuse took place so the DON sent Staff #7 to investigate. The DON stated that Staff #7 told her that no contact was made. Staff #84 reviewed the Progress note on Resident #37 regarding the altercation. Staff #37 stated that does not sound like Staff #84 was unsure what happened. Staff #84 stated that if residents hit each other then that is abuse with the concern of causing injury to other residents. Staff #98 stated that she thought that if they could confirm that no contact was made they did not have to complete a full investigation and report to the appropriate state agencies. The DON stated that the video of the incident was not saved because it is beyond the 14 days. A policy and procedure titled Abuse Prevention Policy & Procedure, revised April 2025, revealed that it is the policy of the facility to take appropriate steps to prevent the occurrence of abuse. The policy also revealed the definition of physical abuse as hitting, slapping, pinching, and kicking.

Based on record review, staff interviews, facility documentation, and policy review, the facility failed to ensure controlled medications were recorded, stored, and reconciled accurately for one of three sampled residents (#1). The deficient practice could result in the inability to ensure the safe and effective use of medication.Findings Include:Resident #1 was initially admitted on [DATE], and re-admitted on [DATE], with a diagnosis that included Senile degeneration of the brain, dementia, cellulitis of the toe, nutritional deficiency, psychotic disturbance, anxiety, Pneumonia, and chronic pain. The individual Resident Controlled Substances record dated March 4, 2025, for Resident #1 revealed that Morphine Sulfate was received in an amount of 30 mL (milliliter). It further identified that the dosage to be given to the resident was 0.25mL by mouth. The physician's order dated March 05, 2025, revealed orders for Morphine- Schedule II solution; 20 mg(milligram)/ 5mL (milliliter) (4mg/ml); amount 0.25mL; oral for pain, every 4 hours as needed. The medication was initiated on March 05, 2025.The care plan dated March 14, 2025, had a focused care area for Resident #1 for having an altercation in comfort related to end of life, aging, as evidenced by pain interview results, and pain medication use. Interventions included: addressing complaints of pain promptly with medications, administering pain medication as ordered, assessing characteristics of pain location, severity, on a scale of 1-10, type, and frequency, assessing the effectiveness of pain medication, monitoring for potential side effects of medication: altered mental status, anxiety, constipation, depression, dizziness, loss of appetite, nausea, pruritus, respiratory, depression, sedation, urinary retention or vomiting. The interventions also included to assure that pain medication is available if needed, notify the physician of any changes in level or frequency of pain, any increase in use of as-needed pain medication, and note side effects of pain medication, position resident for comfort using pillows if needed and report diaphoresis, moaning, restlessness, grimacing, & crying.The individual Resident Controlled Substance record for Resident #1 for Morphine Sulfate revealed a steady count down in increments of 0.25 until July 31, 2025, where there was an undated signature line below July 31, 2025, and above the next date of August 05, 2025. On July 31, 2025, the amount remaining was recorded at 25.25 mL. At the undated signature line, the amount remaining is documented at 20 mL. The next dose administered, on August 5, 2025, documents the administration of 0.25 mL with the remaining amount of medication recorded as 19.75 mL. The record continued to reveal a steady count down in increments of 0.25 until January 18, 2026, a dosage was given 0.25 and the remaining dosage left was recorded at 10.25ml. The medication administration record for Morphine- II solution; 20 mg/ 5mL (4mg/ml); amount 0.25mL; oral for pain, every 4 hours as needed for January 2026 revealed on January 18, 2026 the medication was administered. An observation was conducted on February 17, 2025, at 3:33 PM with the Licensed Practical Nurse (Staff #3) and Registered Nurse (RN/ Staff #2) verifying the narcotics count before starting the shift. In the process, one nurse reads the name and the written amount of the narcotic from the narcotics book and another visibly reviews the medication and verifies the count. Additionally, observed was the narcotics book sign in and out sheet per shift or narcotic count. On February 17, 2026, at 3:13 PM a RN (Staff #2), stated that the facility's process for administering medication, including liquid narcotics, is to administer the narcotics separately from other regular medication. She stated that for morphine liquid, she pulls up the electronic medication administration record (eMAR) for the resident, double-checks the order, then open the narcotics drawer, prepares the medication, signs it out in the book, rechecks it on the eMAR, closes the drawer, and locks the med cart. She said she then administers the medication, and ensures the resident consumes it completely. She stated that morphine liquid medication comes in bottles along with a syringe, to measure with and deliver to the resident. Staff #2, stated there was a recent incident when she was doing her narcotics check prior to her shift when the narcotic count was not correct. She said that about 7 mL of Morphine Liquid was missing from what was actually documented for Resident #1. Then she immediately notified the Director of Nursing (DON). The RN stated that the bottles for Morphine medication came from Resident #1's hospice provider and did not have markings on the side of the bottle so she is unable to measure how much is left, and can only determine the amount by eyeballing it. She further stated that she does not know where the medication went. Additionally, on February 18, 2026, at 08:52 AM Staff #2, stated that when she administers medication, she uses measuring devices and syringes, and it is very obvious to her when they use syringes to administer medication how much is given by mouth. She said the reason it was hard to measure the morphine medication from hospice in liquid form was that the hospice usually gets the bottles from Safeway or Walmart where they do not have measuring lines on the side of the bottle. She stated that when the bottles from their own facility pharmacy, it comes colored and also has the measuring lines. She said that's the reason it took so long for them to know that medication was missing. She said that just glancing at the bottle for Resident #1, she knew it was missing liquid medication, and it was not 10mL. She stated the risk of not having measuring lines on the bottle would not allow for accurate measurements. Staff #2 stated that the only way for the nursing staff to accurately know the amount of liquid medication would be to pour the liquid medication into a measuring device. She stated that risk for this would be loss if every day nurses have opened the bottle to pour it into the measuring cup. There may be a spillage of the medication. Staff #2 stated that there were a couple of incidents where nursing staff would not write in the narcotics book that they had removed morphine medication or checked out in the eMAR on the computer, and vice versa, when they were checking the system after the incident. She said the risk to all of this would be improper measurement of the narcotics medications. On February 18, 2026, at 09:24 AM the DON (Staff #3), said that her role is to oversee the nursing team and ensure residents receive quality of care, staff members receive education, oversight, and they review policies and procedures and ensure they are updated with Centers for Medicare and Medicaid Services (CMS) guidelines. She stated that the facility's process for administering medications is to ensure it is the right dose, right patient, right route, right reason, and should be done before the medication administration. After the administration, the expectation is the nurse should do the follow-up tasks that need to be assessed and documented, for example, pain medication, as-needed medication (PRN), nausea medication, and bowel protocols.The DON stated that for pain medication administration, Nurses need to look over the order before administering, prepare the medication, identify that it is the correct time for the medication, identify the site of pain and review the physician order. The nurse should administer medication if it is appropriate, and sign out the medication on the eMar and on the narcotics sheet. She stated the process is the same for liquid morphine medication as for oral narcotics. She stated that with a syringe that is provided with the medication you would draw the correct amount into the syringe. The DON said that morphine medication bottle types are dependent on the pharmacy. With USA Pharmacy, (the primary pharmacy the facility uses) morphine comes with a paper narcotics log sheet, and the medication arrives in bottles that have a clear panel top to bottom, and they have marking amounts (increments). She stated the medication can be either pink or blue. The DON stated the pharmacy bottles from hospice have a clear bottle panel top to bottom, but do not have increments on the side of the bottle. The hospice medication comes with the syringe. She also stated that it is hard to know with hospice bottles how much medication is left in there; there is no way to visualize it. Before the incident, they found the nursing staff would just look at the bottle, not fully measure or quantify. She further stated that prior to the incident the nurses would receive medication from the hospice provider, sign in the medication on the narcotics sheet and fill out the in-house count form. She stated that on January 26, 2026, staff #2 noticed that the bottle did not match what was recorded on the log for January 18, 2026. She stated that when she found the bottle, it did not have markings of the doses, and she viewed the bottle at eye level and it did not look like 10.25ml. She said she then pulled the medication remaining into a syringe it was not 10.25ml. DON stated this could pose a risk to residents because they could miss a medication dose, remain in pain, not receive medication at all. She stated with Resident #1's incident of missing medication, the documented amount on the narcotics log sheet did not to match the amount in the bottle. When the DON reviewed the narcotics log sheet she noticed that the staff was using in-house syringes because the provided syringe with the medication bottle was not sanitary. She stated that the in-house syringe is different than the one provided by hospice because it is leur-lock syringe. She stated that the tip of the syringe is different, and it is for administering IV medication The DON said that there was a risk the risk of keeping morphine medication in the lower space of the syringe. She further stated that this could also cause leakage of medication. She stated the risk of having a spillage and liquid trapped in the syringe, would be that the resident could run out of the medication. An LPN brought a morphine bottle in the interview, revealing that the hospice morphine medication bottle had no increments on the side of the bottle nor a measuring line. The DON that they are doing ongoing training and education with staff members, and also talking to hospice services to get medication from their pharmacy, monitoring bottles closely to ensure there is no discrepancy.The facility policy titled Medication Management, last revised October 2015, revealed that nurses shall follow the five rights of medication administration. Narcotics shall be kept in a separate locked drawer inside the med cart, and shall be accounted for at each shift change. Medication is stored in the original label container according to the instructions on the label.

Based on clinical record review, interviews, and review of policies, the facility failed to ensure one resident (#61), did not receive medication prescribed to another resident (#71). The deficient practice could result in complications and adverse medication side effects.Findings include:-Regarding resident #61Resident #61 was admitted on [DATE] with diagnoses that included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and primary anxiety.Resident #61 had medication orders for over the counter (OTC) calcium carbonate as needed, claritin (OTC) once a day, famotidine (OTC) at bedtime, lidocaine pain relief adhesive patch (OTC) twice a day, Systane eye drops (OTC) four times a day, and Tylenol as needed.Resident #61 had no orders for any prescription medication to be administered.A minimum data set (MDS) quarterly assessment dated [DATE] identified the resident's cognition as continuously inattentive with disorganized thinking. Resident scored a 04 on a brief interview for mental status (BIMS) indicating severely impaired cognition.Review of resident #61's care plan that was reviewed on November 5, 2025 identified a problem of cognitive impairment and that the resident displayed confusion, forgetfulness and inattention at times. This problem also included that the resident speaks and understands Navajo language. Interventions were identified. A progress note, dated December 31, 2025 at 12:29 pm, documented that the resident was observed lying on the floor in the dining room next to a chair she had been sitting in. The note revealed the resident (#61) was responsive but was very tired and her speech was slow. The progress note further revealed that the resident was breathing more rapidly than normal, she was unable to stand on her own and staff assisted her to a sitting position. Additionally, the note revealed that the resident denied pain and was moving around but was very confused. It was documented that the on-call [provider] was notified, an order was received and the resident was sent to the emergency department (ED) for evaluation.Facility documentation of vital signs for this event were recorded in the nursing documentation.December 31, 2025 at 11:50 am: respirations: 28 per minute, temperature: 97.6 F, pulse: 57 per minute, blood pressure: 62 / 40 mmHg, O2 Saturation: 87 %, and pain: 0 of 10.An ED physicians note on December 31, 2025 at 12:26 pm documented that the resident (#61) had an unwitnessed fall out of her w/c in dining hall at the facility. Per this physician report there was a report per emergency medical services (EMS) that they were called to the nursing home for a concern of an elderly woman who accidentally got another patient's trazodone and seroquel. This documentation further included that a report from the nursing home indicated that she took 150 mg of Seroquel and 75 mg of trazodone that was mixed in another resident's drink. Also noted was that when EMS arrived the patient (resident #61) was breathing comfortably and her oxygen level was 93% on 2 liters of oxygen. EMS reported that her blood pressure was in the 90's systolic. This physicians note revealed that it was unclear exactly when she fell, how she fell, or if she struck her head and that the resident (#61) was found by nursing home staff about an hour prior to arrival in the ED, and the ingestion occurred sometime with breakfast this morning.ED Assessment of resident revealed no bony extremity injury and resident #61 was mildly somnolent but arousable to voice, oriented x 0, moves all extremities at baseline.The ED physician note documented that poison control was contacted by nursing and recommended that the patient could go home once she is at her baseline, but that it could take 6 to 8 hours for her to be less sleepy. Patient was observed in the ED for several hours until she was more alert and could be discharged back to the nursing home in stable condition. -Regarding resident #71Resident #71 was admitted most recently on July 6, 2025 with diagnoses that included Unspecified dementia, unspecified severity, with other behavioral disturbance.Resident #71 had medication orders that included seroquel (quetiapine) tablet; 100 mg; amt: 1; oral07:00 am - 11:00 am and quetiapine tablet; 50 mg; amt: 1 tablet; oral with special instructions: give in addition to scheduled doses, twice a day 07:00 am - 11:00 am, evening 07:00 pm - 11:00 pm (this would equal a dosage of 150mg for the 7 am to 11am dose). Also noted was an order for trazodone tablet; 50 mg; amt: 1/2 tab = 25 mg; oral, three times a day 07:00 am - 09:30 am, noon 11:00 am - 01:00 pm, evening 07:00 pm - 09:00 pm.A minimum data set (MDS) quarterly assessment dated [DATE] identified the resident's cognition as continuously inattentive with disorganized thinking. Resident scored a 04 on a brief interview for mental status (BIMS) indicating severely impaired cognition.Resident #71's care plan that was reviewed on December 24, 2025 identified a problem of cognitive impairment and that the resident displayed forgetfulness and confusion. This problem also included that the resident speaks and understands English. Interventions were identified.A progress note, dated December 31, 2025 at 3:55pm, revealed that the resident (#71) refused her initial medication administration that morning when it was first offered to her crushed in pudding. This note further documented that the resident (#71) was refusing medications whole and crushed in pudding when she was on the other unit and nursing began giving her the medications crushed in hot chocolate. The note revealed the resident accepted and said she liked it that way. Additionally, the progress note identified that on this day the resident (#71) started to drink the hot chocolate, as usual, with the medication in it, but then later pushed the cup away and tried to give the medication to another resident sitting at the table in the dining room with her.On January 2, 2026 at approximately 1:15 pm an observation of the central dining area revealed no medications at any table or unattended. Observation of all four units revealed no medications at bedside, no medications in dining areas, no medications unattended, and no medications were observed in any common areas. An interview with a licensed practical nurse (LPN), Staff # 12, was conducted on January 2, 2026 at approximately 2:32 pm. During this interview the LPN stated that the morning medication pass is not a heavy medication pass however it can be difficult as some residents will not take their medications if you don't get them to them while they are eating as they think it is more food and refuse to take them. The LPN stated that she does pass medications on both behavioral halls.Staff #12 stated that crushed medications are usually put in pudding but that there are a couple residents who prefer medications in a drink such as a Boost or in hot chocolate. The LPN said she will usually mix the medication in a little hot water to help dissolve the medication.The LPN stated that it is not typical of me to leave medication ever. The LPN stated that last week when working with a resident (resident#71) the LPN identified that the resident does not care to be watched when taking her medications. The LPN stated that once resident #71 picks up the cup she usually drinks the entire thing. The LPN said that while watching from the door, she saw resident #71 pick up the cup and once the LPN saw the resident sipping from the cup the LPN stated I made a poor judgement this one time and felt the resident would finish the drink so I walked away before she drank it all.During the interview the LPN explained that later resident #61 fell out of her chair and they called the LPN to assess her. The LPN said the resident (#61) was lethargic but able to talk and move. The LPN also stated that resident #61 couldn't walk and she normally could walk with a boost from the floor. The LPN verbalized that the cup (from resident # 71) was in front of where resident #61 was sitting and the LPN assumed it was a good possibility that resident #61 had ingested some of the medication. The LPN further stated that resident #61 had no obvious signs of injury but was sent her to the ED for evaluation. The LPN explained that the ED sent resident #61 back to the facility and that her vitals were fine and CT was negative. Additionally, the LPN revealed the when the resident (#61) came back she was able to walk and talk per usual and there was no bruising or abrasions seen.This LPN (Staff # 12) remarked that they had worked with resident #71 for eight months and had learned or thought they had learned her patterns. The LPN stated I made a mistake and the resident should not have been left until the medication was gone.The LPN staff # 12 stated that if a resident refuses medication the goal is to try again a couple times and if they still refuse the medications are destroyed.The LPN stated that residents with behaviors are often difficult with medications and habits and behaviors have to be learned.During an observation on January 2, 2026 at approximately 3:20 pm medications were observed to be delivered and taken under observation of a nurse for 5 residents.An observation of all four units revealed no medications at bedside, no medications in dining areas, no medications unattended, and no medications in any common areas. Medication carts were either attended or locked. Medication storage rooms were locked. On January 2, 2026 at approximately 3:40 pm an interview was held with the Director of Nursing, staff # 33. The DON stated that her expectations of nurses performing medication administration would be to follow the five rights of medication administration that include: the right drug, right dose, right resident, right time, and right route.The DON stated that if a medication is refused the expectation of the nurse is to return and attempt again and if refused then to mark the medication as refused and dispose of the medication.The DON explained that with an order, medications for residents can be mixed in applesauce or pudding or a drink if that is preferred.The DON stated that the expectation of the nurse is to ensure that residents take all of the medication delivered.The DON clarified that leaving medications on a medication cart, leaving the medication cart unlocked or leaving a medication with a resident that has not been completed would constitute leaving medications unattended. DON stated this would include crushed medications in pudding or hot chocolate.The DON expressed that the expectation was that if the medications were not fully consumed they should not have been left with the resident.On January 2, 2026 at approximately 3:45 PM a video was reviewed with the DON that showed resident #71 with a blue cup, that was identified by DON as having medication in it, sitting in front of her (resident #71) as she was shuffling and appeared to be sorting papers. Resident #71 lifted the cup and appeared to take a sip and thenresident#71 handed the cup to her left to resident #61who appears to take the cup from resident #71 at approximately 10:57 am. Resident #61 was seated with her back to the camera however resident #61appeared to be making extended drinking motions. At approximately 11:38 am resident #61 appears to slump over and falls to the floor. At this time there is no blue cup seen. The facility was unable to provide a copy of this video. Review of the RN, LPN Charge Nurse included in the nurses duties and responsibilities is the responsibility to ensure that prescribed medication for one resident is not administered to another.Review of the facility policy titled Medication Management and dated effective or revision date 10/15 [sic] revealed that only medications ordered by a medical practioner should be administered to a resident. In addition the policy identified staff shall not leave medication unattended.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to ensure that residents are free from abuse from another resident (Residents #1 and #3). The deficient practice could lead to additional resident-to-resident altercations, thereby creating an unsafe environment.Findings include:-Regarding Resident #1:Resident #1 was admitted on [DATE], with diagnoses that included unspecified dementia, unspecified severity, with other behavioral disturbance, and unspecified dementia, severe, with psychotic disturbance.A quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed a BIMS (brief interview for mental status) score of 05, indicating that the resident had severe cognitive impairment. The MDS assessment also revealed that within the last seven days before the assessment, Resident #1 exhibited verbal behavioral symptoms directed towards others one to three days out of the seven; other behavioral symptoms not directed towards others occurred four to six days, but not daily; rejection of care and wandering occurred daily.An order dated December 1, 2025, revealed that Resident #1 exhibited aggressive/combative behavior, and to move the resident to a quiet room until the episode is resolved; to remove potentially harmful objects from the immediate environment; protect other residents in the immediate area from harm; and to document behavior in the progress notes for 72 hours every shift.A progress note dated December 1, 2025, at 7:05 PM revealed that Resident #1 had been in the dining room when she took the food off of another resident's plate. The note also documented that the other resident swatted at Resident #1 and proceeded to grab her right breast. The progress note also noted that Resident #1 had an assessment completed, reporting three scratches on the right breast measuring 3.5 cm (centimeters), 5 cm, and 2 cm. The note also documented that the two residents were separated immediately and that contact was made with the DON (Director of Nursing), the police, and APS (Adult Protective Services). A progress note dated December 1, 2025, at 9:22 PM, revealed that Resident #1 will be on behavior charting and exhibited no further behaviors towards the other resident, or signs or symptoms of distress or discomfort. The note also documented no signs of infection to the three scratches on the right breast of Resident #1. A progress note dated December 2, 2025, at 1:39 PM, revealed that Resident #1 was still on behavior charting and exhibited no further behaviors or signs or symptoms of distress or discomfort. A care plan focus, dated December 2, 2025, revealed that Resident #1 had scratches on her right breast related to a resident-to-resident altercation, with a target goal to have the scratches heal without complication.A progress note dated December 3, 2025, at 4:26 AM, revealed that Resident #1 was still on behavior charting for the resident-to-resident altercation, as well as an unrelated fall, and exhibited no further behaviors or signs or symptoms of distress or discomfort. A behavioral health consult note, dated December 4, 2025, revealed that Resident #1 had been seen for a resident-to-resident altercation in which Resident #1 attempted to grab another resident's food from the dining room table. The other resident grabbed Resident #1's right hand, then squeezed her right breast. The note also documented that staff will implement monitoring during meal times as an intervention to avert further interactions.A progress note dated December 6, 2025, at 3:46 AM, revealed that Resident #1 was still on behavior charting and exhibited no further behaviors or signs or symptoms of distress or discomfort. The note also documented that the scratches on her breast are healing appropriately.-Regarding Resident #3:Resident # 3 was re-admitted on [DATE], with diagnoses that included vascular dementia, unspecified severity, with other behavioral disturbance, and unspecified mood affective disorder.An order dated December 1, 2025, revealed that Resident #3 had been involved in a resident-to-resident altercation and directed that the altercation be documented in progress notes.An annual MDS assessment dated [DATE], revealed a BIMS score of 99, indicating that the resident was unable to complete the interview.A progress note dated December 1, 2025, at 7:21 PM, revealed that Resident #3 had been sitting at a dining room table during dinner when another resident approached her and attempted to grab at her food. The note also revealed that Resident #3 grabbed the hand of the other resident to push that arm away, and then grabbed, twisted, and scratched the right breast of the other resident. The progress note also documented that the two residents were separated, placed on behavior monitoring to be kept apart, and that contact was made with the DON (Director of Nursing), the police, and APS. A progress note dated December 1, 2025, at 9:24 PM, revealed that Resident #1 was still on behavior charting due to a resident-to-resident interaction and exhibited no further behaviors or signs or symptoms of distress or discomfort. A progress note dated December 2, 2025, at 1:43 PM, revealed that Resident #1 was still on behavior charting due to a resident-to-resident interaction and exhibited no further behaviors or signs or symptoms of distress or discomfort. The note also documented that the two residents did not come into contact with each other and that they were kept separated.A care plan approach with a start date of December 2, 2025, revealed that Resident #3 exhibited behaviors of physical/verbal aggression towards others and will redirect wandering residents away from Resident #3's room or when Resident #3 is eating. A progress note dated December 3, 2025, at 1:44 PM, revealed that Resident #1 was still on behavior charting due to a resident-to-resident interaction and exhibited no further behaviors or signs or symptoms of distress or discomfort. The note also documented that the two residents did not come into contact with each other and that they were kept separated.A behavioral health consult note, dated December 4, 2025, revealed that Resident #3 had been seen for a resident-to-resident altercation in which another resident, Resident #1, wandered to Resident #3, and attempted to grab Resident #3's food from the dining room table. Resident #3 grabbed the right hand of Resident #1, then squeezed her right breast in an attempt to get Resident #1 away. The note also documented that staff will implement monitoring during meal times as an intervention to avert further inappropriate interactions.An interview was attempted with Resident #3 on December 16, 2025, at 10:25 AM; however, Resident #3 was unable to provide coherent sentences and repeated sounds. An interview was attempted with Resident #1 on December 16, 2025, at 10:30 AM; however, the Resident was located in bed in their room and presented unarousable and therefore unable to be interviewed.An interview was conducted on December 16, 2025, at 10:43 AM with an LPN (Licensed Practical Nurse/Staff #33), who stated that within her role, allegations of abuse, whether verbal, physical, mental, or emotional, would need to be reported immediately to the charge nurse and the DON. Regarding Residents #1 and #3, Staff #33 stated that she had been in the dining room providing dining assistance to an unrelated resident and that her back had been facing the altercation. Staff #33 stated that she overheard the altercation from behind her and, by the time she turned around, a CNA (Certified Nursing Assistant) had separated the two residents. Staff #33 stated she had reviewed the video footage from the dining room and noted that the video had shown Resident #1 approach Resident #3's table to grab her food, and Resident #3 reacted physically, which resulted in Resident #1 obtaining three scratches on her right breast. Staff #33 stated that Resident #3 had a history of aggressive behavior toward others and had been involved in a resident-to-resident incident before this altercation, and that Resident #1 had no history of aggressive behavior before this incident. Staff #33 also stated that she had been unsure if the incident would be considered abuse due to both Residents #1 and #3 exhibiting severe cognitive deficits; however, it was treated as an abuse allegation due to the nature of physical harm that Resident #1 experienced to her right breast.An interview was conducted on December 16, 2025, at 10:43 AM, with a CNA (Staff #23), who stated that, within her role, allegations of abuse are to be reported immediately or within 2 hours to the nurse, the charge nurse, and the DON. Staff #23 also stated that every staff name badge includes examples of abuse and instructions on what to do if identified, and then showed this writer her badge, which contained the stated information. Regarding the incident between Residents #1 and #3, Staff #23 stated that Resident #3 had her meal set up and prepared. Staff #23 explained that Resident #3 had been set up with a magic bowl, a dining device that assists residents who have difficulty eating off a flat plate. Staff #23 also stated that Resident #3 is unable to speak coherent words and will repeat the sounds '[NAME] da [NAME] da [NAME]'. Staff #23 stated that she observed Resident #1 on the left side of Resident #3 when Resident #1 grabbed at the plate of Resident #3, to which Resident #3 stated the repetitive sounds, while also grabbing at the breast of Resident #1. Staff #23 stated that Resident #3 has a history of aggressive behavior, such as swatting at other residents who wander into her personal space, and that staff had been instructed to redirect residents who wander into Resident #3's personal space to other activities in a different area. Staff #23 also stated that they are unsure if this would be considered abuse due to cognitive deficits that both Resident #1 and #3 exhibit; however, the abuse policy would still need to be followed, as Resident #3 did make physical contact with Resident #1's breast. An interview was conducted on December 16, 2025, at 2:16 PM, with a CNA (Staff #53), who stated that, within her role, allegations of abuse are to be reported immediately to the nurse, the charge nurse, and the DON. Staff #53 also stated that if a resident-to-resident altercation were to happen and a resident were to obtain scratches to their body, whether cognitively intact or not, it would be seen as abuse and would need to be reported and investigated as abuse.An interview was conducted on December 16, 2025, at 2:42 PM, with the DON (Staff #43), who stated that staff are expected to report any allegations of abuse immediately so that an investigation can begin. Staff #43 stated that if the alleged perpetrator is a staff member, staff are expected to ensure the resident's safety and notify the chain of command. Staff #43 identified physical abuse as the willful action of causing harm or bodily harm, with the intent to harm. Regarding Residents #1 and #3, Staff #43 stated that she had spoken with both Staff #23, who witnessed the incident, and Staff #33, who reviewed the video footage of the incident. Staff #23 stated that Staff #23 had been with another resident documenting their meal percentages when Resident #1 had set off the unit alarm in an attempt to open the locked unit doors. Staff #43 continued to say that Staff #23 left the dining room to disarm the alarm and, upon returning to the dining room, Staff #23 observed Resident #1 grab at the bowl in front of Resident #3, in which Resident #3 grabbed at the right breast of Resident #1. Staff #43 stated Staff #23 was able to separate the two residents, but at that point, Resident #3 had grabbed at and scratched at the breast of Resident #1. Staff #43 stated that both residents had been assessed head-to-toe and confirmed that Resident #3 had three scratches on their right breast. Staff #43 identified the altercation between Residents #1 and #3 as abuse, as it was determined to be physical aggressive behaviorA review of a facility policy titled Abuse Prevention Policy, last revised in April 2025, defined abuse as the willful infliction of injury, unreasonable confinement, or punishment that can have the result of physical harm, pain, or mental anguish or deprivation. The policy also revealed that instances of abuse of all residents, irrespective of any mental or physical condition, cause bodily harm, pain, or mental anguish. The policy indicated that physical abuse includes hitting, slapping, pinching, and kicking, as well as controlling behavior through corporal punishment.

Based on observation, interviews, review of records, and review of facility policy and procedures, the facility failed to ensure that two sampled residents (#88 and #71) were not physically abused by residents (#76 and #84). The sample size was 6. The deficient practice could lead to physical and psychosocial harm to residents.Findings Include:-Regarding residents #88 and #76Resident #88 was admitted to the facility on [DATE] with diagnoses including: unspecified dementia, with other behavioral disturbance, and insomnia.An admission minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 7, indicating severe cognitive impairment. Review of the care plan for resident #88 reveals a focus starting on July 16, 2025, for exhibiting behaviors of pacing in common areas, wandering, invading others personal space.A nursing progress note dated September 12, 2025 revealed that resident #88 was self-ambulating in the hallway when another female resident (#76) approached her while sitting in a wheelchair and kicked resident #88 in the leg. Residents were separated and assessed for physical injuries. No physical injuries were noted in skin assessments.Resident #76 was admitted to the facility on [DATE] with diagnoses including: dementia with psychotic disturbance, anxiety disorder, and hearing loss.A quarterly minimum data set (MDS) assessment dated [DATE] revealed resident #76 had a brief interview for mental status (BIMS) score of 9, indicating severe cognitive impairment. Further, resident #76 was noted to have physical behavioral symptoms directed towards others 1 to 3 days per week.A nursing progress noted dated September 12, 2025 at 7:30 a.m. revealed that resident #76 was sitting in her wheelchair outside her room door and when she saw resident #88 self-ambulating. Resident #76 self-propelled her wheelchair towards resident #88, stopped resident #88 in hallway, and kicked her in the leg. Staff members separated both female resident from each other. When interviewed by staff, resident #76 stated she was upset with resident #88 for entering her room and taking her things.An interview was conducted on September 30, 2025 at 9:05 a.m. with staff Licensed Practical Nurse (LPN/staff #89) Staff #89 stated that on September 12, 2025, shortly after 7:00 a.m., she witnessed resident #88 walking and was stopped by resident #76. Staff #89 stated she witnessed resident #76 kick resident #88, Staff #89 then called out to resident #76 to stop. Staff #89 then immediately separated the residents and assessed both residents for injuries. She saw no physical injuries to either resident.An interview was conducted on September 30, 2025 at 11:28 a.m. with the Director of Nursing (DON/staff #108). She stated that the surveillance video for September 12, 2025 was no longer accessible. DON #108 stated that she had reviewed the footage before its deletion and saw the video of resident #76 kick resident #88. DON #108 stated that the events would be considered abuse and did not meet her expectations. -Regarding residents #71 and #84Resident #71 was admitted to the facility on [DATE] with diagnoses including: unspecified dementia, with behavioral disturbance, insomnia, sleep apnea, chronic pain, encephalopathy, and age-related physical debility.An admission minimum data set (MDS) assessment dated [DATE] revealed resident #71 had a brief interview for mental status (BIMS) score of 5, indicating severe cognitive impairment. No indicators for behaviors were noted in the MDS. A nursing progress note dated September 23, 2025 at 6:14 p.m. revealed that at 4:17 p.m. Registered Nurse (RN/staff #62) witnessed an altercation between resident #71 and another resident. Resident #71 was noted to have no physical injuries from the incident. Skin assessments revealed no physical injuries to either resident.Review of the care plan for resident #71 revealed a focus dated September 24, 2025 that resident #71 may strike out at men that are in her area and that she is fearful of men she doesn't know.Resident #84 was admitted to the facility on [DATE], with diagnoses including: Altered mental status, reduced mobility, depression, alcohol abuse, chronic pain, and dysphagia.A quarterly minimum data set (MDS) assessment dated [DATE] revealed resident #84 had a brief interview for mental status (BIMS) score of 6, indicating severe cognitive impairment. No behaviors were noted in the MDS assessment.A nursing progress note dated September 23, 2025, at 6:10 p.m. revealed that at 4:17 p.m. resident #84 was witnessed by staff #62 hitting another resident before both residents were separated by staff. An interview was conducted on September 30, 2025 at 10:11 a.m. with staff #62. Staff #62 stated that she witnessed residents #84 and #71 sitting in their wheelchairs in the television room as she was working at the med cart nearby. Staff #62 stated that on September 23, 2025 in the afternoon, she observed residents #71 an #84 hitting and slapping towards each other. Staff #62 separated both residents. Staff #62 stated she was unsure if either resident made contact with the other. Staff #62 assessed both residents and no physical injuries were noted.On September 30, 2025 at 11:21 a.m. video surveillance of the incident was reviewed. Video timestamp revealed that the incident occurred at 4:17 p.m. on September 23, 2025. Video showed resident #71 sitting in her wheelchair when resident #84 self-propelled himself next to resident #71. The two residents exchanged words for several seconds and resident #71 began making slapping motions towards resident #84. Resident #84 then began slapping resident #71 and making contact. Staff #62 arrived to the scene and separated the two residents.An interview was conducted on September 30, 2025 at 11:28 a.m. with DON #108. DON #108 stated that this incident would be considered abuse and did not meet her expectations for the facility and could result in psychosocial and physical harm.Review of the facility's abuse policy titled Abuse Prevention Policy and Procedure; revised April 2025 revealed that it is the policy of the facility to take appropriate steps to prevent the occurrence of abuse. The policy defines abuse is defined at willful inflection of injury, intimidation or punishment, irrespective of any mental or physical condition.

Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#6) was not abused by another resident (#3). The deficient practice could lead to physical and psychosocial harm to residents. Findings Include: Regarding Resident #6: Resident #6 was readmitted to the facility on [DATE], with diagnoses that included senile degeneration of brain, paroxysmal atrial fibrillation, hypertension, chronic obstructive pulmonary disease, and type 2 diabetes mellitus. A quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had a brief interview for mental status (BIMS) score of 4, indicating severe cognitive impairment. A progress note dated April 18, 2025, revealed at 7:45 AM, the nurse was notified by certified nursing assistants (CNAs) that another resident hit Resident #6 in the right arm during breakfast. CNAs intervened and immediately separated the residents. Upon review of video recording, it was observed that the resident was trying to back up his wheelchair from the table. The other resident's wheelchair was bumped unintentionally, making the other resident offended, then hitting Resident #6 in the right arm. Resident #6 was assessed, with no injuries noted except for slight redness to his wrist. Notifications were made to the provider, the resident's family, and the administrator. Regarding Resident #3: Resident #3 was readmitted to the facility April 7, 2025, with diagnoses that included expressive language disorder, type 2 diabetes mellitus, hypertension, sepsis, Parkinsonism, and hemiplegia and hemiparesis affecting the left side. A quarterly MDS assessment dated [DATE], revealed the resident had a BIMS assessment that was unable to be completed. A progress note dated April 18, 2025, revealed at approximately 7:40 AM, Resident #3 was at breakfast in the main dining room and was sitting at his table when another male resident whom was sitting at another table next to each other had attempted to move his wheelchair backwards, and bumped into Resident #3. Both residents began to move themselves backwards and when Resident #3 was able to see the other male resident, Resident #3 hit the other male resident in the right arm. Resident #3 had used his own right hand to do this. Both residents were separated. Notifications were made. A witness statement dated April 18, 2025, by a CNA (Staff #8) revealed that Staff #8 was assisting a resident when she turned around and saw Resident #3 swing once at Resident #6 's right arm. Staff #8 quickly got between the residents and separated them. Staff #8 stated that he was hit in the chest. A witness statement dated April 18, 2025, by another CNA (Staff #32) revealed that at approximately 7:35 AM, in the dining room, Staff #32 witnessed Resident #3 swing and contact Resident #6's arm and chest area. Staff #32 and another CNA quickly separated the residents. A Facility Reportable Event Record dated April 24, 2025, revealed at approximately 7:39 AM, Resident #6 was seen pushing his wheelchair back to get away from the dining table and then Resident #3's chair is backed into in the process. While Resident #6 moved his chair back, Resident #3 attempted to move away. The two residents came side to side in their wheelchairs, and Resident #3 looked at Resident #6 and used his right arm to contact with a closed fist Resident #6's right forearm. Upon review of the incident, it was noted that Resident #6 was not in his usual seating area at the dining table. Staff were made aware due to Resident #6 wanting to leave when he was done with meals, to leave him in his original seating area, which is on the opposite side of the table. Both residents were assessed and no injuries were noted. In conclusion, the facility found that Resident #3 contacted Resident #6 in the right forearm. An observation was conducted on April 28, 2025, at 3:04 PM, of the video footage of the incident. Resident #6 and Resident #3 were positioned back to back at tables next to each other, sitting in their wheelchairs. The wheelchairs were very close to each other. Resident #6 attempted to back up and appeared to get his wheelchair wheels stuck against Resident #3's wheelchair wheels. The residents turned in their wheelchairs so they were positioned side by side, and then looked at each other. Resident #3 then hit Resident #6 in the right forearm with his fist. CNAs approached the residents and separated them. An interview was conducted with a CNA (Staff #8) on April 28, 2025, at 12:54 PM. Staff #8 stated that she was sitting at the same horseshoe-shaped table, and the other CNA (Staff #32) was looking at the residents and called out suddenly. Staff #8 looked, and Resident #3 already had his right arm extended. Staff #8 stated the residents backed into each other, and that Staff #8 believed Resident #3 hit Resident #6 in the chest. Staff #8 stated that she jumped up and separated the residents. Additionally, Staff #8 stated she asked Resident #6 where did he hit you? and that the Resident #6 answered my chest. An interview was conducted with Resident #6 with a translator on April 28, 2025, at 12:59 AM. Resident #6 stated he remembered the incident and that the other resident hit him in the chest and the hand. An additional interview was conducted with Staff #32 on April 28, 2025, at approximately 1:10 PM. Staff #32 stated that she saw the incident and that Resident #3 hit Resident #6 in the chest and upper arm area approximately 2 to 3 times, and that it was somewhat forceful. Staff #32 stated the residents were separated. An interview was conducted with the Director of Nursing (DON / Staff #70) on April 28, 2025, at 2:58 PM. The DON stated that the facility does not tolerate any forms of abuse and that abuse is prevented by monitoring residents, assessing risk factors, and reporting any allegations of abuse. The DON stated that her understanding of the incident between Resident #6 and Resident #3 was that Resident #6 was not sitting in his usual spot in the dining room, and was positioned directly behind Resident #3. Resident #6 was attempting to back up in his wheelchair and bumped into Resident #3. Resident #3 turned to see who was backing into him and then struck out with his right hand and contacted Resident #6's right forearm. The DON stated that the residents were separated and have been monitored to ensure retaliation does not occur. Review of the facility's policy titled Abuse Prevention Policy and Procedure, revised April 2025, revealed that resident to resident physical altercations must be reported and include any willful action that results in physical injury, mental anguish, or pain. Examples include: hitting, slapping, punching choking, shoving. Abuse means the willful infliction of injury resulting in physical harm, pain, or mental anguish. Willful, as used in the definition means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm.

Based on clinical record reviews, staff interviews, and review of facility documentation and policy, the facility failed to evaluate and implement effective care plan interventions related to falls for one resident (#11). The deficient practice resulted in the resident experiencing multiple falls in the facility, and could result in other residents failing to receive effective fall-prevention measures. Findings include: Resident #11 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, cardiomyopathy, and pulmonary fibrosis. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. Review of the resident care plan revealed a problem initiated on February 15, 2021, which indicated that the resident was at risk for falls related to advanced aging, dementia, and a history of falls. This problem also indicated that the resident refused to use the wheelchair and would get physically aggressive when this was suggested. Initial interventions initiated on February 15, 2021 included to provide an environment free of clutter, to leave a night light on, to keep the call light within reach at all times, and to give verbal reminders to not ambulate or transfer without assistance. Review of the resident observations charting in the Electronic Health Record (EHR) revealed six documented falls had occurred after the initial care plan entry, before a new care plan intervention was implemented. An additional review of the care plan problem related to falls revealed a new intervention was added on April 14, 2023 to include the addition of a Call, Don't Fall sign in the resident's room. Further review of resident observations charting revealed two additional unwitnessed falls occurred after the addition of the latest care plan intervention. A new care plan intervention was added on September 27, 2023 to include that staff change pull-ups regularly, per family request, so that the resident does not slip if urine gets onto the floor. The review of the resident observations charting revealed an unwitnessed fall occurred on October 24, 2023, and a new care plan intervention was therefore added on October 30, 2024 to indicate the usage of a bed alarm for the resident. Further review of resident observations charting revealed Resident #11 suffered three additional falls before a new care plan intervention was added on July 25, 2024, which instructed staff to encourage the resident to ask for assistance with toileting. Review of the observations charting and care plan revealed that the resident proceeded to have two more unwitnessed falls, on August 16, 2024 and December 23, 2024. New interventions were care planned for these falls appropriately, including the usage of a wheelchair pad alarm and for staff to ensure that alarms were on and working. The documented observations charting included that the resident experienced a witnessed fall on January 7, 2025 and an unwitnessed fall on February 4, 2025. No new interventions were added to the resident's care plan following these incidents. Further review of the charted observations revealed that the resident was found to have bruising to the right eyelid and complaints of pain to her right arm on March 15, 2025. At the time, staff were unsure of how the injury had occurred. The resident was sent to the hospital following this discovery, and returned the same day. The resident experienced an additional unwitnessed fall on March 16, 2025, and a new care plan intervention was added on this date to include that staff should ensure that the bed alarm is working properly every shift. Interview was conducted on March 27, 2025 at 07:59AM with a Licensed Practical Nurse (LNA/Staff #26), who stated that the facility had several interventions that could be utilized for fall prevention, such as safety belts, chair and bed alarms, padding around beds, wedges on beds, and floor mats. The LPN confirmed that she was familiar with Resident #11, and stated that the resident often wanted to do things her own way. The LPN stated she was aware of a few falls from Resident #11, which occurred due to the resident self-transferring. The LPN stated that she did not witness these falls but heard about them through report. She reported that interventions in place for this resident included reminding her to not self-transfer, safety belts, and alarms on her bed and wheelchair, which the resident would often remove. Interview was conducted on March 27, 2025 at 08:19AM with a Certified Nursing Assistant (CNA/Staff #47), who stated that fall risk residents would have care plan entries that identified them as a fall risk and any interventions in place for them. She identified some fall prevention techniques available at the facility to include safety belt alarms, bed alarms, chair alarms, bolsters on the beds, and floor mats. When asked what interventions are utilized for residents with frequent falls, the CNA identified multiple interventions that could be utilized. These interventions included having the resident begin physical therapy to keep them busy and occupied, walking with the resident, and the usage of dementia attendants that provide one-on-one activities for the resident. The CNA stated that the facility does not always have dementia attendants available for every hall, but they are added to the schedule as needed. The CNA also expressed that she felt that staffing was inconsistent to meet the needs of the residents. She stated that between CNAs and dementia attendants, she felt that some days had enough staff while others were lacking, especially on weekends. When asked about Resident #11, the CNA confirmed that she was familiar with the resident. The CNA stated that the resident often wanted to walk, and her steadiness varied day-to-day. The CNA revealed that she did not witness Resident #11's most recent fall, but had heard that the resident had fallen and hit the footboard to her bed. The CNA identified that Resident #11 had a bed and chair alarm in place, but stated that when staffing is lacking, it can be hard to respond to the alarms in a timely manner without leaving another resident in need unattended. Interview was conducted on March 27, 2025 at 10:48AM with the Director of Nursing (DON/Staff #55). When asked how staff are to know what interventions or care is needed for a resident, the DON stated that staff obtain the needed information through report. She stated that if the staff have never cared for the residents before, they are expected to communicate with their peers and manager, and to reference the residents' care plans. She also stated that staff can determine what interventions should be utilized for fall-prevention by viewing a resident's orders and care plan. The DON revealed that falls are also discussed in meetings with all department heads to discuss what is in place and what is needed, and care plans will be adjusted if needed. The DON identified interventions available to use for fall-prevention to include safety devices (such as wheelchair alarms, self-release seatbelt alarms, bed alarms), low beds, fall mats, and bolsters on beds. The DON also stated that care plans are reviewed at the time of any events, such as when a fall occurs, to see if adjustments are needed. She stated that the care plan should be updated or reviewed after a fall occurs. When asked if she would expect new interventions to be placed for a resident after a fall, the DON stated that it would be on a case-to-case situation. The DON elaborated that if it was the resident's first fall, the staff would attempt to figure out why the fall occurred. The DON explained that if the resident was self-transferring, the staff would consider interventions such as more frequent rest periods if the fall occurred while attempting to get out of bed. If the fall occurred as the resident attempted to go to the restroom, more frequent toileting would be utilized. If the resident was attempting to ambulate, then staff would encourage more ambulation. The DON also stated that if the resident's fall occurred because they slid out of the wheelchair, adaptive safety devices would be considered for the wheelchair itself. When asked about Resident #11, the DON identified fall-prevention interventions in place for this resident to include: bed in lowest position, ensuring alarms were on and functional, wheelchair and bed alarms, giving verbal reminders to call for help, keeping the call light within reach, a night light on in the room, keeping the environment free of clutter, and encouraging asking for help with toileting. When reviewing the falls that Resident #11 had experienced, the DON identified that some falls had new interventions added, while others did not. The DON stated that some of the falls did not require new interventions due to the circumstances of the fall. For example, the DON stated that for the fall that occurred in December 2024, the resident slid out of the wheelchair, as opposed to attempting to self-transfer, so the DON did not believe new interventions were needed at that time. When asked if a dementia attendant or sitter was considered for Resident #11, the DON replied that this was not appropriate, as a dementia attendant would be assigned for a whole unit, not necessarily for one specific person. The DON also stated that sitters were only used for residents with consistent, frequent impulsiveness throughout the day, and the DON did not feel that the resident fit the criteria. Review of the facility policy titled, Fall Prevention Policy, revealed that each resident will be assessed for falls at least quarterly, annually, and when a significant change of status occurs. The policy also stated that a plan of care will be developed for a resident found to be at risk for falls on the comprehensive care plan that provides appropriate interventions and will be revised as necessary. The policy revealed that falls should be reviewed daily in the morning meets and staff should ensure that immediate interventions were in place and that the care plan had been updated. The policy also stated that interventions should be immediate after every fall, and the care plan approaches should be reviewed and revised as appropriate.

Based on clinical record reviews, facility documentation, observation, staff interviews and policy review, the facility failed to ensure that one resident (#41) was free from physical abuse by a resident (#37). The deficient practice could result in further incidents of resident to resident abuse and could lead to injury. Findings include: Resident #41 was admitted to the facility on [DATE] with diagnoses that included nontraumatic subarachnoid hemorrhage, dementia without behavioral disturbance, and stage five chronic kidney disease. Review of the Minimum Data Set (MDS) dated [DATE] revealed that Resident #41 had a short-term memory problem and had a moderate impairment to decision making skills. Resident #37 was admitted to the facility on [DATE] with diagnoses that included dementia without behavioral disturbance, restlessness and agitation, and major depressive disorder. Review of Resident #37's care plan revealed a problem, initiated on November 27, 2024, which indicated that Resident #37 may show behaviors that included throwing items at staff or other residents, verbal aggression towards caregivers, hallucinations, and delusions. The goal in place was to minimize behaviors and to reduce the risk of harming self or others. Interventions included to offer the resident a baby doll, to document behaviors, and to make sure basic needs are met. Review of the MDS dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 7, indicating severe cognitive impairment. The nursing progress note dated March 9, 2025 at 3:56PM revealed that Resident #37 was experiencing false beliefs that Resident #41 was her ex-husband. The note indicated that Resident #37 was telling Resident #41 that he should not be here and he need to leave. The note indicated that these comments occurred repeatedly, and the two residents were separated. The nursing progress noted dated March 13, 2025 at 6:03PM revealed that shortly before dinner time, Resident #37 had gone into Resident #41's room and attempted to close the door behind her. When staff attempted to remove her from the room, Resident #37 became upset. The note indicated that Resident #37 believed Resident #41 was her abusive ex-husband. Staff were able to remove her from the room and calm her down. The nursing progress note dated March 14, 2025 at 5:48AM revealed that Resident #37 had stated that she wanted to hit Resident #41. Resident #37 stated that Resident #41 did not belong here, and that staff needed to get him out of her house. The note indicated that Resident #37 believed Resident #41 was her ex-husband and had changed his name. The staff redirected the resident and reassured her that she was safe. An additional note was added on March 14, 2025 at 1:40PM, indicating that Resident #37's Seroquel dosage was increased due to increased behaviors. A nursing note dated March 15, 2025 at 09:16PM revealed that at approximately 7:05PM, staff witnessed Resident #37 approaching Resident #41, and Resident #37 was stating that she had a restraining order on Resident #41. Resident #37 told Resident #41 that he should not be here. The two residents were separated. The nursing note indicated that staff checked the cameras and confirmed physical contact between the two residents. The note indicated that in the footage, Resident #37 could be seen approaching and kicking Resident #41's wheelchair and then placing him into a room. After Resident #41 exited the room, Resident #37 re-approached him and kicked his right leg. The note detailed that staff then intervened and separated both residents, and no injuries were noted to either resident. Review of the behavior charting note dated March 17, 2025 at 05:50AM revealed that Resident #37 was observed panicking upon seeing Resident #41 approaching. The note indicated that Resident #37 was triggered and anxious upon seeing Resident #37. Staff were able to assure Resident #37 that she was safe and that Resident #41 was staying on his side of the hall. A nursing note dated March 17, 2025 at 1:50PM revealed that Resident #37 and her family agreed to move Resident #37 to a room on a different hallway from Resident #41. An additional nursing note dated March 18, 2024 at 02:57AM revealed that Resident #37 appeared much calmer after moving to another unit, and the resident expressed that she was glad that she had moved. Interview was conducted on March 27, 2025 at 7:59AM with a Licensed Practical Nurse (LPN/Staff #26), who had witnessed a conflict between Resident #37 and Resident #41 that occurred on March 13, 2025. The LPN explained that Resident #37 had mistaken Resident #41 for her abusive ex-husband. The LPN explained that Resident #37 was crying and yelling at Resident #41 in the Navajo language. The resident then started going into his room. The LPN stated that the resident made it just past the doorway and attempted to close the door. The staff were able to grab under her arms and remove her from the room. The LPN stated that she was able to calm down Resident #37 by explaining that Resident #41 was not her ex-husband and that he would not hurt her. The LPN stated that she had heard of one or two prior incidents where Resident #37 mistook Resident #41 for her ex-husband and got upset, though staff did not immediately understand what had triggered Resident #37 to become so upset. Interview was conducted on March 27, 2025 at 08:19AM with a Licensed Nursing Assistant (LNA/Staff #47), who also confirmed witnessing a conflict between Resident #37 and Resident #41 on March 13, 2025. The LNA reported that she was sitting in the hallway when she witnessed Resident #37 entering Resident #41's room. The LNA explained that Resident #37 was yelling at Resident #41, and Resident #37 began throwing the personal protection equipment (PPE) outside of the room at staff who had attempted to intervene. Staff were able to remove Resident #37 by hooking under her arms and re-directing her out of the room and closing Resident #41's door. The LNA stated that staff were able to calm the resident by reassuring her that Resident #41 was not her ex-husband and by telling her that he would not hurt her. When asked if this incident had been reported, the LNA stated that she had brought the incident up in the staff meeting the next day, and she had also reported it to the Assistant Director of Nursing (ADON). The LNA also stated that nightshift staff was aware of this pattern of behavior from Resident #37, which was directed at Resident #41. She stated that night shift had reported at least two times over a period of approximately one to two months to dayshift staff about these behaviors. Interview was conducted on March 27, 2025 at 10:48AM with the Director of Nursing (DON/Staff #55), who confirmed that on March 15, 2025 at approximately 7:05PM, Resident #37 approached Resident #41 and kicked him in the right leg. The DON stated that the nursing staff on duty during the incident heard Resident #37 tell Resident #41 that she had a restraining on him and that he should not be here. Following the event, the nursing staff placed Resident #41 in his room and walked Resident #37 to the other end of the hall. The DON stated that both residents were assessed and no injuries were noted. Additionally, Resident #37 was moved to a separate hall from Resident #41, as recommended by the consulting psychiatric physician. The DON stated that during the incident, staff re-assured Resident #37 that Resident #41 was not her ex-husband. When asked if the two residents had any history of behaviors or aggression toward each other, the DON stated that the two residents did not know each other prior to coming to the facility and that they had not had any resident to resident altercations prior to this incident on March 15, 2025. The DON then reviewed the nursing progress notes and noted that on March 13, 2025, it was noted by a nurse that Resident #37 believed Resident #41 was her abusive ex-husband. When asked if this had been reported to her or other management, the DON stated that the nursing note did not indicate that the nurse had notified other staff. The DON further reviewed the nursing progress notes and stated that on March 9, 2025, a nursing note was entered that indicated that Resident #37 was witnessed telling Resident #41 that he should not be here and that he needed to leave. The DON again stated that the nursing note did not indicate that staff brought this up to management or other staff. A review of the camera footage for March 15, 2025 at 7:00PM was conducted with the DON on March 27, 2025 at 11:58AM. In this footage, both residents can be seen at 7:02PM on opposite ends of the hallway. The DON identified both residents as Resident #37 and Resident #41. She stated that at this time, Resident #37 was seen looking down the hallway at Resident #41. At 7:03PM, Resident #37 was seen getting up from her seat. She attempted to enter a resident's room before turning and approaching Resident #41's wheelchair. At this time, Resident #37 kicked her leg out, though it was unclear what she had kicked. The DON stated that it appeared that she had kicked the wall beside Resident #41. The DON described the footage, stating that it appeared that Resident #37 was looking at Resident #41, touching the locks on his wheelchair, and pointing for him to go down the hall. At 7:04PM, Resident #37 kicked the wheel of Resident #41's wheelchair, causing him to turn slightly. Resident #37 then went behind Resident #41's wheelchair and began to push him down the hallway and pushed him into a resident's room. The DON identified that the room did not belong to Resident #37. Resident #37 then wheeled himself out of the room at 7:05PM. The DON described that the footage then revealed that Resident #37 re-approached Resident #41, who had turned toward Resident #37. Resident #37 was seen talking to Resident #41 before kicking his right leg and pushing him back into a room. At 7:06PM, staff was seen approaching the two residents and separating them. The DON identified the staff who assisted and stated that this staff had assisted Resident #41 into his room while Resident #37 walked down to the other end of the hall. In March 2025, the facility began Dementia Capable Care training for all nursing staff and certified nursing assistants, using the Crisis Prevention Institute program. Additionally, a meeting was held with the psychiatrist, medical director, administrator, nursing leadership, and admission coordinator to review the behavioral units. The discussion focused on current interventions and identifying changes to reduce resident-to-resident altercations and improve overall care. On March 18, 2025, a nursing meeting was conducted to review the changes made to the behavioral units. This included updates to care plans and the implementation of safety devices to prevent falls. Following this, on March 20, 2025, all staff received in-service training on the updates to the behavioral units. The facility has also held weekly interdisciplinary meetings involving nursing management, social services, and therapy staff. These meetings focus on reviewing fall incidents, updating care plans, and assessing the effectiveness of current safety measures. As a result of these reviews, therapy evaluations were ordered for certain residents, environmental safety devices were inspected and repaired as needed, and additional safety equipment was provided to ensure resident safety. Review of the facility policy titled, Abuse Prevention Policy and Procedure, indicated that it is the policy of the facility to take appropriate steps to prevent the occurrence of abuse, neglect, and mistreatment. The policy indicated that physical abuse included hitting, slapping, punching, biting, pinching, and kicking. This policy also indicated that the interdisciplinary team would attempted to identify residents whose personal histories may render them at risk for abusing other residents and develop intervention strategies to prevent occurrences and monitor for changes that would trigger abusive behavior.

Based on clinical record review, facility documentation, observation, staff interviews, and policy review, the facility failed to ensure that two residents (#25 and #20) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse and lead to injury. Findings include: -Regarding Resident #25: -Resident #25 was readmitted to the facility on [DATE], with diagnoses that included dementia with other behavioral disturbances, other pulmonary embolism, cardiomyopathy, and pulmonary fibrosis. Review of an annual minimum data set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment score of 3, indicating severe cognitive impairment. The MDS further indicated that the resident had noted physical behavioral symptoms directed toward others. A care plan dated February 15, 2021, revealed that Resident #25 may exhibit behaviors of physical aggression toward staff and other residents, with interventions to avoid placing the resident in area of other residents if agitated, to redirect the resident with activities she enjoys, and to document behaviors. A progress note dated February 28, 2025, revealed that at 5:44 PM, a dementia aide notified the nurse of a possible resident to resident altercation. The camera footage was reviewed and confirmed that physical contact was made. Resident #25 approached the other resident in the hallway and attempted to interact verbally. The other resident ignored Resident #25 at first, then became agitated and began swatting at Resident #25's left leg. Resident #25 then shoved Resident #20 on the right shoulder. Resident #20 again swatted at Resident #25's left leg, and Resident #25 shoved Resident #20 on the right shoulder a second time. A dementia unit aide intervened at that time. The residents were separated and assessed with no injuries noted. Appropriate notifications were made. -Regarding Resident #20: Resident #20 was readmitted to the facility May 11, 2023, with diagnoses that included vascular dementia with other behavioral disturbance, unspecified mood disorder, cerebral infarction, and aphasia. A quarterly minimum data set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment was not conducted due to the resident being rarely or never understood. A care plan dated December 17, 2015, indicated that Resident #20 has exhibited behaviors of physical / verbal aggression of pushing others and yelling at other residents, with interventions to redirect the resident and remove from the area, to talk to her in brief statements and allow time to answer, and to distract her with activities including coffee, cards, and sewing, and to document her behaviors. An Event note dated February 28, 2025, revealed that at 5:44 PM, a dementia unit aide informed the nurse of a possible resident to resident altercation. The camera footage was reviewed and confirmed that physical contact was made between the two residents. A progress note dated March 1, 2025, revealed that Resident #20 was on alert charting for a resident to resident altercation. There was no bruising to the resident's right hand or shoulder, no complaints of pain, and no discomfort noted. The note revealed that camera footage was reviewed and confirmed that there was physical contact between two residents, Resident #20 and Resident #25. At first, Resident #20 ignored Resident #25, however Resident #25 continued to try to interact with Resident #20. Resident #20 became agitated and swatted at Resident #25's left leg. Resident #25 then in return shoved Resident #20 on the right shoulder. Resident #20 then swatted again at Resident #25's left leg, and Resident #2 shoved Resident #20 again on the right shoulder a second time. A dementia unit aide intervened at that time, the residents were separated and assessed with no injuries noted. Appropriate notifications were made. A Behavior Charting note dated March 1, 2025, revealed the resident was in an altercation with another resident and that the cause of the behavior was that Resident #20 is non-verbal and did not want to be bothered by the other resident. An observation was conducted on March 3, 2025, at 1:34 PM, of the video footage of the resident to resident altercation in the hallway of the 400 unit on February 28, 2025. Resident #20 was sitting in her wheelchair outside of the doorway of a room, facing the hallway. Resident #25 wheeled her wheelchair out of a room and approached Resident #20 from behind and on the right side of her. Resident #25 attempted to talk to Resident #20, who then appeared to become agitated. Resident #20 then turned toward Resident #25 and struck her multiple times in the left leg with her hand. An interview was conducted on March 3, 2025, at 1:34 PM, with a Registered Nurse and Behavioral Unit Manager (RN / Staff #6), who stated that she was informed by the dementia unit aide that the aide had heard yelling on the unit and got up and saw Resident #20's hand moving at Resident #25. The aide informed the RN that the residents had been separated, and the RN assessed both residents and there were no injuries. The RN stated that the aide had informed her immediately after the incident, and that within 5-10 minutes of the incident the camera footage was reviewed, and a report was made to the administrator and Director of Nursing (DON) right away. The RN stated that when reviewing the camera footage, that it was determined that physical contact occurred between the residents and that it was aggressive in nature. An interview was conducted with the DON (Staff #39) on March 3, 2025, at 1:51 PM. The DON stated that she had been informed of the resident to resident altercation, and that she had reviewed the camera footage and observed Resident #25 roll her wheelchair out of a room and try to talk to Resident #20. Resident #20 struck out at Resident #25's leg and that the DON believed there was physical contact. The DON stated that moving forward from this incident, that the facility was coordinating with the provider team to review the residents' medications, that additional staff were present on the unit to supervise, and that the residents are being kept in separate areas on the unit. The DON stated that abuse is prohibited in the facility. Additionally, the expectation for staff if abuse is alleged to occur is to report it immediately and within 2 hours, and to follow policies and procedures. The DON stated that the impact on residents if abuse occurs could be a negative impact on the physical or mental health of a resident. Review of the facility policy titled Abuse Prevention and Procedure, revised June 2024, revealed that it is the policy of the facility to take appropriate step to prevent the occurrence of abuse. Violations or alleged violations will be reported to the State agencies in accordance with State laws, and will be thoroughly investigated by the Administrator or designee. Abuse is defined as the willful infliction of injury with physical abuse further described to include, but not limited to, hitting, slapping, punching, biting, pinching, and kicking.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to ensure eight residents (#1, #2, #3, #4, #5, #6, #7 and #8) were provided adequate supervision to prevent resident abuse. The deficient practice could result in residents being at risk for abuse. Findings included: Regarding Resident #1 and Resident #2: -Resident #1 was admitted to the facility on [DATE] with diagnoses of chronic kidney disease, dysphasia, and anemia. Review of care plan dated March 7, 2023 revealed resident has decreased communication skills related to hard of hearing. The interventions included adjust voice and repeat as needed, communicate in the resident's language whenever possible, make sure all basic needs are met, and use quiet setting as needed. Review of care plan dated March 7, 2023 revealed resident has minimal visual impairment. The interventions included assist resident through doorways, and around corners and objects as needed. Review of resident's quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8.0, indicating moderately impaired. Review of clinical record dated February 4, 2025 revealed a progress note stating a Resident to Resident altercation occurred at approximately 1414 in activity room. Resident #2 was motioning back and forth with a closed fist towards alleged victim/resident #1 as if to provoke him when resident #1 entered the activity room via his wheelchair. As resident #1 passed resident #2, Resident #1 made a fist to resident #2 per resident #1. Resident #2 then struck resident #1 on the right wrist/hand according to resident #1. Resident #1 then hit resident #2 in the right arm. Per staff, resident #2 tried striking resident #1 again but staff was able to separate residents before that occurred. Resident #1 was evaluated for injuries and he denies pain or discomfort. No bruising or marks observed. The director of nursing (DON), resident #2's nurse, provider, case manager, and family were all notified. Resident was placed on alert charting. -Resident #2 was admitted to the facility on [DATE] with diagnoses of mood disorder due to known physiological condition, anxiety disorder, major depressive disorder, and recurrent moderate impulse disorder. Review of resident's admission MDS assessment dated [DATE] revealed a BIMS score of 99.0, indicating that there is no BIMS score. Review of care plan dated October 30, 2024 revealed resident shows cognitive impairment. He does have mumbled speech and unable to communicate with others. The interventions included to minimize background noise, speak in resident's usual language. Make every effort to have interpreter available if needed. Review of care plan dated November 20, 2024 revealed resident #2 may exhibit the behaviors of wandering into other rooms, eating meals off of other resident's plates. He may also do things to trigger unwanted responses from other residents. The interventions included resident will have 1one to one when available from 8a-8p, if staff sees resident having triggering behaviors towards another resident, remove resident from the situation to de-escalate, resident responds better to male redirections. If a male certified nursing assistant (CNA) is available, ask for assistance. Review of clinical record dated February 4, 2025 revealed a progress note stating nurse was notified by helping hand of altercation between two residents. Per camera review, at approximately 1414 pm, per staff, resident #2 was motioning back and forth with a closed fist towards victim as if to provoke him when the other resident entered the same room. As other resident was passing resident #2, the other resident made a fist towards resident #2 and per the other resident, resident #2 hit him in the hand/wrist. The other resident then hit resident #2 in the right arm. No words were exchanged. Per staff resident #2 tried hitting again but before this occurred, residents were separated. No injuries noted. Resident denies any pain or discomfort. Vital signs were stable. The provider, DON, case manager, family, law enforcement, and administrator were notified. Regarding Resident #3 and Resident #4: -Resident #3 was admitted to the facility on [DATE] with diagnoses of unspecified dementia. Review of care plan dated December 5, 2022 revealed that resident may exhibit the behaviors of agitation, verbalizing hallucinations, verbal aggression, and physical aggression toward other residents. The intervention included monitor for and document any verbal or attempted physical aggression toward other residents. Remove from situation immediately to a calm area. Review of care plan dated December 13, 2022 revealed that resident shows cognitive impairment related to aging and dementia. The interventions included minimize background noise, speak in resident's usual language, and make every effort to have interpreter available if needed. Review of care plan dated December 13, 2022 revealed that resident has visual impairment related to aging and glaucoma. The interventions included assist resident through doorways, around corners and objects as needed, and identify yourself and what you plan to do before providing care. Review of resident's quarterly MDS assessment dated [DATE] revealed a BIMS score of 4.0 indicating severely impaired. Review of clinical record dated February 9, 2025 revealed a progress note that states nurse, (licensed practical nurse (LPN)/Staff #20) was standing in a hall just outside dining room talking with staff. The dementia aid (staff #70) and resident exited the dining room into hallway and the aid stated that the other resident just punched resident #3 in the arm. Staff #20 and a registered nurse (RN) reviewed the camera footage. At 17:46 it is observed that the dementia aid who is on one on one with a resident attempt to escort resident from the dining room after dinner. The resident is seen resisting and reenters the room and walks over to a table where resident #3 is seen sitting alone and trying to fold her cloth bib. The other Resident approaches and attempts to take the cloth from resident #3. There is a brief tug and pull back and forth and the dementia aid is seen trying to intervene when the other resident with her right arm punches resident #3 in the left arm. Resident #3 looks up at her. The aid then removed the other resident from the dining room. -Resident #4 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, wandering, and major depressive disorder. Review of care plan dated November 1, 2024 revealed resident may exhibit the behaviors of wandering, verbalizing hallucinations, making false accusations, packing belongs/bed linens, physical and verbal aggression towards staff and others behaviors related to dementia. The interventions initiated on December 2024 included monitor interactions with others and remove from situation if showing agitation, aggressiveness, one on one monitoring from 8a-8p and as needed, staff to be with her when wandering, or in dining area/activity room, provide conversation, snacks, fluids and redirection away from other residents as needed, and make sure all basic needs are met. Review of resident's MDS assessment dated [DATE] revealed a BIMS score of 8.0 indicating moderately impaired. Review of care plan dated November 20, 2024 revealed resident shows cognitive impairment, does prefer to speak in native language, and resident will need a translator. The interventions included minimize background noise, speak in resident's usual language and make every effort to have interpreter available if needed. Review of care plan dated November 20, 2024 revealed resident has decreased communication skills related to impaired cognition. The interventions included adjust voice and repeat as needed, communicate in the resident's language whenever possible, and make sure all basic needs are met. Review of clinical records dated February 9, 2025 revealed a progress note stating LPN/Staff #20 was standing in a hall just outside dining room talking with staff. The dementia aid/Staff #70 and resident #4 exit the dining room into hallway and aid states that resident #4 just punched another resident in the arm. This nurse/Staff #20 and a RN reviewed the camera footage. At 17:46 it is observed that the dementia aid who is on a one on one with resident #4 attempts to escort resident #4 from the dining room after dinner. Resident #4 is seen resisting and reenters the room and walks over to table where the other resident is seen sitting alone and trying to fold her cloth bib. Resident #4 approaches and attempts to take the cloth from resident. There is a brief tug and pull back and forth and the dementia aid is seen trying to intervene when resident #4 with her right arm punches resident #3 in the left arm. The aid then removes resident #4 from dining room. DON notified by phone and followed protocol for reporting altercation. Regarding Resident #5 and Resident #6: -Resident #5 was admitted to the facility on [DATE] with diagnoses of unspecified dementia, Alzheimer's disease, unspecified psychosis not due to a substance or known physiological condition, and major depressive disorder. Review of resident's quarterly MDS assessment dated [DATE] revealed a BIMS score of 99.0, indicating no score available. Review of clinical record dated February 12, 2025 revealed a progress note stating Resident was being wheeled to room by staff when staff attempted to maneuver around a female resident which was combative at this time and as they passed by, the female swung her arm and hit resident #5 in the arm. Staff intervened and removed the female resident from the area. Nurse assessed resident and no injury was observed and resident denies pain or discomfort. Vitals signs were obtained and protocol for resident to resident were followed. Review of care plan dated June 15, 2021 revealed resident has visual impairment related to macular degeneration. The interventions included assist resident through doorways, around corners and objects as needed, and identify yourself and what you plan to do before providing care. Review of care plan dated July 25, 2018 revealed resident shows cognitive impairment and has communication skills related to dementia and hard of hearing. The interventions included adjust voice and repeat as needed, be sure resident can hear you, communicate in the resident's language whenever possible, make sure all basic needs are met, and use quiet setting as needed. -Resident #6 was admitted to the facility on [DATE] with diagnoses of dementia, major depressive disorder, and Alzheimer's disease with early onset. Review of quarterly MDS assessment dated [DATE] revealed a BIMS score of 3.0 indicating severely impaired. Review of resident's care plan dated February 23, 2021 revealed resident shows cognitive impairment, has visual impairment, and has impairment hearing The interventions included be sure resident can hear you, minimize background noise, speak in resident's usual language, make every effort to have interpreter available if needed, assist resident through doorways, around corners and objects as needed eye exam as needed or appropriate, adjust voice and repeat as needed and identify yourself and what you plan to do before providing care. Review of clinical record dated February 11, 2025 revealed a behavioral charting progress note stating Staff was attempting to remove resident from dining room after lunch because resident was attempting to take food of other residents' plates after everyone was cleared from dining room. Resident was becoming combative with staff. This nurse intervened and distracted resident and was able to redirect her with an offer of a boost shake. Resident then complained she was cold and blanket provided. Resident then calmed down and was sitting in hall with no further behaviors observed at this time. Review of clinical record dated February 11, 2025 (Recorded as Late Entry on February 12, 2025) revealed a progress note stating Resident was removed from dining room and this agitated her. Staff wheeled resident down hall and resident then wheeled over yelling at a male resident. Another staff was wheeling a male resident to his room and attempted to go passed resident and she swung her arm and hit the male resident in his arm. Staff separated resident and removed her from others. Regarding Resident #7 and Resident #8: -Resident #7 was admitted on [DATE] with a diagnosis of epilepsy, transient cerebral ischemic attack, and traumatic brain injury (TBI). Review of care plan dated October 16, 2023 revealed resident may show cognitive impairment. Resident is alert, able to make needs known, and does display distraction and/or confusion at time. The intervention included to conduct interview in a private setting, and minimize background noise. Review of care plan dated February 5, 2024 revealed resident may exhibits the behaviors of verbally rude to staff and other residents, and short temper with other residents. The interventions included an approach dated December 31, 2024 which states when resident is ambulating, please watch so he doesn't grab onto other resident's wheelchairs. Review of resident's quarterly MDS dated [DATE] revealed a BIMS score of 8.0, indicating moderately impaired, resident has social isolation sometimes, and behavioral symptoms not exhibited. Review of clinical record dated February 19, 2025 revealed a progress notes that stated At 1545 RN/Staff #52 was notified by the assistant director of nursing (ADON) that resident and another resident had an altercation. Per statements and video recording, it was observed that other resident was trying to propel himself in his wheelchair and accidently bumped into resident #7 right calf. Resident #7 got offended and grabbed the other resident's shirt at his chest and his left upper sleeve. Residents were separated by staff. Resident's calf assessed, no injuries noted. No redness or bruising, resident denies any pain. Vital signs stable. The administrator, DON, provider were notified. -Resident #8 was admitted at the facility on October 11, 2024 with diagnoses of Type 2 diabetes mellitus, shortness of breath, and congestive heart failure. Review of care plan dated December 1, 2024 revealed resident may exhibits the behaviors of agitation, verbal aggression, physical aggression towards other residents related to miscommunication due to limited mobility, and decreased vision. The intervention included monitor for and document any verbal or attempted physical aggression toward other residents and remove from situation immediately to a more calm area. Review of quarterly MDS dated [DATE] revealed a BIMS score of 12.0 indicating moderately impaired. Review of clinical records dated February 19, 2025 revealed a progress note stating At 1545 RN/Staff #52 was notified by ADON that resident and another resident had an altercation. Per statements and video recording, it was observed that resident #8 was trying to propel himself in his wheelchair and accidently bumped into other resident right calf. The other resident got offended and grabbed Resident #8's shirt at his chest and his left upper sleeve. Residents were separated by staff. Resident's arm and chest assessed, no injuries noted. No redness or bruising, resident denies any pain. Vital signs stable. The administrator, DON, provider, and family were notified. An interview was conducted on February 19, 2025 at 2:16 pm with a certified medical assistant/Staff #40. Staff stated that she works in their long term care unit. She stated that she was not aware of any resident to resident altercation. She added that if there is a resident to resident altercation, she will report it immediately, separate the residents, have someone stay with the residents, and report it to DON. She stated that resident #1 was in the hospital and came back, and no issues with the resident. Staff identified resident #1 who is in dining room having bingo activity. An interview was conducted on February 19, 2025 at 2:22 pm with the Behavior unit director/Staff #12 in her office in the 400 unit. She stated that they had two incidents of resident to resident altercations which involved resident #3 and resident #4 and another incident which involved resident #5 and resident #6. Surveyor 49399 in staff #12's office to watch the video camera footage of the incidents. Staff stated that they can only look at the video camera for the last 14 days and anything pass that, they cannot see. At 2:25pm, looking at resident #3 and resident #4 incident on February 9, 2025 at 5:45pm. Staff stated that resident #4 is standing with the dementia unit attendant/Staff #70. Staff stated that the dementia unit attendant is trying to redirect resident #4 and resident #4 is resistive. The other resident, resident #3 is folding a crumb catcher, then resident #4 approaches resident #3 , Staff #70 was trying to intervene, as resident #4 is reaching for the crumb catcher, Staff #70 hand was in between them, to keep resident #4 from getting the crumb catcher, resident #3 is pulling back the crumb catcher, and Staff #70 was trying to let resident #4 to let go, resident #4 is pulling the crumb catcher, Staff #70 has both hands trying to let resident #4 to let go, Resident #4 right hand makes contact with resident #3's left arm. Staff #12 stated that resident #4 is on a one on one, and was placed on provider's visit list to be seen tomorrow. Staff #12 added that Staff #70 or one of the CNAs notified the nurse of what had happened. Staff #12 described the incident as a willful act, a resident to resident altercation, and whether the resident meant to harm the other resident or not. In addition, staff stated that there was no bruising, no pain, and neither one of the residents remembered it the next day. On February 19, 2025 at 2:41 pm, Staff #12 was viewing the video camera footage of resident #5 and resident #6. Staff stated that the incident happened in one of the hall, on February 11, 2025 at 6:10 pm, during the time they were bringing residents back from the dining room. Resident #6 was sitting in the wheelchair in the hallway, then resident #6 moved herself from sitting against the wall over by the nurses' cart parked to the left, resident #5 sitting in a wheelchair was being pushed by the CNA, trying to pass by resident #6 from her right side because resident #5's room is next to the nurses' cart. They were coming up to pass resident #6, and looks like resident #6 made contact with her right arm with resident #5's left arm, the CNA/staff #74 got resident #5 in his room, and resident #6 was taken further down the hallway so others can get by. Staff #12 stated that resident #6 made contact with her arm, making contact is a resident to resident altercation, and added that it does not matter how hard it is, it is a willful act. Staff #12 stated that the nurse was notified, and then the nurse notified the DON and the administrator, and completed a report. Staff #12 stated that the two incidents were the only ones that she can show through the video camera due to video timeframe of 14 days. On February 19, 2025 at 2:58 pm, an attempt to speak with resident #6 and resident is sleeping, not available for interview. An interview was conducted on February 19, 2025 at 2:59 pm with activities assistant/staff #32. Staff stated that she has no knowledge of any recent resident to resident altercation. She stated that for any resident to resident altercation, she will get the residents apart and notify the nurse. She stated that she receives her abuse training from their healthcare academy, and as needed training with her supervisor. An interview was conducted on February 19, 2025 at 3:05 pm with resident #5 who was in the activity room, and reading a magazine. Resident #5 stated that he is alright. On February 19, 2025 at 3:08 pm, observed resident #4 in the activity room sitting at the round table with three other residents, and helping hand/staff #25 stated that last week resident #6 was getting upset, and resident #6 hit resident #5 on his arm as they were wheeling them after dinner. Staff #25 stated that while they strolled by resident #6, resident #6 hit resident #5 by the arm. On February 19, 2025 at 3:14pm resident #3 was sitting in her wheelchair watching television by the hallway, holding a doll, and CNA/staff #30 stated that she is not aware of any resident to resident altercation. An interview was conducted on February 19, 2025 at 3:18 pm with LPN/staff #20. Staff stated that between resident #5 and resident #6 incident, resident #6 has tendency to get upset when told to leave the dining room, so the dietary aid can clean the dining room and mop the floor and the resident can go back to do activities there. Staff remembered the incident that happened the first week of February. She stated that one of the staff removed resident #6 from the dining room, and resident became combative by grabbing rails, and then the staff took resident #6 in the hallway. While resident #6 is in the hallway, resident #6 wheels over to another resident. And, when another aid was pushing resident #5's wheelchair to go around resident #6, resident #6 wacked resident #5 in the arm. Resident #6 was removed from the crowd. She took vital signs and assessment, and resident #5 denied being hurt, and there were no marks or bruise. Staff stated that she discussed the incident with the behavioral unit/staff #12. When asked where staff #20 was during the incident, she stated that she was at the nurses' station about 6:00 pm charting and they came and told her that an incident occurred so she watched the video camera footage by the nurses' station and after reviewing the camera footage she made her report. Since then, they no longer force resident #6 to leave the dining room to prevent resident from getting agitated. In addition, Staff #20 remembered the other incident in the other hall involving the incident with resident #1. She stated that the aid came out and stated that resident #1 was the aggressor and hit resident #2. Resident #2 hit resident #1 first, he was the initial aggressor, happened during activities, and staff were present at the time. Resident #1 was coming to the activities, resident #2 raised his fist and resident #1 raised his fist, and when they pass by each other resident #2 hit resident #1 first, and then resident #1 reacted. Staff stated that resident #2 has been on a one on one, and that means that a staff is dedicated to one resident, to interact with the resident and stay with the resident. Furthermore, staff stated that when she worked another hall, resident #4 also is on a one on one always with a dementia aid. Staff stated that when she is made aware of resident incident, she will separate the residents, remove the residents from the situation, redirect and calm them down, and assess both residents for any injuries. Staff stated that nobody had any injuries for those two incidents she described and after this type of incident, they do 3-day alert charting. Regarding abuse training, she stated that abuse includes physical, verbal, emotional, they cannot restraint residents, and abuse is anything that cause harm to residents. On February 19, 2025 at 3:38 pm an interview was conducted with CNA/staff #36. Resident #2 was not in his room. Staff stated that resident might be in activities located in the dining room. While in the dining room, staff identified resident #2 in the dining room doing bingo activity. On February 20, 2025 at 09:10am in resident #2's room who is in bed lying down. An interview was conducted with helping hand/staff #48 who was sitting in resident #2's room. Staff stated that her role is to keep an eye on the resident, when resident gets out of bed that she will call a CNA, she makes sure the resident do not wonder in other rooms and no physical contact with other residents. She stated that this is her third week working as a helping hand, she has been working for four months and sitting/one on one with resident #2 for three weeks. She stated that she heard some residents get mad about resident #2's outburst, and when that happens, they calm him down and redirect him. On February 20, 2025 at 9:19 am surveyor was looking for resident #1 in his room. The activity staff/Staff #50 identified resident #1 in activity participating in their corn hole game tossing bean bag. An interview was conducted on February 20, 2025 at 10:22 am with RN/Staff #52. Staff stated that regarding a recent resident to resident altercation, she stated that she reported yesterday an incident between resident #7 and resident #8 that happened on February 19, 2025 at 3:40 pm. She stated that she was in her office, she heard yelling, while the residents were playing bingo at the dining area. She stated that resident #8 was in his wheelchair trying to go around resident #7 and he accidentally bump resident #7's leg. Resident #7 took it as an offense and then resident grabbed resident's #8 by the shirt on the chest and on his right arm. By that time they were already separated by the activity staff/staff #50 and a young gentleman who also works in activities. Staff stated that for her abuse training, if she witnessed it, it is reported immediately to the DON, she gets vital signs, she will notify the administrator, law enforcement, and report it online to the department of health services (DHS). She stated that during the incident, resident #7 and #8 had no injury. She stated that abuse is physical, verbal, and emotional. She stated that the one she witnessed or just mentioned was a physical abuse because resident #7 grabbed and made contact with resident #8, and there is a camera in the dining room. In addition, Staff stated that she documented resident #2's progress note when she was working in that hall regarding the February 4, 2025 incident. She stated that no injuries found in resident #2 and resident #2 was on a one on one sitter at that time. An interview was conducted on February 20, 2025 at 10:38 am with helping hand/staff #80. Staff stated that her role as a helping hand is to check briefs, restock rooms with briefs, gloves, clean drawers, tables, spills in the room, and make beds on shower days. She added that she has been on a one on one sitter for resident #4 and resident #2. Staff stated that regarding the incident on February 4, 2025 with resident #1 and resident #2, the incident happened in the activities room around the afternoon after lunch. She stated that she had been with resident #2, and that resident #2 wanted to get up and when they got in the activity room they sat there at the round table. Resident #2 pulled away from her because she had to put the snack on top of the popcorn machine because resident #2 is on puree diet and is not to have crackers. Resident #2 got upset. Since her role is helping hand, she cannot transfer resident #2 back to bed. Then, resident #2 removed himself from the beside while she removed the snack and placed it were resident #2 could not reach it. She stated that resident #2 was facing towards the door and she thought that resident was just waving him in and both resident #1 and resident #2 were side by side and resident #1 made a gesture by extending his arm and making a fist and resident #2 took it as a threat and went and swung his right arm to resident #1. Resident #1 went and swung back at resident #2 and that is when she got up while sitting by the table, and separated the residents, and after that she ask one activity staff to get her the nurse. Regarding her abuse training, she stated that abuse is financial, mental, physical, and emotional. She stated that the incident is physical because they were trying to hurt each other with their hands. In addition, she stated that her abuse training is done in the computer and they have monthly trainings through videos and from their care academy. An interview was conducted on February 20, 2025 at 11:02 am with activity assistant/staff #50. Staff stated that yesterday in the dining room while playing bingo game, resident #7 went to the table where he calls the bingo numbers, while he left to go to a resident who had won a bingo game. When he turned around, he saw resident #7 standing up and resident #8 was on his wheelchair. When he turned around, he saw resident #8 trying to get around resident #7. He stated that he did not see the part where resident #8 bumped resident #7's leg. He was not aware of it until he looked at the camera footage with the DON. Resident #7 got really upset and grabbed resident #8's jacket, and that is when he got in between them and separated the residents. Staff stated that the incident would be probably a physical altercation between two resident because one resident grabbed one's jacket and if he has not step in the middle, resident would have hit the other resident. Staff stated that resident #7 was very upset, and very angry looking. Staff stated that he is not aware of any behavior in the pass between the two residents. He added that once they separated them, another activity staff was there and he stayed while he went to the DON office to report the incident. An interview was conducted on February 20, 2025 at 11:46 am interview with resident #8. Resident #8 stated that he was playing bingo, they were giving present away, he was hit on his left leg, pointing on his left leg, and staff #50 saw it and said don't do that. He stated that he did not do anything with resident #7 because he is an old. Resident stated that there is nothing wrong with his leg now, and it is not hurting. Resident stated that they split them up after it happened. On February 20, 2025 at 11:53 am resident #7 was observed walking with his walker from the hall towards the dining room. Resident did not want to stop and speak with the surveyor. An interview was conducted on February 20, 2025 at 11:59 am with the DON/Staff #10 and present during the interview is ADON/Staff #90. DON stated that regarding abuse, abuse is sexual, physical, verbal, financial, and is reported immediately to appropriate agencies and investigated. DON stated that regarding resident #1 and resident #2 incident, it took place in the activity room, resident #1 raised his arm with closed fist, resident #2 raised his right hand with closed fist and make contact with resident #1's right hand, and resident #1 responded with his closed fist and made contact with resident #2. DON stated that it is a resident to resident altercation, classified under their physical abuse policy. DON stated that regarding resident #3 and resident #4 incident, resident #4 was seen walking over to resident #3 at the dining room table. Resident #4 attempted to take the cloth from resident #3, they had a tug, the dementia aid attempted to intervene, resident #4 made contact with her left arm to resident #3. DON stated that it is a resident to resident altercation. They do their best to prevent it. It is a reportable incident classified under their physical abuse policy. DON stated that regarding resident #5 and resident #6 incident, resident #6 swung her arm and made contact with resident #5's arm. DON stated that it is classified under their physical abuse policy for a resident to resident altercation. DON stated that regarding resident #7 and resident #8 incident, resident #7 was standing at the dining area attempting to go around , resident #7 loses balance and pushes William's wheelchair. Resident #7 became upset and grabbed resident#8's jacket sleeve, there were 2 activity staff there, and they intervened and separated the residents. DON stated that it is under their physical abuse policy for a resident to resident altercation abuse policy. Regarding interventions, the DON stated that they have done in-services to staff in regards to resident to resident altercation, and they plan to add dementia intervention training from their health care academy dementia training. During the interview with the DON, at 12:13

Based on observations, clinical record review, staff interviews and facility policy, the facility failed to ensure that 7 residents were not abused (72, 76, 92, 42, 67, 54, 32 and 19). The deficient practice could result in physical and emotional harm to residents. Findings include: Regarding the incidents between resident #72 and unknown victim -Resident #72 was admitted on [DATE] with diagnoses of traumatic brain injury, other frontotemporal neurocognitive disorder and mild cognitive impairment. A care plan dated February 5, 2024 included this resident may exhibits the behaviors of verbally rude to staff and other residents and short temper with other residents. Interventions include document behaviors and psychiatric consult. A progress note [DATE] included that the writer overheard a Certified Nursing Assistant (CNA) in the hallway saying (Resident #72) Stop!. This note included that Resident #72 was observed holding onto another male resident's wheelchair handles and aggressively shaking the wheelchair with attempts to push into the wall and that staff were trying to hold the male resident's wheelchair steady while telling [NAME] to let go. This note included that multiple staff responded to area and Resident #72 was cursing and yelling at all staff. An interview was conducted on [DATE] at 9:04 AM with Social Services (staff #171) who said that he was not there when this incident happened but that he was told about it. This staff said that he believed that it happened because the resident often believed that others were talking about him and would leave abruptly if he asked a question and was not given the answer he was looking for. Regarding the incidents between resident #76 and resident #92 -Resident #92 was admitted on [DATE] with diagnoses of moderate intellectual disabilities, Major depressive disorder, and metabolic encephalopathy. A care plan dated [DATE] included that this resident may exhibit the behaviors of wandering into other rooms, eating meals off of other resident's plates. He may also do things to trigger unwanted responses from other residents. An intervention dated [DATE] included that if staff sees resident having triggering behaviors towards another resident, remove resident from the situation to de-escalate. A progress note dated [DATE] included This nurse was notified by CNA of altercation between 2 residents. Per camera review, at approx. 3:30 pm, a male resident was preventing (resident #92) from entering the common TV room area. Male resident observed speaking to (resident #92) along with hand gestures(pointing) and noted lifting of right leg towards (resident #92). (resident #92) reacted by kicking back towards other resident and making contact with male resident's right foot. (Resident #92) then backed himself backwards away from male resident in wheelchair. Staff did separate both residents. No injuries noted. Resident denies any pain or discomfort . A progress note dated [DATE] included Witnessed on camera another resident wheeling self toward (resident #92), other resident swung arm out and made contact with (resident #92). All documentation completed, appropriate agencies notified. Residents interviewed. Continuing to monitor -Resident #76 was admitted on [DATE] with diagnoses of hemiplegia and hemiparesis following cerebral infarction, aphasia, and need for assistance with personal care. A care plan dated [DATE] included that this resident may exhibit the behaviors of combative with staff during cares and that he also may display verbal and/or physical aggression towards other residents. This care plan included an intervention dated [DATE] that if the resident appears agitated, to remove him from areas where he could harm others. A progress note dated [DATE] included This nurse was notified by CNA of altercation between 2 residents. Per camera review, at approx. 3:30 pm, (resident #76) was preventing another male resident from entering the common TV room area. (resident #76) observed speaking to male resident along with hand gestures (pointing) and noted lifting of right leg towards male resident. Other resident reacted by kicking back towards (resident #76) and making contact with (resident #76) ' right foot. Staff did separate both residents. No injuries noted. Resident denies any pain or discomfort to right foot. A progress note dated [DATE] included Resident was witnessed on camera wheeling self toward another resident and swung out arm and made contact with upper arm. All documentation completed, appropriate agencies notified. Residents interviewed. Continuing to monitor An observation and interview was conducted on [DATE] at 12:45 PM of a video of this altercation with Behavioral Director (staff #239). This staff pointed out resident 76 and 92 on the video and notes that resident 76's foot hangs over the chair and that he is kicking at resident #92 and pointing at him. Then this staff said that resident #92 brings his leg up and got resident #76's foot. This staff then said that from what could see resident #92 got his foot and #76 brings his foot up again and resident #92 is backing away and removes himself from the area. This staff said that right now we have someone sitting with #92, It looks like around the 26th they put a sitter in place. An observation and interview was conducted on [DATE] at 11:17 AM with the Registered Nurse Behavioral Health Unit Manager (RN/staff #129 ) who said that she watched the [DATE] interaction on the camera, and that she could see resident #76 approach resident #92 from behind, and hit him. This nurse said Resident #92 just looked and moved forward. The video was turned on and that staff said that the video was in the bird room, and that the resident in the plaid shirt was resident #92 and behind him is resident #76 and that resident #76 comes up and hits him on the back of the arm, then a CNA walks between them and takes resident #76 out of there. An interview was conducted on [DATE] at 10:20 AM with the Director of Nursing (DON/staff #244) regarding the incident between resident #76 and #92 included that her expectation was that residents should not be kicking each other and that a resident kicking or hitting another resident by definition is abuse. This DON said that it does not meet her expectation that abuse is happening in her facility. Regarding resident #72, this DON said that she is unaware who the resident in the wheelchair was and that pushing a wheelchair into a wall is abuse. This DON said that residents should be free of abuse. 49399 Regarding the Altercation Between Resident #19 and Resident #42 -Resident #19 [alleged victim] was admitted at the facility on [DATE] and reentered the facility on [DATE] with a diagnosis that include vascular dementia, Alzheimer's disease, and major depressive disorder. Review of care plan dated [DATE] revealed resident shows cognitive impairment related to neurocognitive disorder. Resident speaks in clear English, at times very demanding with staff. He can make needs and wants known. The intervention included be sure resident can hear you. Review of care plan dated [DATE] revealed resident has decreased communication skills related to neurocognitive disorder. Resident may not always understand completely what is said to him. Give resident time to comprehend. The interventions included adjust voice and repeat as needed and make sure all basic needs are met. Review of quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 6.0 indicating severe cognitive impairment. Resident has not exhibited physical and verbal behavioral symptoms, wandering and rejection of care. Review of clinical records dated [DATE] revealed a nursing progress notes that stated licensed practical nurse (LPN)/staff #256 was in hallway charting when a sound of a slap was heard, looked over and resident #42 was standing over resident. He heard a certified nursing assistant (CNA) yell out for resident #42 to not do that and to move away from resident. Staff #256 was notified by CNA that resident #42 had struck resident #19 on the right arm. He talked to residents after incident why they hit each other and both exclaimed I don't know. Staff #256 notified Adult Protective Services (APS), Department of Health Services (DHS), director of nursing (DON), law enforcement, Administrator, family member, and the case manager. -Resident #42 [alleged perpetrator] was admitted at the facility on [DATE] with a diagnosis that included cerebrovascular accident (CVA), unspecified dementia, wandering, and Alzheimer's disease with early onset. Review of annual MDS dated [DATE] revealed a BIMS score of 3.0, indicating severe cognitive impairment. Physical and verbal behavioral symptoms were not exhibited. And, wandering behavior occurred. Review of clinical record dated [DATE] revealed a nursing progress notes by LPN/Staff #256. Staff #256 stated that he was in hallway charting when a sound of a slap was heard, looked over and resident #42 was standing over resident, heard CNA yell out for resident #42 to not do that and to move away from resident, staff #256 was notified by CNA that resident #42 had struck resident #19 on the right arm. He spoke to both residents after incident why they hit each other and both exclaimed I don't know. Staff #256 notified APS, DHS, DON, law enforcement, Administrator, family member, and the case manager. Review of care plan dated [DATE] revealed resident may exhibit the behaviors of verbalizing delusions, anger outbursts, rummaging through others belongings related to dementia. The interventions included trade her one of her belongings if she does take something of someone else's thinking it is hers, if she tries to help staff after meals (because she thinks it's her job) offer her towels to fold or yarn to roll. She does have a set of plastic dishes she can wash and sort. Staff can tell her she is on vacation and not needing to work. And, make sure all basic needs are met. Review of care plan dated [DATE] revealed resident shows cognitive impairment related to dementia and refusal to participate. Resident is alert and able to communicate in both English and Navajo. Resident is often confused, but can answer simple questions. The interventions included are to be sure resident can hear you, speak in resident's usual language, and make every effort to have interpreter available if needed. An attempt to interview CNA/staff #269 on [DATE] at 02:07 PM via phone was unsuccessful. An interview was conducted on [DATE] at 02:12 PM with CNA/Staff #300. She stated that she works day shift from 6 am to 6 pm. She stated that regarding resident #42, resident is supervision/touch assistance, the resident requires supervision when ambulating, resident can follow direction fairly well. Staff stated that usually when resident to resident incident happens, she will separate the residents and let her nurse know of the incident. Regarding her training, she stated that she receives an online class, her course last year had 30 modules such as behavioral, cardiopulmonary resuscitation (CPR) related, deescalating a situation and how to provide better care for her residents. Regarding resident #19, she stated that resident needs assist with transfer, brief change, changing clothes, and he can get up and stand but she has not seen him take steps. Resident is on his wheelchair and can only pivot transfer. Regarding resident's behavior, resident #19 has been involved in yelling help and it annoyed his roommate. Furthermore, staff stated that for any abuse such as physical, emotional, and verbal, she will report it to her chain of command, to her nurse, charge nurse or the DON or report it directly to state. She reports it because she is a mandatory reporter, and to prevent the abuse incident from happening again. An interview was conducted on [DATE] at 02:30 PM with LPN/staff #207. Staff #207 stated that she works day shift, she passes medications, she does wound care treatments, and applying lotion and bio freeze. She has not witnessed any abuse incident recently and has no knowledge regarding resident #19 and resident #42 altercation. She stated that if she witnessed or is made aware of any allegations of abuse, she will separate the residents, report it to her DON, and contact the case manager and family. The types of abuse she will report are physical, verbal, emotional, financial and anything that will harm the resident in any shape or form. She gets training through in-services every month, training on various things, such as on resident to resident altercation. An interview was conducted on [DATE] at 10:21 AM with LPN/Staff #256. Staff #256 stated that he works from 7am to 7pm shift, he gets reports from the nurse on how the patients were, any issues or concern during night shift, and he usually works on Thursdays, Fridays, and Saturdays. Staff stated that regarding resident to resident altercation that occurred between resident #19 and resident #42, he did not see what happened. Staff stated that resident #19 was sitting close by to him, resident #42 hit resident #19 like a slap on the arm, it happened last week on Thursday, he was working that shift. The incident occurred about 5:30 pm, in the a hall in the hallway right pass the double doors. After the incident, he stated that he took resident #42 and sat her with the dementia aid staff. The other resident, resident #19, stayed close to his room because his room is close to the double doors. Staff #256 stated that he asked both residents what had happened and both residents said they do not know. Staff made sure the residents were distant apart after the incident. Staff stated that he was doing his behavioral charting standing by his nurses' cart and that is when he heard the slap, the other staffs were down in the dining room because some residents were still eating, another staff, Staff #167 was bringing resident out of the dining room and she was the one that saw the incident when resident #42 hit him, and he heard staff #167 say No (resident #42's name) don't do that. Furthermore, staff stated that after the incident, the process is to do a report, notify staff to monitor residents and do their 72-hour monitoring. Regarding his training, he has continuing in-services on how to talk to resident and how to handle those types of incident, and reporting to APS. He stated that resident to resident altercation is consider a form of abuse and the incident is reported to the DON and administrator. An attempt to contact CNA/Staff #167 on [DATE] at 10:48 am was unsuccessful. An interview was conducted on [DATE] at 11:15 am with the DON/Staff #244, and present during the interview was nurse consultant/staff #305. DON stated that their abuse process is that it should be reported to the nurse assigned to the unit, the witnesses will report it, the nurse assigned to that unit is responsible in reviewing and investigating the claim made, and if found suspicious and is reportable then it must be report within 2 hours. The DON stated that their staff receive training through their healthcare academy as well as in person in-services and what they are told to do. Regarding training, for training purposes they define the types of abuse, who the abuse needs to be reported to, time sensitivity of reporting to the right department and the notification that need to be made. The DON stated that regarding resident #42, the CNA heard a slapping sound. The DON stated that they have camera surveillance throughout the building located in their television room, reception area, dining hall, their nurse station located in each hall, in the main nurse station, and in the cubby of nurses' station . The DON stated that the types of abuse can be emotional, financial, sexual, physical, and she described hitting, punching, slapping, biting as a form of abuse. Review of facility's policy titled, Abuse Prevention Policy and Procedure, revised date [DATE] revealed that it is the responsibility of all employees to immediately report any suspected or alleged violation of abuse, neglect, injury of unknown source and/or misappropriation of resident property to the administrator, director of nursing, charge nurse or department head. Such violations or alleged violations are also reported to the State agencies in accordance with existing State law. Each alleged violation will be investigated thoroughly. 51159 Regarding the altercation between Resident #54 and Resident #32 Resident #54 [alleged victim ] was admitted to the facility on [DATE] with diagnoses of dementia, cardiomyopathy, and gastro-esophageal reflex. Review of resident #54 care plan dated [DATE] revealed a goal of minimizing behaviors, and to reduce the risk of harming himself and/or others. A review of the quarterly assessment MDS, dated [DATE] reveals resident #54 had a BIMS score of 3 which indicated the resident was severely cognitive impaired. Review of clinical records dated [DATE] revealed a nursing progress revealed that a certified nursing assistant (CNA) informed nurse that resident #54 was hit in the chest by another resident. Resident # 32 [ alleged perpetrator ] was admitted to the facility [DATE] with a diagnosis of dementia, alzheimer's, and hypertension. A review of the quarterly assessment MDS, dated [DATE] reveals residents # 32 had a BIMs score of 99 which indicated assessment was not completed. Review of resident # #32 care plan dated [DATE] revealed a goal of minimizing behaviors and reducing the risk of harming themself and/or others. Review of clinical records dated [DATE] revealed a nursing progress notes revealed that a certified nursing assistance (CNA) informed nurse that resident #32 hit another resident on the chest. A review of a witness statement completed by Staff #179 revealed that at 6:38 PM resident # 54 wheeled her wheelchair toward resident # 32. The witness statement further revealed staff #179 witnessed resident #32 hit resident # 54 on the chest. A review of the camera view incident document dated [DATE] revealed that resident #32 pushed resident #54 left upper arm to move resident # 32 out of their way. This document further revealed that resident # 32 swung her arm toward resident # 54 hitting her with the back of hand on the upper left chest/arm area. A video camera review was conducted on [DATE] at 10:06AM with behavior unit director Staff 239 who stated resident # 54 is wearing a blue jacket and it has designs on it. Staff # 239 stated that resident # 54 leaded forward toward resident # 32 and resident # 32 moved resident # 54 out of her way. She further stated that resident # 32 used the back of her hand on resident #54 and resident # 32 held resident #54 arm from getting in her face. An interview was conducted on [DATE] at 11:15 am with the DON/Staff #244, and present during the interview was nurse consultant/staff #305. DON stated that their abuse process is that it should be reported to the nurse assigned to the unit, the witnesses will report it, the nurse assigned to that unit is responsible for reviewing and investigating the claim made, and if found suspicious and is reportable then it must be reported within 2 hours. The DON stated that their staff receive training through their healthcare academy as well as in person in-services and what they are told to do. Regarding training, for training purposes they define the types of abuse, who the abuse needs to be reported to, time sensitivity of reporting to the right department and the notification that need to be made. The DON stated that the types of abuse can be emotional, financial, sexual, physical, and she described hitting, punching, slapping, biting as a form of abuse. -Regarding to resident # 67 and resident #54 Resident #67 [ alleged victim ] was admitted to the facility on [DATE] with diagnoses of dementia, hypertension, and hypercholesterolemia. A review of the admission assessment Minimum Data Set (MDS), dated [DATE] , revealed resident #67 had a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident assessment was not completed. A review of resident's # 67 care plan dated [DATE] revealed that it was revised on [DATE] and included a a goal of minimizing behaviors and reducing the risk of harming themself and/or others. A review of a progress note dated [DATE] revealed that resident # 67 was in the hall at the CNA station in her wheelchair. This document further revealed that a staff had witness resident # 54 tell resident # 67 that she was in the way and resident # 57 reached over slapping resident # 67. Related to resident #54- Resident #54 [alleged perpetrator]was admitted to the facility on [DATE] with diagnoses of dementia, cardiomyopathy, and gastro-esophageal reflex. A review of the quarterly assessment MDS, dated [DATE] reveals resident #54 had a BIMS score of 3 which indicated the resident was severely cognitive impaired. A review of the progress note, dated [DATE] revealed that staff # XX witness resident #54 tell resident #67 that she was in her way and resident number #54 reached over slapping resident #67 on the thigh. Review of resident #54 care plan dated [DATE] revealed a goal of minimizing behaviors and to reduce the risk of harming himself and/or others. A review of the video footage was conducted on [DATE] at 10:31 AM with behavior unit director Staff # 239who stated that in the video footage of the incident resident # 67 is wearing a black or blue pants with a printed top. Staff #239 stated that resident # 54 starts to come and moves the trash can out of her way. Staff #239 stated that resident # 54 came close to resident # 67 and in the video resident # 54 turns in her wheelchair and it appears that both resident wheelchairs are scraping together. She also states that it looks like resident # 54 brushed her two fingers on the knee of resident #67. She further stated that this incident had happened right when residents were done eating. An interview was conducted on [DATE] at 11:15 am with the DON/Staff #244, and present during the interview was nurse consultant/staff #305. DON stated that their abuse process is that it should be reported to the nurse assigned to the unit, the witnesses will report it, the nurse assigned to that unit is responsible for reviewing and investigating the claim made, and if found suspicious and is reportable then it must be reported within 2 hours. The DON stated that their staff receive training through their healthcare academy as well as in person in-services and what they are told to do. Regarding training, for training purposes they define the types of abuse, who the abuse needs to be reported to, time sensitivity of reporting to the right department and the notification that need to be made. The DON stated that the types of abuse can be emotional, financial, sexual, physical, and she described hitting, punching, slapping, biting as a form of abuse. Review of facility's policy titled, Abuse Prevention Policy and Procedure, revised date [DATE] revealed that it is the responsibility of all employees to immediately report any suspected or alleged violation of abuse, neglect, injury of unknown source and/or misappropriation of resident property to the administrator, director of nursing, charge nurse or department head. Such violations or alleged violations are also reported to the State agencies in accordance with existing State law. Each alleged violation will be investigated thoroughly.

Based on record reviews, staff interviews and reviews of facility policies and procedures, the facility failed to ensure that basic life support, including CPR (cardio-pulmonary resuscitation) in accordance to the advance directives for one resident (#1). The deficient practice resulted in actual harm to the resident and has the potential to result in advance directives not being followed for additional residents. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care was identified. Findings include: On [DATE] at 4:25 p.m., a condition of IJ was identified. The administrator and the director of nursing (DON) were informed of the facility's failure to ensure that CPR was provided for resident #1. The nurse on duty on [DATE] stated that she resident #1 was a full code and was found the resident with no breath sounds and pulse on [DATE]; however, she did not initiate CPR or called EMS (emergency medical services). The clinical record review revealed that the resident #1 was a full code; and that, resident #1 expired on [DATE]. On [DATE] at 5:06 p.m., the administrator submitted a removal plan which was not acceptable because it failed to include interviews conducted, in-service training provided to staff, specific procedures and timelines involved in the removal plan. A revised removal plan was received on [DATE] at 4:20 p.m. and was accepted. The accepted removal plan included: -Resident rooms had new orange and black labels posted indicating code status; -The nurse who did not initiate CPR was terminated; and, the nurse who knew about the incident but did not follow protocol was placed on probation; -Residents code status was reviewed to ensure that code status match with the physician order and paper copy; -Personnel file review/audit to ensure all staff have current CPR certification; -Facility DNR book audit to ensure all residents had current DNR forms and directives; -Ongoing in-service training on protocol to follow on implementing code status of residents; and, -Ongoing in-service training on who was responsible for making changes in the resident's code status and protocols in place should the resident move to another room. Multiple observations were conducted on the facility implementing their removal plan which included resident rooms with new orange and black labels posted indicating code status. Multiple staff interviews were conducted to ensure all staff training had been completed according to their removal plan. On [DATE] at 8:53 a.m., the administrator was informed that the condition of IJ had been removed. -Resident #1 was admitted on [DATE] with diagnoses of adult failure to thrive, repeated falls, dysphagia, orthostatic hypotension, hyperglycemia, dementia, protein-calorie malnutrition and chronic pain. The baseline care plan dated [DATE] included that the resident had potential for compromised nutritional status, was at risk for fall and required assistance with self-care. The baseline care plan did not include resident's advance directives of code status. The admission MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 8 indicating the resident had moderate cognitive impairment. The specific treatment for healthcare form signed and dated [DATE] included that the resident had a full code status which means that CPR will be employed in the plan of treatment; and, resident will be transferred to the hospital for further evaluation and treatment. The nursing progress note dated [DATE] revealed that the resident attempted to participate in OT (occupational therapy) this afternoon and after 1 ,d+[DATE] minutes, oxygen saturation dropped to 70% on 4 liters of oxygen via NC (nasal cannula). Per the documentation, the oxygen was increased to 5 liters and the head of bed was elevated to 45 degrees. The documentation also included that the resident was hypotensive and required midodrine (vasopressor) as prescribed. The social services note dated [DATE] included a BIMS score of 8 indicating the resident had moderate cognitive impairment. Per the documentation, the resident was alert, oriented with some confusion, was able to make needs known and received assistance with ADLs (activities of daily living). There was no evidence found in the clinical record and facility documentation that resident's code status was changed after it was executed on [DATE]. A nursing progress note dated [DATE] at 6:30 a.m. included the resident was assisted out of bed, morning care was done, had his oxygen on, was sliding out of the wheelchair; and that two persons assisted the resident a sitting position. Per the documentation, the certified nursing assistant (CNA) who assisted left the room due to a shift change; and the licensed practical nurse (LPN/staff #44) was working on taking the resident's BP (blood pressure). The documentation included that the LPN observed a change in skin color and she attempted a sternal rub but there was no response from the resident. It also included that the resident did not have a pulse and breath sounds; and that, the LPN called a CNA to assist the resident into bed. According to the documentation, the LPN notified the director of nursing (DON), nurse practitioner (NP), physician and resident's family. Further, the documentation included that the LPN also notified the mortuary. The documentation did not include whether or not CPR was initiated; and that, EMS (emergency medical services)/911 was called. The nursing note dated [DATE] at 9:47 a.m. included that the facility offered to refer the incident to a medical examiner but the family declined. There was no evidence found in the clinical record and facility documentation that CPR was initiated and/or EMS/911 was called. A physician order note dated [DATE] with no documented time included that the resident's death was determined by assessment and observation by two LPNs (staffs #44 and #74) for absence of vital signs, absence of heart rate and breath sounds. Per the documentation, the physician was notified via text and the resident's body may be released to the mortuary of choice. Further, the documentation included that the physician accepted the nurses' assessment. A review of the facility documentation revealed an interview conducted on [DATE] by the director of nursing (DON) with the LPN (staff #44) who was the nurse on duty at the time of the incident. Per the documentation, the LPN reported that she did not start CPR after transferring the resident with assistance to his bed and did not call EMS. The documentation also included that the LPN did not respond when asked what she would do if she did not know the resident's code status. A telephone interview with the LPN (staff #44) was attempted on [DATE] at 1:39 p.m. but was not successful. There was no answer and the LPN did not return the call. An interview was conducted on [DATE] at 1:55 p.m. with a certified nursing assistant (CNA/staff #3) who stated that if a resident was found non-responsive, she would first try a sternum rub and if there were no response she would start CPR. She stated that she would call for assistance and follow nursing staff direction. The CNA said that she would look on the resident's face sheet to determine the resident's code status. In an interview with another LPN (staff #23) conducted on [DATE] at 2:45 p.m., the LPN said that if she found a resident non-responsive, she would yell for help, ensure that the resident was not bleeding or unsafe, check the resident's vitals and start CPR, if the resident had not opted for a DNR. The LPN said that staff can check the face sheet in the electronic health record (EHR) or check the hard copy form in the CPR/DNR book located in the unit to determine a resident's code status. She further stated that if CPR had been initiated for any resident, it would be documented in the progress notes in the EHR. During the interview, a review of the clinical record was conducted with the LPN (staff #23) who stated that she did not see any evidence that CPR was started for resident #1. An interview was conducted on [DATE] at 3:00 p.m. with a registered nurse (RN/staff #111) who stated that there was a folder on each unit designating which residents are noted to have a DNR in place. She said that the information could also be found on the resident's face sheet in the EHR. The RN stated that the only time a staff would not conduct CPR was if the resident was breathing or had a DNR in place. A review of the clinical record was conducted with the RN who stated that resident #1 was full-code; and based on the clinical record, CPR should have been initiated and documented in the progress notes. She further stated that the risk for not conducting CPR for a resident known to be a full-code could be death. An interview was conducted on [DATE] at 3:11 p.m. with the DON who stated that the expectation was that staff would start CPR if a resident has no breath sounds and no pulse. The DON said that if a staff did not know the resident's code status, CPR should be started; and that, if CPR was initiated or provided, it would be documented in the progress notes. During the interview, a review of the clinical record was conducted with the DON who stated that there was no evidence that CPR was documented as initiated for resident #1 and/or EMS was called. Further, the DON said that the risk for not following the resident's code status and not contacting EMS if a resident had no breath sounds and/or no pulse could be death. An interview was conducted on [DATE] at 10:20 a.m. with an LPN (staff #74) who was also working on another unit at the time of the incident. The LPN stated that she was asked by another LPN (staff #44) to check on resident that staff #44 thought had passed. The LPN stated that it was reported to her that the resident had no apical pulse and no blood pressure. Further, the LPN stated that she was not aware that resident #1 was a full-code. A review of the facility policy entitled Advanced Healthcare Directives revealed that advance healthcare directives, executed in accordance with applicable state law, will be honored by the facility. The facility policy on Cardiopulmonary Resuscitation Certification and First Aid Training included that in accordance with a resident's advance directives, or in the absence of advance directives or a Do Not Resuscitate (DNR) order, prior to the arrival of emergency medical services (EMS), the facility shall provide basic life support including initiation of CPR, to a resident who experiences cardiac arrest.

Based on clinical record reviews, observations, staff interviews, and review of current facility practices and policies, the facility failed to protect the rights of one of 5 sampled residents (#103) to be free from neglect; and, the facility failed to ensure 28 of 52 sampled residents (#'s 111, 1, 24, 70, 109, 56, 124, 6, 114, 101, 99, 44, 116, 97, 31, 41, 26, 33, 115, 105, 68, 107, 102, 95, 35, 38, 57, 120) were free from abuse. Failure to prevent neglect or abuse could result in residents more residents being neglected or abused. Findings include: Regarding Resident #103 -Resident #103 was admitted to the facility for hospice respite services on [DATE] with diagnoses of malignant neoplasm of the kidney, malignant pleural effusion, and acute respiratory failure with hypoxia. The hospital physician progress note dated [DATE] revealed a left PleurX catheter (a tube inserted in the chest wall and into the pleural space to drain fluid and treat conditions like pleural effusions) was placed on [DATE]; and that, the tube was to be drained twice a week. The hospital patient discharge instructions revealed an instruction to drain left PleurX catheter twice a week. The nurse admission record dated [DATE] revealed the resident was awake, responsive, oriented to person; status post left lower lobe aspiration; and that, the resident had a dressing on his left lower chest. The documentation did not include whether or not the resident had a PleurX catheter. The admission observation dated [DATE] included that the resident had expiratory wheezing and decreased breath sounds in the left lower lobe. The documentation did not include whether or not the resident had a PleurX catheter. The hospice physician order recap dated [DATE] revealed an order for oxygen at ,d+[DATE] liters per minute via nasal cannula as needed for shortness of breath. The order recap had no orders regarding the care or draining of the PleurX catheter. The facility physician order recap dated [DATE] orders for bronchodilator inhalers as needed for shortness of breath. There were no orders for the care or draining of the PleurX catheter. Review of the baseline care plan revealed that the resident may require the use of oxygen (O2) for comfort related to end of life care. The goal was that the resident would not have any signs or symptoms of respiratory distress. Interventions included to provide O2 as ordered and check O2 saturation every shift. The baseline care plan did not mention the PleurX catheter or its care. A nursing progress note dated [DATE] included that the resident received bronchodilator inhaler with fair effect; and that, the dressing to the left flank drain was clean, dry, and intact (C/D/I). A nursing progress note dated [DATE] at 6:29 p.m. revealed the resident was assessed by hospice services and there were no new orders for the resident's care. Review of the clinical record revealed no further mention of the PleurX catheter or dressing on the resident's side from [DATE] to [DATE]. The medication administration record (MAR) for [DATE] revealed the resident received bronchodilator inhalation on [DATE] at 12:53 p.m. for SOB. The medication was noted to have been effective. Review of the treatment administration record (TAR) for [DATE] revealed that a weekly skin assessment was completed on [DATE] on the day shift. The Event Report dated [DATE] revealed that the reported was for a dislodged nephrostomy tube (a tube to drain urine from the kidney); and that, the resident had complained of excessive pain to the left side of his chest. Per the documentation, the resident reported the pain intensity as very severe, horrible and the character of the pain as burning. It also included that the physician was notified. 10:32 p.m. on [DATE]. A nursing note dated [DATE] at 11:11 p.m. included that resident #103 had excessive pain from the left chest; and that, the chest tube had been pulled out and the dressing was soaked with watery exudate. Further, the note included that the provider was notified and the resident was transferred to the emergency room (ER). Review of the hospital history and physical dated [DATE] revealed the resident was transferred from the medical center ER to another hospital. Per the documentation, the facility initially thought the PleurX catheter/tube was a nephrostomy tube; and that, the PleurX catheter/tube had to be drained every couple of days. However, the documentation included that the catheter/tube had not been drained since the resident's admission to the facility resulting in the resident being hypoxic and tachypneic and sent to the emergency room . The documentation also included that due to the worsening of the resident's shortness of breath, the resident was transferred from the medical center ER to another hospital where the resident was admitted for the replacement of the PleurX catheter/tube. Further review of the clinical record revealed the resident returned to the facility on [DATE] and expired on [DATE]. An interview was conducted on [DATE] at 3:40 p.m., the licensed practical nurse (LPN/staff #124) who stated that when admitting a new resident at the facility, she would complete the admission observation, conduct skin assessment and a fall risk assessment, transcribe the orders, and would get report from the hospital. Regarding resident #103, the LPN stated that the resident was admitted on [DATE]; and that, the resident had a chest tube and was admitted for hospice services. The LPN also said that she did not get a report from the hospital and she conducted the observations and assessments of resident #103; and that, she conducted the skin assessment with the hospice nurse. She said she saw the PleurX catheter/tube on the resident; and that, the hospice nurse seemed to know all about it. The LPN stated that she transcribed the admission orders, missed the order to drain the tube two times a week and did not document any orders for a dressing change around the tube. Further, the LPN stated that she thought the hospice nurse was taking care of the orders for the tube; and that, there were no supplies that came with the resident for care of the tube. The LPN also said that the PleurX catheter/tube had a [NAME] lock on the end and she replaced the dressing that the hospice nurse had removed. In an interview with another LPN (staff #153) conducted on [DATE] at 3:45 p.m., the LPN stated that he was the nurse that sent the resident to the hospital on [DATE]. The LPN stated that he thought the PleurX catheter/tube was a nephrostomy tube because it was just below the ribs on the side of the resident's back. He said that the catheter/tube was s draining a lot of fluid so he called the nurse practitioner (NP) who ordered to send the resident to the emergency room . Further, the LPN said that prior to this incident, he did not even know that the resident had the PleurX catheter/tube; and that, he discovered the tube when he went to change the dressing which was all soaked in fluid. The LPN also said that when he called the NP, he reported it as a nephrostomy tube and the NP was also not aware that the resident had the PleurX tube. An interview with the director of admissions (DOA/staff #85) was conducted on [DATE] at 10:40 a.m. The DOA stated the admission process begins with her receipt of an inquiry from the hospital or case manager; then, she would review the insurance and then would refer the information to nursing to determine if the facility was able to meet the needs of the resident. The DOA said that after nursing approves the admission, she would obtain and review the orders and complete the necessary documentation. She stated that when the necessary documentation was complete, she would notify the hospital and make transportation arrangements (which usually takes ,d+[DATE] hours) for the admission of the resident at the facility. Regarding resident #103, the DOA stated that resident #103 was admitted on a Saturday; and that, the resident was coming from another city and the facility would have all of the information ready prior to Saturday when the resident was admitted . During an interview with the Director of Nursing (DON) conducted on [DATE] at 11:10 a.m., the DON stated that incident regarding resident #103 was a result of communication breakdown and lack of staff education. The DON stated that the DON reviewed the case of resident #103 prior to the resident's admission at the facility; and that, the DON took note that the resident had PleurX catheter/tube. The DON said that the resident was admitted on a Saturday and the DON planned to educate the staff on the care and draining of the tube the following Monday; but, the DON did not do the education of staff. The DON said that the resident was sent to the hospital shortly thereafter. The DON stated that the DON did not provide education to staff on the care of the PleurX catheter/tube during the 4 days that the resident was at the facility prior to the resident's discharge to the facility. The facility policy on Abuse Prevention defined neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Review of the facility policy on Resident Rights, revealed the it was the resident's right to be free from neglect. Regarding resident #70 and resident #111 -Resident #70 was admitted on [DATE] with diagnoses including dementia, emphysema, and dependence on wheelchair. The Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04 indicating the resident had severe cognitive impairment. The assessment also included that the resident had exhibited verbal and physical behavioral symptoms directed toward others on 1 to 3 days of the 7-day lookback period. Further, the MDS revealed that the resident used a wheelchair for locomotion and required extensive assistance with ADLs (activities of daily living). The behavioral care plan-initiated [DATE] revealed that the resident may exhibit the behaviors of rejection of care, verbal aggression and physical aggression related to dementia, aging and territorial about area in TV room. The goal was that the resident would cause no harm to self or others. Interventions included to monitor the resident and ensure she was redirected away from other residents sitting in area in TV room she prefers. Review of the Behavior and Mood Event Report dated [DATE] at 5:20 p.m. revealed that resident #70 hit another resident (#111) on the right forearm while propelling self from the dining room to the TV room. The nursing progress note dated [DATE] at 5:21 p.m. included that that resident #70 hit another resident (#111) on the forearm; and that, both residents were separated at time of incident. -Resident #111 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia with behavioral disturbances, and age-related physical disability. The resident was discharged from the facility on [DATE]. The MDS assessment dated [DATE] revealed the resident was not able to be interviewed for a BIMS score; and that, the resident had short- and long-term memory impairment and modified independence to make decisions regarding daily tasks. The assessment also included that the resident had fluctuating periods of inattention and disorganized thinking; and that, the resident had exhibited other behavioral symptoms not directed toward others on 1 to 3 days of the 7-day lookback period. Further, the MDS included that the resident used a wheelchair for locomotion and required supervision or limited assistance with ADLs. Review of the Behavior and Mood Event Report dated [DATE] at 5:31 p.m., revealed that resident #111 was hit on the right forearm by another resident (#70); and that, there was no injury. The nursing progress note dated [DATE] at 5:21 p.m. included that resident #111 was hit on the right forearm by another resident (#70); and that, there was no bruising noted. Review of the facility allegation of abuse/neglect investigation report form dated [DATE] revealed an event of [DATE]; and that, resident #111 reported that resident #70 had hit her. There were no witness/es to the event; however, the facility camera recording revealed that resident #70 struck resident #111 on the right forearm. Further, the facility concluded that resident #70 did hit resident #111. Regarding resident #1 and resident #18 -Resident #1 was admitted on [DATE] with diagnoses of senile degeneration of the brain, major depressive disorder, dementia with behavioral disturbance, and Alzheimer's disease. The nursing progress note dated [DATE] revealed that the Behavioral Unit Manager had reported having viewed on camera that resident #18 struck resident #1 at 2:45 p.m. on [DATE]. -Resident #18 was admitted on [DATE] with diagnoses of vascular dementia with other behavioral disturbance, cerebral infarction, eating disorder, and major depressive disorder. The behavior care plan dated [DATE] revealed the resident could exhibit aggression. The goal was that the resident would not cause harm to himself or others. Interventions included to ensure basic needs were met and to document behaviors every shift. Review of the MDS assessment dated [DATE] revealed the resident was not able to be interviewed for a BIMS score; and that, the resident had short- and long-term memory impairment and moderately impaired skills requiring cues and supervision for daily decision making. The MDS also included that the resident had fluctuating periods of inattention and disorganized thinking; had exhibited physical and verbal behavioral symptoms directed toward others on 4 to 6 days of the 7-day lookback period. Further, the assessment included that that the resident used a wheelchair for locomotion; and, required extensive assistance with ADLs. The nursing progress note dated [DATE] revealed that the Behavioral Unit Manager had reported having viewed on camera that resident #18 struck resident #1 at 2:45 p.m. on [DATE]. The Behavior and Mood Event Report dated [DATE] at 5:35 p.m. revealed that resident #18 and resident #1 struck out at each other; and that, neither residents sustained injury. Per the documentation, resident #18 wandered and significantly intruded on the privacy or activities of others. Further, the report included that resident #18 was redirected and staff prevented further contact with resident #1. Review of the facility allegation of abuse/Neglect Investigation Report Form dated [DATE] revealed there were no witnesses to the event of [DATE] and that the incident was observed via video review. The report also indicated that resident #111 related in an interview that resident #70 had hit her. It was also reported that camera recording was reviewed and confirmed that resident #70 struck resident #111 on the right forearm. The report concluded resident #1 was hit by resident #18 and resident #1 hit resident #18 in response. Regarding resident #24 and resident #125 -Resident #24 was admitted on [DATE] with diagnoses of dementia with behavioral disturbance, age-related osteoporosis with pathological fracture, anxiety disorder, and pain. Review of the MDS assessment dated [DATE], revealed the resident had short- and long-term memory impairment and moderately impaired skills requiring cues and supervision for daily decision making. It also included that the resident had fluctuating periods of inattention and disorganized thinking; and, had exhibited verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others on 1 to 3 days of the 7-day lookback period. Further, the MDS included that the resident used a wheelchair for locomotion and required extensive to total assistance with ADLs. The Behavior and Mood Event Report dated [DATE] at 1:51 p.m., revealed that resident #24 was hit by another resident (#125); and that, there were no injuries noted. s. The progress note dated [DATE] at 2:43 p.m. included that resident #24 was at the dining table and was unable to move her wheelchair out of the way of resident #125. Per the documentation, resident #125 reached out and struck resident #24 in the face. -Resident #125 was readmitted on [DATE] with diagnoses that included dementia with behavioral disturbance and impulsiveness. The behavior care plan dated [DATE], revealed that resident #125 could exhibit behaviors of exit seeking, rejection of care, and impulsiveness related to dementia. The goal was that the resident would not cause harm to himself or others. Interventions included to ensure basic needs were met and to document behaviors every shift. The Behavior and Mood Event Report dated [DATE] at 1:49 p.m., revealed that resident #125 hit another resident (#24); and, there were no injuries noted. Review of the MDS assessment dated [DATE] revealed the resident had short- and long-term memory impairment and moderately impaired skills requiring cues and supervision for daily decision making. Per the MDS, the resident had fluctuating periods of inattention and disorganized thinking; and, had exhibited physical behavioral symptoms directed toward others and other behavioral symptoms not directed toward others on 1 to 3 days of the 7-day lookback period. Further, the MDS included that the resident used a wheelchair for locomotion and required extensive to total assistance with ADLs. Review of the facility Allegation of Abuse/Neglect Investigation Report Form dated [DATE] revealed an incident was witnessed by a certified nursing assistant (CNA/staff #138), and a video recording of the event was reviewed in which resident #125 struck resident #24 in the face. The report also indicated that staff intervened and removed resident #125 from the dining room. The report also indicated there was no injury to either resident. The report concluded that resident #125 hit resident #24 in the face. Regarding resident #70 and resident #104 Resident #70 was admitted on [DATE] with diagnoses of dementia, emphysema, and dependence on wheelchair. Review of the behavioral care plan initiated [DATE] revealed that the resident may exhibit the behaviors of rejection of care, verbal aggression and physical aggression related to dementia, aging, being territorial about area in TV room. The goal was that the resident would cause no harm to self or others. Interventions included to monitor resident #70 and ensure she is redirected away from other residents sitting in the area in the TV room she prefers, to ensure basic needs were met, and to document behaviors every shift. The MDS assessment dated [DATE] revealed the resident had a BIMS score of 6 indicating the resident had severe cognitive impairment. It also included that the resident had exhibited physical behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, and had rejected care on 1 to 3 days of the 7-day lookback period. A progress note dated [DATE] included that resident #70 was hit by her roommate (resident #104); and that, resident #70 responded by grabbing the roommate's arms causing scratches to roommate's forearm and right hand. Review of the progress notes dated [DATE] through [DATE], revealed no further altercations between the two residents; and, resident #70 was moved to a different room on [DATE]. -Resident #104 was admitted to the facility on [DATE] with diagnoses including depression, type 2 diabetes mellitus, and calcific tendinitis of both shoulders. A review of the MDS assessment dated [DATE] revealed the resident had a BIMS score of 6 indicating the resident had severe cognitive impairment. It also included that the resident had exhibited physical and verbal behavioral symptoms directed toward others, and had rejected care on 1 to 3 days of the 7-day lookback period. The Behavior and Mood Event Report dated [DATE] revealed that resident #104 accused roommate (resident #70) of stealing a blanket and began to hit the resident #70 who then grabbed the arm and hand of resident #104. Per the documentation resident #104 had scratches on the left arm and right hand as a result of this. The report also indicated that resident #104's behavioral symptoms put resident #104 and others at significant risk for injury. Review of the clinical record of resident #104 revealed a progress note dated [DATE] at 8:12 PM, which stated that at 6:30 PM resident #104 was yelling and hitting her roommate [resident #70]. The note continued, the roommate yelled and grabbed resident #104's arms causing scratches to resident #104's left forearm and right hand. Notifications to resident #104's daughter, nurse manager, administrator, police, case manager, and the DOH were also documented. Review of the progress notes dated [DATE] through [DATE], revealed no further altercations between the resident and the roommate who was moved to a different room on [DATE]. Review of the facility Allegation of Abuse/Neglect Investigation Report Forms dated [DATE] revealed that an interview with the nurse who reported that the incident between resident #70 and #104 occurred outside the door to the residents' room. The report included that resident #104 hit resident #70 who then hit resident #104 in return which resulted in scratches to the left forearm and right hand of resident #104; and that, resident #70 had no injuries. The investigation report also included interviews conducted with resident #70 and resident #104; and that, neither resident recalled hitting the other. Further, the report included a review of the video recording of the event which showed that resident #104 reached out for resident #70 who reached back out for resident #104; and that, the residents were separated quickly. Further, per the documentation, the facility concluded that both residents hit each other. Regarding resident #70 and #109 -Resident #70 was admitted on [DATE] with diagnoses of dementia, emphysema, and dependence on wheelchair. Review of the behavioral care plan initiated [DATE] revealed that the resident may exhibit the behaviors of rejection of care, verbal aggression and physical aggression related to dementia, aging, being territorial about area in TV room. The goal was that the resident would cause no harm to self or others. Interventions included to monitor resident #70 and ensure she is redirected away from other residents sitting in the area in the TV room she prefers, to ensure basic needs were met, and to document behaviors every shift. The MDS assessment dated [DATE] revealed the resident had a BIMS score of 6 indicating the resident had severe cognitive impairment. It also included that the resident had exhibited physical behavioral symptoms directed toward others, other behavioral symptoms not directed toward others, and had rejected care on 1 to 3 days of the 7-day lookback period. The progress note dated [DATE] revealed that resident #70 reached out and hit another resident (#109) in the stomach area when the other resident (#109) was trying to move past resident #70. Review of the Behavior and Mood Event Report dated [DATE] revealed that resident #109 was hit in the abdomen by resident #70 on [DATE] at 3:55 p.m. The report also indicated that resident #70's behavioral symptoms put others at significant risk for physical injury and intrude on the privacy or activity of others; and that, the resident was redirected and that this was an effective intervention. -Resident #109 was admitted [DATE] with diagnoses of chronic obstructive pulmonary disease and type 2 diabetes mellitus. Review of the MDS assessment dated [DATE] revealed that the resident had no memory problems and had not exhibited behavioral symptoms during the 7-day lookback period. The MDS also included that the resident required extensive assistance with ADLs and used a wheelchair for locomotion. The care plan for resident #109 revealed no behavioral problems. The progress note dated [DATE] revealed that resident #109 was attempting to move past another resident (#70) when the other resident reached out and hit resident #109 in the abdomen. Review of the facility Allegation of Abuse/Neglect Investigation Report Forms dated [DATE]. revealed that an altercation occurred when resident #109 tried to pass through a doorway which was partially blocked by resident #70. The report included that staff reported that resident #70 hit resident #109 in the abdomen; and that, the residents were separated and no other incidents occurred that evening. Further, the report concluded that resident #70 punched resident #109 in the abdomen. The Behavior and Mood Event Report dated [DATE] at 1:47 p.m. revealed that resident #70 hit another resident in the abdomen on [DATE] at 3:55 p.m. Per the documentation, resident #109 did not sustain any injury; and that, staff intervened and redirected resident #104 with good effect. Regarding resident #56 and resident #10 -Resident #56 was admitted on [DATE] with diagnoses of dementia with behavioral disturbance, pseudobulbar effect, major depressive disorder, anxiety disorder, and age-related osteoporosis. The behavioral care plan initiated February 24, 2020 revealed that the resident may exhibit the behaviors of verbal aggression, rejection of cares, and making false statements related to dementia, aging, MDDO. The goal was that the resident would cause no harm to self or others. Interventions included to ensure basic needs were met and to document behaviors every shift. The MDS assessment dated [DATE] revealed a BIMS score of 12 indicating the resident had moderate cognitive impairment. The MDS also included that the resident had exhibited verbal behavioral symptoms directed toward others on 1 to 3 days of the 7-day lookback period. Per the assessment, the resident required extensive assistance with ADLs and used a wheelchair for locomotion. The progress note dated February 3, 2023 at 10:40 a.m. revealed that the CNA responded to resident's call for help and found the roommate (resident # 10) hitting, holding and twisting the resident #56's arm. Per the documentation, the residents were separated and there were no injuries noted. The progress notes from February 4 through February 7, 2023 revealed no further interaction with resident #10. -Resident #10 was admitted on [DATE] with diagnoses including dementia with behavioral disturbance and late onset Alzheimer's disease. Review of the MDS assessment dated [DATE] revealed a BIMS score of 06 indicating the resident had severe cognitive impairment. The MDS also included that the resident had exhibited verbal behavioral symptoms directed toward others, other behavioral symptoms not directed at others, and wandering behaviors on 1 to 3 days of the 7-day lookback period. It also included that the resident required extensive assistance with ADLs and used a wheelchair for locomotion. The progress note dated February 3, 2023 revealed that at 10:40 a.m., the CNA found resident #10 hitting, holding and twisting the arm of the roommate (resident #56). Per the documentation, both residents were separated from each other; and, resident #10 was moved to a different room. Review of the behavioral care plan initiated February 4, 2023 revealed the resident may exhibit the behaviors of verbal aggression towards staff, impulsiveness, and wandering related to dementia, aging. The goal was that the resident would cause no harm to self or others. Interventions included to ensure basic needs were met and to document behaviors every shift. The progress notes from February 4 through February 7, 2023 revealed no further interaction with resident #56. Review of the facility Allegation of Abuse/Neglect Investigation Report Form dated February 7, 2023 revealed that resident #10 admitted to grabbing the right arm and twisting it and hitting resident #56. Per the documentation, the facility concluded that resident #10 grabbed and twisted the right arm and then hit resident #56 who reported soreness in the right arm which resolved with rest. Regarding resident #17 and resident #124 -Resident #17 was admitted on [DATE] with diagnoses of dementia with behavioral disturbance and major depressive disorder. The behavioral care plan dated [DATE]revealed that the resident may exhibit the behaviors of physical aggression towards staff, rejection of cares, physical and verbal aggression toward other residents related to dementia. The goal to minimize behaviors and reduce the risk of harming self and/or others secondary to socially inappropriate and/or disruptive behavior. Interventions included to remove the resident from the area if showing physical or verbal aggression toward others, document behaviors every shift and make sure all basic needs are met. Review of the MDS assessment dated [DATE] revealed the resident had a BIMS score of 03 indicating severe cognitive impairment; had fluctuating periods of inattention; and, had delusions. The assessment also included that the resident used a wheelchair for locomotion and required supervision with ADLs. The progress note dated [DATE] at 2:11 p.m. revealed that the nurse responded to yelling and arguing and saw resident #17 and another resident (#124) pointing at each other and blaming one another. Per the documentation, the camera footage review revealed that resident #17 kicked resident #124 on the buttocks and the left leg; and that there were no injuries noted. Review of the Behavior and Mood Event Report dated [DATE] revealed that resident #17 kicked another resident (#124) on [DATE] at 1:08 p.m. The documentation included that both residents did not sustain any injury; and that, staff intervened and redirected resident #17 and prevented further contact with the other resident. It also included that the interventions were effective. -Resident #124 was admitted on [DATE] with diagnoses of dementia with behavioral disturbance, hallucinations, wandering, anxiety disorder, and Alzheimer's disease with early onset. Review of the behavioral care plan initiated [DATE] revealed the resident may exhibit the behaviors of physical aggression, impulsiveness, rejection of mediations, verbalizing hallucinations related to dementia. The goal was to minimize behaviors and reduce the risk of harming self and/or others secondary to socially inappropriate and/or disruptive behaviors. Interventions included to document behaviors every shift, and make sure all basic needs are met. The MDS assessment dated [DATE], revealed that the resident had a BIMS score of 5 indicating severe cognitive impairment; had fluctuating periods of inattention and disordered thinking; had delusions; and, had exhibited verbal behavioral symptoms directed toward others and other behavioral symptoms not directed toward others on 1 to 3 days of the 7-day lookback period. The assessment also included that the resident used a wheelchair for locomotion and required supervision with ADLs. A progress note dated Au [TRUNCATED]

Based on clinical record reviews, staff interviews, reviews of facility investigative documentation, policy and procedure, the facility failed to ensure residents (#106, #84, #90) were free from abuse by failing to protect the residents from further abuse from alleged perpetrators. The deficient practice put residents at increased risks for further abuse. As a result, the Condition of Immediate Jeopardy (IJ ) and Substandard Quality of Care (SQC) were identified. Findings include: On August 22, 2023 at 3:02 p.m., a condition of IJ was identified. The administrator and the Director of Nursing were infomred of the facility's failure to ensure residents were free from abuse by failing to protect the residents from further abuse from the alleged pertpetrator. During the complaint investigation, there were multiple incidents of resident-to-resident abuse/altercations in the secured behavioral unit involving the same alleged perpetrator/s. There was no evidence found that the facility implemented appropriate interventions to protect the residents in the unit from the alleged perpetrator/s. Review of the clinical records of the residents involved with the incident revealed that alleged perpetrator/s had used front-wheel walkers, plastic floor signs, hands, fisits and feet to cause injury to other residents in the unit. The administrator presented a plan of correction (POC) on August 22, 2023 at 7:03 p.m. The administrator was informed that the POC was not acceptable and failed to include the following: the assessment tool to use to identify resident at risk for aggressive/abusive behavior or abuse; identify the resident-specific acivities for the identified residents with aggressive behaviors; education provided to staff; interventions implemented to prevent furthe abuse of residents in the unit; and, include behavior monitoring and documentation. The second POC was received from the administrator on August 22, 2023 at 8:45 p.m. The administrator was informed that the POC was not acceptable and failed to include: timeline for the completion of risk assessment of all residents in the unit; and, effective date for additional staff, adequate staffing and monitoring. A revised POC was received on August 22, 2023 at 10:24 p.m. The administrator was informed that the POC was not acceptable and failed to include: staff responsible for behavioral charting; timeline for completion of risk assessments; and, timeline for revision of care plan with interventions implemented for residents identified with risks. On August 23, 2023 at 10:00 a.m., another POC was received and was accepted at 10:30 a.m. Multiple observations were conducted of the facility implementing their POC which included additional staff in the secured behaioral unit. Multiple staff interviews were conducted to ensure all staff training had been completed according to their POC. On 08/24/23 at 5:00 p.m., the Administrator was informed that the condition of IJ had been abated. Regarding resident #81 (alleged aggressor) and #106 -Resident #81 was admitted on [DATE] with diagnoses of dementia with agitation and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. The behavior care plan dated February 18, 2022 included that the residnt exhibited behaviors of combativeness with cares, yelling out, wandering, punching walls, throwing items, physical aggression with other residents and placing self on the floor from the wheelchair or bed. The goal was that the resident will not cause harm to self or others. Interventions included every 15 minute checks, medications as ordered, make sure all basic needs were met, documenting behaviors, discouraging from hitting others, calling staff for assistance if needed, and if wandering and looking for family, to convey to resident that they were ok. The care plan dated March 1, 2022 revealed the resident had cognitive impairment, visual impairment and decreased communication skills. Interventions included respect the rights not to participate, provide activities of preference or interest, interventions to promote increased participation, and commuicate in e resident's language whenever possible. -Resident #106 was admitted on [DATE] with diagnoses of unspecified dementia with agitation, unspecified psychosis and wandering. The baseline care plan dated April 28, 2022 included the resident may exhibit behaviors of rejection of cares, inappropriate bowel habits, physical agression towards other residents and may exhibit wandering behaviors. Goals included that resident will be able to wander within the common areas, be free of incident to self and others and minimize behaviors and reduce risk of harming self and/or others secondary to socially inappropriate and/or disruptive behavior. Interventions included 15 minute checks, discourage resident from pushing other resident's wheelchair, document behaviors, wanderguard on at all times, direct supervision when outside, evaluate when and where resident wanders and how this affects others. Incident #1: March 14, 2023 The assistant director of nursing (ADON) note dated March 14, 2023 included that according to the video review, resident #81 was going down the hallway in her wheelchair when another resident (#106) came up from behind and began pushing the resident's wheelchair as if to assist the resident. Per the documentation resident #81 hit resident #106 two times then resident #106 hit resident #81 several times and hits were exchanged between the two residents. It also included that staff intervened and no one was injured. The social services note dated March 14, 2023 included that resident #81 was informed to call for staff if she was having issues with any other residents. Per the documentation, the resident confirmed that she was ok, showed the staff her hand and motioned in a way of hitting. It also included that staff told the resident that it was not okay to hit others and it was not safe to anyone. The facility report dated March 14, 2023 included the type of allegation was physical abuse and video surveillance was reviewed. The report revealed that resident #106 started pushing the wheelchair of resident #81 who then hit resident #106. Per the report, resident #106 hit resident #81 back and several hits were exchanged between the two residents. Per the documentation, there were no injuries sustained and the two residents did not require medical treatments. On March 14, 2023, the care plan was revised to include an intervention to discourage resident from pushing other residents wheelchairs; however, no methods of interventions were identified. Incident #2: August 6, 2023 A nursing note dated August 6, 2023 included that a nurse was walking into the hall and witnessed resident #81 attempted to kick resident #106 while grabbing into the walker of resident #106. The documentation included that the review of the video revealed resident #81 was looking into the room of resident #106 who after coming into the hall was grabbed onto the walker by resident #81 who began striking resident #106 while pulling the walker away. The documentation included that resident #106 struck at the hand of resident #81; and, resident #106 grabbed the walker and tried to pull it away. According to the documentation, the nurse walked into the hall and witnessed both residents kicking at each other; and that, resident #81 kicked resident #106 in the elbow. The facility reportable event record dated August 9, 2023 included that resident #81 was see grabbing the walker of resident #106. Per the report, residents #81 and #106 were kicking each other. The report included a nurse interview conducted by the facility during their investigation. According to the report, the nurse had to come back into the hall to see resident #81 was kicking at and grabbing the walker of resident #106 who began kicking back at resident #81 but did not make contact. The report included that the two residents were separated and resident #81 would not let go of resident #106's walker and kept stating that it was hers and not resident #106's. The report also included that the surveillance tape was reviewed and revealed that resident #81 kicked resident #106 in the elbow; and that, resident #81 instigated the situation. Further, the nurse reported that resident #81 first grabbed the walker and began to swing at resident #106 who swatted the hand of resident #81 to get the walker back. The facility concluded that this was a resident to resident altercation; and that, resident #81 thought the walker was hers and tried to get it back resulting in physical contact. Regarding resident #81 (alleged aggressor) and #84 -Resident #84 was admitted on [DATE] with diagnoses of unspecified dementia with other behavioral disturbance and Alzheimer's disease. The behavior care plan dated August 17, 2018 included that the resident had history of exit seeking, refusal of wearing briefs for incontinence of urine, showers and other cares, striking out at staff and other residents, wandering into other resident rooms and helps herself to thier snacks, rummaging through their belongings and packing her belongings related to dementia and delusions. Incident #1: May 11, 2023 The nursing note dated May 11, 2023 included that a CNA witnessed resident #81 hit resident #84 with a wet washcloth on the right shoulder and right arm. Per the documentation, the two residents were separated and there were no injuries noted. The facility report dated May 11, 2023 included that on May 11, 2023 at 6:22 a.m., resdient #84 was sitting in her wheelchair when resident #81 hit the right shoulder and arm of resident #84 with a wet washcloth. The facility report included an undated written statement from staff who wrote that at or around 6:22 a.m. (date of the incident was not indicated), the staff was conducting vitals when she saw resident #81 hitting resident #84 on the right arm and shoulder with a washcloth. The case manager status notification dated May 11, 2023 included that both residents were separated and intervention included 72-hour charting/monitoring for resident #81, to monitor behaviors and to discourage resident #84 from hitting others. Review of the clinical record revealed 72-hour charting was documented on May 13 and 14, 2023. However, there was no charting documented on May 12, 2023. The facility reportable event record dated May 12, 2023 included type of incident as resident-to-resident altercation. Per the documentation, review of the facility camera showed resident #84 was sitting in the hallway outside of resident #81's room; and that, resident #81 wheeled herself up to and hit resident #84 on the arm with a white cloth. It also included both residents were interviewed and were separated from each other. Per the documentation, resident #81 reported that resident #84 was going through, taking her things and cutting up her shoes. It included that when interviewed, resident #84 started talking about other things. The report also included that when the facility reviewed the camera and resident #84 was not seen going into resident #81's room anytime prior to event; and visual inspection of resident #81's shoes revealed no cuts or tears. Incident #2: August 5, 2023 The clinical record of resident #81 revealed the following: -August 1, 2023 - resident was kicking at other residents door and was taunting other residents and telling them to come out; -August 5, 2023 - Staff reported that resident #81 was sitting at the end of the hallway and while staff was helping propel the other resident, resident #81 swung her right arm with closed fists and hit the other female resident on the left side of the face. The facility reportable event record/report dated August 8, 2023 included that a staff member was bring resident #84 back in the hallway from theoutside patio; and while the staff was wheeling resident #84 past resident #81's wheelchair, resident #81 struck out at resident #84. Per the documentation, the video surveillance camera was reviewed and revealed that a staff member moved resident #81 to the side of the hallway then went out to the back patio. Resident #81 then wheeled herself backward to the middle of the hallway. Per the documentation, another resident came in from the patio area and started passing resident #81 on her lft side but stopped. Staff member thaen was seen bringing in resident #84 from the patio and was moving past resident #81 on her right. Per the documentation, resident #81 struck out with a closed fist and made contact with resident #84 as staff and resident #84 was was moving past resident #81. The report included an interview conducted with an unnamed staff who reported that as the staff and other residents began to make their way inside from the patio, resident #81 blocked the entranced way. According to the documentation, resident #81 was asked to back up or move out of the way but the resident refused; and that, the staff tried to move resident #81 but the resident tried to grab the staff. The report also included that as the staff was bringing resident #84 back in, resient #81 swung and hit resident #84 in the face. The facility concluded that this was a resident to resident altercation that was neither provoked or seen. Regarding residents #81 (alleged aggressor) and #90 Resident #90 was admitted on [DATE] with diagnoses of dementia with behavioral disturbance and senile degeneration of brain. The baseline care plan dated December 5, 2022 included that resident may exhibit behaviors of agitation, verbalizing hallucinations, verbal aggression, continually placing self on floor from the wheelchair related to dementia. Interventions included making sure basic needs were met and document behaviors every shift. The facility investigation dated June 16, 2023 included that at 2:50 p.m. on June 15, 2023, a CNA heard resident #81 was yelling from her room and the CNA found resident #90 in the room. Per the documentation, the CNA moved resident #81 to get resident #90 out of the room; and that, resident #81 moved backwards and swung her arms backwards and hit resident #90 on the right upper arm/elbow. Despite documentation of aggressive behaviors of resident #81 to other residents, the clinical record of resident #81 revealed no evidence that new interventions were implemented to prevent resident #81 from hitting or striking at other residents. The behavioral care plan of resident #81 was not revised to include interventions implemented to address the resident's behavior, increase monitoring and supervision and how to prevent resident #81 from potentially abusing other residents since March 15, 2023. Regarding residents #106 (alleged aggressor) and #109 -Resident #109 was readmitted on [DATE] with diagnosis of unspecified dementia with agitation. The behavior care plan dated August 19, 2020 revealed the resident may exhibit wandering behaviors into other personal spaces, combativeness with staff, aggressive behaviors towards other residents related to demntia. Intervention included documenting behaviors and ensuring all basic needs were met. -Resident #106 was admitted on [DATE] with diagnoses of unspecified dementia with agitation, unspecified psychosis and wandering. The baseline care plan dated April 28, 2022 included the resident may exhibit behaviors of rejection of cares, inappropriate bowel habits, physical agression towards other residents and may exhibit wandering behaviors. Goals included that resident will be able to wander within the common areas, be free of incident to self and others and minimize behaviors and reduce risk of harming self and/or others secondary to socially inappropriate and/or disruptive behavior. Interventions included 15 minute checks, discourage resident from pushing other resident's wheelchair, document behaviors, wanderguard on at all times, direct supervision when outside, evaluate when and where resident wanders and how this affects others and remove the resident from other resident's room or unsafe conditions. The MDS assessment dated [DATE] included a BIMS score of 3 indicating the resident had severe cognitive impairment. The facility investigative report included that review of camera footage revealed resident #106 walked behind resident #109 who was in the wheelchair. The report included that the nurse who reported that she was standing at her medication cart when she heard a raised voice, looked over and saw resident #106 pushing the wheelchair of resident #109 who attempted to push back on her wheelchair. It also included that resident #106 was seen hitting resident #109 twice on the shoulder before the nurse could get to them. An interview was conducted with the administrator on August 22, 2023 at 10:10 a.m. The administrator stated that the 400 hallway where these incidents occurred was for higher acuity dementiat with behavior unit. The Administrator stated that there was an increase in resident-to-resident altercations in July 2023; and that, resident #106 had been discharge to another facility and resident #81 was in process of getting discharge. An interview was conducted on August 23, 2023 at 11:15 a.m. with a CNA (staff #76) who stated that abuse comes in many ways i.e., physical, mental, emotional; and that it could mean hitting, grabbing, pushing, name calling, teasing and if staff are not providing the good care. The CNA stated that he can see or hear abuse but mainly if the resident was acting out and if resident begin to act differently then something was going on. The CNA stated that if he witnessed abuse happening, he would remove the resident to safety, ensure that the resident was okay and notify the charge nurse. The CNA said that if the alleged perpetrator was the nurse, he would go to someone else to report it. The CNA stated that staff, provider, family, visitor or anyone can abuse a resident. The CNA stated that he had abuse in residents at the facility such as residents pushing others of the way or yell at one another if they were mad or angry or if someone was in their room. An interview with the activity assistant (staff #7) was conducted on August 24, 2023 at 11:41 a.m. Staff #7 stated that she remembered the incident between resident #81 and #106 on March 14, 2023. She stated that resident #81 does not like resident #106 and both residents should not be left together because of history. Staff #7 stated that she was never interviewed regarding the incidents between resident #81 and #106. In an interview with a CNA (staff #99) conducted on August 23, 2023 at 1:00 p.m., the CNA stated that abuse was failure to care for a resident in the way they should be treated; and, it could be verbal, pysical and spiritual. The CNA stated that if she sees abuse happening, she will report the incident to her charge nurse and if not available, she would report it to the assistant director of nursing (ADON). The CNA said that if she sees a resident going towards a resident that they had an encounter before, she would step in and try to re-direct or put the residents in their room and/or offer them snacks. 49332 Regarding residents #95 (alleged aggressor) and #106 -Resident #95 was admitted on [DATE] with diagnoses of delusional disorder, major depressive disorder, trisomy 21 (Downs Syndrome), and altered mental status. The care plan dated May 13, 2021 revealed the resident exhibited behaviors of physical aggression towards staff and the inability to tolerate other residents coming into her room. Interventions included encouraging the resident to come and get a staff member or to use the call light if another resident was wandering into their room. The Minimum Data Set assessment (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 1 indicating resident had severe cognitive impairment. Further review of the resident's care plan revealed that no new interventions were implemented and that the care plan was not reviewed and updated on 8/6/23. -Resident #106 was admitted on [DATE] with diagnoses of unspecified dementia with agitation, unspecified psychosis and wandering. The baseline care plan dated April 28, 2022 included the resident may exhibit behaviors of rejection of cares, inappropriate bowel habits, physical agression towards other residents and may exhibit wandering behaviors. Goals included that resident will be able to wander within the common areas, be free of incident to self and others and minimize behaviors and reduce risk of harming self and/or others secondary to socially inappropriate and/or disruptive behavior. Interventions included 15 minute checks, discourage resident from pushing other resident's wheelchair, document behaviors, wanderguard on at all times, direct supervision when outside, evaluate when and where resident wanders and how this affects others and remove the resident from other resident's room or unsafe conditions. The MDS assessment dated [DATE] included a BIMS score of 3 indicating the resident had severe cognitive impairment. The facility investigative report dated August 6, 2023 revealed that resident #95 was yelling and an unnamed certified nursing assistant (CNA) found resident #106 inside the room of resident #95 and was attempting to push resident #95 in her wheelchair without permission. Per the documentation, the CNA redirected resident #106 out of the room and resident #95 told the CNA that resident #106 had hit her right shoulder. An interview conducted with an assistant Director of Nursing (ADON/staff #85) was conducted on August 23, 2023 at 3:20 p.m. The ADON stated that the CNA mentioned in the incident on August 6, 2023 was CNA (staff #66). During an interview with an activity assistant (staff #7) conducted on August 23, 2023 at 10:30 a.m., staff #7 stated that abuse means not helping or giving care, not giving the resident anything to eat or drink, yelling, hitting and being mean to the resident. Staff #7 stated that if she witnessed abuse, she ould go tell the nurse; and, if the nurse was the alleged staff, then she will do report the incident to the DON (Director of Nursing). She stated that she had seen resident-to-resident altercations i.e., she had seen resident pushed another resident. She stated she thinks the residents in the unit did not really know better; and that, she does not think that the alleged residents mean to hurt someone. In an interview with the CNA (staff #66) conducted on August 24, 2023 at 11:37 a.m. the CNA stated resident #95 was heard yelling at approximately 9:45 a.m. on August 6, 2023 and was found resident #95 sitting in her wheelchair in the doorway of her room facing the hallway. The CNA stated that resident #106 was standing behind resident #95 trying to push resident #95's wheelchair; and that, resident #95 reported that she did not want to go anywhere. The CNA stated that she redirected resident #106 back to her own room. The facility policy on Safety and Supervision of Residents included that the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision are facility-wide priorities.Resident supervision is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs and identified hazards in the environment. The individualized, resident-centered approach to safety addresses safety for individual residents. The care team shall target interventions to reduce individual risks related to hazards in the environment including adequate supervision.

Based on observations, interviews, facility documentation, policies review, the Center for Disease Control (CDC) guidelines and the Centers for Medicare and Medicaid Services (CMS) guidance, the facility failed to maintain an effective infection control program, by allowing COVID-19 positive residents who were not wearing masks to roam halls that housed COVID-19 positive residents and COVID-19 negative residents, allowing staff not wearing full personal protective equipment (PPE) and not donning PPE properly to be in the same halls, and having the fire doors to the halls and the residents' room doors open. As a result, the Condition of Immediate Jeopardy (IJ) was identified. The census was 99. Findings include: On December 15, 2020 at 10:55 a.m., the Condition of Immediate Jeopardy (IJ) was identified. The Administrator (staff #122 ) was informed of the facility's failure to implement infection control procedures, as doors to rooms with COVID-19 positive residents were open along with the doors of residents who were COVID-19 negative and one resident who was on neutropenic precautions who resided on the same halls (Hall 100 and Hall 200); the fire doors to Hall 100 and Hall 200 were open, COVID-19 positive residents were wandering the hall, touching things, including the handrails and not wearing face masks, and the staff were observed in the same halls not wearing full PPE. The Administrator presented a plan of correction on December 15, 2020 at 3:19 p.m. The Administrator was informed that the plan of correction needed to address additional processes, in order to correct the identified concerns. A revised plan of correction was presented on December 15, 2020 at 3:26 p.m. and was accepted at 3:27 p.m. The plan of correction included for all four units to be designated as COVID-19 units and the fire doors to remain closed on the units; signage will to be added to designate clean and contaminated areas with PPE requirements to enter these areas; a zipper barrier bubble will be constructed on Hall 100 and Hall 200 to create an area for staff to don PPE prior to entering a COVID-19 unit and the zipper walls will remained closed unless staff are entering or exiting the unit; staff will wear full PPE while on a unit (face shield, N95 covered with a surgical mask, goggles and gown); staff will don full new PPE (face shield, N95 covered with a surgical mask, gown and gloves) when entering a room where the resident is COVID-19 negative or unknown. Staff will clean their face shield prior to entering a resident's room who is COVID-19 negative and upon leaving a room, staff will remove the PPE, clean the face shield, and replace the surgical mask. Signs will be placed outside the residents' rooms regarding donning and doffing PPE, cough etiquette, and hand hygiene. Dietary will deliver meals past the first zipper barrier into the bubble area and announce to designated staff working in the contaminated hall that meals are ready. Dedicated staff will unzip the barrier to retrieve the meals. After the meals have been served, the food cart will be pushed out of the building through the back-exit door, where it will be sanitized by kitchen staff and then returned to the kitchen. Laundry and garbage on all halls will be removed through the back door exits. The room door to the resident who is on neutropenic precautions will remain closed, staff will don full new PPE (face shield, N95 covered with a surgical mask, goggles, gloves and gown) before entering the room, staff will clean their face shield prior to entering a resident's room, and will remove the PPE, clean the face shield, and replace the surgical mask, and signs will be placed outside the room regarding donning and doffing PPE, cough etiquette, and hand hygiene. Additional staff training will be provided for PPE, barriers, and unknown/COVID-19 negative will begin December 15, 2020. Any staff reporting to work, will receive training prior to reporting to duty. -During the entrance conference conducted on December 14, 2020 at 10:45 a.m., the Director of Nursing (DON/staff #72) provided a facility map and stated Hall 100 and Hall 200 were COVID-19 Units, but that there were a few residents on the halls that were COVID-19 negative. She identified 4 resident rooms on the 100 hall and one resident room on the 200 hall of residents who were COVID-19 negative. The majority of the residents on hall 100 and hall 200 were COVID-19 positive. The DON stated that the entire building was on precautions due to a COVID-19 outbreak. The DON stated all staff in the halls should be wearing protective eyewear and an N95 mask. She stated that staff providing resident care will wear a reusable gown while in the residents' rooms. The DON also stated that administrative staff that do not provide resident care are not required to wear a gown while on the units. On December 14, 2020 at 12:05 p.m., the fire doors to Hall 100 and Hall 200 were observed open. The doors opened to the centralized nursing station in the middle of the facility. Regarding hall 200: An observation was conducted of Hall 200 on 12/14/2020 at 12:15 p.m. Multiple residents' room doors were observed opened. The residents' room doors opened included a resident who was on neutropenic precautions that was COVID-19 negative. During an observation conducted of Hall 200 on 12/14/2020 at 2:21 p.m., a resident positive for COVID-19 was observed in the hall not wearing a face mask or gloves using the handrail in the hall to scoot in the wheelchair. A staff member not wearing a gown but wearing an N95 and a face shield, was observed encouraging the resident to return to the resident's room. After the resident returned to the room, no disinfection of the hand rail was observed. Another resident positive for COVID-19 who resided on hall 200 was observed in the hall on 12/14/2020 at 2:28 p.m. without having a face mask donned. An observation of Hall 200 was conducted on 12/14/2020 at 3:21 p.m. A resident positive for COVID-19 was observed walking down the hall with no face mask on. The resident was using a cane in one hand and using the hall hand rail to walk with the other hand. The resident was observed to walk past resident rooms with their room doors open, past the shower room continuing towards the main dining when another staff member donned in an N95 and a face shield but not wearing a gown, intervened and asked the resident to return to their room. After retrieving an item from the main dining room, the staff member assisted the resident back to their room. On 12/14/2020 at 4:15 p.m. on Hall 200, a resident who was COVID-19 negative (who later tested COVID-19 positive on 12/15/2020) was observed on a gurney without having a face mask donned. A staff member was asked if the resident needed to don a face mask. The staff member, wearing an N95 and a face shield but not wearing a gown, did not respond. The resident was wheeled down hall 200 past multiple resident rooms with their doors open without wearing a face mask out of the facility. On 12/15/2020 at 10:20 a.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff#84). The LPN stated that yesterday (12/15/2020) multiple residents tried to come out of their rooms. She stated that two of the residents that were in the hall yesterday were repeat offenders and have to be reminded often to return to their rooms. The LPN stated that clinical and non-clinical staff are in the COVID-19 hall and that all staff share the nursing station and other common areas. Regarding the resident being transported out of the facility, the LPN stated a resident being transported through the halls out of the facility should be wearing a mask. Later at 3:20 p.m., the LPN stated that the resident being transported on the gurney on 12/14/2020 had tested positive for COVID-19 on 12/15/2020. An interview was conducted with a Certified Nursing Assistant (CNA/staff #67) on 12/15/2020 at 1:25 p.m. The CNA stated the process for transferring residents to outside appointments or the hospital included placing a face mask on residents before they leave their room. Staff #67 stated that it did not matter if the resident was COVID-19 positive or COVID-19 negative; all residents need to have a face mask on before they leave their rooms. Regarding hall 100: An interview was conducted on December 14, 2020 at 12:10 p.m. with the DON (staff #72) on Hall 100 (COVID-19 Unit). She stated that the staff were not required to wear gowns in the hall. She said that there are gowns hanging on hooks for staff to use when they enter the resident's room. The hooks were observed on the outside of the doors of each resident's room. One room had three hooks and two gowns were observed hanging on the middle hook. The two gowns had different staff names on them. Staff #72 stated that there was only supposed to be one gown on each hook to prevent cross contamination. An interview was conducted on December 14, 2020 at 12:16 p.m. with a Certified Nursing Assistant (CNA/staff #5), who stated she had received training on donning and doffing PPE. The CNA stated she was required to wear a N95 with a surgical mask over it when on Hall 100 and Hall 200 in the hall. She said that eye protection is optional, but that she chooses to wear it when she is in the hall. She stated the doors to the residents' rooms are kept open. During this time, all the doors on Hall 100 were observed to be open along with the fire doors leading to the centralized nursing station in the middle of the facility. The CNA said that since the doors were open, the hall was contaminated. She said there was a risk of becoming contaminated if she did not wear a face mask and goggles in the hall. On December 14, 2020 at 12:25 p.m., a CNA (staff #39) who was donned in an N95 and eye protection was observed on Hall 100 (COVID-19 Unit) without a gown on. She took a gown from a hook on the door of a resident's room who was COVID-19 negative and had [MEDICAL CONDITIONS]. She donned the gown before entering the resident's room. The door to the resident's room along with multiple other residents' room doors and the fire doors to the hall were all observed opened. On December 14, 2020 at 1:13 p.m., the Administrative Assistant (staff #60) was observed walking down Hall 100 to let staff know that a family member was at the window to see one of the residents. She was wearing a N95 with a surgical mask over it. She was not wearing eye protection or a gown. The door to multiple residents' rooms and the fire doors to the hall were observed opened. An interview was conducted on December 14, 2020 at 3:35 p.m. with the DON (staff #72). She acknowledged that the residents' room doors were open on Hall 100 and Hall 200 and the fire doors to these halls were also open. The DON also acknowledged that there was no barrier between the halls and the centralized nursing station in the middle of the facility. She stated that she considered the entire building infected with the COVID-19 virus. The DON said that once staff left the reception area through the closed fire doors and entered the area where the centralized nursing station was located, staff were in a contaminated area. She stated that anyone in a COVID-19 unit/contaminated area should be wearing a N95 with a surgical mask over it, eye protection, and a gown. The DON acknowledged that none of the staff were wearing gowns while in the halls on Halls 100 and 200. The facility's policy Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures dated March 2020 stated that for residents with known or suspected COVID-19 staff are to wear gloves, isolation gown, eye protection and an N95 or higher-level respirator if available ( a facemask is an acceptable alternative if a respirator is not available); and the resident is placed in a private room with a dedicated bathroom (if available) and close the door: or the resident is cohorted per national, state, or local public health authority recommendations. If there are COVID-19 cases in the facility staff are to wear all recommended PPE (i.e., gloves, gowns, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms. Residents are restricted (to the extent possible) to their rooms except for medically necessary purposes. When residents leave their room, they wear a facemask, perform hand hygiene, limit their movement in the facility, and perform social distancing (efforts are made to keep them at least 6 feet away from others). The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic guidance stated that if admitted , place a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection in a single-person room with the door closed. The CDC Preparing for COVID-19 in Nursing Homes guidance stated that because of the higher risk of unrecognized infection among residents, universal use of all recommended PPE for the care of all residents on the affected unit (or facility-wide depending on the situation) is recommended when even a single case among residents or HCP is newly identified in the facility; this could also be considered when there is sustained transmission in the community. The guidance also included residents should wear a cloth face covering or facemask (if tolerated) whenever they leave their room, including for procedures outside the facility. The CDC Responding to Coronavirus (COVID-19) in Nursing Homes stated facilities should assign dedicated healthcare personnel (HCP) to work on the COVID-19 care unit. To the extent possible, restrict access of ancillary personnel (e.g., dietary) to the unit. Regarding meal service: -On December 14, 2020 at 12:25 p.m., a CNA (staff #39) was observed on Hall 100 laying a cardboard box that contained a lunch meal on top of the PPE cart by the resident's room who had [MEDICAL CONDITION] and place a second cardboard box that contained a lunch meal on top of another PPE cart. She then returned to the resident's room who had [MEDICAL CONDITION] and began donning PPE. The CNA took a gown from a hook on the outside of the door of the resident's room [ROOM NUMBER], don the gown, and took the cardboard box into the resident's room and placed it on the resident's mobile tray. She removed the containers of food from the cardboard box and placed them on the resident's mobile tray. She then sat down and assisted the resident with eating the meal. The CNA's gown was observed to be loosely tied around the neck and opened at the back. The gown hung low around the shoulders exposing the CNA's clothing in the back and upper shoulder area. An interview was conducted on December 14, 2020 at 2:33 with staff 39, who stated that she received training on donning and doffing PPE and meal service. Staff #39 said she needed to place the cardboard box containing the meal on top of the PPE cart, so she could don her PPE and thought this was okay. She then acknowledged it was possible that the PPE cart was contaminated. She acknowledged that she had put the cardboard box on top of the resident's mobile tray, which meant the mobile tray could be contaminated and increased the possible risk of transmission to the resident. She said she knew the back of her gown was open when she was assisting the resident with eating the meal, but that it is difficult to make sure her back area was covered She stated that if her back is not covered, her clothing can become contaminated. -On December 14, 2020 at 12:55 p.m., a CNA (staff #94) was observed on Hall 200 laying a cardboard box that contained a lunch meal and a Styrofoam cup with a drink in it on top of the PPE cart outside a resident's room who was COVID-19 positive while she donned her PPE. She stated that she was not trained to serve meals. The CNA stated that she thought it was possible that the PPE cart could be contaminated which would mean the cardboard box and Styrofoam cup could be contaminated. She acknowledged that she took the cardboard box and the Styrofoam cup into the resident's room and placed them on the resident's mobile tray. She said that meant the tray could possibly be contaminated. An interview was conducted on December 15, 2020 at 3:35 p.m. with the DON (staff #72), who stated that when the CNAs serve meals to the residents in their rooms, they should sanitize their hands, don PPE, remove the meal from meal cart rack and place it on the resident's mobile tray or nightstand. She said the meal should remain on the rack until it is served to prevent cross contamination. The CDC, Correct Sequence for Donning Personal Protective Equipment (PPE), stated the gown must fully cover torso from neck to knees, arms to end of wrists, and wrap around the back. Fasten in the back of neck and waist. The facility's policy regarding Assistance with Meals stated the nursing staff and/or feeding assistants will take the food trays into the resident's rooms. All employees who provide resident assistance with meals will be trained and shall demonstrate competency in the prevention of food borne illness, including personal hygiene practices and safe food handling. Regarding COVID-19 screening: On December 15, 2020 at 8:10 a.m., the Assistant Director of Environmental Services (staff #1) who was not wearing a mask, the Environmental Director (staff #76), and the Laundry Supervisor (staff #87) were observed in the reception area waiting to be screened for COVID-19. The Administrative Assistant (staff #60) was attempting to screen the surveyor, but the thermometer did not work. She went into the facility to see if she could find another thermometer. During this time, staff #1 and staff #87 each tried to use the thermometer and did not sanitize their hands or the thermometer between uses. Staff #1 and staff #87 were not observed to practice social distancing and were approximately 1 to 3 feet apart. When staff #60 returned without a thermometer, staff #1 stated that he was going to look for another thermometer and went into the facility without being screened. An interview was conducted on December 15, 2020 at 10:05 a.m. with staff #1, who stated that he has received training on the screening process and social distancing. He said he knew that he did not complete the screening process. He said he was in a hurry and wanted to find a thermometer. Staff #1 said that he should have disinfected the thermometer after he tried to use it. He also stated that he knows he is supposed to practice social distancing and acknowledged that he did not do this. An interview was conducted on December 15, 2020 at 10:10 a.m. with staff #87, who stated that she had received information on the screening process. Staff #87 said she is supposed to sanitize her hands and take her temperature, and then she usually wipes down the thermometer. She said that she uses an alcohol wipe to clean the thermometer before she uses it because she does not know who has handled the thermometer and it may be contaminated. She said that she is supposed to practice social distancing when she is in the facility, which is being 6 feet apart from another person. Staff #87 acknowledged that she and staff #1 did not practice social distancing this morning during the screening process. During an interview conducted on December 15, 2020 at 3:35 p.m. with the DON (staff #72), the DON stated that everyone must be screened for COVID-19 before entering the facility. She also stated that it is her expectation that staff practice social distancing during the screening process, which is being at least 6 feet apart from another person. She stated that the thermometer should be sanitized between uses to prevent cross contamination. Review of the facility's policy Coronavirus Disease (COVID-19) - Infection Prevention and Control Measures stated anyone arriving at the facility (including staff) is screened for fever and symptoms of COVID-19 before entering. The CDC, Preparing for COVID-19 in Nursing Homes, stated to screen all HCP at the beginning of their shift for fever and symptoms of COVID-19. Actively take their temperature and document absence of symptoms consistent with COVID-19. The CDC, Disinfection and Sterilization, stated to perform low-level disinfection for noncritical patient-care surfaces (e.g., bedrails, over-the-bed table) and equipment (e.g., blood pressure cuff) that touch intact skin. The CDC guidance regarding Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic revealed everyone entering the healthcare facility are to be screened for symptoms consistent with COVID-19 or exposure to others with [DIAGNOSES REDACTED]-CoV-2 infection and ensure they are [MEDICATION NAME] source control. Take steps to ensure that everyone adheres to source control measures and hand hygiene practices while in a healthcare facility. Provide supplies for respiratory hygiene and cough etiquette, including alcohol-based hand sanitizer (ABHS) with 60 - 95% alcohol, tissues, and no-touch receptacles for disposal at healthcare facility entrances. Regarding environmental infection control the guidance stated routine cleaning and disinfection procedures (e.g., using cleaners and water to preclean surfaces prior to applying an EPA-registered, hospital-grade disinfectant to frequently touched surfaces or objects for appropriate contact times as indicated on the product's label) are appropriate for [DIAGNOSES REDACTED]-CoV-2 in healthcare settings. Review of CMS guidance for Infection Control and Prevention of Coronavirus Disease 2019 (COVID-19) in Nursing Homes states to increase the availability and accessibility of alcohol-based hand rubs (ABHRs) and reinforce hand-hygiene practices at healthcare facility entrances. The guidance included providing additional work supplies to avoid sharing (e.g., pens, pads,) and disinfecting workplace areas. Regarding PPE: During an interview conducted with maintenance staff (staff #91) on 12/14/2020 at 12:17 p.m., staff #91 stated that staff had been educated on PPE. She stated that staff are required to wear an N95 and a face shield when the halls. Staff #91 stated that protective gowns are not worn unless staff are in a resident's room providing care or cleaning. After being screened on 12/14/2020 at 12:41 p.m., a staff member entered the facility donned in a N95 onto the COVID unit. The staff member was not observed to be wearing protective eyewear or a gown. On 12/14/2020 at 12:42 p.m., a Social Services staff (staff #17) wearing an N95 was observed going to the DON's office which was located at the beginning of Hall 100 (COVID-19 hall) and then to the nurses' station where she used the copy machine. Staff #17 was not observed to be wearing protective eyewear or a gown. Multiple staff members were observed working in and around the nurses' station. Staff #17 then walked to the front lobby and retrieved an item from the front lobby desk. The social worker then entered an office across from the receptionist desk. During an interview conducted on 12/14/2020 at 12:50 p.m. with staff #17, she stated that she wears an N95 mask while in the facility. Staff #17 stated that she is only required to wear a mask and that she wears her prescription eyewear as her protective eyewear. She stated that she is able to go into the nurses' station to use the copy machine and is not concerned about the spread of infection because those staff members wear gowns in the residents' rooms. She also stated that she does not provide resident care. Staff #17 stated the required PPE for staff on the COVID unit is gloves, gowns, masks, and face shields. On 12/14/2020 at 2:30 p.m., an observation was made of Hall 100. A housekeeper (staff #93) was observed in the hall transporting soiled linen. Staff #93 was observed wearing an N95 but was not observed to be wearing a gown or protective eyewear. Following this observation, an interview was conducted with the housekeeper. The housekeeper stated that staff on the COVID unit are required to wear an N95 mask and protective eyewear while in the hallway. Staff #93 stated that when performing laundry service, staff will wear an apron, a facemask, and protective eyewear. The facility's Coronavirus Disease (COVID-19) Infection Prevention and Control Measures policy stated this policy is based on current recommendations for standard precautions and transmission-based precautions, environmental cleaning and social distancing for COVID-19. While in the building, personnel are required to strictly adhere to established infection prevention and control policies including appropriate use of PPE, transmission-based precautions where indicated and laundry practices. To address asymptomatic and pre-symptomatic transmission, universal source control is being implemented. The policy included that if there are COVID-19 cases in the facility, staff will wear all recommended PPE (i.e., gloves, gown, eye protection and respirator or facemask) for the care of all residents on the unit (or facility-wide based on the location of affected residents), regardless of symptoms. The facility's policy regarding soiled laundry and bedding included soiled laundry/bedding shall be handled in a manner that prevents gross microbial contamination of the air and persons handling the linen. Anyone who handles soiled laundry must wear protective gloves and other appropriate protective equipment (e.g., gowns if soiling of clothing is likely). The CDC Interim Infection Prevention and Control Recommendations for Healthcare Personnel during the Coronavirus Disease 2019 (COVID-19) Pandemic regarding implementing universal use of PPE stated HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 infection. Wear eye protection in addition to the facemask to ensure the eyes, nose, and mouth are all protected from exposure to respiratory secretions during patient care encounters. Recommended infection prevention and control practices when caring for a patient with suspected or confirmed [DIAGNOSES REDACTED]-CoV-2 infection included donning eye protection (i.e., goggles or a face shield that covers the front and sides of the face) upon entry to the patient room or care area. Management of laundry, food service utensils, and medical waste should also be performed in accordance with routine procedures. Regarding abating IJ: Multiple observations were conducted in the morning and midday on December 17, 2020, of the facility implementing their plan of correction. Staff in-services had been completed and staff interviewed were knowledgeable of infection control procedures, including required PPE permitted to work with residents on any unit. Also, units had signage indicating the required PPE for each unit and details on donning and doffing procedures. Every hallway had a double barrier in place. In-between the outside and inside closed doors or plastic barriers was an area for staff to don and doff PPE. All staff members were observed wearing the correct PPE while on the units and while providing individual care to residents. There was an observation of laundry and dietary services using a designated exit from the units. These exits allowed carts to be sanitized in a designated area outside of the building. The carts that enter the COVID-19 units were not allowed back into the facility until they have been properly sanitized. As the facility was implementing their plan of correction and staff were knowledgeable about the new processes that had been put into place, and there were no additional concerns identified, the Condition of Immediate Jeopardy was abated at 2:10 p.m. on December 17, 2020.

Based on clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility neglected to ensure one resident (#4) was free from physical abuse involving another resident (#265). The deficient practice has the potential for further abuse resulting in physical harm to residents. Findings include: -Resident #4 was admitted to the facility on (MONTH) 24, (YEAR), with [DIAGNOSES REDACTED]. A quarterly Minimum Data Set (MDS) assessment dated (MONTH) 6, (YEAR) included the resident had short and long term memory problems and was severely impaired with cognitive skills for daily decision making. The MDS also included the resident required extensive to total dependence with activities of daily living. The care plan for behavioral symptoms included the resident has a history of showing verbal and physical aggression. Interventions included cares provided per resident's unique preferences and routines, document any and all behaviors every shift and to report any change in behaviors. Regarding the incident on (MONTH) 22, 2019: Review of a program manager progress note dated (MONTH) 23, 2019 revealed that on (MONTH) 22, 2019, a CNA (Certified Nursing Assistant) heard loud talking in the resident's room. The CNA entered the room, and the resident's roommate (resident #265) was standing next to resident #4 and her covers had been removed. Resident #265 was telling resident #4 to get up and resident #4 then hit the hand of resident #265, then resident #265 hit resident #4 in the chest. A nursing note dated (MONTH) 23, 2019 included that resident #4 had no complaints of acute pain related to hitting roommate's hand and after being shaken and hit by her roommate (resident #265). Regarding the incident on (MONTH) 30, 2019: A physician note dated (MONTH) 30, 2019 included that yelling was heard and a CNA found resident #4 face down next to the bed, with the bolster propped open, and blood was noted on resident #4's head. Resident #4 was awake, readily consoled, was cooperative and was no longer crying. Physical examination included a laceration to the right forehead measuring 2.5 cm (centimeters) to 3 cm, the right eye was swollen shut, right cheek was bruised and swollen, had a right knee bruise and had a periorbital bruise. A fall from the bed landing face down was suspected and the resident was transported to the ED (emergency department). The hospital emergency room documentation dated (MONTH) 30, 2019 included the resident had a fall with laceration and direct blow. The character of symptoms included pain, bleeding, swelling, ecchymosis, abrasion and contusion. Location of the injury was right forehead, face and periorbital eye(s). Physical examination included swelling and ecchymosis, 5.5 cm (centimeters) of full thickness avulsed, stellate laceration of the right eyebrow and right forehead, superficial skin tear to the right dorsal wrist and dorsal swelling of the right wrist with mild deformity. The x-ray of the right wrist revealed a comminuted [MEDICAL CONDITION] distal radius. Impressions included closed head injury, right facial laceration 5.5 cm with complex repair, skin tear to right wrist, comminuted [MEDICAL CONDITION] distal radius, right knee contusion and closed nasal fracture. A nursing note dated (MONTH) 31, 2019 included that resident #4 was heard screaming from her room. Resident #4 was lying face down on the floor next to the bed and was crying. The roommate (resident #265) was standing next to her and was holding the bedding of resident #4. The note also included that resident #4 was bleeding from her head and nose, and was transported to the ED. Another nursing note dated (MONTH) 31, 2019 revealed the report from the hospital included the resident sustained [REDACTED]. A physician progress notes [REDACTED]. Per the note, resident #4 stated Mother hit her. The note included the resident had bilateral nasal fractures, the right had sutures over the right eyebrow and the eye was less swollen and she was able to open it. -Resident #265 was admitted to the facility on (MONTH) 5, (YEAR), with [DIAGNOSES REDACTED]. A behavior care plan dated (MONTH) 5, (YEAR) revealed the resident exhibited behaviors of striking out, wandering and refusing medications. A goal was that the resident would not cause harm to self or others. Approaches included the use of a wander guard, documenting behaviors and to make sure all basic needs were met. Regarding the incident on (MONTH) 22, 2019: Review of the physician progress notes [REDACTED].#265 was frequently hitting staff and trying to elope. Under assessment it included the resident had dementia with behaviors. The care plan for cognitive loss and dementia dated (MONTH) 11, 2019 included the resident had physical and aggressive behavioral symptoms towards other residents and/or staff. The care plan included that others had been hit, struck, kicked, shoved and/or scratched by resident #265. The goal was the resident will not harm self or others. Approaches included avoiding over-stimulation and maintain a calm approach and a calm environment for the resident. A program manager progress note dated (MONTH) 16, 2019 revealed that resident #265 wandered into other resident's rooms and laid on their beds. According to a neurology consultation note dated (MONTH) 18, 2019, the resident continued to have significant behavior issues and ongoing aggressive behaviors of hitting at staff and attempts to elope from the facility. Under assessment it included a [DIAGNOSES REDACTED]. A nursing progress note dated (MONTH) 20, 2019 included the resident continued to wander from room to room and needed constant redirection. Another nursing progress note dated (MONTH) 20, 2019 revealed that resident #265 continued to need redirection and close supervision during interaction with other residents, was wandering/pacing down the hallways and was wandering into other resident's rooms and invading on their privacy. On (MONTH) 21, 2019, a nursing progress note documented the resident was wandering into various rooms and required constant redirection from staff. Resident #265 was refusing assistance and use of the wheelchair, was constantly looking for children and attempted to open all locked doors. A nursing progress note dated (MONTH) 22, 2019 included the resident displayed exit seeking behaviors and had asked staff to open the patio exit, so she could go home. Per the note, the resident verbalized delusions and asked staff where the little boy went and that she was looking for her baby. It also included the resident wandered into other resident rooms to lie down and sleep. Review of a facility's investigative report revealed that on (MONTH) 22, 2019 at 6:22 a.m., a CNA (staff #13) reported that she heard yelling from the room of resident #4 and resident #265. The CNA reported that resident #265 pulled off the bed linens of resident #4 and was yelling at the resident to get up. Resident #265 was pulling and shaking resident #4. Resident #4 then hit the hand of resident #265, who then hit resident #4 on the chest. The residents were separated. Further review of the facility's investigative report revealed the facility substantiated abuse and resident #265 was placed on 1:1 supervision. The care plan for cognition loss and dementia was revised on (MONTH) 22, 2019 to reflect the need for 1:1 supervision 24/7. Review of the MAR for (MONTH) 2019 revealed the resident was found hitting and shaking her roommate on (MONTH) 22 and was on 1:1 supervision. A program manager progress note dated (MONTH) 23, 2019 included that on (MONTH) 22, 2019, a CNA witnessed resident #265 shaking resident #4 and telling her to get up. Resident #4 hit the hand of resident #265, who then hit resident #4 back. Resident #265 was directed to her bed and insisted that she needed a match to start a fire. However, there was no further clinical record documentation that resident #265 was provided 1:1 supervision after (MONTH) 22, and there was no documentation of the rationale as to why the 1:1 supervision was discontinued, as the care plan included for 1:1 supervision 24/7. In addition, the documentation included that resident #4 and #265 remained roommates. Continued review of the (MONTH) 2019 MAR indicated [REDACTED]. Regarding the incident on (MONTH) 30, 2019: A social service note dated (MONTH) 23, 2019 included the facility was considering transferring resident #265 to a higher level of care, due to multiple behaviors with a most recent resident to resident occurrence. CNA documentation on (MONTH) 30, 2019 included the resident manifested wandering behaviors, which placed the resident at a significant risk for danger, by intruding on privacy or activity of others. The nursing progress note dated (MONTH) 30, 2019 revealed that resident #265 came out of the room pushing a male resident in his wheelchair and asked staff where the male resident was supposed to go. Another nursing progress note dated (MONTH) 30, 2019 revealed that resident #265 took a female resident's belt alarm and began to push this resident in the hall. Further review of the clinical record revealed there was no evidence that the neurologist was notified regarding the resident's escalating behaviors, as per the neurologist note from (MONTH) 18. Review of the facility's investigative report revealed that at approximately 10:35 p.m. on (MONTH) 30, 2019, resident #4 was found face down on the floor in her room by a CNA (staff #40). The CNA immediately requested the help of a nurse and the medical director who was in the facility at the time of the incident. Resident #265 was found standing over resident #4 and was holding the bed pad of resident #4 in her hands. Review of a written statement from a CNA (staff #40) revealed that on (MONTH) 30, 2019 at approximately 10:35 p.m., he was charting when he heard talking from down the hall which seemed more like short bursts of fairly loud argument and then sounded more like a loud cry. Staff #40 reported that the light was on in the room of resident #265 and resident #4, and he found resident #4 face down on the floor. He reported that resident #265 was holding a bed pad and was standing over resident #4, and the bed bolster was standing against the wall near the bed. It also included that the pillow from the bed of resident #4 was on the bed of resident #265. He reported that he then noticed the head of resident #4 was in a puddle of blood. The statement also included that the nurse and physician arrived on the scene and 911 was called. A written statement from a licensed practical nurse (LPN/staff #136) included that on (MONTH) 30, 2019 at 10:45 p.m., staff #40 asked for assistance and when she rushed to the room, resident #4 was face down on the floor next to her bed and she was screaming. Staff #136 reported there was blood on the floor and her face was bloody. She reported that resident #265 was just walking around the room carrying the bed pad of resident #4. A statement from another LPN (staff #148) revealed that at approximately 10:45 p.m., staff #40 informed him that someone was seriously injured. He and the physician went into the room and found resident #4 face down on the floor next to her bed and there was a pool of blood on the floor. The resident was bleeding from a laceration to the right side of her face and forehead. Further review of the facility's investigative report revealed that resident #4 and #265 were interviewed and both residents could not tell what happened. The report also included that the allegation of physical abuse was unable to be substantiated based on the results of the resident interviews, and that the incident was unwitnessed. A nursing progress note dated (MONTH) 31, 2019 included that resident #265 was believed to have pulled her roommate (resident #4) off the bed onto the floor, while she was sleeping. Resident #4 sustained serious injuries to the head and face and was sent to the emergency room . The note also included that resident #265 was now placed on 1:1 observation until the resident could be transferred to a higher level of care. A physician's orders [REDACTED]. Per the documentation on the MARs, the resident was provided 1:1 supervision 24/7 until discharged . A program manager note dated (MONTH) 1, 2019 revealed that resident #265 was discharged to home with family. An attempt was made to conduct an interview with resident #4 on (MONTH) 11, 2019 at 8:34 a.m., however, she was unable to respond to questions appropriately. An interview was conducted on (MONTH) 11, 2019 at 11:24 a.m., with a CNA (staff #40 who found resident #4 on the floor). He stated that he was working the night shift when he heard someone crying out and went into the room of resident #4 and #265 who were roommates. He stated the bed of resident #4 was in lowest position and resident #4 was crying and sobbing loudly and she was on the floor face down. He stated that he could not remember if there was blood on the floor. He said resident #265 was holding the bed pad of resident #4 and she was standing over resident #4. He said the resident was sent to the hospital because of a large open wound in the forehead and right temple. Regarding resident #265, staff #40 stated that resident #4 and #265 had been roommates for at least a month or more and had altercations in the past, but the altercation had not happened on his shift. He said resident #265 had behaviors such as resistive to care and could be aggressive. He stated that prior to the incident, resident #265 was not acting different from the ordinary, but ordinary was on the aggressive side. An interview with a LPN (staff #136) was conducted on (MONTH) 11, 2019 at 12:15 p.m. She stated the night of the incident on (MONTH) 30, staff #40 reported there was something going on in the room of resident #4 and #265. She stated when she went into the room, resident #4 was on the floor crying, but she could not tell her what happened. Staff #40 said there was blood on the floor and the resident was bleeding from her nose all over her face. She stated resident #4 was sent to the hospital and resident #265 was placed back to bed on 1:1, meaning someone was with the resident all the time. In an interview with a registered nurse (RN/staff #76) conducted on (MONTH) 11, 2019 at 1:46 p.m., she stated that all staff in the unit are involved with the supervision of residents. She said residents are parked in their wheelchair in the hallway, so the nurse can supervise the residents while the CNA's are providing cares. She stated when a resident is on 1:1, it means any staff in the hall is responsible in providing 1:1 when able, and there is no specific staff assigned to a resident who requires 1:1 supervision. She further stated the only occasion when the administrator assigns one person per shift for 1:1, is when a resident is verbally and physically aggressive. An interview was conducted on (MONTH) 12, 2019 at 7:06 a.m. with the CNA (staff #13 who reported the incident on (MONTH) 22, 2019). She stated that she heard resident #265 yelling and when she entered the room, resident #265 took the blanket off resident #4. She stated the bed of resident #4 was in low position and resident #265 was standing over her bed. She said resident #265 was asking resident #4 to get up and help find her kids/babies. She stated that she redirected resident #265 out of the room and she stayed in the hall for the rest of the shift. She said resident #4 went back to sleep and resident #265 was watched closely and placed on every 15 minute checks. However, she stated the 15 minute checks she conducted were not documented because there was no place to document them any where in the clinical record. Regarding resident #265, staff #13 stated the behaviors of resident #265 included resisting cares, refusing medications, could be combative with staff or other residents and could be verbally and physically aggressive to staff and other residents. She said resident #265 would yell at other residents who would then yell back and that resident #265 had a tendency to hit residents. She stated that resident #265 would not sleep for 2-3 days and then would sleep for one whole day and then would be awake again for 2-3 days. She stated if the resident did sleep at night, it was usually only for 45 minutes and then she would be awake the entire time. She stated that during the night time, resident #265 is the only resident wandering in the hallway, so staff can closely monitor her. She stated after the incident on (MONTH) 22, 2019, resident #265 was on close watch and every 15 minute checks, but there was no specific staff assigned to resident #265 for 1:1, until after the second incident that resulted in the transfer of resident #4 to the hospital. She further stated that both residents remained as roommates after the incident on (MONTH) 22. Regarding resident #4, staff #13 stated the resident was sweet and did not have any temperament and would just keep to herself. She stated that she has not seen resident #4 to have any behaviors and had not seen resident #4 provoke resident #265 or any other residents. During an interview with the Director of Nursing (DON/staff #98) conducted on (MONTH) 12, 2019 at 1:24 p.m., she stated that on (MONTH) 22, 2019 it was reported to her that resident #265 pulled the blanket off of resident #4 and tried to wake her up and had swatted resident #4, who then swatted her back. She said the facility substantiated the allegation of abuse on (MONTH) 22 because the CNA (staff #13) witnessed the incident. She stated that resident #4 and #265 continued to be roommates after this incident, because she did not think it was abuse because both residents had dementia and they did not know what they were doing. She stated resident #265 was care planned for and was placed on 1:1 supervision, meaning there was one staff assigned to care for resident #265 the entire shift starting (MONTH) 22, and that the assigned staff changes after every shift. She said when resident #265 was redirected, she became aggressive and would hit staff or other residents. However, she could not find documentation that 1:1 supervision was provided after (MONTH) 22, 2019. During the above interview, the clinical record was reviewed with the DON and the Assistant Director of Nursing (staff #47 who later joined the interview). Staff #47 provided documentation of resident #265 being on 15 minute checks from (MONTH) 23-30, 2019. The DON stated that resident #265 was placed on 1:1 supervision on (MONTH) 22. However, both staff #98 and #47 stated that they could not find documentation that resident #265 was provided 1:1 supervision after (MONTH) 22, as care planned. Regarding the incident on (MONTH) 30, 2019, staff #98 stated she was not at the facility when the incident happened and she learned about the incident the next day. She stated facility unsubstantiated the allegation because the facility really did not know if resident #265 did something to resident #4 or if resident #4 just rolled out of bed and resulted in injury. She said the bed of resident #4 was in the low position, meaning it was approximately one and a half feet from the floor. She said because resident #4 has a [DIAGNOSES REDACTED]. She said resident #4 was found on the floor and resident #265 was holding the incontinent pad also known as bed pad from the bed of resident #4. She said the bed pad is usually placed on top of the sheet of a resident's bed. She stated that the medical director was at the facility at the time of the incident and assessed resident #4 and ordered the transfer to the hospital. Staff #98 continued to say that she reviewed the video surveillance on the date and time of the incident and stated that prior to the incident, the video showed that resident #265 pushed her wheelchair out of her room, re-entered her room and came out later with either a blanket or a pillow and was placing these items on her wheelchair. She stated there were no other persons seen in the video entering their room other than resident #265, until staff #40 entered the room at the time of the incident. Review of the policy on Behavior Management revealed the facility takes a cautionary and safe approach in treating and caring for individuals who exhibit challenging behaviors that may pose a threat to the health or safety of the resident or other individuals in the facility. Review of the Abuse Prevention policy revealed the facility will take appropriate steps to prevent the occurrence of abuse. It also stated, Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm pain or mental anguish. Physical Abuse includes hitting, slapping, pinching and kicking. The policy also included that the IDT (Interdisciplinary Team) will attempt to identify residents whose personal histories may render them at risk for abusing other residents and develop intervention strategies to prevent occurrences and monitor changes that would trigger abusive behavior. Additionally, the IDT team will attempt to identify those residents whose personal histories may render them at risk for abuse and develop intervention strategies to protect them. The policy further included the facility makes reasonable efforts to determine the cause of the alleged violation and takes corrective action consistent with the investigation findings and to eliminate any ongoing dangers to the resident. It also stated that appropriate steps are taken by the facility to prevent recurrence of abuse. If a suspected violation occurs, the facility shall take immediate action to stop the alleged or suspected abuse, neglect or exploitation of a resident. If the suspected perpetrator is another resident, the DON or designee separates the residents so they do not have access to each other until the circumstances of the alleged incident can be determined.

Based on a review of the closed clinical records, hospital records, staff interviews, and review of facility policy, the facility failed to ensure that the physician was notified in a timely manner and that the resident (#1) was frequently monitored and assessed when she experienced a change of condition, and the facility failed to provide on-going monitoring and assessment of an injury for one resident (#15). The sample size was 3. Findings include: Resident #1 was readmitted on [DATE], and discharged on [DATE], to the hospital. The resident's [DIAGNOSES REDACTED]. A nursing note entry dated April 23, 2014, included that the resident participated in self-directed activities and some craft activities of her choice. A second nursing note entry dated April 29, 2014, included that the resident was non-verbal but alert to self and able to make some needs known. On May 5, 2014 at 12:25 a.m., the nursing note entry included, the resident was unresponsive, did not open her eyes, and was not moving her arms around or grabbing at her gown as was her custom. Although the entry included that the resident would continue to be monitored, the note did not include any documented evidence that the physician had been notified of the resident's change of condition or any additional documented evidence of on-going assessments and monitoring of the resident's health status. The next nursing note entry dated May 5, 2014 at 1:44 p.m. included that the resident was alert, but responsive to tactile stimuli only and that she was sleepy and lethargic. This was over 12 hours later. This note included that the physician had been notified in the morning (the exact time of notification was not documented) of the resident's change in health status and that some of the resident's medications were discontinued. Per the documentation, the resident would continue to be monitored for any further changes in condition. A continued review of the closed clinical record also revealed no documented evidence that the resident's vital signs had been monitored from 12:25 a.m. through 1:44 p.m. The next nursing note entry was at 7:34 p.m. on May 5, 2014. Now at this time, the documentation included that the resident's blood pressure was 93/51, pulse rate was 110, respirations were 28, and temperature was 101.5 Fahrenheit. According to the documentation, the physician was notified and an order was obtained to send the resident to the hospital. This was approximately 19 hours after the resident was first found to be unresponsive. A review of the hospital records revealed that the resident had been diagnosed with [REDACTED]. An interview was conducted on August 26, 2014, with the DON (Director of Nursing), who stated when the resident was found to be unresponsive, the physician should have been notified, "Right away," since this was a change of condition. The DON also stated that the resident's vital signs should have been monitored at minimum every shift. A facility policy titled, Charting and Documentation, included, "All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record." The policy also included the following: 3. All accidents, incidents, or change in the resident's condition must be recorded in the resident's medical record,...Change in resident's condition will be documented on till resolved or resident is discharged to a higher level of care and the physician will be notified upon noticing change of condition. -Resident #15 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record revealed that on April 20, 2014 at 7:30 a.m., the resident was struck in the face by another resident, which resulted in the resident sustaining a red area on her right cheek. According to the documentation, the red area measured 2 cm (centimeters) by 0.5 cm and that a cold pack was applied to the area. However, the clinical record did not include any documented evidence that the red area on the resident's right cheek and been monitored or assessed after the initial incident on April 20, 2014. An interview was conducted on August 27, 2014, with the DON (Director of Nursing), who stated that an on-going assessment of the red area on the resident's cheek should have been provided for the next 72 hours after the injury. At this time, the DON stated that she was unable to locate any documented evidence that it had been provided. A facility policy titled, Charting and Documentation, included, "All services provided to the resident, or any changes in the resident's medical or mental condition, shall be documented in the resident's medical record." The policy also included the following: 3. All accidents, incidents, or changes in the resident's condition must be recorded in the resident's medical record, including the required 72 hour documentation after any accident or incident;...

Based on clinical record review, observations, staff and complianant interviews, and review of facility documentation, the facility failed to ensure that one resident (#163) was provided adequate supervision and assistance as assessed to prevent a fall with injury resulting in actual harm to the resident. The sample size was four. Findings include: Resident #163 was originally admitted to the facility December 4, 2003, and was readmitted [DATE], with [DIAGNOSES REDACTED]. A Care Area Assessment (CAA) with an assessment date of July 12, 2011, included that the resident was not ambulatory, and was dependent on staff for most of her cares and for transfers, and that her biggest risk for falls was during transfers. Review of a monthly summary dated September 29, 2011, and January 4, 2012, included that the resident required full staff performance and two person physical assistance for transfers to and from the bed, chair, wheelchair, and standing position and that the resident was not ambulatory. Review of the quarterly MDS (minimum data set) assessment dated [DATE], included that the resident required the assistance of two people for transfers, and was totally dependent for transfers with full staff performance every time during the entire seven day look back period. Review of the resident care plan with a problem start date of July 19, 2011, revealed that the resident was at risk for falls related to limited mobility, poor balance and medications, and that the resident had a right above the knee amputation, and to assist with all transfers. However, despite the fact that the resident was assessed on her quarterly MDS to require two persons for transfers, the care plan failed to document whether the resident required the assistance of one or two staff members for transfers. A fall risk assessment conducted January 4, 2012, included that the resident had intermittent confusion, visual impairment and no history of falls. Additionally, the same fall risk assessment evaluation included that the resident had a score of 16, and that a score of 10 or higher represented a high risk for fall. Despite the fact the resident was assessed as a high risk for falls, this assessment included that no referrals, including a falls prevention program, was necessary Review of the resident progress notes dated January 23, 2012, revealed that the resident was sitting on the edge of the bed, the CNA (certified nursing assistant) turned to get the resident's wheelchair, and the resident fell forward onto the floor hitting her face on the floor. The progress note failed to clearly reveal whether the resident was physically assisted during transfer by one or two staff members and whether a gait belt was in place to be used during the transfer of the resident. The resident was transported to an emergency department for evaluation and was found to have a nasal fracture. Continued review of the same care plan included an approach dated January 24, 2012, the day after the resident fell , to have everything ready prior to transfer, so that she is not left at the edge of the bed without staff next to her. The same care plan also included an approach dated January 27, 2012, that included "assist with all transfers". Again, the care plan did not indicate whether the resident required transfer assistance of one or two staff members. In an interview conducted May 10, 2012, the complainant stated that on January 24, 2012, the resident was seated on the edge of her bed and the CNA left the resident unattended while she went to get the wheelchair. The complainant further stated that since the resident's right leg had been amputated, the resident should not have been left unattended. The resident fell on her face on the floor while the CNA left her to get the wheelchair and shattered her forehead and nose. During an interview conducted July 3, 2012, a CNA stated that a resident that was able to weight bear would require the assistance of one person for transfers, and a resident that could not "stand up fully" would require the assistance of at least two persons for transfers. Additionally, the CNA stated that when a staff member did not know what type of transfer assistance a resident required, it would be documented and located in the CNA care plan book kept at the nurses station, and that the information would also be available by asking the resident's nurse how many staff were required to transfer the resident. Additionally, she included that you would not turn your back on residents during transfers, "not with the patients we have here." During an interview conducted July 3, 2012, licensed staff stated that the number of staff required to transfer a resident would be located in the electronic record in the MDS and the resident's care plan, and that the information for the resident's care plan was obtained from resident assessments in the clinical record, monthly summaries, and MDS information, and that all transfers of resident's required the use of a gait (transfer) belt. Staff also stated that you could not determine from the resident's care plan the number of staff required for transfer. A facility policy titled "Moving a Resident, Bed to Chair/Chair to Bed included to review the resident care plan for any special needs of the resident. Continued review of the same policy included when moving a resident from a bed to a chair, place the chair so that it touches the side of the bed and faces the foot of the bed, and to support the resident by placing a belt around the resident's waist to steady the resident. Resident #163 sustained an accident on January 24, 2012. At the time of the accident, the facility failed to provide adequate supervision to prevent resident #163's fall with injury and was not in compliance with F323. This noncompliance occurred after the exit date (May 12, 2011) of the facility's last standard recertification survey. During the current recertification survey, seven residents were identified via chart reviews to have met the criteria for accident hazards. Of those seven, three residents (#s 33, 72, 119) were randomly selected and investigated for current deficient practice related to accident hazards. In addition, observations and interviews were conducted with direct care staff during the survey. No evidence was revealed that staff did not have knowledge of how to transfer residents in a safe manner No current noncompliance was identified at F323.

Based on a review of the facility investigative report, staff interviews, State Agency documentation, and review of facility policy and procedure, the facility failed to implement their policies and procedures to protect one resident (#86) from receiving skin tears in an incident with staff #1 and staff members failed to report the observed abuse for 12 days. In addition the facility failed to adequately protect other residents from potential confinement and verbal abuse from staff #1 when this potential had been observed and was known by staff #4. The sample size was three. Findings include: On February 21, 2012, the State Agency received a report regarding an allegation of staff to resident abuse. Review of the intake included that the incident occurred on February 9, 2012. The certified nursing assistant (CNA) who witnessed the incident did not come forward until 12 days later. The incident involved staff #1, a licensed practical nurse (LPN), who allegedly pulled and twisted resident #86's arm. Staff #2 witnessed the incident, and staff #3, also a CNA, was a partial witness (she left the room, and did not see the contact between the nurse and the resident). Review of State Agency documentation revealed that resident #86 received skin tears as a result of the incident. Review of the facility investigation included written statements by those directly involved, interviews of those witnesses documented by the assistant administrator, and statements from other staff members who had heard or witnessed similar behavior by staff #1. Review of staff #2's written statement revealed that resident #86 had been turning on her call light every two minutes, when staff #1 came in, he grabbed the resident's arm and expressed his frustration with her, and stated that he did not care if she reported his behavior. The transcript of the interview with staff #2 included that when staff #1 went into the room, there were words exchanged, and a struggle with the resident's dinner tray, which resulted in a spill. This was when staff #3 left the room for towels to clean the spill. When administration questioned staff #2 for the reason the incident was not reported immediately, she stated that it was the weekend, and late at night. She stated that she was scared to report the incident, due to staff #1's behavior, and because she had never seen anything like the incident. During an interview conducted June 28, 2012, staff #2 stated that she worked nights, but on that evening was called into work early. She stated that right after the incident happened, she was "in shock" because she had never witnessed any nurse do anything like that to a resident before. When asked why she waited 12 days to report the incident, at first she said that she did not know, but on further questioning she stated that after the incident, the nurse, she and the other CNA were talking, and the nurse confided in them that the resident reminded him of his own mother, who also was placed in a nursing home. She then said that he looked at her, and the look in his eyes seemed to communicate a warning, and she became afraid. She said she told the night nurse (staff #5) about the incident, but that the night nurse told her the resident was confused. Review of the written statement, and interview transcript included staff #3, who went into the resident's room to collect the dinner tray; she and staff #2 followed staff #1 into the room. Staff #3 witnessed the physical struggle over the dinner tray, then left the room. The statements also included much of what was said between staff #1 and the resident, and staff #3 and the resident, especially what the resident said after the incident. During an interview conducted June 28, 2012, staff #3 stated that she too had never before witnessed a nurse behave that way toward a resident; she was taken by surprise. She stated that she thought staff #1 would report the incident himself. The written statement and interview transcript of staff #5, also an LPN, included that the resident asked her to write a note to the director of nursing (DON), about a man who had grabbed and twisted her arm, but she told the resident it would be better if she spoke to the DON in the morning. She also stated that she did not report what the resident had told her because the resident was often confused. During an interview conducted June 29, 2012, staff #5 stated that she did not report what the resident said because she was confused; that in between her statements about a male nurse grabbing her arm, she was saying nonsensical things. She acknowledged that residents with periods of confusion and dementia were often accurate, and related events truthfully. She also stated that in the future, she would report any incident right away. A telephone interview was attempted with staff #1, who was terminated after the incident. Unfortunately, the phone had been disconnected. The facility investigative report also included written statements from a registered nurse (staff #6), and the facility social services director (staff #4). Although they did not witness nor have any knowledge regarding the incident with resident #86, their statements documented witnessing staff #1 speak to three different residents (in three separate incidents) in an disrespectful, harsh, and loud aggressive manner. Documentation related to the incidents observed by staff #4 included the nurse verbally reprimanding a resident in an authoritative manner, that the resident was not allowed down a certain hallway. The tone of his voice prompted staff #4 to come out of her office. A second incident also involved staff #1 speaking to a resident in a loud, aggressive manner. During an interview conducted June 28, staff #4 stated that the first incident was in January 2012. She stated that she did not report this incident because she counseled staff #1 at the time of the incident, and that she had taken care of it. She stated that the second incident, documented as occurring on February 9, was reported to the assistant director of nursing (ADON). During an interview conducted the same day, the ADON stated that although she could not remember specifically the incident that staff #4 reported, she stated that she would have spoken to staff #1 about his behavior. She also stated that staff #1 had not exhibited any behaviors severe enough to warrant a verbal or written warning, "just little things" here and there. During an interview conducted the same day, staff #6 stated that she heard staff #1 speaking disrespectfully and harshly to another resident, a few months earlier. She also stated that other staff had heard and seen the same things. She stated that she did not report his behavior "because it was just the one time", and that he was having problems at home, so she let it go. Review of a facility policy, entitled Abuse Prevention Program, included that the facility abuse program provided "...policies and procedures that governed, as a minimum: b. Mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse..."