**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to protect residents' rights to be free from physical abuse for two of three sampled residents (#28 and #14). The deficient practice could result in psychosocial or physical harm to residents. -Regarding resident #14 Resident #14 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, bipolar disorder, hyperlipidemia, type 2 diabetes, mood affective disorder, anxiety disorder, benign prostatic hyperplasia, depression, hypertension, gastro-esophageal reflux disease, and insomnia. An Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment. A behavior progress note dated September 6, 2025 at 12:15 p.m. revealed that the resident was observed to become agitated with another resident over a seating arrangement, which escalated into a verbal and physical altercation. The note revealed that one Certified Nursing Assistant (CNA) tried to break the altercation up and was not strong enough to get them apart, and was injured in the process. The note further revealed that two CNA's and one nurse were able to separate and calm the residents down, and Resident #14 was noted to have a mildly painful skin tear and bruise on his right hand. A care plan focus initiated on September 6, 2025 revealed a psychosocial well-being problem risk related to a resident to resident altercation. A change of condition assessment dated [DATE] revealed that the resident responded to threats from another resident, and began a physical and verbal altercation. The assessment also revealed the resident sustained a right hand contusion and skin tear. -Regarding Resident #28 Resident #28 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, atherosclerotic heart disease, hyperlipidemia, hypothyroidism, Parkinson's disease, bipolar disorder, and generalized anxiety disorder. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. A care plan focus initiated on September 6, 2025 revealed a psychosocial well-being problem risk related to a resident to resident altercation. A change of condition assessment dated [DATE] revealed that the patient was observed to have become agitated with another patient that escalated into an argument and became physical. The assessment revealed that the resident sustained a contusion on his right hand with no pain, and the physician recommended a 72-hour one on one supervision to keep the resident safe. Review of video footage from September 6, 2025 at 10:39 a.m., revealed that Resident #14 was wiping something off of a recliner seat in the day room next to Resident #28 when Resident #28 appeared to be waving his arm near Resident #14. The video revealed a verbal altercation began and caught the attention of several residents in the dayroom before Resident #14 attempted to sit in the recliner. The video further revealed that as Resident #14 tried to sit down, Resident #28 swung his arm to push Resident #14, who then began swatting his hands while Resident #28 kicked his legs at him. The video revealed that Resident #14 pulled the legs of Resident #28 and attempted to take him out of the chair as the CNA's and nurse rushed into the room to help separate the residents. The video revealed that the altercation lasted approximately one minute, and the dayroom had one CNA and 12 residents. An interview was conducted on September 8, 2025 at 2:02 p.m. with a Registered Nurse (RN/Staff#37) who stated that Residents #14 and #28 had an altercation on September 6, 2025, and that a CNA got hurt in the altercation as well. The RN stated that she was not in the room when the altercation broke out, but she ran to the dayroom when she heard screaming. The RN stated that at the time of the altercation, there was one staff member in the room with several residents in the dayroom, and both residents had an almost identical injury to their right hands. The RN stated that the CNA, Staff #56, told her that Resident #28 was sitting in a recliner second closest to the door when Resident #14 entered the room to sit in his usual spot. The RN stated that both residents talk with their hands and tend to be aggressive and posturing, and that Resident #14 said something toResident #28 about the chair in front of him and made contact with their hands before the kicking started. The RN stated that Resident #28 was sitting in the chair while Resident #14 grabbed his legs and attempted to pull him out of the chair, The RN further stated that by the time she walked into the dayroom, both residents were standing up. The RN stated that she knows the incident occurred because of the injuries the residents had, the huffing and puffing that both residents were doing when she entered the room, both residents spoke to her about the fight afterwards, and there was a camera in the room. An interview was conducted on September 8, 2025 at 3:20 p.m. with a CNA, Staff #56, who stated that she was scratched up in an altercation between two residents over the weekend. The CNA stated that they were all in the dayroom when the residents began bickering, and by the time she got to them they were full-on trying to get at each other by kicking and clawing. The CNA stated that she yelled for assistance and the nurse and CNA came to intervene because she had difficulty separating them. The CNA stated that Resident #28 was sitting in the chair and was the one kicking, clawing, and hitting, and that Resident #14 was in his face telling him something. The CNA stated that she witnessed Resident #14 grabbing the other residents legs to stop him from kicking, but Resident #28's arms were free and she attempted to put her arm in between the residents, which is how she got scratched. An interview was conducted on September 8, 2025 at 3:30 p.m. with a CNA, Staff #70, who stated that she witnessed an altercation between two residents over the weekend, but by the time she arrived they were already being separated. The CNA stated that she grabbed Resident #14 to separate him, and he was very upset and called the other resident all kinds of names. The CNA stated that the residents both had skin tears on their right hands and she reported the injuries to the nurse. An interview was conducted on September 8, 2025 at 3:46 p.m. with the Administrator (Admin/Staff#46) who stated that there was an altercation over the weekend between two residents, and both residents had a scratch on their hands. The administrator stated that he watched the video footage and exactly what was reported is what took place. The administrator stated that it appeared to him that Resident #14 tried to sit next to Resident #28, which resulted in a push, shove, and cat fight involving both residents throwing hands around. The administrator stated that the video showed one CNA with several residents in the dayroom at the time of the incident, and she was sitting behind the gate. Review of a policy revised in September of 2022 titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revealed a definition of abuse being the willful infliction of injury with resulting physical harm, pain or mental anguish. The policy further revealed a definition for willful being that an individual acted deliberately. Review of a policy revised in April of 2021 titled, Abuse, Neglect, Exploitation or Misappropriation - Prevention Program, revealed that residents have a right to be free from abuse, and the facility was committed to ensuring residents were protected from abuse by anyone, including other residents. Review of a policy revised in February of 2021 titled, Resident Rights, revealed that residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to ensure adequate supervision was provided to one resident (#10). The deficient practice resulted in placing resident's safety at risk with a non-authorized person. Findings include:Resident #10 was admitted to the facility on [DATE], with diagnoses that included Unspecified Dementia, Unspecified Severity with Agitation, and Schizoaffective Disorder, Bipolar. Review of a care plan initiated on April 24, 2025 revealed that resident #10 had an Activities of Daily Living (ADL) self-care performing deficit related to Dementia diagnosis. The goal was the resident will maintain current level of function in (Specify) through the review date. The interventions were to encourage the resident to participate to the fullest extent possible with each interaction. (with a target date of 4/24/25). Review of a Minimum Data Set (MDS) assessment dated [DATE] revealed the resident #10 had moderate severe cognitive impairments with daily decision-making skills. Review of medical record revealed that resident #10 had a guardian listed as the responsible party and emergency contact. Others listed on the admission record for contacts were resident's sister, a case worker and resident #10 as self. Review of the medical record on 8/22/2025 did not reveal any paperwork documenting guardianship and did not list any restrictions of visitors for resident #10. Review of the incident report indicated that resident #10 was under Court Ordered Treatment residing in the locked memory care unit. Resident #10 was allowed to leave the premises on 06/09/2025 with the sister without the permission and awareness of the assigned Maricopa County Public Fiduciary. An interview was conducted Admission's (staff #50) on August 22, 2025 at 12:25pm. When asked about the admission process and who responsible for obtaining the necessary paperwork and communicating the information to the staff she stated that typically she does all the admission paperwork. Staff #50 stated once paperwork is received it is uploaded into the electronic charting system. When asked who is responsible for getting the Power of Attorney, Guardianship or Court orders treatment paperwork, staff #50 stated she usually does. When asked where the Court Ordered Treatment and a court appointed guardian paperwork for resident #10 was in the medical record, she stated it was an oversight on her part and this paperwork was not in resident #10's medical record's chart. Staff #50 then stated she had received that paperwork in reference on April 18, 2025 on her phone and forgot to upload to resident #10's medical record chart. An interview was conducted with Licensed Practical Nurse (LPN/Staff #70) on August 22, 2025 at 12:45 pm to discuss contact information on resident's demographic sheet which has who is the responsible party. When asked staff #70 how do you know who to communicate and how do you know who to contact if you need to inform someone regarding the condition of any changes with a resident. Staff #70 stated that the resident face sheet has that and that what they go by. When asked what the process is if a resident wants to leave the facility, is there a process? Staff #70 stated they would look in the resident's chart to see which is the responsible party and make sure there was a Doctors order. Staff #70 also stated there is a time frame for fours to being out of building. When asked staff #70 if there is a restriction list she stated she would check the chart or ask administration. When asked if there are sign in and sign out sheets for residents that are leaving and coming back, staff #70 stated yes that there is a sign in and sheet out sheet. An interview was conducted with Licensed Practical Nurse (LPN/Staff #55) on August 22, 2025 at 3:17 pm to discuss incident that occurred on June 9, 2025. LPN stated that on June 9, 2025 resident's sister was there visiting. She was informed that his sister wanted to take him out to lunch. LPN said she called the Doctor and the Doctor gave the order for resident to go out to lunch with his sister. LPN stated she called the sister before dinner time to check to see if he would be back for dinner. Resident's sister stated that she had dropped the resident off about an hour and a half ago at the front door. LPN stated she called management and stated that management then called police. LPN stated that resident was located but not sure on the time. LPN stated that this was their first time for her that resident went off premises and did not know anything about resident having a guardian or any restrictions regarding the sister taking him out. An interview was conducted with Executive Director (ED/Staff #60) on August 22, 2025 at 2:01pm to discuss incident of resident leaving the facility with an unauthorized person on June 9, 2025 and not returning to the facility, ED stated on June 9, 2025, resident's sister came to visit resident. ED stated that he escorted resident's sister to his room and that resident was visibly excited to see his sister. Order was obtained for resident to leave facility with sister to go to lunch. Per ED, staff did not check resident #10's information sheet and let resident out of the facility with a non-authorized person. Documentation revealed that resident #10 never check back in to the facility. Per ED there are no working security cameras that would have captured the area in which he may have been dropped off. When asked ED what is your expectation for your staff to ensure that resident is signed out with Medical Power of Attorney, Court ordered Treatment or Guardian? ED stated that staff should verify the face sheet. Who is responsible for ensuring all the resident information is received and in the clinical record? ED stated that the Admissions department is responsible for that. When asked if resident that leave on pass, do they need to sign out? ED sated yes, they need to sign out. When presented with facility documentation to inquire if resident had signed out on June 9, 2025 documents revealed he did not and ED verified resident did not sign out on June 9, 2025. On August 22, 2025 at 2:25 pm a telephone interview was conducted with the Residents Listed Guardian that was listed on the resident information sheet. Guardian stated that she had visited the facility a few times when and staff knew who she was. Guardian stated she was never notified on June 9, 2005 that resident left the facility with his sister. Guardian stated that sister came to the facility and he staff did not check his information she and let him go with his sister. Guardian stated that the sister dropped him off and he was later found by a nearby gas station and emergency medical services were called. A police report obtained by the Scottdale Police Department dated June 9, 2025 at 22:19 stated that they were called to the facility in reference to a missing person and met by facilty management to inform of the details of missing resident #10. Police report stated that they then entered resident #10 into the ACJIS as a missing person and sent out a missing person bulletin to all Scottsdale Police employees. An Arizona Department of Public Safety Silver alert was completed with resident 10' information. At approximately 2032 hours, Honor Health [NAME] called Scottsdale police and reported they had a male matching the description who they identified as resident #10. A review of the facility's policy Signing Resident Out each resident leaving the premises must be signed out and signed in upon retuen to the facility. It also states that restrictions noted on the resident's chart concerning who may not sign resident out must be honored unless otherwise prohibited by the facility or state/federal law governing such release.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews and record review, the facility failed to protect residents' rights to be free from physical abuse for 22 residents (#129, #123, #67, #127, #124, #32, #24, #130, #75, #36, #7, #29, #51. #182, #57, #112, #114, #43, #115, #117, #118, #59). The deficient practice could result in psychosocial or physical harm to residents. Findings Include:-Regarding residents #57 and #29: Resident #57 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, encounter for palliative care, major depressive disorder, and dementia. Review of the care plan focus dated October 2, 2023 revealed that resident #57 had a behavior problem regarding dementia. Staff was to intervene as necessary to protect the rights and safety of others, remove resident #57 from situation, and take to an alternate location. An admission minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment. The MDS further noted the resident #57 had exhibited physical behavior symptoms directed towards others four to six times a week. Resident #29 was admitted to the facility on [DATE] with diagnoses including: dementia, mild, with behavioral disturbance, metabolic encephalopathy, cognitive communication deficit, hyperlipidemia, symbolic dysfunctions, altered mental status, insomnia, adult failure to thrive, and abnormalities of gait and mobility. Review of the care plan focus dated June 4, 2021 revealed that resident #57 had an activity deficit related to the diagnosis of dementia. A quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 00, indicating resident #29 was unable to complete the interview. The MDS further noted the resident #57 had exhibited other behavior symptoms directed towards others one to three times a week. A nursing progress note on November 26, 2023 at 10:00 a.m. revealed that staff members observed residents #57 and #29 punching each other in the face. Residents were immediately separated. No injuries were noted in skin checks and each resident was placed on checks every fifteen minutes. An interview was conducted with the facility Administrator (staff #9) on August 7, 2025, at 12:48 PM. The Administrator stated he considered the altercation between Resident #57 and Resident #29 as abuse. -Regarding residents #182 and #138 Resident #182 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, delusional disorders, unspecified mood affective disorder, peripheral vascular disease, restlessness and agitation, anxiety disorder, and insomnia. Review of a care plan focus, revised April 14, 2023 revealed that resident #182 had a history of dementia with behaviors and interventions included redirection of resident #182 and keep the resident away from other residents. A quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 00, indicating the resident was unable to complete the interview. Resident #138 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and dementia in other diseases classified elsewhere, severe, with agitation. Review of a care plan focus, revised January 17, 2024 revealed that resident #138 had behavior symptoms related to dementia. Interventions included positive attention and interaction by caregivers. An admission minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 00, indicating the resident was unable to complete the interview. The MDS further noted the resident #138 had exhibited physical behavior symptoms directed towards others one to three times a week. Review of an incident progress note dated February 10, 2024 at 10:34 a.m. revealed resident #138 was observed by staff walking in the dayroom with a snack. While walking to his chair, resident suddenly reached out and smacked resident #182 very forcefully. Resident #138 then became extremely aggressive and began punching a CNA in the stomach. Resident #182 attempted to strike back at resident #138 but both residents were separated and calmed down by staff. No physical injuries were noted to either resident. The facility investigation, dated February 15, 2024 further revealed that staff was actively guiding resident #138 through the dining room when the event occurred. Staff attempted to stay between resident #138 and other residents while he was ambulating. On this occasion, resident #138 was able to reach out and make contact with resident #182. An interview was conducted with the facility Administrator (staff #9) on August 7, 2025, at 12:48 PM. The Administrator stated he considered the altercation between Resident #182 and Resident #138 as abuse. -Regarding residents #51 and #125 Resident #51 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, unilateral primary osteoarthritis of the left hip, and insomnia. Review of the care plan focus dated July 9, 2021 revealed that resident #51 had history of abuse with a goal of eliminating or avoiding triggers that may cause re-traumatization. A quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment. Resident #125 was admitted to the facility on [DATE] with diagnoses including: Neurocognitive disorder with Lewy bodies, dementia in other diseases classified elsewhere, severe, with agitation, sensorineural hearing loss, major depressive disorder, and insomnia. Review of the care plan focus dated May 23, 2023 revealed that resident #125had a behavior problem as evidenced by physical and verbal aggression to staff. A quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 00, indicating resident #125 was unable to complete the interview. A nursing progress noted dated October 20, 2023 at 7:44 p.m. revealed that resident #125 was physically aggressive and combative with other residents. Resident #125 was observed throwing shoes, clothes, brief and cups at staff. Resident#125 was not alert and oriented to his surrounds at that time. Three staff members helped resident to the bathroom, and resident was intrusive with other residents, touching and throwing their food. Resident #125 had staff walking with him outside of the dayroom when he suddenly turned and hit another resident (#51) on the left eye, unprovoked. The facility investigation, dated October 26, 2023 further revealed that when resident #125 struck resident #51, resident #51’s glasses were knocked off of her face. Both residents were assessed but no physical injures were noted. An interview was conducted with the facility Administrator (staff #9) on August 7, 2025, at 12:48 PM. The Administrator stated he considered the altercation between Resident #125 and Resident #51 as abuse. -First Incident Regarding Resident #111 and Resident #24 Resident #111 was admitted on [DATE] with diagnoses that included schizoaffective disorder (bipolar type), schizoaffective disorder, bipolar disorder, Asperger's syndrome, anxiety disorder, autistic disorder, and hypertension. A care plan focus initiated on March 8, 2023 revealed a behavior problem as evidenced by physical aggression and history of peer altercations. A progress note dated April 25, 2023 at 7:37 p.m. revealed that the executive director was notified of a resident-to-resident altercation and an investigation was initiated. A progress note and behavior note dated April 25, 2023 at 8:30 p.m. revealed that the nurse was told by a CNA that Resident #111 was involved in a physical altercation with a female peer, and when the nurse arrived on the unit they observed Resident #111 being verbally and physically aggressive with staff and peers. The note further revealed that one of the CNA’s held the resident to redirect her and prevent her from hurting her peer. The note revealed that the nurse left the CNA’s in the hallway for 20-30 minutes before one of them reported to the nurse the Resident #111 was on the floor in the hallway. The note also revealed that when the nurse arrived in the hallway, Resident #24 was already bitten by Resident #111 on the forearm and lower leg while walking in the hallway. An admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Resident #24 was admitted on [DATE] with diagnoses that included schizoaffective disorder (bipolar type), psychotic disorder with delusions, systemic lupus erythematosus, major depressive disorder, vascular dementia, extrapyramidal and movement disorder, generalized anxiety disorder, and major depressive disorder. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. A progress note dated April 25, 2023 at 7:39 p.m. revealed that the executive director was notified of a resident-to-resident altercation and an investigation was initiated. A progress note dated April 25, 2023 at 8:30 p.m. revealed that the nurse was notified by a CNA that Resident #24 was involved in a physical altercation with a female peer. The note further revealed that when the nurse arrived on the unit, Resident #130 was already bitten by Resident #111 on his left forearm and left lower posterior leg while he was walking in the hallway. The note further revealed that the left arm and left leg were assessed and cleaned with dressings applied and orders for amoxicillin. Review of a facility investigation dated April 28, 2023 that was submitted to the Arizona Department of Health Services (AZDHS) revealed that Resident #111 was trying to call her mom for over 30 minutes and was unsuccessful. The investigation further revealed that the CNA told Resident #111 her phone usage time was up, which upset her, and resulted in her throwing items at the staff and another resident in the dayroom. The investigation revealed that the staff told her to go to her room, and at that time, Resident #24 was walking in the hallway past Resident #111’s door. The resident opened her door and tried to go after Resident #24, which resulted in her biting his arm and causing a circular mark that was bleeding. The investigation also revealed that when staff came up behind Resident #111 to lower her to the floor, she bit Resident #24’s lower calf and left a small mark. The investigation revealed an interview that was conducted on April 25, 2023 at 7 p.m. with the CNA’s who witnessed the incident, Staff #43 and Staff #91, who documented that Resident #111 tried to call her mom and was unsuccessful, so staff asked for the phone back to place it at the nurses station. When staff were speaking with another resident, Resident #111 became angry and started to yell and curse at staff while throwing items into the hallway before storming into the dayroom and throwing a chair at another resident. The investigation revealed that Staff #91 got ahold of the chair and hugged Resident #111 from the back to keep her from hitting the other resident before assisting her back to her room. The CNA’s documented that while Resident #111 was in her room, she opened the door while Resident #24 was walking by, she took a hold of him, and bit his arm. Staff #91 went behind the resident again and lowered her to the floor where she then leaned forward and bit Resident #24 in the leg before the nurse came over to assist and assess Resident #24. A request was made for the facility to provide a copy of the investigation, and the facility verified that they were unable to provide any investigation documents beyond 12 months. An interview was conducted on August 7, 2025 at 12:48 p.m. with the Administrator and abuse coordinator (Administrator/Staff #9) who stated that an altercation involving a resident who bites another resident on the arm and leg would be considered abuse and would need to be reported. -Second Incident Regarding Resident #111 and Resident #24 Resident #111 was admitted on [DATE] with diagnoses that included schizoaffective disorder (bipolar type), schizoaffective disorder, bipolar disorder, Asperger's syndrome, anxiety disorder, autistic disorder, and hypertension. A care plan focus initiated on March 8, 2023 revealed a behavior problem as evidenced by physical aggression and a history of peer altercations. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A progress note dated August 20, 2023 at 11:07 p.m. revealed that the nurse was attempting to administer Resident #111’s medication when she told the nurse to give Resident #24 his medications first because she wanted to continue to walk the hallways. The note further revealed that the nurse explained that she could continue to walk after receiving her medications, which resulted in Resident #111 yelling at the nurse and pointing her finger close to her face before turning around and charging at Resident #24. The note revealed that Resident #111 grabbed Resident #24’s left arm, attempting to drag him to the floor, and 3 staff members attempted to separate the two residents with difficulty. The note revealed that the resident grabbed a chair and attempted to throw it, but was stopped by staff. The note further revealed that the nurse told the resident she cannot abuse other residents, and the resident stated that she did not care and that Resident #24 should not have been in the hallway. A progress note dated August 21, 2023 at 12:08 p.m. revealed that an investigation was initiated and all parties were notified. A progress note dated August 22, 2023 at 12:35 p.m. revealed that the facility spoke with the resident’s family due to concerns with behaviors, resident-to-resident altercations, and to seek alternation placement if the resident continued to exhibit the behaviors. Resident #24 was admitted on [DATE] with diagnoses that included schizoaffective disorder (bipolar type), psychotic disorder with delusions, systemic lupus erythematosus, major depressive disorder, vascular dementia, extrapyramidal and movement disorder, generalized anxiety disorder, and major depressive disorder. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. A progress note dated August 20, 2023 at 11:58 p.m. revealed that Resident #24 was pacing in the hallway when the nurse was trying to give another resident her medication. The note further revealed that the other resident refused her medication and turned toward Resident #24 and grabbed his left arm to drag him to the floor, and he did not fight back or fall to the floor. The note revealed that staff attempted to separate the residents with difficulty because she would not let go of his arm, but eventually they successfully separated the residents. The note revealed that upon assessment, Resident #24’s left arm had slight discoloration noted and the sleeve to his shirt was ripped off. The progress note also revealed that the doctor, power of attorney, and behavioral manager were notified. A progress note dated August 21, 2023 and 12:08 p.m. revealed that an investigation was initiated and all parties were notified. An interdisciplinary team (IDT) progress note dated September 15, 2023 at 1:57 p.m. revealed that the resident had a room and unit change following the second resident-to-resident altercation. An interview was conducted on August 7, 2025 at 12:48 p.m. with the Administrator and abuse coordinator, Staff #9, who stated that an altercation involving residents attempting to drag other residents to the ground with skin discoloration noted and a shirt sleeve being ripped off would be considered a resident-to-resident abuse and would need to be reported. A request was made for the facility to provide a copy of the investigation, and the facility verified that they were unable to provide any investigation documents beyond 12 months. -Regarding Resident #111 and Resident #130 Resident #111 was admitted on [DATE] with diagnoses that included schizoaffective disorder (bipolar type), schizoaffective disorder, bipolar disorder, Asperger's syndrome, anxiety disorder, autistic disorder, and hypertension. A care plan focus initiated on March 8, 2023 revealed a behavior problem as evidenced by physical aggression and history of peer altercations. An admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A progress note dated January 23, 2024 at 9:06 p.m. revealed that an incident report with the police department was filed. A progress note dated January 24, 2024 at 5:56 a.m. revealed an incident where resident #111 was upset about the phone not being fully charged, and she attempted to punch the nurse in the face. The note revealed that the staff began attempts to calm the resident down and move other residents who were in the hall back to their rooms when Resident #111 pushed a CNA and kicked Resident #130 in the leg. The note further revealed that the staff grabbed Resident #130 to keep him from falling and assisted him back to his room. Resident #130 was admitted on [DATE] with diagnoses that included dementia, Alzheimer's disease, schizophrenia, depression, hypertension, generalized anxiety disorder, impulsiveness, major depressive disorder, paranoid schizophrenia, bipolar disorder, insomnia, hyperlipidemia, and polydipsia. A care plan focus initiated on July 7, 2023 revealed a behavior problem related to dementia and schizoaffective disorder as evidenced by a peer altercation. The care plan further revealed interventions initiated on January 25, 2024 that the resident was immediately separated from his peer, staff was educated, replaced the unit phone, and the provider was contacted to provide behavior education. A quarterly Minimum Date Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A progress note dated January 24, 2024 at 3:12 a.m. revealed that Resident #130 was standing by the nursing station waiting for his medication when Resident #111 was observed going up to him and kicking him in the back of his legs. The note further revealed that the CNA grabbed Resident #130 to prevent him from falling, and the resident declined to press charges. Review of a facility investigation dated January 30, 2024 submitted to the Arizona Department of Health Services (AZDHS) revealed that at 9 p.m. on January 23, 2024 Resident #111 was upset regarding the usage of the phone on the behavioral unit because she felt that two bars of charge was not sufficient for her phone call. The investigation revealed that the 1:1 CNA made the decision to take Resident #111 off of the residents’ unit to another unit to use the phone, and upon arrival at the other unit, Resident #111 continued to escalate which resulted in her kicking Resident #130 who was standing at the desk. The investigation further revealed that Resident #130 did not sustain an injury from the incident. The investigation revealed an interview was conducted with a Licensed Practical Nurse (LPN/Staff#139) on January 23, 2024 who stated that she was giving a report to the on-coming nurse when Resident #111 came to the desk to ask why she could not use the phone. The LPN revealed that she asked the resident to go back to her unit, the resident became upset at her, the resident attempted to open the gate to the nurses station and hit the nurse, and ultimately she kicked Resident #130 who was standing nearby. The investigation also revealed an interview that was conducted with a LPN, Staff #368, who stated that Resident #130 was upset because she wanted to make a phone call, the resident refused to leave the unit when asked to, and she unsuccessfully attempted to hit the day shift nurse. The LPN further revealed that resident #111 kicked Resident #130, and he did not sustain an injury to the leg. The investigation revealed an interview that was conducted on January 23, 2024 with a CNA, Staff #89, who stated that Resident #111 was upset about the phone not having enough bars. The CNA revealed that staff took the phone and sat it on the counter, and the resident began yelling at the nurse. The CNA interview further revealed that Resident #111 kicked Resident #130 on the leg. A request was made for the facility to provide a copy of the investigation, and the facility verified that they were unable to provide any investigation documents beyond 12 months. An interview was conducted on August 7, 2025 at 12:48 p.m. with the Administrator and abuse coordinator, Staff#9, who stated that an altercation involving a resident who kicks another resident in the back of the leg out of frustration with staff would be considered abuse and would need to be reported. -Regarding Resident #36 and Resident #75 Resident #36 was admitted on [DATE] with diagnoses that included Alzheimer's disease, Parkinson's disease with dyskinesia, bipolar disorder, and generalized anxiety disorder. A behavioral care plan initiated on April 29, 2025 revealed that Resident #36 had behaviors of physical and verbal aggression. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. The MDS also revealed that the resident exhibited behaviors not directed towards others 1-3 days. A change in condition assessment initiated on July 12, 2025 revealed a physical and verbal resident-to-resident altercation that occurred for several minutes before staff was able to separate them. The assessment further revealed that the resident reported he was experiencing new pain following the altercation, with complaints of achiness to the right front shoulder, occasional moans and groans, facial grimacing, and distressed pacing. The assessment also revealed that the resident was experiencing increased agitation throughout the day before the incident occurred, and during the altercation the resident was punching, grabbing, clawing, and pinching. A progress note dated July 12, 2025 at 8:10 p.m. revealed that the resident was nudged by another resident to get out of their way, and a physical and verbal altercation between the two residents began. The note further revealed there was punching, clawing, grabbing, pinching, cursing, and yelling between the two residents for several minutes before staff was able to separate them, and the resident reported front right shoulder pain. A care plan focus revised on July 14, 2025 revealed that the resident was at risk for psychosocial well-being problems related to a resident-to-resident altercation he was involved in. Resident #75 was admitted on [DATE] with diagnoses that included dementia with agitation, bipolar disorder, mood affective disorder, major depressive disorder, anxiety disorder, depression, hypertension, and insomnia. A behavioral care plan initiated on May 6, 2025 revealed that Resident #75 had behaviors of severe agitation, cursing, striking out and threats. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment. The MDS also revealed that the resident exhibited behaviors not directed towards others 4-6 days. A change in condition assessment initiated on July 12, 2025 revealed a physical and verbal resident-to-resident altercation that occurred for several minutes. The assessment further revealed that the resident was experiencing agitation, aggression, yelling, and delusions towards staff before the altercation occurred, and the resident reported he was experiencing worsened lower back pain following the altercation. A progress note dated July 12, 2025 at 5:00 p.m. revealed that the resident was nudged by another resident to get out of their way, and a physical and verbal altercation between the two residents began. The note further revealed there was punching, clawing, grabbing, pinching, cursing, and yelling between the two residents for several minutes before staff was able to separate them, and the resident reported that the back of his head was sore, and his lower back pain was worse. The note revealed that an as needed (PRN) order for hydroxyzine was ordered. A care plan focus revised on July 14, 2025 revealed that the resident was at risk for psychosocial well-being problems related to a resident-to-resident altercation he was involved in. Review of a facility investigation dated July 12, 2025 revealed that Resident #36 pulled Resident #75 by the arm out of a recliner because he thought that Resident #75 was sitting in his seat. The investigation revealed an interview that was conducted with a Certified Nursing Assistant (CNA/Staff#70) who said that Resident #75 was sitting in a recliner when Resident #36 expressed that he wanted to sit in the recliner. The CNA revealed that Resident #75 told him no, and then Resident #36 grabbed his hands and pulled him up from the recliner which is when Resident #75 stood up and pushed Resident #36 into the wall. The CNA revealed that both of the residents began throwing punches and the staff attempted to separate them with difficulty due to the altercation taking place against the wall. The investigation also revealed an interview conducted with another CNA, Staff #78, who revealed that Resident #36 got upset because Resident #75 was in the recliner, which led to Resident #36 trying to get him out of the recliner and ultimately pushing Resident #36 against the door. The CNA revealed that she tried to separate them when Resident #36 started hitting Resident #75 and pulling his hair while Resident #75 hit Resident #36 back. An interview was conducted on August 6, 2025 at 8:30 a.m. with a CNA, Staff #78, who stated that she witnessed the incident between Resident #36 and Resident #75. The CNA stated that Resident #75 was sitting in the recliner that Resident #36 usually sat in when Resident #36 made Resident #75 stand up by pulling him up before Resident #75 pushed Resident #36. The CNA further stated that staff attempted to separate the residents but they were unable to for several minutes. The CNA also stated that Resident #36 pulled Resident #75’s hair, and the two residents did have prior altercations with one another. An interview was conducted on August 6, 2025 at 9:11 a.m. with a Registered Nurse (RN/Staff#159) who stated that she witnessed the altercation between Resident #36 and Resident #75. The RN stated that she ran into the dayroom because the CNA’s were screaming for help, and when she got to the room she witnessed Resident #36 grabbing Resident #75 by the back of the head in a “hair hold” while the residents were punching each other. The RN stated that they punched her and the other staff who were present on accident as well, and they could not get Resident #36 to let go of Resident #75, but they eventually were able to pry Resident #36 off of him. The RN stated that she knew the two residents had issues prior to the altercation because she had to intervene in a couple of altercations before this one. The RN stated that the fight started because Resident #75 pushed Resident #36 after he was told he was sitting in Resident #36’s chair. An interview was conducted on August 7, 2025 at 11:38 a.m. with the Director of Nursing (DON/Staff#163) who stated that it was reported to him that Resident #75 was sitting in Resident #36’s usual chair in the dayroom when Resident #36 asked for his seat back. The DON stated that when Resident #36 said no, Resident #36 took him by the hands and pulled him out of the chair. The DON stated that the altercation did occur, but the facility did not allow for the abuse to take place. An interview was conducted on August 7, 2025 at 12:48 p.m. with the Administrator and abuse coordinator, Staff #9, who stated that an altercation involving residents dragging other residents out of their seats, punching, clawing, grabbing, pinching, cursing, and yelling was absolutely resident-to-resident abuse and would need to be reported. -Regarding Resident #7 and Resident #31 Resident #7 was admitted on [DATE] with diagnoses that included anxiety, major depressive disorder mood affective disorder, and dementia A Quarterly Minimum Date Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08, which indicated moderate cognitive impairment. A progress note dated August 3, 2025 at 2:09 p.m. revealed that the resident called the police on Resident #31 for hovering over another resident in the dining room because he perceived that Resident #31 was being aggressive. The note revealed that the police arrived at the facility and explained to the resident that there was nothing to be worried about. A care plan focus initiated on August 4, 2025 revealed a psychosocial well-being problem potential related to a resident to resident altercation. A skin assessment completed on August 4, 2025 revealed a red and purple discolored bruise to the right eye and a skin scrape on the left thumb. A change in condition assessment dated [DATE] at 3:39 p.m. revealed a resident-to-resident altercation that occurred on August 3, 2025 in the afternoon. A progress note dated August 4, 2025 at 4:02 p.m. revealed that the resident was involved in a resident-to-resident altercation and received a hit to his face by another resident. The note revealed that the resident was noted to have a black eye, and he stated that the other resident hit him on his face. A progress note dated August 4, 2025 at 4:52 p.m. revealed that the resident was noted with increased confusion and no physical aggression during the shift with discoloration still noted around his right eye. Resident #31 was admitted on [DATE] with diagnoses that included type 2 diabetes, chronic atrial fibrillation, angina pectoris, hyperlipidemia, hypertension, major depressive disorder, vascular dementia, schizoaffective disorder, panic disorder, insomnia, and obsessive-compulsive disorder. An admission Minimum Date Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 05, which indicated severe cognitive impairment. The MDS also revealed that the resident had exhibited other behavior symptoms not directed towards others for 1-3 days. A late-entry progress note dated August 3, 2025 at 4:11 p.m. revealed that the resident was involved in a resident-to-resident altercation with another resident and he hit

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facilityfailed to ensure that the abuse policy was adhered to following an incident of resident-to-resident abuse for two residents (#111 and #24). The deficient practice could result in continued resident-to-resident abuse. -Regarding Resident #111 Resident #111 was admitted on [DATE] with diagnoses that included schizoaffective disorder (bipolar type), schizoaffective disorder, bipolar disorder, Asperger's syndrome, anxiety disorder, autistic disorder, and hypertension. A care plan focus initiated on March 8, 2023 revealed a behavior problem as evidenced by physical aggression and a history of peer altercations. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A progress note dated August 20, 2023 at 11:07 p.m. revealed that Resident #111 grabbed Resident #24's left arm, attempting to drag him to the floor, and 3 staff members attempted to separate the two residents with difficulty. The note revealed that the resident grabbed a chair and attempted to throw it, but was stopped by staff. The note further revealed that the nurse told the resident she cannot abuse other residents, and the resident stated that she did not care and that Resident #24 should not have been in the hallway. A progress note dated August 21, 2023 at 12:08 p.m. revealed that an investigation was initiated and all parties were notified. A progress note dated August 22, 2023 at 12:35 p.m. revealed that the facility spoke with the resident's family due to concerns with behaviors, resident-to-resident altercations, and to seek alternation placement if the resident continued to exhibit the behaviors. -Regarding Resident #24 Resident #24 was admitted on [DATE] with diagnoses that included schizoaffective disorder (bipolar type), psychotic disorder with delusions, systemic lupus erythematosus, major depressive disorder, vascular dementia, extrapyramidal and movement disorder, generalized anxiety disorder, and major depressive disorder. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. A progress note dated August 20, 2023 at 11:58 p.m. revealed that Resident #111 grabbed Resident #24's left arm to try and drag him to the floor, and he did not fight back or fall to the floor. The note revealed that upon assessment, Resident #24's left arm had slight discoloration noted and the sleeve to his shirt was ripped off. The progress note also revealed that the doctor, power of attorney, and behavioral manager were notified. A progress note dated August 21, 2023 and 12:08 p.m. revealed that an investigation was initiated and all parties were notified. An interdisciplinary team (IDT) progress note dated September 15, 2023 at 1:57 p.m. revealed that the resident had a room and unit change following the resident-to-resident altercation. An interview was conducted on August 7, 2025 at 12:48 p.m. with the Administrator and abuse coordinator (Administrator/Staff#9) who stated that an altercation involving residents attempting to drag other residents to the ground with skin discoloration noted and a shirt sleeve being ripped off would be considered a resident-to-resident abuse and would need to be reported. A request was made for the facility to provide a copy of the investigation, and the facility verified that they were unable to provide any investigation documents beyond 12 months. Review of a policy revised in September of 2022 titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revealed that if resident abuse was suspected, the suspicion must be reported immediately to the administrator and other officials according to state law. The policy also revealed that immediately is defined as within two hours of an allegation involving abuse. Review of a policy revised in April of 2021 titled, Abuse, Neglect, Exploitation or Misappropriation - Prevention Program, revealed that residents have a right to be free from abuse, and the facility was committed to ensuring residents were protected from abuse by anyone, including other residents. The policy also revealed that the facility would develop and implement policies and protocols to prevent and identify abuse of residents, and they would investigate and report any allegations within the timeframe required by federal requirements. Review of a policy revised in February of 2021 titled, Resident Rights, revealed that residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facilityfailed to ensure that an incident involving abuse between two residents (#111 and #24)was reported in a timely manner. The deficient practice could result in continued resident to resident abuse. -Regarding Resident #111 Resident #111 was admitted on [DATE] with diagnoses that included schizoaffective disorder (bipolar type), schizoaffective disorder, bipolar disorder, Asperger's syndrome, anxiety disorder, autistic disorder, and hypertension. A care plan focus initiated on March 8, 2023 revealed a behavior problem as evidenced by physical aggression and a history of peer altercations. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A progress note dated August 20, 2023 at 11:07 p.m. revealed that the nurse was attempting to administer Resident #111's medication when she told the nurse to give Resident #24 his medications first because she wanted to continue to walk the hallways. The note further revealed that the nurse explained that she could continue to walk after receiving her medications, which resulted in Resident #111 yelling at the nurse and pointing her finger close to her face before turning around and charging at Resident #24. The note revealed that Resident #111 grabbed Resident #24's left arm, attempting to drag him to the floor, and 3 staff members attempted to separate the two residents with difficulty. The note revealed that the resident grabbed a chair and attempted to throw it, but was stopped by staff. The note further revealed that the nurse told the resident she cannot abuse other residents, and the resident stated that she did not care and that Resident #24 should not have been in the hallway. A progress note dated August 21, 2023 at 12:08 p.m. revealed that an investigation was initiated and all parties were notified. A progress note dated August 22, 2023 at 12:35 p.m. revealed that the facility spoke with the resident's family due to concerns with behaviors, resident-to-resident altercations, and to seek alternation placement if the resident continued to exhibit the behaviors. -Regarding Resident #24 Resident #24 was admitted on [DATE] with diagnoses that included schizoaffective disorder (bipolar type), psychotic disorder with delusions, systemic lupus erythematosus, major depressive disorder, vascular dementia, extrapyramidal and movement disorder, generalized anxiety disorder, and major depressive disorder. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. A progress note dated August 20, 2023 at 11:58 p.m. revealed that Resident #24 was pacing in the hallway when the nurse was trying to give another resident her medication. The note further revealed that the other resident refused her medication and turned toward Resident #24 and grabbed his left arm to drag him to the floor, and he did not fight back or fall to the floor. The note revealed that staff attempted to separate the residents with difficulty because she would not let go of his arm, but eventually they successfully separated the residents. The note revealed that upon assessment, Resident #24's left arm had slight discoloration noted and the sleeve to his shirt was ripped off. The progress note also revealed that the doctor, power of attorney, and behavior\al manager were notified. A progress note dated August 21, 2023 and 12:08 p.m. revealed that an investigation was initiated and all parties were notified. An interdisciplinary team (IDT) progress note dated September 15, 2023 at 1:57 p.m. revealed that the resident had a room and unit change following the resident-to-resident altercation. An interview was conducted on August 7, 2025 at 12:48 p.m. with the Administrator and abuse coordinator (Administrator/Staff#9) who stated that an altercation involving residents attempting to drag other residents to the ground with skin discoloration noted and a shirt sleeve being ripped off would be considered a resident-to-resident abuse and would need to be reported. A request was made for the facility to provide a copy of the investigation, and the facility verified that they were unable to provide any investigation documents beyond 12 months. Review of a policy revised in September of 2022 titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revealed that if resident abuse was suspected, the suspicion must be reported immediately to the administrator and other officials according to state law. The policy also revealed that immediately is defined as within two hours of an allegation involving abuse. Review of a policy revised in April of 2021 titled, Abuse, Neglect, Exploitation or Misappropriation - Prevention Program, revealed that residents have a right to be free from abuse, and the facility was committed to ensuring residents were protected from abuse by anyone, including other residents. The policy also revealed that the facility would investigate and report any allegations within the timeframe required by federal requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews and policy review, the facility failed to ensure that documentation was completed accurately for six residents (Residents #11, 43, 113, 114, 25 and 115) regarding abuse and resident assessment. This deficient practice could lead to incomplete documentation in residents' medical records.Findings include: -Regarding Resident #11: Resident #11 was admitted to the facility on [DATE], with diagnoses that included Alzheimer’s disease, vascular dementia, end-stage renal disease, dependence on renal dialysis, hypotension, depression and anxiety. On July 29, 2025, upon entrance to the facility, Resident #11 was identified as a resident who received dialysis treatment. During an initial pool interview with Resident #11 on July 29, 2025, at 12:18 PM, he stated that he goes to dialysis on Mondays, Wednesdays and Fridays. He stated that the staff do not check on him when he returns from dialysis. A nursing care plan, revised September 8, 2023, listed an intervention to complete a dialysis worksheet before and after dialysis treatment. A review of the resident’s medical record revealed no evidence of staff completing assessments before or after the resident went to dialysis. An interview was conducted with a Registered Nurse (RN/staff #148) on July 31, 2025, at 9:55 AM. The RN stated that the dialysis center checks Resident 11’s vital signs and weight following dialysis. The RN stated that when the resident returns to the facility, staff ensure he is accounted for, but do not perform an actual assessment. Staff #148 stated they do not assess the resident’s fistula site and do not document a progress note or assessment note in the medical record. An interview was conducted with the Director of Nursing (DON/staff #163), on July 31, 2025 at 12:47 PM. The DON stated the facility does not have a formal assessment tool they use for residents going to, or returning from, dialysis. The DON stated that staff check Resident 11’s vital signs and monitor his fistula site upon his return. However, the DON was unable to locate documentation showing that the condition of the fistula site was assessed before or after dialysis treatments in Resident #11’s medical record. The DON stated that the assessment information should be documented in the medical record. -Regarding Resident #43: Resident #43 was admitted to the facility on [DATE], with diagnoses that included bipolar disorder, schizoaffective disorder, dementia, depression, anxiety and chronic pain syndrome. On December 9, 2023, the SA received a report from the facility regarding a physical altercation that Resident #43 was involved in with another resident. A review of Resident #43’s medical record did not reveal any documentation of a physical altercation on December 9, 2023. An interview was conducted with the DON (staff #163) on August 6, 2025, at 9:05 AM. The DON could not locate any documentation in Resident #43’s medical record regarding the physical altercation that occurred on December 9, 2023. -Regarding Resident #113: Resident #113 was admitted to the facility on [DATE], with diagnoses that included dementia, Parkinson’s disease, anxiety, depression and insomnia. On February 9, 2024, the SA received a report from the facility regarding a physical altercation that Resident #113 was involved in with another resident. A review of Resident #113’s medical record did not reveal any documentation of a physical altercation on February 9, 2024. An interview was conducted with the DON (staff #163) on August 6, 2025, at 9:05 AM. The DON could not locate any documentation in Resident #113’s medical record regarding the physical altercation that occurred on February 9, 2024. -Regarding Resident #114: Resident #114 was admitted to the facility on [DATE], with diagnoses that included depression, dementia, cerebral infarction and a sleep disorder. On February 9, 2024, the SA received a report from the facility regarding a physical altercation that Resident #114 was involved in with another resident. A review of Resident #114’s medical record did not reveal any documentation of a physical altercation on February 9, 2024. An interview was conducted with the DON (staff #163) on August 6, 2025, at 9:05 AM. The DON could not locate any documentation in Resident #114’s medical record regarding the physical altercation that occurred on February 9, 2024. -Regarding Resident #115: Resident #115 was admitted to the facility on [DATE], with diagnoses that included dementia, hypertension and insomnia. On December 9, 2023, the SA received a report from the facility regarding a physical altercation that Resident #115 was involved in with another resident. A review of Resident #115’s medical record did not reveal any documentation of a physical altercation on December 9, 2023. An interview was conducted with the DON (staff #163) on August 6, 2025, at 9:05 AM. The DON could not locate any documentation in Resident #115’s medical record regarding the physical altercation that occurred on December 9, 2023. -Regarding Resident #25 Resident #25 was admitted on [DATE] with diagnoses that included dementia, type 2 diabetes, generalized anxiety disorder, major depressive disorder, Parkinson's disease, insomnia, hypertension, gastro-esophageal reflux disease, macular degeneration, and allergic rhinitis. A Quarterly Minimum Date Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08, which indicated moderate cognitive impairment. Review of a facility investigation dated March 18, 2024 revealed that a self-report was reported to the Arizona Department of Health Services on March 12, 2024 at 10:30 a.m. regarding an allegation of misappropriation of resident personal property. The investigation revealed that the resident made a statement that someone took her ring off of her in the night, but she did not remember who it was. The investigation further revealed that the resident stated it was a female who took it, she last saw the ring at dinner, and she wanted the police to be called. The investigation revealed that staff searched the room and were interviewed, and one Certified Nursing Assistant (CNA/Staff#49) stated that she saw the ring on the resident while giving her a shower, and again while changing the resident. Review of the inventory sheet for Resident #25 revealed that there was no evidence that the residents’ ring was documented on the inventory sheet in the “Items Lost, Damaged, Replaced, or Removed” section of the inventory sheet. There was no evidence that an allegation of misappropriation or a missing ring was documented in the clinical record of Resident #25. An interview was conducted on August 7, 2025 at 11:38 a.m. with the Director of Nursing (DON/Staff#163) who stated that he would expect staff to document allegations of misappropriation in the clinical record as a progress note or behavioral assessment, but that the business office sometimes keeps files regarding financial misappropriation. The DON noted that even if there was documentation by the business office, he would still expect staff to put some information on the incident in the clinical record. The DON pulled up Resident #25’s clinical record to find any documentation of the incident and he stated that there was no evidence of documentation in her clinical record regarding the misappropriation allegation or incident. Review of a policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, was revised in April of 2021 and revealed that residents have the right to be free from abuse, neglect, and misappropriation of resident property and exploitation. The policy also revealed that the facility would need to develop and implement policies and protocols to prevent and identify misappropriation of resident property. Review of a policy titled, Charting and Documentation, was revised in July of 2017 and revealed that all services provided to the resident, progress towards the care plan and goals, or any changes in the resident's mental, physical, functional, or psychosocial condition should have been documented in the resident’s medical record. The policy further revealed that events, incidents, or accidents involving the resident would need to be documented in the medical record, and it must be objective, complete, and accurate. A policy titled, End-Stage Renal Disease, Care of a Resident with, revised September 2010, states that staff will be educated regarding the type of assessment data that is to be gathered about the resident’s condition. A policy, titled Abuse and Neglect—Clinical Protocol, revised March 2018, states that when alleged abuse occurs, the nurse is to assess the individual and document related findings.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#87) was not abused by another resident (#91). The deficient practice could lead to physical and psychosocial harm to residents. Findings Include: Regarding resident #87: Resident #87 was admitted to the facility on [DATE] with diagnoses including: Alzheimer's disease, dementia, personality change due to known physiological condition, chronic ischemic heart disease, heart failure, hypertension, major depressive disorder, and anxiety disorder. A quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 08, indicating moderate cognitive impairment. A nursing progress note dated June 18, 2025 at 2:49 p.m. revealed that resident #87 ate resident #91 ' s cookie and resident swung at resident #87and hit him on the left ear. Residents were separated and no pain was reported by resident #87 and no physical injuries were noted to the residents. Regarding resident #91: Resident #91 was admitted to the facility on [DATE] with diagnoses including: Parkinson ' s disease, neurocognitive disorder with Lewy bodies, dementia, personal history of traumatic brain injury, and major depressive disorder. A quarterly minimum data set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 3, indicating severe cognitive impairment. A nursing progress note dated June 18, 2025 at 1:37 p.m. stated that after resident #87 ate resident #91 ' s cookie, resident #91 started to stand and swing at the other resident, hitting him on the left ear. Resident #91 kept trying to swing at resident #87 and staff stood in between them and separated them to prevent any other harm. A physician progress note at 6:26 p.m. June 18, 2025 stated that resident #91 was to be placed on one-on-one supervision by staff and his medications were to be reviewed. An interview with Licensed Practical Nurse (LPN/staff #43) on June 20, 2025 at 11:45 a.m. revealed that on June 18, 2025, LPN #43 was at the nurse ' s station overlooking the residents as they were finishing lunch. She heard verbal commotion and immediately went to assist. LPN #43 stated she heard resident #91 yelling and swearing at resident #87. She intervened with assistance from other staff and attempted to physically restrain resident #91, but resident #91 did make contact with resident #87 ' s ear. LPN #43 stated that redirection will usually work to diffuse conflicts between residents but in this case, resident #87 did suffer verbal and physical abuse. An interview with the director of nursing (DON/staff #65) at 12:28 p.m. revealed that physical abuse would be classified as any unwanted contact between two individuals. He further stated that speaking to another person in a manner that is unacceptable would constitute verbal abuse. Review of a policy revised in September of 2022 titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revealed a definition of abuse being the willful infliction of injury with resulting physical harm, pain or mental anguish. The policy further revealed a definition for willful being that an individual acted deliberately. Review of a policy revised in April of 2021 titled, Abuse, Neglect, Exploitation or Misappropriation - Prevention Program, revealed that residents have a right to be free from abuse, and the facility was committed to ensuring residents were protected from abuse by anyone, including other residents. Review of a policy revised in February of 2021 titled, Resident Rights, revealed that residents have the right to be free from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#67) was provided with adequate supervision. The deficient practice could result in residents being subjected to preventable accidents and sustaining injuries. Findings include: Resident #67 was admitted to the facility on [DATE] with diagnoses including: dementia with other behavioral disturbance, hypertension, anxiety disorder, hyperlipidemia, and major depressive disorder. Resident #67's care plan initiated on January 28, 2025 revealed that the resident was at risk for psychosocial emotional distress regarding resident-to-resident altercation. The interventions included one-on-one care as needed. Another care plan initiated on March 12, 2025 stated that resident #67 had the potential to be physically aggressive in regards to dementia. Interventions included monitoring, documenting and reporting behaviors as needed. Review of the facility's 2024-2025 Incident Log revealed resident to resident altercations involving resident #67 on January 28,2025, February 2,2025, and May 30, 2025. A nursing alert progress note dated June 9, 2025 at 11:03 p.m. revealed that resident #67 was involved in another altercation with another resident. The note documented that resident #67 hit resident #41 at the back of his head with his open hand because the other resident was sitting on his seat in the dayroom. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Further review of the MDS dated [DATE] revealed that the resident exhibited physical behavioral symptoms directed towards others 1-3 days during the assessment period. Additionally, the resident also exhibited other behavioral symptoms not directed towards. A revised care plan dated May 30, 2025 pertaining to psychosocial emotional distress directed an intervention for frequent observation. A Behavior Charting assessment dated [DATE] revealed that resident #67 exhibited agitation, aggression, and poor boundaries. Interventions implemented by staff included redirection. The assessment did not indicate 1:1 monitoring. A Behavior Charting assessment dated [DATE] documented that resident #67 exhibited agitation, aggression, poor boundaries, yelling/screaming/cursing/abrasive tone, and delusions. The assessment indicated that interventions implemented included encouraged activity, redirection, and offered food/beverage. Another Behavior Charting assessment dated [DATE] indicated that resident exhibited agitation, aggression, sundowning, exit seeking, and intrusive behavior. Interventions implemented included 1:1 monitoring, encouraged activity, and redirection. A progress note dated June 10, 2025 documented that resident continues to be on 1:1 monitoring post physical aggression behavior. A Behavior Charting assessment dated [DATE] revealed that resident exhibited agitation, aggression, poor safety, disorganized thinking, repetitive behavior, delusions, and exit seeking behavior. The assessment noted that the interventions implemented included emotional support, education on alternative behaviors, review of positive coping skills, redirection, reduced emotional stimuli, and 1:1 monitoring. An interview with a Certified Nursing Assistant (CNA/staff #44) on June 17, 2025 at 10:01 a.m. revealed that staff gets to know the residents in the behavior unit and gets to learn their behavior triggers. She stated that resident #67 is now receiving one-on-one care by CNA staff. An interview with Licensed Practical Nurse (LPN/staff #11) on June 17, 2025 at 10:21 a.m. revealed that the one-on-one care is now provided to resident #67 during all shifts. This care is scheduled for when the resident is in his room or out of his room. An Interview with the Director of Nursing (DON/Staff #65) was conducted on June 17, 2025 at 3:55 p.m. Staff #65 stated that one-on-one care is provided to residents when the resident could potentially harm themselves or others. Review of the facility policy titled Abuse and Neglect - Clinical Protocol, revised March 2018, revealed the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse. The policy further states the physician and staff will address appropriately causes of problematic resident behavior where possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that six residents (#67, #17, #97, #111, #77, and #50) did not abuse seven residents (#41, #14, #83, #36, #84, #21, and #2). The deficient practice could result in residents being physically harmed. -Regarding Resident #97 and Resident #84 Resident #97 was admitted on [DATE] with diagnoses that included vascular dementia, unspecified mood affective disorder, depression, intracranial hypertension, major depressive disorder, anxiety, adjustment disorder with mixed disturbance of emotions, and presence of cardiac pacemaker. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. A nursing progress note dated August 30, 2022 at 3:59 p.m. revealed that the doctor was notified of the resident becoming more sexually inappropriate. The progress note further revealed that the resident was caressing female peers' arms and touching his private area in front of female peers. A nursing progress note dated August 31, 2022 at 4:08 p.m. revealed a resident to resident incident that occurred with an inquiry to move the resident to a higher acuity behavioral unit. The note also revealed the resident was to remain on one-on-one monitoring until the room change would occur. A behavioral care plan dated August 31, 2022 revealed that following the incident, the resident was never to be unsupervised with female residents, staff were supposed to keep him at a significant distance away from female peers at all times, female caregivers were to position themselves in a fashion as to not be in a position to be inappropriately touched by him, and he was not allowed to be near Resident #84 or another unnamed resident at any time. A care plan initiated on September 23, 2024 revealed a focus on sexually inappropriate behavior, groping residents and staff, walking on the unit without clothing, and touching his genitalia in front of others in public spaces with an intervention to redirect residents to his room when he exposed himself Resident #84 was admitted on [DATE] with diagnoses that included dementia, mood disorder due to known physiological condition with manic, hypertension, [NAME] ' s encephalopathy, anxiety, anoxic brain damage, mood disorder due to known physiological condition. An admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06, which indicated severe cognitive impairment. An Executive-Director progress note dated August 31, 2022 at 4:04 p.m. revealed a resident to resident incident that occurred, and a message was left to notify the family. A nursing progress note dated August 31, 2022 at 4:23 p.m. revealed a Certified Nursing Assistant (CNA) reported that the resident received physical aggression by a male resident. The note revealed that Resident #84 was going to her room when a resident pushed her against the wall and started to fondle her breasts. The progress note further revealed that the CNA stated the resident had a frightened look on her face, and she stated He is a pervert he is always touching me. The progress note revealed that the nurse confronted the male resident to leave the female resident alone and separated the female resident to another area. Review of a facility investigation dated September 6, 2022 revealed that on August 31, 2022 at approximately 1:50 p.m., the Executive Director was notified by a CNA that she witnessed Resident #84 being held up against the wall and touched on the breasts by Resident #97 in the smoking area. The investigation revealed that the CNA told Resident #97 to stop and go back to his room where he hid behind his divider curtain. The investigation revealed that a CNA, Staff #70, gave a statement that revealed she saw Resident #97 grabbed Resident #84 against the wall and rubbed on her breast before she yelled at him to stop. The investigation further revealed that the CNA grabbed Resident #84 who stated she was scared and told her that man is a perve, he ' s always bothering me, I need to get away from him. The investigation also revealed an interview with Resident #97 who stated that he had gotten to know Resident #84 fairly well over the last few weeks, she was married, so was he, and he thought she was pregnant. The investigation revealed that Resident #97 further stated It ' s nice to have the touch of another person being in here, you don ' t get that, and he stated that he asked if he could touch her breasts and she said yes. The investigation revealed an interview with Resident #84 who stated that he asked if he could touch her breasts and she said yes, and she further stated it ' s not like it was sex. An interview was conducted with a Licensed Practical Nurse (LPN/Staff#33) on June 17, 2025 at 2:15 p.m. who stated that she could recall the incident occurring because one of the residents fondled the other residents ' breast, which resulted in a room change. The LPN stated that she was very good at documenting incidents like this one, and if she documented anything in the clinical record, it was right. An interview was conducted with a CNA, Staff #70 on June 17, 2025 at 2:33 p.m. who stated that she could recall that altercation between the two residents. The CNA further stated that she observed Resident #97 being very inappropriate with Resident #84 who was not all there. The CNA stated that she was walking in the hallway when she witnessed Resident #97 approach Resident #84 and push her up against the wall and touch her. The CNA also stated that Resident #84 talked to her after the incident and mentioned that Resident #97 had touched her inappropriately. The CNA stated that Resident #84 had a good recollection of the incident right after it happened. The CNA stated that she felt that Resident #97 knew what he was doing because he was inappropriate to staff and would make remarks such as I like your breasts and If I was your husband I would think you were so beautiful. The CNA stated that Resident #84 told her that she was scared after the incident. -Regarding Resident #111 and Resident #83 Resident #111 was admitted on [DATE] with diagnoses that included paranoid schizophrenia, vascular dementia, bipolar disorder, chronic obstructive pulmonary disease, psychotic disorder, major depressive disorder, anxiety, hypertension, history of traumatic brain injury, delusional disorders, alcohol dependence, and hallucinations. An Annual Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. A behavior progress note dated August 26, 2022 at 7 p.m. revealed that Resident #111 was yelling at staff and one of her neighbors in the dayroom at the start of the shift. The progress note revealed that the resident was asked to leave the common area until she could calm herself. A behavior progress note dated August 26, 2022 at 7:40 p.m. revealed that Resident #111 was aggressive. A behavior progress note dated August 26, 2022 at 8:03 p.m. revealed that the Executive Director was notified of a resident-to-resident altercation, the residents were separated, and there were no injuries noted. A behavior progress note dated August 27, 2022 at 3:34 p.m. revealed that Resident #111 hit Resident #83 in the face while the two of them were in the dayroom. The progress note further revealed that Resident #111 stated I punched her ass because she talks too much, and further stated that she hit her two times in the face and she was lucky that she couldn ' t hit her with her stick. The progress note revealed that the police department was notified and a case was created. A care plan focus initiated on November 26, 2024 revealed a behavioral problem with physical and verbal behaviors as evidenced by a history of peer altercations. Resident #83 was admitted on [DATE] with diagnoses that included schizoaffective disorder bipolar type, borderline personality disorder, anxiety, epilepsy, traumatic brain injury history, bipolar disorder, insomnia, and hyperlipidemia. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. The MDS also revealed that the resident exhibited verbal behaviors for 1-3 days. A behavioral care plan from August 19, 2022 revealed a history of physical aggression towards peers and staff at the facility. The care plan revealed that the resident needed to be closely monitored in public areas with peers present, she was not allowed to help peers in any fashion, if she was inciting another resident she would need to leave for no less than 30 minutes, and resident #83 should never be near resident #111 at any time. A behavior progress note dated August 27, 2022 at 4:12 p.m. revealed that Resident #83 was hit in the face by Resident #111 while the two were sitting in the day room. The progress note revealed that Resident #83 was talking loudly when Resident #111 suddenly hit her two times in the face. The progress note further revealed that Resident #83 stated it hurts a little, and there was no injury noted. Review of a facility investigation dated September 1, 2022 revealed that on August 26, 2022 at approximately 7:30 p.m., Resident #83 reported that she was hit in the face by Resident #111 on the porch in the dayroom. The investigation further revealed that Resident #111 was questioned about why she hit the other resident and she stated that it was because Resident #83 would not shut up and kept talking about how rich her father was. The investigation revealed that before the staff member could get to Resident #83, Resident #111 stood up and hit the resident in the face per reports from both residents. The investigation revealed that a CNA, Staff #120, was interviewed and stated that before she could get to the residents, arms were swinging and the residents were yelling before she separated them and told the nurse. The investigation revealed that a CNA, Staff #40, was interviewed and stated that she saw Resident #111 outside and she ran outside because she hit Resident #83, and was unsure of exactly which body part was hit. The investigation also revealed an interview with Resident #111 who stated that she did not feel safe there, Resident #83 was making her life miserable, and she was going to hit her again. The investigation further revealed an interview with Resident #83 who stated that Resident #111 must have hit her 10 times, and she felt that Resident #111 would hit her again after she got out of her room. An interview was conducted with a CNA, Staff #40, on June 17, 2025 at 2:05 p.m. who stated that she could recall the incident between the two residents, she heard yelling, ran to see what was happening, and when she arrived at where the residents were, she witnessed Resident #111 with her hand outstretched towards Resident #83. The CNA stated that another staff member was near the altercation and they both worked to separate the residents by moving the resident in the wheelchair and the other with the walker. An interview was conducted with a CNA, Staff #120, on June 17, 2025 at 4:21 p.m. who stated that she could only somewhat recall the incident, but mostly she remembered that both of the residents had bad days. -Regarding Resident #50 and Resident #36 Resident #50 was admitted on [DATE] with diagnoses that included major depressive disorder, anxiety, type 2 diabetes, epilepsy, antisocial personality disorder, emphysema, hypertension, and intermittent explosive disorder. A care plan initiated on December 28, 2020 revealed a focus on a behavioral problem targeting behaviors including verbal aggression, physical aggression to staff, and interfering with peers' care. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. A behavioral care plan dated August 18, 2022 revealed a history of physical and verbal aggression. Following the incident, the resident would not be allowed near Resident #36 at any time on the unit, and staff needed to be present at all times when the two residents were in the dayroom at the same time. A nursing progress note dated August 18, 2022 at 5:43 p.m. revealed that resident peers informed staff that another peer was in the dayroom fighting over the TV remote when a resident was hit in the head by another resident for refusing to give up the TV remote. The progress note further revealed that Resident #50 stated I told that motherfucker to give me the remote control, and he put it in between his legs. I can ' t stand that motherfucking bastard. So yeah I hit him in his motherfucking head, and I ' ll do it again. Call the fucking police, I don ' t give a shit. A nursing progress note dated August 18, 2022 at 6:36 p.m. revealed that the police officer spoke with the resident and peer and a case was created. Resident #36 was admitted on [DATE] with diagnoses that included bipolar disorder, nontraumatic subdural hemorrhage, seizures, hypertension, major depressive disorder, alcohol dependence, insomnia, muscle spasms, and focal traumatic brain injury with loss of consciousness. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. A nursing progress note dated August 18, 2022 at 5:25 p.m. revealed that resident peers informed staff that another peer was in the dayroom fighting over the TV remote when a resident was hit in the head by another resident for refusing to give up the TV remote. The progress note revealed that neuro checks were started and no injuries were noted. The progress note further revealed that the resident stated he refused to give the peer the TV remote and the peer hit him in the back of the head. A nursing progress note dated August 18, 2022 at 5:45 p.m. revealed that the police were notified of the incident. A nursing progress note dated August 18, 2022 at 6:35 p.m. revealed that the police officer spoke with the resident and peer and a case was created. Review of a facility investigation dated August 25, 2022 revealed that on August 18, 2022 at approximately 3:15 p.m., Resident #36 was watching tv in the dayroom in his wheelchair when Resident #50 accused him of having and hiding the TV remote. The investigation further revealed that Resident #50 got up, grabbed at Resident #36 ' s blankets looking for the remote, grabbed the remote, and slapped Resident #26 in the back of the head before the two residents were separated and assessed for injuries. The investigation revealed an interview was conducted with Resident #36 who stated that he had the remote in his lap, Resident #50 wanted it, and so he grabbed it out of his lap and slapped him on the back of his head before another guy came over and told him to leave him alone. The investigation also revealed an interview with Resident #50 who stated that he asked him for the remote, he said he didn ' t have it even though he knew he had it between his legs, so he grabbed it and slapped him upside his head. The investigation revealed that Resident #50 stated he functioned higher than the other residents there and he wanted another place. The investigation also revealed an interview with the resident who witnessed and reported the incident who stated that the two residents were in the dayroom, there was an argument about the remote, Resident #50 hit Resident #36 on the back of the head and grabbed the remote with another witness named. The investigation revealed the other witness was interviewed and stated that the two residents used to be roommates, they never got along, and when they were in the dayroom Resident #50 said he knew where the remote was, grabbed the blankets off of Resident #36 ' s lap, grabbed the remote, and then began to slap the back of his head. An interview was conducted with a former LPN, Staff #154, on June 17, 2025 at 2:41 p.m. who stated that she could recall the altercation between the two residents. The LPN further stated that Resident #50 hit Resident #36 in the head over a dispute regarding the television remote. The LPN stated that two other residents witnessed the incident and reported it to her immediately at the nurses station. An interview was conducted with the Director of Nursing (DON/Staff#65) on June 17, 2025 at 3:55 p.m. who stated that he would define sexual abuse as any unwanted sexual behavior, and it did not have to be physical. The DON further stated that if a resident was held against a wall and touched on their privates, he would consider it sexual abuse. The DON stated that he would define physical abuse as any unwanted touch, and there would not have to be physical injuries to consider an altercation abuse. The DON stated that he would define verbal abuse as speaking in a verbally threatening manner, and it could be considered abuse if a resident stated shut up or I ' ll hit you. An interview was conducted with the Administrator (Administrator/Staff#78) on June 17, 2025 at 4:06 p.m. who stated that he would define sexual abuse as unwanted touching, and if one resident had a high BIMS score and the other resident had a low BIMS score, any sexual contact would not be appropriate. The administrator stated that if a resident were [NAME] up against the wall and touched in the privates by another resident, it would be sexual abuse and was a reportable event. The administrator stated that he would define physical abuse as hitting, slapping, touching, throwing objects, and kicking, and abuse did not need to be witnessed to be considered abuse. The administrator defined verbal abuse as name calling, yelling, and cursing, and stated that if a resident stated shut up or I ' ll hit you, he would say it could be abusive and if they did hit them, it would be both physical and verbal abuse. The administrator stated that the definition of abuse was intent, and whether someone meant to do something. -Regarding Resident #67 and Resident #41 Resident #67 was admitted on [DATE] with diagnoses that included unspecified dementia with other behavioral disturbance, anxiety disorder, and major depressive disorder. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. A nursing alert progress note dated June 9, 2025 at 11:03 p.m. revealed that resident #67 was involved in an altercation with another resident. Licensed Practical Nurse (LPN/staff #48) stated resident #67 hit resident #41 at the back of his head with his open hand, because he was sitting on his seat in the dayroom. Residents were separated and redirected. Review of resident #67's care plan revealed a focus for resident #67's potential to be physically aggressive. Interventions included monitoring as needed for any signs of resident posing danger to self and others. Behavioral charting for resident #67 revealed behaviors including agitation/aggression and poor boundaries displayed on June 8 and 9, 2025. The interventions implemented by staff included redirection of the resident. Resident #41 was admitted on [DATE] with diagnoses including unspecified dementia with agitation, major depressive disorder, and insomnia. An admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. A nursing progress note dated June 9, 2025 at 11:19 p.m. revealed that resident #41 was observed sitting in the dayroom when resident #67 hit resident #41 on the back of the head with an open hand. Review of the facility's investigation, initiated June 9, 2025 revealed a conclusion that both residents lacked the intent to cause harm. Additionally, the investigation concluded that all current care plan interventions for resident #67 were in place at the time of the incident. An interview with LPN #48 on June 17, 2025 at 10:29 a.m. revealed that on the day of the incident, LPN #48 overheard resident #67 tell resident #41 to get out of his chair in the dayroom. A few seconds later LPN #48 observed resident #67 hit resident #41 in the back of the head knocking the resident's hat off his head. LPN #48 assisted in separating the residents immediately. -Regarding Resident #77 and Resident #21 Resident #77 was admitted on [DATE] with diagnoses including Alzheimer's disease, dementia in other diseases classified elsewhere, anoxic brain damage, major depressive disorder, unspecified psychosis, delusional disorders, and disruptive mood dysregulation disorder. A quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 06, which indicated severe cognitive impairment. Review of resident #77's clinical record revealed a behavior progress note on July 11, 2022. This note stated at 6:10 a.m. a loud boom was heard from resident #77's room and upon entering the room resident #77 was observed hovering over his roommate and punching him twice. Resident #77 was removed from the room and redness was noted on the back of his right hand. The roommate was noted to be bleeding from the head. Review of resident #77's care plan revealed a focus for behavior problems, initiated March 19, 2018. Interventions included monitoring resident #77 for significant behavioral and medical changes to ensure proper placement of resident. Resident #21 was admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, delusional disorders, unspecified mood disorder, peripheral vascular disease, epilepsy, restlessness and agitation, anxiety disorder, insomnia, generalized anxiety disorder, difficulty in walking, muscle weakness, and sensorineural hearing loss. A review of resident #21's clinical record revealed a nursing progress not dated July 11, 2022 at 7:30 a.m. that stated resident #21 was attacked by another resident while laying in bed. Resident #21 was assessed and noted to be bleeding from a laceration to the left side of the head. 911 was called and resident #21 was transported by ambulance to the emergency room. A change in condition assessment dated [DATE] at 7:32 a.m. revealed that resident #21 was bleeding and suffered trauma. Review of the facility investigation dated July 15, 2022 revealed resident #77 received a medical workup and psych medication review and is now in the room by himself and will remain by himself. On June 17, 2025 at 12:29 p.m. an interview was conducted with Licensed Practical Nurse (LPN/staff #82) LPN #82 stated that she could recall the residents but not the specific events of the incident. She stated that physical abuse is unwanted physical contact and must be reported to the administrator immediately. -Regarding Resident #17 and Resident #14 Resident #17 was admitted on [DATE] with diagnoses including vascular dementia, Alzheimer's disease with early onset, alcohol dependence in remission, type 2 diabetes mellitus, bipolar disorder, and other psychoactive substance dependence in remission. A quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment. Census records revealed that on July 20, 2022, resident #17 was reassigned to room [ROOM NUMBER]A at 9:20 a.m. An alert progress note dated July 20, 2022 at 7:22 p.m. revealed that around 5:00 p.m. resident #17 attacked the resident that was sitting on his bed in room [ROOM NUMBER]. Resident #17 was then escorted back to room [ROOM NUMBER]. Care plan for resident #17 revealed a focus initiated on November 2, 2018 for cognitive deficit and interventions included reality orientation and to anticipate his needs. Resident #14 was admitted on [DATE] with diagnoses including Alzheimer's disease, vascular dementia, legal blindness, persistent mood disorder, anxiety disorder, major depressive disorder, and glaucoma. A Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08, which indicated moderate cognitive impairment. Census records revealed that on July 20, 2022, resident #14 was reassigned to room [ROOM NUMBER]P at 8:57 a.m. A nursing progress note dated July 20, 2022 at 6:18 p.m. revealed that at about 5:00 p.m. resident #14 was not in his room for medication administration. Resident #14 was found in room [ROOM NUMBER] and sitting on the bed. When asked why he was not in his room, resident told staff the that guy beat me up, I'm scared of that guy and I don't want to stay in that room. Resident was assessed and blood was removed from his mouth and lips. Review of the facility investigation dated July 27, 2022 revealed that resident #17 is believed to have been turned around after going to the bathroom and thought resident #14 was in resident #17's bed. An interview was conducted with Licensed Practical Nurse (LPN/staff #11) on June 17, 2025 at 2:53 p.m. LPN #11 stated that she does not recall the specific altercation but recalled that resident #17 struggled with roommates and needed to have his own room. LPN #11 further stated that resident #14's blindness caused significant vulnerability. -Regarding Resident #17 and Resident #2 Resident #17 was admitted on [DATE] with diagnoses including vascular dementia, Alzheimer's disease with early onset, alcohol dependence in remission, type 2 diabetes mellitus, bipolar disorder, and other psychoactive substance dependence in remission. A quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 04, which indicated severe cognitive impairment. A behavior progress note dated September 18, 2022 at 7:38 p.m. revealed that resident #2 had wandered into resident #17's room and a peer to peer resulted due to the intrusive wandering. Resident #2 was admitted on [DATE] with diagnoses including unspecified dementia, major depressive disorder, and insomnia. An admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, which indicated severe cognitive impairment. Record review revealed an assessment communication form titled SBAR Communication Form dated September 19, 2022. The evaluation noted that resident #2 was evaluated for skin wound and change in condition after resident-to-resident altercation with skin tears and redness to left side of face. The advance care planning recommendations stated staff is to monitor resident #2 while wondering and treatments for skin tears to left side of face. An alert progress noted dated September 20, 2022 at 2:20 p.m. revealed slight redness and facial swelling to left side of his face. Left eye was slightly redden with blood clot present to lower aspect his left eye, with eye clear eye drainage and left squinting. Resident #2 was complaining of pain to left side. He remained on observation post peer to peer altercation. Review of the facility investigation dated September 22, 2022 revealed that on September 19, 2022 at around 8:30 p.m. resident #17 was observed with blood on his hands and told staff that he threw a guy out of his room. An interview was conducted with Licensed Practical Nurse (LPN/staff #11) on June 17, 2025 at 2:53 p.m. LPN #11 stated that she does not recall the specific altercation but recalled that resident #17 struggled with roommates and needed to have his own room. Review of a policy revised in March of 2018 titled, Abuse and Neglect - Clinical Protocol, revealed that sexual abuse was defined as non-consensual sexual contact of any type with a resident. The policy also revealed that abuse included verbal abuse, sexual abuse, physical abuse, and mental abuse. Review of a policy revised in September of 2022 titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revealed a definition of abuse being the willful infliction of injury with resulting physical harm, pain or mental anguish. The policy further revealed a definition for willful being that an individual acted deliberately. Review of a policy revised in April of 2021 titled, Abuse, Neglect, Exploitation or Misappropriation - Prevention Program, revealed that residents have a right to be free from abuse, and the facility was committed to ensuring residents were protected from abuse by anyone, including other residents. Review of a policy revised in February of 2021 titled, Resident Rights, revealed that residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure a resident (#27) was not abused by another resident (#13). The deficient practice could lead to physical and psychosocial harm to residents. Findings Include: -Regarding resident #27: Resident #27 was admitted to the facility on [DATE] with diagnoses that included dementia with other behavioral disturbance, hypertension, post-traumatic stress disorder, adjustment disorder with mixed disturbance of emotions and conduct, migraine, Alzheimer's disease, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 06, indicating severe cognitive impairment. A nursing progress note dated May 30, 2025 at 10:21 a.m. revealed that resident #27 was in the dayroom awaiting breakfast when resident #13 tapped him on the shoulder and told him to move before resident #13 hit resident #27. The nurse de-escalated the situation and removed each resident to their respective rooms and reported the incident. Resident #27 was noted to have had two discolorations on the right eye. An observation of Resident #27 was conducted on June 6, 2025 at 11:48 a.m. and revealed discoloration to his right eye. An interview was conducted on June 6, 2025 at 11:48 a.m. with resident #27 who stated that he was punched by a person that he did not know and was punched for no reason at all. -Regarding resident #13: Resident #13 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, behavioral disturbance, anxiety disorder, and major depressive disorder. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 03, indicating severe cognitive impairment. Review of a care plan focus dated January 28, 2025 revealed that resident #13 was at risk for psychological emotional distress following a resident-to-resident altercation, and interventions included 1 on 1 as needed, and to monitor for verbal and nonverbal symptoms of psychosocial emotional distress. Multiple behavior charting nursing assessments dated May 25, 26, 28, and 29 of 2025 revealed that the resident displayed agitation, aggression, disorganized thinking, yelling, delusions, and exit seeking behaviors. The documented interventions for those dates included: emotional support, redirection and reduced emotional stimuli. An observation of resident #13 was conducted on June 6, 2025 at 12:00 p.m. who was observed in the dining area eating lunch and seated between two other residents. An interview was conducted on June 6, 2025 at 12:36 p.m. with Resident #13 who stated that he had no concerns about the facility and stated he had not had any conflicts with any other residents. Resident #13's daughter was also present during the interview and she stated that she, too, had no concerns. An interview was conducted on June 6, 2025 at 12:51 p.m. with a licensed practical nurse (LPN/staff #82) who stated that on May, 30, 2025 in the morning she was assisting another resident when she overheard resident #13 tell resident #27 to move out of his way or he was going to punch him in the face. The LPN immediately turned to deescalate the situation and witnessed resident #13 punch resident #27 in the right eye. As she approached the residents, resident #27 was using his hands to defend himself. The LPN stated she was able to separate the two residents before any further harm. The LPN stated that resident #13 can often be verbally and physically aggressive with staff and other residents and feels the facility could better assess residents to have them placed into the proper units. Review of the facility's investigation revealed that they concluded that both residents lacked the intent to cause harm or understand the consequences of their actions. The review further stated that the facility continued to keep all residents safe and follow all facility policies and procedures related to behavioral management and abuse reporting and investigation. Facility policy titled Abuse and Neglect-Clinical Protocol stated the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse. Further the physician and staff will address appropriately causes of problematic resident behaviors where possible. Review of a policy revised in September of 2022 titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revealed a definition of abuse being the willful infliction of injury with resulting physical harm, pain or mental anguish. The policy further revealed a definition for willful being that an individual acted deliberately. Review of a policy revised in April of 2021 titled, Abuse, Neglect, Exploitation or Misappropriation - Prevention Program, revealed that residents have a right to be free from abuse, and the facility was committed to ensuring residents were protected from abuse by anyone, including other residents. Review of a policy revised in February of 2021 titled, Resident Rights, revealed that residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#76) did not abuse another resident (#81). The deficient practice could result in residents being physically harmed. Findings include: -Resident #81 was admitted on [DATE] with diagnoses that included type 2 diabetes, chronic atrial fibrillation, hypertension, major depressive disorder, vascular dementia, schizoaffective disorder, panic disorder, and obsessive-compulsive disorder. An Annual Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment with no behaviors exhibited. A skin assessment dated [DATE] at 2:52 p.m. revealed a new skin tear with a flap measurement of 2x2 to the back of his left hand following the resident-to-resident altercation. A progress note dated May 20, 2025 at 3:08 p.m. revealed that Resident #81 reported that his roommate (#76) hit him with his fist while inside of their room while he was attempting to open the door to leave. The note revealed that the resident sustained a skin tear on the left hand due to the altercation, and the incident was reported. A care plan focus initiated on May 21, 2025 revealed a focus on the resident having a potential psychosocial well-being problem related to a resident to resident altercation. -Resident #76 was admitted on [DATE] with diagnoses that included dementia, hypertension, major depressive disorder, personal history of traumatic brain injury, and anemia. A care plan focus initiated on April 24, 2025 revealed a focus on the resident having potential to be physically and verbally aggressive due to his dementia. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 06, which indicated severe cognitive impairment with behaviors exhibited 1 to 3 days. A progress note dated May 20, 2025 revealed that another resident (#81) reported that Resident #76 hit him while inside their room. The note further revealed that the other resident (#81) was attempting to leave the room when resident #76 struck him with a fist, and the altercation resulted in a skin tear on the left hand of other resident (#81). A progress note dated May 20, 2025 at 5:03 p.m. revealed that the resident had a room change due to an incident that occurred with his roommate. A care plan focus initiated on May 21, 2025 revealed a focus on the resident having a psychosocial well-being problem related to his lack of acceptance to his current condition and a resident to resident altercation. Review of the facility investigation dated May 20, 2025 revealed that it was reported that Resident #76 hit the left hand of Resident #81 which resulted in a skin tear to the left hand of resident #81. The investigation revealed that both residents were interviewed and gave conflicting nonsensical recollections of the incident, which resulted in the facility investigation being unsubstantiated. The investigation further revealed that Resident #81 reported to a nurse that Resident #76 hit him when he was trying to get into his room; and when the nurse asked the resident #76 as to why he hit his roommate (resident #81), reisdent #76 replied that resident #81 had the keys to his airplane, he was concerned about its location. It also included that Resident #76 reported that Resident #81 hit him first. The investigation also included that Resident #76 approached resident #81 in an aggressive manner and Resident #81 protected himself by making contact with his knuckles, which sustained a skin tear with blood before the residents were separated and the skin tear was assessed and cleaned. An interview was conducted on May 29, 2025 at 1:18 p.m. with a Licensed Practical Nurse (LPN/Staff#41) who stated that she was not in the room for the altercation that occurred, but she found it evident that an altercation did occur between the residents because of the bloody knuckle and skin tear on Resident #81. The LPN stated that Resident #81 went to the dayroom to tell her what happened, she took him to the nurses station to treat his hand wound, and she asked Resident #76 why he hit Resident #81. The LPN stated that Resident #76 told her he hit Resident #81 because he hit him first, and the resident again lunged at Resident #81 who then put up a defensive stance to protect himself from a second physical altercation. The LPN stated that the residents ' explanations of the altercation were clear and sensible. An interview was conducted on May 29, 2025 at 2:23 p.m. with the Administrator and Abuse Coordinator (Administrator/Staff#41) who stated that Resident #81 was entering the room when Resident #76 told him that he wanted the keys to his airplane back. The administrator stated that Resident #81 reported the altercation immediately to the nurse who then asked Resident #76 why he touched Resident #81, and Resident #76 stated that it was because he had the keys to his airplane. The administrator further started that Resident #76 attempted to make contact with Resident #81 again in the dayroom when the residents were reporting the altercation to the nurse, and the facility decided to do a room change immediately. The administrator stated that there was an injury in the altercation which was a skin tear to the left hand of Resident #81, and the facility knows there was an exchange of words between the residents. The administrator further stated that because the altercation was unwitnessed, they could not substantiate their investigation. A follow-up interview was conducted on June 5, 2025 at 3:07 p.m. with a Licensed Practical Nurse (LPN/Staff#41) who stated that the residents did not have prior issues with each other, but Resident #76 had another altercation with a different resident prior to this altercation. The LPN also stated that Resident #76 had a history of taking Resident #81 ' s belongings and would say they were his. Review of a policy revised in September of 2022 titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revealed a definition of abuse being the willful infliction of injury with resulting physical harm, pain or mental anguish. The policy further revealed a definition for willful being that an individual acted deliberately. Review of a policy revised in April of 2021 titled, Abuse, Neglect, Exploitation or Misappropriation - Prevention Program, revealed that residents have a right to be free from abuse, and the facility was committed to ensuring residents were protected from abuse by anyone, including other residents. Review of a policy revised in February of 2021 titled, Resident Rights, revealed that residents had the right to be free from abuse, neglect, misappropriation of property, and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff and resident interviews, facility documentation, and policy and procedures, the facility failed to ensure residents (#44, #33, #70 and #180) were free from abuse. The deficient practice could lead to further resident to resident abuse. Findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder, anxiety disorder, and adjustment disorder with mixed disturbance of emotions and conduct. The care plan dated October 4, 2024 revealed that resident #44 is at risk for psychological emotional distress related to a resident to resident altercation. Interventions included to monitor for any verbal or non-verbal serious symptoms of psychosocial emotional distress for 72 hours, allow resident to verbalize concerns as needed, and psych consult as needed if indicated. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. The progress note dated February 2, 2025 revealed that at approximately 1:30 p.m. on February 2, 2025, a resident (#400) reported to the east unit nurse that there was an issue in the courtyard between resident #44 and resident #33. The nurse and CNA went to investigate and did not find the two residents together. Both were interviewed. Resident #44 had no recollection of the event. Resident #33 who was in his room reported that after lunch he confronted resident #33 regarding going into other people's rooms. He further stated that resident #33 swung at him and he lost his balance and fell. He stated that he did not swing back nor continue to engage with resident #33. Both residents were assessed head to toe. Resident #33 has no marks/injuries nor indication that he made contact with resident #44. Resident #44 has a scrape to his knee and shoulder that he equates to falling on the ground after losing his balance. The care plan dated February 3, 2025 revealed that the resident is at risk for psychological emotional distress related to a resident to resident altercation. Interventions included to monitor for 72 hours and monitor/document resident's usual response to problems: internal - how the individual makes own changes, External -expects others to control problems or leaves to fate, or luck. -Resident #33 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, moderate, with other behavioral disturbance, and hypertension. The care plan dated December 4, 2024 revealed that the resident is an elopement risk related to being disoriented, to place, impaired safety risk. Interventions included to one-to-one as needed to provide resident safety, and to distract the resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, or book. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 3 indicating the resident had a severe cognitive impairment. Behavior charting dated January 28, 2025 revealed that the resident displayed agitation/aggression (verbal/physical towards others - hitting, kicking, grabbing, throwing objects, etc.) The resident was exit seeking and physically aggressive with staff. A physician note dated February 3, 2025 revealed that the resident was transferred from an outside unit due to increased agitation and lability. He was at a memory care facility before and was sent out due to his agitation. He was transferred here for continued care. He denies any chest pain, shortness of breath, or fevers. He is confused and was guided to his room where he was happy to find his belongings. He denies any other issues at this time. The resident was apparently involved in an altercation with another resident on his previous unit. The resident was transferred to his new unit. The resident was seen and evaluated on his new unit. The resident was asked if he had any altercations over the weekend, but could not recall. He states that he was at a funeral type event. He denies any trauma injury or any recollection of an altercation. An interview was conducted on February 7, 2025 at 9:57 a.m. with a certified nursing assistant (CNA/staff #128) who stated she has received training on abuse and if a resident tries to hit another resident, and doesn't make contact, but the resident falls down and is injured, this is resident to resident abuse. She stated that they have residents who wander on the unit, which included resident #33, but he was moved to another unit over the weekend where resident's with increased behaviors can be watched more carefully. She received a report that resident #33 had an incident with resident #44. She stated that resident #33 has a history of wandering into other residents' rooms and is supposed to be checked on every 15 minutes. She stated that the CNA assigned to him is the one who signs the 15-minute check sheet, but any staff can check off that they saw the resident. An interview was conducted on February 7, 2025 at 11:48 a.m. with a nurse (staff #43), who stated that staff check the residents every two hours, but may check sooner, every 30 minutes. She stated that staff do not check on the residents every 15 minutes unless something happened and resident (#33) was not on 15-minute checks the day that he hit resident #44 because he had been calm that day, but he is aggressive and always trying to leave. She stated that resident #33 has pushed her and other staff. She stated that resident (#400) came into the dining room and said that resident #33 punched someone and he is laying on the floor. Then resident #44 came into the dining room and had scrapes on his knee and elbow and stated that staff had to do something about resident #33 because he was a danger to the staff and the residents. Resident #44 stated that resident #33 had hit him in the jaw and there was a big red area around the jaw going up around the cheek area. She stated that you could tell that he had been punched in the face. She said she called the police. While she was cleaning resident #44's injuries, (CNA/staff #136) was outside with resident #33 and she sent another CNA to help monitor the resident; resident #400 told the CNAs that he hit resident #33 because he was going to hit him. Staff #43 stated that this was abuse. A phone was made to resident (#400's) case manger on February 7, 2025 at 1:12 p.m. and she stated that resident #400 discharged from the facility to the assisted living section at the same address. During an interview conducted on February 7, 2025 at 1:50 p.m. with resident #44, his voice was elevated and he appeared agitated and upset. He stated that last Sunday (February 2, 2025) a man with dementia kept going into peoples' rooms and he told the man to stop. Resident #44 pointed to the right side of his chin and stated that the man hit him near the right side of his chin. There was no injury observed to the chin area and the resident stated that it was better. He stated that he fell down and hit his right elbow and right knee. He stated that his knee was still hurting and pulled back the blanket where a bandage approximately 3 inches by 3 inches was observed on his right knee. He didn't want to pull back the blanket to show the right elbow. He stated that the new Administrator came to see him and told him that it was an incident, but he thinks that it was a felony assault. An interview was conducted on February 7, 2025 at 2:23 p.m. with resident (#400), who stated that she was sitting by the doorway getting some fresh air and saw resident #33 trying to open bedroom doors and the other male resident told him to stop and resident #33 said, I heard you. Resident #33 hit the other male resident whose name starts with a D. in the face with a closed fist. Resident #400 closed her fist and demonstrated by making contact with the right side of her chin. She stated that the male resident's chin was big and red and he fell on the ground and hurt his knee and his arm. She stated that she told the nurse that resident #33 hit the other male resident in the face. An interview was conducted on February 7, 2025 at 2:53 p.m. with the Director of Nursing (DON/staff #29), who stated that there are usually three CNAs on the Vista East Unit unless a resident has behaviors. He stated that all the residents are supposed to be checked every 15 minutes, but the staff would only document that the checks occurred if staff was assigned to a specific resident as a one-to-one. He stated that resident #44 was interviewed and stated that he was not hit by resident #33, but when the incident occurred, resident #44 was yelling that resident hit him and wanted to know what staff was going to do about it. He stated that there was a resident (#400) who witnessed the incident between resident #44 and resident #33, but he was not able to interview her because discharged from the facility. He stated that he heard that resident (#400) said resident #44 and resident #33 were arguing. He stated that from what he understands and from the interviews, resident #33 swung at resident #44, but did not hit him, but resident #44 fell and it was observed that he scraped his knee and elbow. Regarding Resident #70 and #180: - Regarding Resident #70: Resident #70 was admitted to the facility on [DATE] with diagnoses including unspecified dementia, unspecified severity, with agitation; major depressive disorder. Review on Resident #70 Behavior assessment dated on January 18, 2025, shows that the resident displayed behaviors such as, Agitation, Exit seeking, and physically aggressive towards another resident. The resident was monitored by staff by frequently checking the resident every two hours. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0, severe cognitive impairment. Review of the care plan revealed, initiated on January 31, 2025, indicated that the resident has potential to be physically aggressive r/t Dementia. This entry addressed that the Resident will not harm self or others initiated on January 31, 2025. - Regarding Resident #180 Resident #180 was admitted to the facility on [DATE] with diagnoses including vascular dementia, severe, with agitation, anxiety disorder, unspecified, major depressive disorder. Review of the care plan revealed, initiated on September 03, 2024 indicated that the Resident at risk for psychosocial emotion distress r/t resident to resident altercation. This entry addressed on January 18,2025, that Resident will not have signs and symptoms of psychosocial emotion distress. Review on Resident #180 Behavior assessment dated on January 18, 2025, shows that the resident displayed sundowning behavior. The resident was on every fifth teen minutes checks. Review on the skin evaluation dated on January 18, 2025, for Resident #180 indicated there is no head injuries, skin still intact, no swelling, drainage or bruising noted. Review of the nursing progress note for Resident #70 and Resident #180 revealed that on January 18, 2025, at approximately five thirty pm, Resident #70 walked past Resident #180 and punched the resident at the back of his head. The incident was witnessed by the CNA staff while she was emptying the plates in the trash from dinner when the incident occurred. The Residents were separated right away. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 0, severe cognitive impairment. An interview was conducted on February 06, 2025 at 1:31 PM with a CNA (Staff #120) who defined abuse as verbal, mental, physical, sexual, money, property, and neglect. The staff stated that resident to resident abuse can happen in the facility. She added that she receives training on residents' rights, abuse, and misappropriation of property. The CNA stated that her day starts by receiving shift report from the from the previous shift if there's any change of condition on the residents. She added that they provide one to one to the resident who like to elope, wanders, and agitated. The CNA added that they redirect the resident by doing activities, or providing snacks. She added that they work with the residents everyday, so they learn what tactics work best work with each residents. The CNA staff stated that she wasn't working the day the incident happened, but it was reported to her that Resident #70 hit Resident #180 in the back of the head while Resident #180 was seated in the day room of the south five hundred of the building. An interview was conducted on February 6, 2025, at 2:14 PM, with the LPN (Staff #34). She stated that she didn't witness the incident. The LPN mentioned that the CNA (Staff #121) reported cleaning the dining room where the residents ate. She added that it was Resident #70 who punched Resident #180 in the back of the head. The LPN noted that she went right away when she heard the commotion. The LPN redirected Resident #180, while the CNA pulled Resident #70 away from the incident. She stated that those two residents were combative and exit-seeking. The LPN mentioned that no one-to-one supervision was provided. She also indicated that staffing is always short and emphasized the need for more CNA staffing at the facility. An interview was conducted on February 6, 2025, at 3:17 PM CNA (Staff #121) witnessed Resident #70 hit Resident #180 in the head. Resident #70 passed by Resident #180 and struck him on the head with an open hand, while Resident #180 appeared ready to fight back. CNA #121 took Resident #70 out of the dining room, and the LPN redirected Resident #180 out of the dining room as well. This incident marks the first time the two residents have encountered such a situation. The CNA stated that Resident #70 has a history of hitting staff members. An interview was conducted on February 7, 2025, at 2:53 PM with the DON (Staff #29), who stated that all staff were trained on physical, sexual, misappropriation, verbal, restraints, and seclusion types of abuse. The DON added that CNAs typically check on residents every fifteen minutes but would only document their checks if assigned as a one-to-one. The DON mentioned that Resident #70 and Resident #180 are still on fifteen-minute checks and are under close supervision by the CNAs. However, the checks for these two residents are not documented because they have not exhibited abusive behavior toward other residents. The DON added that the interpretation of abuse is subjective and, from his understanding and the interviews he conducted, if a resident fall, that doesn't necessarily indicate that abuse occurred. If one resident swings at another but does not make contact, and the other resident falls, the swinging resident may have unintentionally caused the fall. However, if a resident hit another resident, it is considered abuse. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropriation prevention program indicated that Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility documentation, and staff interviews, the facility failed to ensure that adequate supervision was provided to two residents (#13 and #22) to prevent elopement from the facility. The deficient practice can result in other residents to go missing and/or getting injured. Findings include: - Regarding Resident #13: Resident #13 was admitted to the facility on [DATE] with diagnoses including dementia with agitation, anoxic brain damage, and epilepsy. Review of the elopement evaluation completed by the facility on December 31, 2024 revealed a score of 3.0, indicating the resident was considered At-risk for elopement, due to having a history of elopements at home, history of attempting to leave the facility without staff, and wandering behavior. Review of the nursing note dated December 31, 2024 revealed that upon admission, the resident's sister informed the staff that the resident is an elopement risk and had eloped a couple of times before. Review of the physician's progress note dated January 2, 2025 revealed that the resident was alert and oriented to self only, had progressive dementia with sundowning at night, had seizures, and was non-verbal. Review of the careplan initiated on January 2, 2025 revealed a focus that Resident #13 was an elopement risk, with interventions including to distract the resident from wandering by offering diversions and providing structured activities. Review of the nursing progress notes revealed that on January 5, 2025, the resident was seen walking in the hallway at 08:05AM, while the nurse was administering medications to another resident. The nurse detailed that at approximately 08:09AM, the Certified Nursing Assistant (CNA) reported that the resident was missing from the unit. The facility was searched, but the resident was unable to be located, so police were called. At approximately 10:50AM, the police reported to the facility that the resident was found and that they were bringing him to the facility. The note stated the resident arrived back to the unit at approximately 11:00AM. Interview was conducted on January 15, 2025 at 10:36AM with the Licensed Practical Nurse (LPN)/ Unit Manager (Staff #26), who stated that the staffing typically included a nurse and three CNAs. She also included that someone had to be present in the dayroom at all times. She also stated that when Resident #13 eloped, no one had seen which door he had left through. She also reported that there were no alarms sounding on the Kiva unit, though she claimed that there was an alarm sounding somewhere else in the building, which could still be heard on the unit. The Unit Manager also stated that the residents were the responsibility of the facility, and identified risks associated with a resident eloping to be that the resident could be put in harm's way. Observation of the entry to the Kiva unit with the Unit Manager on January 15, 2025 at 11:12AM revealed that the door to the Kiva unit was a large door, locked with a keypad system, positioned next to the lobby front-doors. Observation revealed that when staff or visitors went through the doors by typing a code onto the keypad, the door could then be opened, indicated by the light on the keypad turning green. Observation revealed that the light stayed green for approximately ten to fifteen seconds, including after the door was shut. When asking the nurse unit manager if the door could still be opened after shutting, the Unit Manager assisted visitors through the door, waited for the door to shut, and then attempted to re-open the door. The door was able to be opened without re-entering a keycode. When asked if she thought this was a potential concern for elopement, the Unit Manager replied that she thought it could potentially be a concern and would bring it up to maintenance. Interview was conducted on January 15, 2025 at 1:12PM with the Director of Nursing (DON/Staff #41), who stated that measures in place to prevent elopements included monthly checks of secured doors and elopement assessments completed on admission and quarterly. He also elaborated that several new interventions are being added following the recent elopements. When asked about Resident #13's elopement, the DON described that he was called after the nurse reported that the nurse had not seen the resident on the unit in about five minutes. He reported that at that time, staff checked the whole facility. He noted that there were doors alarming on another unit, which he believed could have masked the alarm in the Kiva unit. The DON explained that it was unclear exactly what happened, but explained that the resident was very cognitive and was familiar with the building as he was a former employee, which may have made it easier for him to leave. - Regarding Resident #22: Resident #22 was admitted to the facility on [DATE] with diagnoses including dementia with behavioral disturbance, essential hypertension, and hyperlipidemia. A review of the elopement risk evaluation created on December 4, 2024 revealed that the resident scored a 0.0, indicating the resident was not at risk for elopement. Review of the careplan revealed a focus, initiated December 4, 2024, indicating that the resident was an elopement risk related to being disoriented to place and impaired safety awareness. Review of the nursing progress note dated December 5, 2025 at 3:40PM revealed that the resident was confused and was roaming into other residents' rooms, requiring constant re-direction. Further review of the nursing progress notes revealed that on December 9, 2024, the resident was wandering the unit and was seeking to leave the premises. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 03, indicating severe cognitive impairment. Review of the nursing progress notes revealed that on January 8, 2025, the resident was last seen at 4:30PM walking in the courtyard. At 4:40PM, staff noticed that the resident was not in his room or the neighboring room, so a search was begun of the unit. The resident was not found, so other units were searched. After the resident was still not found, police were notified. Further review of the nursing notes revealed no evidence of a nursing note entered when the resident was returned to the unit. A Change in Condition Evaluation with an effective date of January 8, 2025 at 4:40PM was completed by the Director of Nursing (DON) on January 10, 2025, which revealed that on January 8, 2025, the resident was noted missing at 4:40PM, and was found by the police and returned to the facility at 7:13PM with no injuries noted. Interview was conducted on January 15, 2025 at 09:56AM with a Registered Nurse (RN/Staff #9) who stated that on January 8, 2025, he had seen the resident walking the hall at about 4:30PM. About ten minutes later, the CNA (Certified Nursing Assistant) had left to check a call light and noticed the resident was not in his room. The RN reported that the facility was thoroughly searched and the resident was not located, so management was notified, who called the police. The RN explained that a woman had found him on the street and picked him up. The resident had mentioned a neighboring town, so the woman took him to the police station in the neighboring town. From there, the police were able to return the resident to the facility around 8:00PM. The RN explained that since the unit required a physical key to get in and out, the resident likely went out with someone, likely a visitor. He explained that the resident was wearing a winter jacket and hat, so visitors may have thought he was also a visitor and let him out. Interview was conducted on January 15, 2025 at 10:36AM with the Unit Manager (LPN/ Staff #26), who stated that the staffing typically included a nurse and three CNAs, and she felt this was adequate most days. She stated that she was present the day that Resident #22 eloped from the facility. She explained that he was last seen around 4:30PM on January 8, 2025 and was returned back to the facility by the police around 7:45PM or 8:00PM. She explained that a head to toe assessment was done, and no injuries were found on the resident. She stated that she was unsure how he had gotten out of the facility, but she explained that the resident often lingered near doors, and she assumed he may have followed someone out. She further explained that the resident was in one of the outdoor units, which had a gate that required a physical key. She described the gate door as slow-moving, and stated the resident may have followed someone out of the gate. Interview was conducted with the Unit Manager (Staff #26) and a maintenance worker (Staff #55) on January 15, 2025 at 11:07PM at the gate leading from the lobby to the Vistas units. The gate hinge device was being worked on by the maintenance worker. The maintenance worker stated that he was fixing the gate, and that the gate was broken. He detailed that the device he was working on is supposed to keep the door from slamming, but he stated that it was causing the gate to not close completely. The Unit manager then stated that she guessed that was the answer on how Resident #22 got out. Interview was conducted on January 15, 2025 at 11:51AM with a Certified Nursing Assistant (CNA/Staff #14), who stated that she did not believe there was enough staff to watch residents closely. She stated that certain units are very busy and require staff to watch the residents closely, due to their behaviors. She further explained that it is often just two CNAs for the unit and it is not enough. She elaborated that sometimes there will be three CNAs, but then one CNA will have to go to an appointment with a resident, leaving just two CNAs. She also stated that the facility will often cancel staff's shifts, leaving the facility with not enough help. When asked about Resident #22, the CNA stated that she had heard that the resident had gotten out from the south gate, and that he had followed someone from the kitchen out of the gate, thinking it was family. The CNA also explained that she knew that the doors do not always lock when closed. She explained that on the units, the door does not always click, so when the staff notice, they close it. She also stated that she noticed the issue everywhere in the facility, including the electrically locked doors. The CNA stated that this has been brought up to maintenance. Interview was conducted on January 15, 2025 at 12:00PM with the Maintenance Director (Staff #67) ho stated that the maintenance team does monthly scheduled inspections for all doors and exits, though they are now doing daily inspections due to the recent elopements. He states that in these inspections, they check the full functions of all the doors, including a fifteen second delay egress for fire safety and making sure the magnets are energized and securing properly. He states that if a door is not functioning properly, staff should put in a work order, and that proper documentation is needed to be held accountable. When asked about the repairs being done to the gate leading to the outdoor Vistas units, the Maintenance Director insisted that the door has been functional. He explained that the closing mechanism, called a [NAME] Slam, was broken that day (January 15, 2025) when kitchen brought the trays to the unit, and it was caught and fixed immediately. Review of the maintenance work order requests from September 2024 to January 2025 revealed several work orders put in due to improperly functioning doors or doors that would not latch or lock. While most of the work orders were marked as completed quickly, the doors appeared to need frequent maintenance, as several work orders were put in due to door issues. Interview was conducted on January 15, 2025 at 1:12PM with the Director of Nursing (DON/Staff #41), who stated that measures in place to prevent elopements included monthly checks of secured doors and elopement assessments completed on admission and quarterly. He also elaborated that several new interventions are being added following the recent elopements. When asked about Resident #22's elopement, the DON explained that the resident was noted by staff to not be in his room, after seeing him shortly before. He explained that a search was conducted and police were notified when he was not found. The DON explained that the resident had gotten to the street, and someone had picked the resident up and brought him to another town. The police were able to identify where he was from and bring him back to the facility with no injuries. The DON stated that he was unsure how the resident made it out of the facility, but stated that no one recalled letting him out of the unit. When asked if the resident's elopement evaluation was accurate of the resident's behaviors prior to eloping, the DON explained that the resident was not an elopement risk at that time because even though he had dementia, the resident seemed purposeful in his movement, and would pace instead of wander. The DON added that a new elopement evaluation was completed after the resident had eloped from the facility. Review of the facility policy titled, Wandering and Elopements, revealed that the facility will identify residents who are at risk of unsafe wandering and will strive to prevent harm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation, interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#26) did not abuse another resident (#32). The deficient practice could result in residents being physically and/or emotionally injured. Findings include: Resident #26 was admitted to the facility on [DATE] with diagnoses that included unspecified psychosis, generalized anxiety, dementia in other diseases classified elsewhere, anoxic brain damage, and disruptive mood dysregulation. The minimum data set (MDS) dated [DATE] included a staff assessment for mental status indicating the resident had a severe cognitive impairment. The care plan dated May 16, 2015 revealed that the resident has a problem with exessive yelling, history of sitting or forcefully placing herself on floor at times, intrusiveness, physically aggressive behaviors, being combative with care, exposing herself, and spitting. Interventions included to attempt to redirect behaviors, and see the behavior plan for up to date distractors. Behavior Charting dated November 30, 2024 revealed that the resident was agitated, aggressive, hitting staff, yelling out, mumbling words, and pacing in room. Behavior Charting dated December 2, 2024 revealed that the resident was agitated, aggressive, demonstrated poor boundaries, and hit another resident. The resident was removed from the common area to her room with a continued one-to-one staff. Snacks and fluids were given. A progress note dated December 2, 2024 revealed that during medication administration , the nurse was notified by staff that the resident was physically aggressive with another resident. Upon arrival to the dayroom the residents had been redirected and separated. The resident was unable to recount the incident. The residents were immediately separated by staff. The resident was reeducated on being at a minimum of arms length away from residents and other staff. The resident's baseline is confused, non compliant and is on psychoactive medications. A change of condition form dated December 2,2024 revealed that the resident made contact with another resident. The care plan dated December 3, 2024 revealed that the resident is at risk for psychosocial emotional distress related to resident to resident altercation. Interventions included to monitor for nonverbal serious symptoms of distress, and a psych consult as needed if indicated. -Resident #32 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with severe agitation, major depression, and anxiety disorder. The care plan dated September 3, 2024 revealed that the resident is at risk for psychosocial emotional distress related to resident to resident altercation. Interventions included to monitor for nonverbal serious symptoms of distress, and a psych consult as needed if indicated. A behavior plan dated November 8, 2024 revealed that the resident has a behavior problem related to posturing and physical aggression, attempting to take peers food/items, and disrobing without sexual intent. Interventions included monitoring behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. The (MDS) dated [DATE] included a staff assessment for mental status indicating the resident had a severe cognitive impairment. A progress note dated December 2, 2024 revealed that during medication administration , the nurse was notified by staff that the resident had an incident with another resident. Upon arrival to the dayroom the residents had been redirected and separated. When resident #32 asked what had happened, he grabbed the nurse's hand and placed it over his left eye/head area. An assessment was performed and no apparent injury or bleeding was noted. A Situation, Background, Assessment, and Recommendation (SBAR) summary dated December 2, 2024 included that the resident was ambulating in the hall when another resident made contact with his face. A change of condition form dated December 2, 2024 revealed that the resident had a resident to resident altercation. An interview was conducted on December 10, 2024 at 11:44 a.m. with a licensed practical nurse (LPN/staff #21), who stated that she has worked with resident #26 and the resident is supposed to have a one-to-one at all times. When she came back to work, she was told that resident #26 had hit resident #32. She stated that resident #26 is smart and fast, and she hits staff all the time. An interview was conducted on December 10, 2024 at 12:56 p.m. with the Director of Nursing (DON/staff #1), who stated that abuse includes a resident hitting another resident. He stated that resident #26 was having a behavior, flinging her arms around and staff was trying to redirect her when resident #32 walked into her path and her arm made contact with his left cheek. On December 10, 2024 at 12:56 p.m., an interview was conducted via phone with a certified nursing assistant (CNA/staff #5), who stated that it was his first day working with resident #26 and knows that she was his responsibility. He stated that he was focusing on resident #26 and didn't see resident #32 coming towards the resident. He stated that resident #26 reached out and hit resident #32 with an open hand in the face. He stated that resident #32 yelled, don't hit me. The facility policy, Abuse, Neglect, Exploitaion and Misappropriation Prevention Program states that residents have the right to be free from abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident #100 did not elope from the facility. The deficient practice could result in residents eloping and being physically and/or emotionally harmed. Findings include: Resident #100 was admitted to facility on June 1, 2015 and readmitted [DATE] with diagnoses that included schizophrenia, anxiety disorder, adjustment disorder with mixed disturbance of emotions and conduct, major depressive disorder, unspecified psychosis, and vascular dementia. The care plan dated February 5, 2016 revealed that the resident was an elopement risk associated with schizophrenia and associated impaired safety awareness. The patient attempts putting different codes in the keypad to leave the unit and pushes the door setting off the alarm. There was an elopement attempt on March 9, 2021. Interventions included to conduct Wanderguard safety check; staff will ambulate the resident up to/through all door(s) one time a week (Thursday) to ensure proper functioning of alarm. Also, check to ensure doors are engaged and working properly every shift, and redirect the resident from the doors. The Wandering Risk Evaluation dated August 9, 2023 revealed a score of 13 and the resident was a high risk for wandering. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 9 indicating the resident had a mild cognitive impairment. An orders administration note dated September 9, 2023 revealed to monitor for behaviors, physical aggression to staff. Document the number of episodes observed. Intervention Codes: 1=redirect, 2=1:1, 3=refer to nurse's note, 4=activity, 5=return to room, 6=toilet, 7=offer food, 8=offer fluids, 9=reposition, 10=adjust room temp, 11=give back rub, 12=behavior plan every shift. The patient is punching and screaming at staff when being redirected from exiting unit more than five times. The patient has refused medication. The medical director is aware. A progress note dated September 14, 2023 revealed that the resident was observed pacing in an out of his room. The resident was redirected a couple of times when seeking an exit. Staff will continue to monitor for changes during the shift. A progress note dated September 21, 2023 revealed that the resident eloped around 7:45 a.m. after the last 15-minute check. Staff found him outside and he was redirected back to the facility. A head-to-toe assessment was done upon arrival, vitals were within normal limits. There was no sign of distress noted and the resident denies pain at this time. A further review showed the exit door malfunctioned during the time of his elopement. Staff will continue 15-minute checks. Facility documentation dated September 21, 2023 revealed that a registered nurse (RN/staff #99) found the resident south of the facility on 68 68th Street. When the resident returned, the main door alarm system was tested and did not work consistently. An interview was conducted on December 12, 2024 with a certified nursing assistant (CNA/staff #74), who stated that the residents have to be supervised so they leave or fight, so staff should be aware of what the residents are doing. Staff are constantly watching the residents and are required to complete 15-minute checks on the residents. She stated that there is an alarm on the exist door which should go off if a resident tries to exit the unit. When she exits the unit, she waits until she hears a clicking noise, so she knows that the door is closed and secured. An interview was conducted on December 11, at 2:59 p.m. with the Maintenance Director (staff #93), who stated that the current practice is to check the doors on the secured units daily. He stated that the door where resident #100 exited needed the electrical wiring replace about a year ago, but did not have documentation to confirm the date. An interview was conducted on December 11, at 3:09 p.m. with the Director of Nursing (DON/staff #1), who stated that all residents are assessed for elopement risk and the current practice is for all secured doors to be maintained. He stated that staff should wait to hear the door click to make sure the door is shut and make sure that a resident doesn't follow the staff out of the unit. The facility, Wandering Residents & Elopement Policy states that it is the duty of the nurse to account for each resident on their unit at the beginning of the shift. Each CNA is then responsible to ensure that the residents are accounted for during their shift.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clincal documentation, staff interviews, and the facility policy and procedures, the facility failed to administer medications within the required timeframe to six residents (#66, #55, #12, #2, #15, and #25). The deficient practice could result in symptoms not being managed effectively and/or adverse effects. Findings include: Resident #66 was admitted to the facility on [DATE] with diagnoses that included obsessive compulsive disorder unspecified, hemorrhoids, rectal prolapse, drug induced subacute dyskinesia, and Parkinson's disease with dyskinesia with fluctuations. The order summary revealed: -September 1, 2024, Benztropine Mesylate oral tablet 0.5 mg give one tablet PO every 12 hours related to drug induced subacute dyskinesia. -September 1, 2024, Docusate Sodium oral tablet 100 mg give two tablets PO two times a day for bowel movement care (BM). -September 1, 2024, Senna oral tablet 8.6 mg give 2 tablets PO two times a day for BC. -September 1, 2024, Sodium Chloride oral tablet 1 gm give one tablet PO three times a day for prophylaxis. -September 2, 2024, Multivitamin give one tablet PO one time a day for supplement. -September 2, 2024, Gabapentin oral capsule 100 mg give one capsule enterally four times a day related to obsessive compulsive disorder, unspecified. -September 2, 2024, Divalproex Sodium Capsule Delayed Release Sprinkle 125 mg give two capsules by mouth (PO) one time a day related to obsessive compulsive disorder, unspecified. -November 7, 2024, Fluoxetine HCI oral capsule 20 mg give PO one time a day related to obsessive compulsive disorder, unspecified. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 4 indicating the resident had a severe cognitive impairment. Review of the medication administration record (MAR) dated December 2024 revealed that the above medications were scheduled to be administered at 8:00 a.m. During an observation of medication administration conducted on December 11, 2024, it was observed that the 8:00 a.m. medications for resident #66 were administered at 9:36 a.m. in the dining room. -Resident #55 was admitted to the facility on [DATE] with diagnoses that included hypertension, atherosclerotic heart disease of native coronary artery without angina pectoris, major depression disorder, gastro-esophageal reflux disease with esophgitis, without bleeding, Parkinson's Disease, and dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. The order summary revealed: -July 25, 2024, Allopurinol oral tablet 100 mg PO one time a day for joint pain and inflammation (gout). -July 25, 2024, Amlodipine Besylate oral tablet 10 mg PO one time a day for hypertension. -July 25, 2024, Aspirin tablet 81 mg give one tablet PO one time a day for coronary artery disease. -July 25, 2024, B-complex oral tablet (B-Complex with Biotin and Folic Acid give one tablet one time a day PO for supplement. -July 25, 2024, Bupropion HCI ER (SR) tablet extended release 12 hour 100 mg give one tablet PO a day for depression as evidenced by sad mood. -July 25, 2024, Ferrous Sulfate tablet 325 mg give one tablet PO one time a day for supplement. -July 25, 2024, Miralax Powder 17 gm/scoop give one scoop PO one time a day for bowel care. -July 25, 2024, Multivitamins tablet give one tablet PO one time a day for supplement. -July 25, 2024, Plecanatide Oral Tablet 3 mg (Plecanatide) give 1 tablet by mouth one time a day for gerd. -July 25, 2024, Docusate Sodium oral tablet 100 mg (Docusate Sodium) give 2 tablets PO two times a day for bowel care. -July 25, 2024, Omeprazole DR 20 mg capsule give 1 tablet PO two times a day related for gastro-esophageal reflux disease with esophgitis, without bleeding. -July 25, 2024, Carbidopa-Levodopa oral tablet 25-100 mg (Carbidopa- Levodopa) give 3 tablets PO three times a day for Parkinson's Disease. -September 9, 2024, Rivastigmine Transdermal Patch 24 Hour 9.5 mg/24 hr. Apply 1 patch transdermally one time a day related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, and remove per schedule. August 3, 2024, Acetaminophen tablet 325 mg give 2 tablets PO three times a day for pain. -October 2, 2024, Lorazepam oral tablet 0.5 mg (Lorazepam) give 0.25 mg by mouth two times a day as evidenced by restlessness related to unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety. -October 9, 2024, Senna tablet 8.6 mg (Sennosides) give 1 tablet PO one time a day for constipation -October 16, 2024, Diclofenac Sodium External Gel 1 % (Diclofenac Sodium (Topical)) apply to both shoulders topically three times a day for pain. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 5 indicating the resident had a severe cognitive impairment. Review of the medication administration record (MAR) dated December 2024 revealed that the above medications were scheduled to be administered at 8:00 a.m. During an observation of medication administration conducted on December 11, 2024, it was observed that the 8:00 a.m. medications for resident #50 were administered at approximately 10:07 a.m. in the dining room. -Resident 12 was admitted to the facility on [DATE] with diagnoses that included major depression, history of transient ischemic attack (TIA), gastro-esophageal reflux disease, and hypertension. The order summary revealed: -October 18, 2024, Miconazole Powder apply to Bil groin folds topically two times a day for fungal rash. Apply lightly and brush away excess. -October 18, 2024, Venelex External Ointment apply to buttocks, groin, scrotum topically two times a day for skin integrity. -October 19, 2024, Aspirin oral capsule 81 mg give 81 mg by PO one time a day for DVT ppx. -October 19, 2024, Cholecalciferol oral tablet give 25 mcg PO one time a day for supplement. -October 19, 2024, Fluoxetine HCl oral capsule give 80 mg PO one time a day for depression. -November 3, 2024, Omeprazole oral capsule delayed release 20 mg give 2 capsules PO one time a day for GERD. Take two capsules (40 mg total) by mouth every morning. November 2, 2024, Sucralfate tablet 1gm give 1 tablet PO four times a day for gastric protection take one tablet by mouth four times daily before meals and at bedtime. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 11 indicating the resident had a mild cognitive impairment. Review of the medication administration record (MAR) dated December 2024 revealed that the above medications were scheduled to be administered at 8:00 a.m. During an observation of medication administration conducted on December 11, 2024, it was observed that the 8:00 a.m. medications for resident #12 were administered at 10:36 a.m. -Resident #2 was admitted to the facility on [DATE] with diagnoses that included history of other venous thrombosis and embolism, olecranon bursitis right elbow, type II diabetes, major depression, gasto-esophageal reflux disease without esophagitis. The order summary revealed: -October 8, 2024, Apixaban oral tablet 5 mg give 5 mg PO two times a day for anticoagulant. -October 8, 2024, Metformin HCl oral tablet 500 mg give 500 mg PO two times a day for DM. -October 8, 2024, Spironolactone oral tablet 25 mg give 25 mg PO two times a day for edema, hold if SBP <100. -October 8, 2024, Simethicone oral tablet 80 mg give 80 mg PO four times a day for gas. -October 9, 2024, Folic Acid oral tablet 1 mg give 1 tablet by mouth one time a day for supplement October 9, 2024, Multi Vitamin oral tablet give 1 tablet PO one time a day for supplement. -November 4, 2024, Diclofenac Sodium External Gel 1 % apply to Lower back topically two times a day for Pain. -November 7, 2024, Fluoxetine HCl oral tablet 20 mg give 1 tablet PO one time a day for depression. -November 24, 2024, application of betadine to right foot 2nd digit toe two times a day d/c when resolved. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. Review of the medication administration record (MAR) dated December 2024 revealed that the above medications were scheduled to be administered at 8:00 a.m. During an observation of medication administration conducted on December 11, 2024, it was observed that the 8:00 a.m. medications for resident #2 were administered at 10:45 a.m. -Staff was observed taking medication to Resident #15's room to administer at 10:55 a.m. -Resident #25 was admitted to the facility on [DATE] with diagnoses that included The order summary revealed: -October 28, 2024, Cyproheptadine HCl oral tablet 4 mg give 1 tablet PO three times a day for allergies. -October 28, 2024, Potassium Chloride ER oral tablet extended release 20 meq give 1 tablet PO two times a day for electrolyte imbalance/hypokalemia. -October 28, 2024, Guaifemesin ER tablet extended release 12 hour 600 mg give 1 tablet by mouth two times a day for allergies. -October 29, 2024, Bumetanide oral tablet 1 mg give 1 tablet PO one time a day for congestive heart failure (CHF). -October 29, 2024, Famotidine oral tablet 20 mg give 1 tablet PO one time a day for GERD. -October 29, 2024, Finasteride oral tablet 5 mg give 1 tablet PO one time a day for benign prostatic hyperplasia (BPH). -October 29, 2024, Nebivolol HCl oral tablet 10 mg give 1 tablet PO one time a day for hypertension (HTN). Hold for systolic blood pressure (SBP) less than 110. -October 29, 2024, prednisone oral tablet 10 mg give 1 tablet PO one time a day for COPD. -October 29, 2024, Roflumilast oral tablet 250 mcg give 1 tablet by PO time a day for COPD. -October 30, 2024, Azithromycin oral tablet 250 mg give 1 tablet PO one time a day every Mon, Wed, Fri for a history of pneumonia (PNA). -November 7, 2024, Myrbetriq oral tablet extended release 24 hour give 25 mg PO one time a day for BPH. -December 5, 2024, Breo Ellipta Inhalation Aerosol Powder Breath Activated 200-25 MCG/ACT 1 inhalation inhale orally one time a day for chronic obstruction pulmonary disease (COPD) * Rinse mouth with water and spit back into cup after use* -December 9, 2024, Morphine IR 5 mg capsule PO (BID) two times a day for shortness of breath. -December 25, 2024, Senna oral tablet 8.6 mg give 1 tablet PO two times a day for constipation. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 6 indicating the resident had a severe cognitive impairment. Review of the medication administration record (MAR) dated December 2024 revealed that the above medications were scheduled to be administered at 8:00 a.m. Facility documentation revealed that medications are administered at 8:00 a.m. and 8:00 p.m. During an observation of medication administration conducted on December 11, 2024, it was observed that the 8:00 a.m. medications for resident #25 were administered at 11:21 a.m. A registered nurse (RN/staff #8) told resident #25 that she was not going to administer his blood pressure medication because his blood pressure (BP) was low. The surveyor had to intervene and asked staff #8 when she took the resident's BP and she stated that she had taken the resident's BP at 7:15 a.m. Then, she stated that it was possible that the BP level had changed since that time and would take the resident's BP again. The BP was 124/71. During an interview conducted on December 11, 2024 at 9:25 a.m. with resident #25, he stated that he had not received his morning medications. An interview was conducted on December 11, 2024 at 9:30 a.m. with a registered nurse (RN/staff #8), she stated that she had started administering the morning medications at 6:15 a.m. She stated that medications are administered at 8:00 a.m. and she can administer medications one hour before and one hour after. Then, she looked at her watch and stated that it was 9:27 a.m. and she still had to give medications to five more residents. An interview was conducted on December 11, 2024 at 9:55 a.m. with a certified nursing assistant (CNA/staff #68), who stated that breakfast was served around 8:15 a.m. Note: medications that need to be administered prior to breakfast, such as resident 12's Sucralfate tablet 1gm give 1 tablet PO four times a day for gastric protection take one tablet by mouth four times daily before meals and at bedtime was adminstered at 10:36 a.m. An interview was conducted on December 11, 2024 at 3:09 p.m. with the Director of Nursing (DON/staff #1), who stated that medications are administered at 8:00 a.m. and 8:00 p.m. He stated that medications can be administered one hour before and one hour after 8:00 a.m. He stated that if a medication is not administered on time, there is a risk of impacting efficacy, potentiation, as well as physical side effects if medication is not received timely. The facility policy, Administering Medications states that medications are adminstered within one hour of their prescribed times, unless otherwise specified (for example, before and after meals).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, facility documentation and staff interviews, the facility failed to ensure that adequate supervision was provided to two residents (#3 and #4) to prevent abuse. The deficient prectice could increase the risk of resident to resident abuse. Findings include: - Regarding Resident #3: Resident #3 was readmitted to the facility on [DATE] with the diagnosis that included Post-Traumatic Stress Disorder, anxiety disorder, other specified depressive episodes, restlessness and agitation, adjustment disorder with mixed disturbance of emotions and conduct. Review of care plan dated May 4, 2021 revealed a trauma informed care, post traumatic stress disorder (PTSD). The goal included to avoid triggers related to previous traumas throughout stay. The intervention includes to continue to monitor for triggers. A review of resident #3 clinical record revealed a progress note, eINTERACT SBAR (Situation, Background, Assessment, Recommendation) Summary for Providers, dated October 4, 2024 at 6:24 pm revealed that resident #3 was observed standing in dayroom with a bloody thumb, being yelled out by Resident #4. A review of resident #3 clinical record revealed a progress note, Alert Note, dated October 4, 2024 at 10:32 pm that a CNA (certified nursing assistant) reported to nurse that resident was screaming and said another resident hit him. The noted stated resident said another resident had gone into their room and started kicking them. Resident said he tried to push his wheelchair away and got an abrasion to his left thumb. Nurse did head to toe assessment and assessed injuries. Resident was able to move all extremities with and without resistance. Resident has abrasion to their left thumb with scant bleeding. Nurse cleaned wound with NS (normal saline), pat dry, and applied bandaid, resident stated 3/10 pain on their thumb and PRN (as needed) Tylenol was given. The note stated that the MD (Medical Director) and DON (Director of Nursing) were notified. - Regarding Resident #4: Resident #4 was readmitted to the facility on [DATE] with diagnosis that included anxiety disorder, postural kyphosis, dysphagia and spinal stenosis. A review of resident #4 clinical record revealed a progress note, eINTERACT SBAR Summary for Providers, dated October 4, 2024 at 5:39 pm revealed Resident #4 was observed sitting in his wheelchair, yelling at another resident and was actively attempting to make his way to other resident but several staff members were observed intervening. A review of resident #4 clinical record revealed a progress note, Alert Note, dated October 4, 2024 at 10:39 pm stated CNA reported to nurse that resident was screaming that another resident hit them. Nurse and CNA separated the two residents and was assessed separately. Both residents had abrasions. Resident had two abrasions to the left arm and stated they are not aware of how it happened. Abrasions cleaned with NS. Resident continues to be aggressive and agitative despite redirection methods. Resident was given PRN hydroxyzine for agitation and was offered fluids and drinks. Resident continues to show aggressive nature and is not redirectable. The note stated 911 was notified and transported resident #4 out. An interview was conducted on October 31, 2024 at 11:05 am with a licensed practical nurse (LPN/Staff #118). Staff #118 stated when there is resident's altercation, they separate them, she will ask them what is the issue, they check on them and it is pass down through report. She stated that 2 weeks ago there was two residents that were fighting, they separated them and keep 15 minutes check. An interview was conducted on October 31, 2024 at 11:23 am with a CNA(Staff #42). Staff #42 stated that resident #3 and resident #4 got into an argument that happened in the courtyard. Staff #42 stated resident #4 is in a wheelchair, can stand but not on his own and resident #3 can walk and is pretty much independent. Staff #42 stated resident #3 was forgetful, did not come out to his room often, he did not socialize with other resident. An interview was conducted on October 31, 2024 at 11:31 am with a CNA(Staff #82). Staff #82 stated that Resident #4 liked his own space and did not like anybody bothering him. Staff stated that residents got into a verbal fight and Resident #4 was screaming in the dayroom at Resident #3. Resident #3 did not hang out in dayroom. Resident #3 was yelling at the nurse and complaint about something every day and yelled everyday out loud and it was disturbing the residents. Resident #4 was yelling at Resident #3. Resident #3 was loud and Resident #4 was trying to shut him down. She added that when residents are in the day room, they make sure no one gets close to Resident #3. An interview was conducted on October 31, 2024 at 11:45 am with Resident #3. Resident #3 stated that resident #4 is very mean, sweared a lot, and at 08:00 am in the morning he pushed him away, at 3:30 pm Resident #4 tried to kick him in his leg and he hurt his thumb, and at about 5:00 pm the police arrested him for a week and then he was back now on the other side. Resident #3 did not remember when/where the incident happened. An interview was conducted on October 31, 2024 at 11:59 am with a CNA(Staff #91). Staff #91 stated that she was working on October 4. She remembered two residents were arguing in the eating area/dining room, one resident said another resident came in his room hitting him. Staff said they told the nurse LPN because of what happened in the resident's room in the afternoon around 4:30-5:00pm and one resident was hitting the other resident. Staff #91 said one of them who was able to walk had a bleeding finger and the resident in the wheelchair was very agitated. Staff #91 stated that she was in the dining room watching residents, the other CNA left to do something, and the nurse was on the other side of the dining room eating their lunch when that incident happened. The fire fighters came and took the resident who is in the wheelchair and then the police came. She stated that she did not know how residents are monitored in the court yard. An interview was conducted on October 31, 2024 at 12:45 pm with the director of nursing (DON/Staff #12) and during the interview, the assistant director of nursing (ADON/Staff #13) and the administrator (Staff #11) were present. The DON stated that the process on how residents are supervised or monitored is that they have surveillance camera and their staff monitor their residents. Their surveillance camera is in the other units while the other units have no surveillance camera but residents are supervised and monitored by staff. DON stated that the supervision by staff is reviewed based on acuity during their meetings such as less staff on other units with lower acuity. The DON stated that their inside units have higher acuity. The DON stated that their lower acuity unit is staffed with two CNAs and a nurse per shift with 15 to 20 residents and three CNAs and a nurse per shift for 25 to 30 residents. The DON stated that for the resident to resident altercation, Resident #3 reported to staff that Resident #4 wheeled in his room and started hitting him, and Resident #3 pushed Resident #4 out of his room. The DON stated that their staff do frequent rounds for visual supervision of residents and provide activity in the day room area. The DON stated that their intervention include resident #4 went out to the hospital then when he came back his room changed. A review of facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021 revealed residents have the right to be free from abuse. (1) protect residents from abuse, neglect by anyone including b. other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure that resident (#2) and or representative was informed of the risks and benefits of psychotropic medications prior to the administration of the medications. The deficient practice could result in residents and/or resident representatives not being aware of the benefits and the potential adverse side effects of psychotropic medications. Findings include: Resident #2 was admitted to the facility on [DATE] with diagnoses that included cerebrovascular accident (CVA), aphasia, non-Alzheimer's dementia, and hemiplegia. A review of resident #2 care plan initiated on May 28, 2024 revealed that resident used psychotropic medications related to schizoaffective disorder, bipolar with hallucinations and disorganized thinking. The interventions included administer antipsychotic medications as ordered by physician. Monitor for side effects and effectiveness every shift. A review of resident #2 MDS dated [DATE] revealed a BIMS score of 3, which indicated resident had severe cognitive impairment. In addition, behavior of physical and verbal symptoms directed to others occurred 1 to 3 days and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) occurred daily. Resident #2 used a wheelchair for mobility. The physician's orders revealed the medication Trazodone HCl Tablet 50 mg was ordered on May 27, 2024. A review of MAR for May 2024 revealed the following medication being administered: -Rexulti Oral tablet 2 mg give 1 tablet by mouth two times a day for mood swings, physical aggression related to schizophrenic disorder start date of 05/15/2024 and discontinue date of 05/21/2024; -hydroxyzine HCl tablet 25 mg give 1 tablet by mouth one time a day for figeting related to anxiety disorder a start date of 05/16/2024 and a discontinue date of 06/19/2024; -Rexulti Oral tablet 3 mg give 1 tablet by mouth one time a day for agitation related to schizoaffective disorder start date of 05/21/2024 and a discontinue date of 06/27/2024; -Sertraline HCl tablet 100 mg give 1 tablet by mouth one time a day for crying related to cognitive social or emotional deficit following other cerebrovascular disease start date of 05/16/2024 and discontinue date of 07/24/2024; -Trazodone HCl tablet 50 mg give 1 tablet by mouth at bedtime for inability to sleep related to cognitive social or emotional deficit following other cerebrovascular disease start date of 05/15/2024. A review of resident #2 clinical record revealed another physician order for Rexulti Oral Tablet 3 mg was ordered on June 28, 2024. A review of MAR for June 2024 revealed the following medication being administered: - hydroxyzine HCl tablet 25 mg give 1 tablet by mouth one time a day for fidgeting related to anxiety disorder, start date of 05/16/2024 and discontinue date of 06/19/2024; - hydroxyzine HCl Oral tablet 25 mg give 1 tablet by mouth every 8 hours as needed for agitation related to anxiety disorder for 90 days, start date of 06/19/2024 and discontinue date of 09/11/2024; - Rexulti Oral tablet 3 mg give 1 tablet by mouth one time a day for agitation related to schizoaffective disorder, start date of 05/21/2024 and discontinue date of 06/27/2024; - Rexulti Oral Tablet 3 MG Give 1 tablet by mouth one time a day for Agitation related to schizoaffective disorder, start date 06/28/2024; - Sertraline HCl Tablet 100 MG Give 1 tablet by mouth one time a day for crying related to cognitive social or emotional deficit following other cerebrovascular disease start date of 05/16/2024 and discontinue date of 07/24/2024; - Trazodone HCl Tablet 50 MG Give 2 tablet by mouth at bedtime for inability to sleep related to cognitive social or emotional deficit following other cerebrovascular disease start date of 05/27/2024. A review of resident #2 clinical record revealed another physician order for hydroxyzine HCl Oral Tablet 25 MG was ordered on September 11, 2024, order for Sertraline HCl Oral Tablet 100 MG was ordered on September 12, 2024, and order forAtivan Oral Tablet 0.5 MG was ordered on September 19, 2024. A review of MAR for September 2024 revealed the following medication being administered: - hydroxyzine HCl Oral tablet 25 mg give 1 tablet by mouth every 8 hours as needed for agitation related to anxiety disorder for 90 days start date of 06/19/2024 and discontinue date of 09/11/2024; - hydroxyzine HCl Oral tablet 25 mg give 1 tablet by mouth every 8 hours as needed for agitation and axiety related to anxiety disorderfor 90 days start date of 09/11/2024; - Ativan Oral tablet 0.5 mg give 1 tablet by mouth every 6 hours as needed for mood lability related to vascular dementia, start date of 09/18/2024 and discontinue date of 09/25/2024; - Ativan Oral tablet 0.5 mg give 1 tablet by mouth one time a day for mood lability related to vascular dementia, start date 09/19/2024; - Ativan Oral tablet 0.5 mg give 1 tablet by mouth every 6 hours as needed for physical aggression related to vascular dementia, for 90 days start date of 09/25/2024; - Rexulti Oral tablet 3 mg give 1 tablet by mouth one time a day for Agitation related to schizoaffective disorder, start date-06/28/2024; - Sertraline HCl tablet 100 mg give 1 tablet by mouth one time a day for restlessness related to anxiety disorder, start date-07/25/2024 and discontinue date of 09/11/2024; - Sertraline HCl Oral tablet 100 mg Give 1.5 tablet by mouth one time a day for restlessness related to anxiety disorder, start date-09/12/2024; - Trazodone HCl Tablet 50 MG Give 2 tablet by mouth at bedtime for inability to sleep related to cognitive social or emotional deficit following other cerebrovascular disease start date of 05/27/2024. A review of resident #2 care plan initiated on September 23, 2024 revealed was at risk for psychosocial emotional distress related to resident to resident altercation. The interventions included monitored 72 hours for psychosocial emotional distress, and allow resident to verbalize any concerns noted from this incident; and that, resident had potential to be physically aggressive related to history of harm to others, Poor impulse control. The interventions included the resident's triggers for physical aggression are increased auditory stimulation. The resident's behaviors are de-escalated by 1:1 and quite environment. Administer medications as ordered and monitor/document for side effects and effectiveness. Analyze times of day, places, circumstances, triggers, and what de-escalates behavior and document. Assess and anticipate resident's needs: food, thirst. toileting needs, comfort level, body positioning, pain. A review of resident #2 clinical record revealed a progress note dated September 23, 2024 at 13:15 that physical aggression directed towards resident #1. The residents were separated. An interview was conducted on October 1, 2024 at 3:22 pm with a licensed practical nurse (LPN)/ Staff #150 who stated that their role in the behavioral locked unit was to do rounds, check residents, review their medications, and monitor so they can see what is going on in the unit. They give routine scheduled psychotropic medications such as for instance Seroquel, Ativan, and sometimes Haldol. They monitor side effects of the psychotropic medications such as decreased mental status, and urine output. Staff #150 added that they get consents for these medications and the consents are in the residents' charts and are in the paper form in the chart. Staff #150 stated that she was working that particular day when an altercation between the two residents happened but she did not witness the incident. She stated that resident #1 was coming in from smoking and resident #2 was in the dining room and resident #2 reached over while a CNA was in between just to prevent resident #2 from reaching over resident #1's arm. The residents were separated. On October 1, 2024 at 4:59 pm, the DON/Staff #184 brought the chart of resident #2 in the conference room. The DON revealed that resident #2 had consents for psychotropic medications for hydroxyzine, trazadone, and rexulti dated February 1, 2024. However, resident #2 was admitted after that date into the facility on May 15, 2024. An interview was conducted on October 1, 2024 at 5:22 pm with the administrator /Staff #10 and DON/Staff #184. The DON stated resident #2 was admitted on [DATE] with his psychotropic medications' consents signed on February 1, 2024 from their sister facility; and that, they utilize the same consent. The DON stated that the process of transfer from one facility to a sister facility was that they review the information provided to determine if its viable for them to use. DON stated that it is a transfer and that their sister facility holds the same policy. A review of facility policy titled, Resident Rights, version 1.2 (H5MAPL0768) revealed 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's rights to: be informed of, and participate in his or her care planning and treatment. A review of facility policy titled, Psychotropic Medication Use, version 1.0 (H5MAPL1554) revealed 13. Residents receiving psychotropic medications are monitored, and for resident evaluations, 4. residents (and/or representatives) have the right to decline treatment with psychotropic medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interviews, the facility failed to ensure one resident (#1) with a diagnosis of mental illness was referred to the appropriate state-designated mental health or intellectual disability authority for review. The deficient practice could result in necessary specialized services not being provided for residents who need it. Findings include: Resident #1 had a Pre-admission Screening and Resident Review (PASRR) level one completed on March 6, 2024 at an outside hospital. A review of resident #1 clinical record revealed a PASRR level one completed and signed from the hospital on March 6, 2024; however, the referral determination section D was blank. Resident #1 was admitted to the facility on [DATE]. Resident #1 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, anxiety disorder, type 2 diabetes mellitus, and bipolar disorder. A review of resident #1 Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which meant resident was cognitively intact. Resident's active diagnoses included diabetes mellitus, anxiety disorder, bipolar disorder, and schizophrenia. In addition, resident exhibited verbal behavioral symptoms directed towards others. A review of resident #1 care plan initiated on April 19, 2024 revealed that the resident used psychotropic medications related to Schizoaffective disorder with hallucinations. The interventions include to administer antipsychotic medications as ordered by physician, monitor for side effects and effectiveness every shift. Moreover, that the resident used anti-anxiety medications related to Anxiety disorder. The interventions include to administer anti-anxiety medications as ordered by physician, monitor for side effects and effectiveness every shift. Furthermore, revealed that the resident used antidepressant medication related to depression. The interventions include to administer antidepressant medications as ordered by physician, monitor for side effects and effectiveness every shift. Review of physician's orders revealed the following medication orders: Haloperidol tablet 10 mg (milligrams), Depakote tablet 250 mg, trazadone HCL (hydrochloride) 100 mg, hydroxyzine 25 mg, and alprazolam 0.25 mg. A review of resident #1 medication administration record (MAR) for April 2024 revealed the following administered: - trazadone 100 mg give 1 tablet by mouth at bedtime for depression start date 4/8/2024 and discontinue date 5/23/2024; - Divalproex Sodium tablet delayed release 250 MG Give 1 tablet by mouth two times a day for Bipolar start date of 4/9/2024 and discontinue date of 5/30/2024; - Haloperidol Oral Tablet 2MG (Haloperidol) Give 1 tablet by mouth three times a day for Schizophrenia: Auditory hallucination start date of 04/09/2024 0800 discontinue date of 04/22/2024 - Haloperidol Tablet 5 MG Give 1 tablet by mouth every morning and at bedtime for related to schizoaffective disorder start date 4/17/2024 and discontinue date of 5/9/2024 - Alprazolam Oral Tablet 0.25 MG (Alprazolam) Give 1 tablet by mouth every 8 hours as needed for posturing at staff related to anxiety disorder for 14 Days start date of 04/11/2024 - Hydroxyzine HCl Tablet 25 MG Give 1 tablet by mouth every 6 hours as needed for agitation start date of 04/11/2024 and discontinue date of 05/02/2024 A review of resident #1 clinical record revealed a progress note dated September 23, 2024 at 14:34 that resident fiduciary was notified of a resident-to-resident altercation. Progress note dated September 23, 2024 at 19:35 revealed that while resident #1 was walking past resident #2 was hit on the right arm. Resident was assessed and no injuries observed nor complaints of pain or discomfort. An interview was conducted on October 1, 2024 at 3:05 pm with a certified nursing assistant (CNA)/Staff #47 who stated that resident #1 was independent and by himself in his room. Resident #1 can be aggressive if other residents are making a lot of noise. Resident #1 does smoke. An interview was conducted on October 1, 2024 at 3:12 pm with resident #1. Resident #1 stated that while he was walking by to go back to his room, a resident hit him on his arm like a smack. Resident #1 stated that it ain't no big deal. An interview was conducted on October 1, 2024 at 3:19 pm with a CNA/Staff #113. Staff #113 who stated that their role was to make sure residents are changed and fed. They get in between residents to prevent anything happening. An interview was conducted on October 1, 2024 at 4:15 pm with the social service director/Staff #16 and present during the interview was Staff #197. Staff #16 stated that her role included attending meetings, care plan meeting, and getting resources for residents. During the interview, Staff #16 reviewed the PASRR for resident #1 and she stated that resident #1's level one PASRR was completed and did not see level 2 PASRR referral. She stated that resident should have a level 2 PASRR for schizoaffective disorder and bipolar disorder. She stated that level 2 PASRR referral was not done and the facility would have to submit for level 2. Staff stated that they were informed about the two residents' altercation, and they spoke to resident #1 and resident told them he got hit on the arm by resident #2, and that they followed up on their psychosocial wellbeing. An interview was conducted on October 1, 2024 at 5:22 pm with the administrator /Staff #10 and DON/Staff #184. The administrator stated that if PASRR triggers level one, then level two should be done and reviewed as indicated. The administrator and DON reviewed Point Click Care (PCC) for resident #1 PASRR, and stated that when resident #1 was admitted from the hospital, the hospital filled out the PASRR. If resident is in their facility for more than 30 days, they will complete a level 2 PASRR. They stated that they do not have a physical copy of the resident #1 level 2 PASRR; and that, they had reached out to ALTCS (Arizona Long Term Care System), but the DON stated that they were not sure when they reached out to ALTCS. A review of facility policy titled, Resident Assessments, version 2.1 (H5MAPL0755) revealed A comprehensive assessment of every resident's needs is made at intervals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to protect the rights of one resident (#40) to be free from sexual abuse by another resident (#49); and, failed to protect the rights of two residents (#25 and #5) to be free from abuse by another resident (#6). The deficient practice could result in the potential for harm and had placed residents at increased risk for further abuse, serious injury, harm and psychosocial harm. Findings include: -Resident #40 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia in other diseases with agitation, with anxiety, other behavioral disturbance, wandering in diseases classified elsewhere. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident had severe cognitive impairment, had physical and verbal behavioral symptoms directed towards others placing the resident at significant risk for physical injury that occurred 1-3 days of the lookback period. The care plan dated July 31, 2024 revealed the resident had impaired cognitive function and had a behavior of wandering aimlessly. The goal was that cognitive function and resident safety will be maintained. Intervention included keeping resident's routine consistent and try to provide consistent caregivers to decrease confusion, distraction from wandering and provide structured activities. The care plan dated August 28, 2024 included the resident had the potential for psychosocial emotional distress related to inappropriate behavior from another resident. Interventions included monitoring for 72 hours for psychosocial, emotional distress, nonverbal signs of psychosocial, emotional distress as exhibited by self-isolation, increased pain, increased behaviors and refer to psych as needed. A nurse note dated August 28, 2024 stated certified nurse assistant (CNA) found resident cornered outside with another resident (#49) who touched resident #40 inappropriately. Per the documentation, the CNA separated both residents,15-minute checks were initiated and the POA (power of attorney), DON (director of nursing) and physician were notified. A Psych Follow-Up Note dated August 28, 2024 included resident was seen for follow up after an incident where another resident (#49) grabbed the resident's breast. -Resident #49 was admitted on [DATE] with diagnoses of vascular dementia with other behavioral disturbance, major depressive disorder, recurrent, moderate and anxiety disorder. The care plan dated July 17, 2024 had revealed the resident had cognitive deficit related to dementia; and, had a behavior problem related to pacing, sexually inappropriate behavior in public spaces, touching his genitalia in front of others, sexually explicit drawings and walking on the unit without clothing. The goal was that resident needs will be anticipated. Interventions included reality orientation, verbal cues and reminders, redirection of behaviors and when resident exposes himself to redirect to his room to ensure privacy and his safety. The quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score 14 which indicated the resident had intact cognition. A behavior note dated August 8, 2024 revealed the housekeeper notified the nurse that resident #49 sitting next to resident #40 and was fondling her private parts. Per the documentation, both residents were immediately separated and the nurse instructed the CNAs to keep the two residents away; and that, plan of care was ongoing. However, there was no evidence of any new interventions put in place to address resident #49's behavior. A behavior note dated August 28, 2024 included that resident #49 cornered and inappropriately touched another resident (#40) outside of his room; and that, the certified nurse assistant (CNA) intervened immediately. Per the documentation, resident #49 reported to the nurse that he was just messing around. It also included that the nurse notified management; and, change of condition and 15 minute checks were initiated for resident #49. A communication note dated August 28, 2024 revealed that the unit manager was notified about resident's sexual behavior towards another resident (#40); and that, both residents were place on every 15 minute checks. A Psych Follow-Up Note dated August 21, 2024 revealed that the last reported behavior reported by staff was on August 10, 2010. Per the documentation, prior behavior included sexual inappropriateness with staff and verbal behaviors were documented. A physician order dated August 30, 2024 included for progesterone (hormone) 100 mg (milligrams) give 1 capsule by mouth once daily x 14 for increased sexual behavior. An interview was conducted with the Administrator (staff #239) on September 4, 2024 at 9:48 a.m. The administrator said that a report on the incident dated August 8, 2024 had not been filed to the SA nor reported to the police because the administrator was not aware of it. An interview was conducted on September 4, 2024 at approximately 9:55 a.m. with a licensed practical nurse (LPN/staff #92) who stated that resident #49 had sexually inappropriate behaviors, mostly directed at female staff. She stated that resident #49 had taken off his brief and was dancing outside of the break room, would fondle himself in front of other residents and/or staff and would need to be redirected back to his room. The LPN stated that resident #49 was closely monitored when awake; and, no concerns related to monitoring the resident at night as the resident sleeps through the night. She also stated that resident #49 was moved to a different unit due to his sexually inappropriate behaviors. The LPN stated that when there was allegation of abuse, she had to report the incident immediately after ensuring the residents are safe. An interview was conducted with a CNA (staff #246) on September 4, 2024 at 10:19 a.m. The CNA stated that another CNA witnessed resident #49 groping one of the female residents; and that, was instructed that if anything else happened staff need to write the incident up. The CNA said that resident #49 would make sexually inappropriate comments towards the female staff, residents and family; and that, in one instance, resident #49 was lying in bed naked and had asked her to lay down with him while she was providing him assistance. The CNA stated that resident #49 was not on 1:1 supervision; but, staff were told to keep a close eye on him. She stated that CNA's rely on the nurses to also monitor the residents; and that, there was a need for more staff for extra monitoring of the residents and the halls/unit. The CNA also said that more staff would give them more eyes and hands, because sometimes when both CNA's on shift were in a room assisting another resident, the nurse cannot always be there to watch the unit. In an interview with the administrator and the Director of Nursing (DON/staff #200) conducted on September 4, 2024 at 11:05 a.m., both staffs stated that they had documentation regarding the incident involving residents #49 and #40 on August 8, 2024. The DON said that stated he had a text message regarding the incident and he had just interviewed the housekeeper. The DON said that resident #49 was sitting with his pants pulled down to his pelvic area and had his hands in his pants pleasuring himself and was sitting near the other resident (#40). The DON further stated that resident #40 did not have the capacity to be affected by what was being done in front of her; and that, resident #49's behavior was about the intent which was to self-gratify and not cause harm. The DON further stated how can this incident be sexual abuse or abuse when resident #40 did not even know what was happening because of her cognitive status. An interview with Director of Nursing (DON/staff #200) and the Administrator (staff #239) was conducted on September 4, 2024 at 12:33 p.m. Both staffs stated that their process for implementing interventions for residents with behaviors was for staff to redirect the resident review the behavior to determine if the behavior affected others and come up with an intervention. The DON stated that interventions were determined based on a review of the resident's chart, medications and an interdisciplinary team meeting if needed; and, an appropriate intervention is put in place and the care plan is revised. The DON said that the interventions implemented are entered in the resident's electronic record, care plan and behavioral tracking on the units. Regarding resident #49, the DON said that the inappropriate behaviors of resident #49 was based on his intent behind the behavior. Both the DON and the administrator stated that they were the ones who make the decisions on whether or not information was to be shared with the state agency. An observation of resident #49 was conducted on September 4 at 2:45 p.m. The resident was in his room with a CNA who was providing 1:1 supervision. An interview was conducted September 4, 2024 at 2:48 p.m. with staff #105 who stated resident #40 had moved to the unit from another unit to keep her safe due to her wandering and able to keep a closer eye on her; and that, resident #40 can be resistive with care, aggressive, hitting at others who may be close by, but has not caused anyone any injuries or injured herself. An interview was conducted on September 4, 2024 at 3:23 p.m. with the housekeeper (staff #128) who stated that she was cleaning the dining room on the unit when she saw resident #49 walking into the dining area and sat down on one side of the dining room. She stated she continued cleaning in the dining room and then saw resident #49 sitting in the chair with his pants down, his penis exposed and making a jerking motion with his hand on his penis. The housekeeper said that resident #49 then got up and to a female resident (#40) who was seated upright in a recliner; and that, resident #49 touched the legs and arms of resident #40 and motioned resident #40 to look at his exposed penis. The housekeeper said that resident #40 looked over at resident #49 exposed penis twice. The housekeeper further stated that she immediately reported the incident to the staff that were in the area and moved on with her work. In an interview was conducted with an LPN (staff #158) conducted on September 4, 2024 at 4:01 p.m., the LPN stated she was familiar with residents #40 and #49. The LPN stated that she did not observe the incident herself; but, she was the assigned nurse on the unit and the housekeeper reported the incident to her. She stated the housekeeper told her that resident #49 was touching himself near another resident (#40) with his pants down; so, she immediately went into the dayroom. The LPN said that she saw resident #49 with his pants zipped up and was seated next to resident #40. She stated she informed the CNAs that resident #49 was touching himself near another resident (#40) with his pants down, but had pulled them up at some point. The LPN said that she instructed the CNAs to keep the two residents separated the remainder of the shift. She said that she then reported in the facility clinical chat that the resident #49 was touching himself in the vicinity of another resident (#40); and, had his pants pulled down, but did not inform that the resident had his penis exposed. Further, the LPN stated that she was aware that resident #49 had a history of being sexually inappropriate with staff; but, was unaware of any prior incidents with other residents. An interview was conducted September 5, 2024 at 10:27 a.m. with the administrator and the DON. The DON stated that residents had a right to privacy and personal space; and, the expectation was that residents that had cognitive capacity need for staff to respect the resident's space; and, there was no facility culpability for residents without the cognitive ability and capacity. The administrator stated that wandering mentally ill residents does not fit in a skilled nursing facility, which is an institution and not the residents' home. Further, the DON stated that the facility does not have sufficient staffing to prevent residents from entering and wandering into other resident's rooms and to prevent it from occurring. The DON stated that it felt like it was an expectation of perfection but, it was not; and that, the facility's current population does not have the cognitive ability to understand the consequences of their actions. Review of the facility policy on Abuse, Neglect, Exploitation and Misappropriation Program revised April 2021, included that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This included but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. -Regarding resident #25 and #6 Resident #25 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with agitation, major depressive disorder, and an anxiety disorder. The care plan dated November 5, 2024 revealed that the resident had a behavior problem related to posturing, physical aggression, verbal aggression, sexually inappropriate gestures, intrusive wandering, and attempting to take peers food/items. Interventions included to administer medications as ordered, monitor and document for side effects and effectiveness, assist the resident to develop more appropriate methods of coping and interacting, and monitor behavior episodes and attempt to determine underlying cause, consider the location, time of day, persons involved, and situations. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 3 indicating the resident had severe cognitive impairment. It also included that the resident exhibited physical and verbal behaviors towards others for 4- 6 days during the lookback period. A psych note dated August 8, 2024 revealed the following documentation: -July 30, 2024 - the resident was wandering and hitting; -July 31, 2024 - the resident threatened to knock the staff's teeth out when being redirected from walking through the gate; -August 1, 2024 - the resident was hitting staff; -August 1, 2024 - the resident became extremely combative when being redirected out of another resident's room and threatened to kill staff; and, -August 5, 2024 - the resident was wandering, aggressive with staff, hitting staff, grabbing staff, pinching staff, kicking staff, yelling at staff, trying to hit other residents, entering other residents' rooms and refusing to leave, and cussing. A progress note dated August 8, 2024 revealed the resident continued to wander along the hallway and day room; and that, he was aggressive, hitting and kicking staff when being redirected. A progress note dated August 16, 2024 at 5:48 a.m. revealed that resident #25 was touching a sleeping female's thighs; and that, the resident was physically aggressive towards staff (hitting). A progress note dated August 16, 2024 at 6:22 p.m. revealed that resident #25 was aggressive, yelling on the unit and used a fork to try and stab another resident. Per the documentation, the resident was stopped, redirected and medications were administered and tolerated. A progress note dated August 16, 2024 at 10:47 p.m. revealed that resident #25 was wandering the hall and came into proximity of another wandering resident (#6); and that, as staff began to intervene, resident #6 tapped resident #25's chest. Per the documentation, resident #25 placed his hand on resident #6's forehead and gave it a push. Staff redirected the two residents to separate areas. The care plan August 20, 2024 included the resident was at risk for psychosocial emotional distress related to a resident to resident altercation. -Resident #6 was admitted to the facility on [DATE] with diagnoses of dementia, agitation, psychotic disorder with delusions, unspecified psychosis and conduct disorder. Review of the care plan dated May 21, 2015 revealed that the resident had a behavior problem related to excessive yelling, history of sitting or forcefully placing self on the floor at times, intrusiveness, physically aggressive behaviors, being combative with care, exposing herself, and spitting. Interventions included to administer medications as ordered, attempt to determine cause of behaviors, and to attempt to redirect behaviors. The minimum data set (MDS) dated [DATE] included a BIMS score of 3 indicating the resident had severe cognitive impairment. It also included that the resident exhibited physical behaviors towards others daily during the lookback period. A progress note dated August 16, 2024 at 6:24 a.m. revealed that the resident was hitting staff and attempting to hit other residents. The resident was redirected when possible. A progress note dated August 16, 2024 at 10: 50 p.m. revealed that the resident hit another resident. The care plan dated August 26, 2024 revealed that the resident was at risk for psychosocial emotional distress related to resident to resident altercation. Interventions included to monitor for 72 hours for psychosocial emotional distress and allow the resident to verbalize any concerns related to this event. Review of the SBAR Communication Form dated August 16, 2024 revealed that the change of condition, symptoms, or signs observed and evaluated are behavioral symptoms (e.g. agitation, psychosis). Resident #6 was involved in a resident to resident altercation where a male resident (resident #25) pushed her in the head after she pushed him in the chest. A psych note dated August 28, 2024 revealed the following information: -August 21, 2024 - the resident was pacing up and down the hall, and hitting staff and other residents; and, -August 22, 2024 - the resident was very aggressive and loud today, hitting anyone or anything in sight the entire shift and getting other residents to be aggressive. Regarding resident #5 and #6 -Resident #5 was readmitted on [DATE] with diagnoses of Alzheimer's disease, dementia, other behavioral disturbance, and an anxiety disorder. The MDS dated [DATE] included a BIMS score of 3 indicating the resident had a severe cognitive impairment. Physical and verbal behaviors were exhibited for one to three days during the lookback period. A care plan dated October 2, 2023 revealed that the resident had a behavior problem related to dementia as evidenced by wandering/intrusive, exit seeking, moving furniture, physical/verbal aggression towards staff, destroying property, peer altercation, resistive to care, and resistive to medications. Interventions included psych evaluation for medication management, intervene as necessary to protect the rights and safety of others, approach and speak in a calm manner, divert attention and to remove from situation and take the alternate location as needed. The care plan dated August 26, 2024 included that the resident had the potential for psychosocial emotional distress related to resident to resident altercation. Interventions included for resident to verbalize any concerns related to this incident, a psych consult as needed if indicated, and to monitor for signs and symptoms of psychosocial emotional distress for 72 hours. The progress note dated August 25, 2024 revealed that at approximately 11:22 a.m., the licensed practical nurse (LPN/staff #85) was sitting at the nursing station when resident #5 was standing in the hallway, and resident #6 came into proximity with resident #5. Per the documentation, as the LPN began to intervene, resident #6 reached around staff #85 and hit resident #5 in the face on the left side near his eye; and that, resident #6 was unprovoked. It also included that both residents were separated, and redirected away from one another; and, the Administrator and power of attorney were notified. A psych note dated August 29, 2024 revealed that on August 26, 2024, resident #6 keeps getting attacked by resident in room [ROOM NUMBER]. No bad or harmful reaction has been shown by the resident. -Resident #6 was admitted to the facility on [DATE] with diagnoses of dementia, agitation, psychotic disorder with delusions, unspecified psychosis and conduct disorder. Review of the care plan dated May 21, 2015 revealed that the resident had a behavior problem related to excessive yelling, history of sitting or forcefully placing self on the floor at times, intrusiveness, physically aggressive behaviors, being combative with care, exposing herself, and spitting. Interventions included to administer medications as ordered, attempt to determine cause of behaviors, and to attempt to redirect behaviors. The minimum data set (MDS) dated [DATE] included a BIMS score of 3 indicating the resident had severe cognitive impairment. It also included that the resident exhibited physical behaviors towards others daily during the lookback period. A progress note dated August 16, 2024 at 6:24 a.m. revealed that the resident was hitting staff and attempting to hit other residents; and that, the resident was redirected when possible. A progress note dated August 16, 2024 at 10: 50 p.m. included that resident #6 hit another resident. A progress note dated August 25, 2024 revealed that the resident was restless for the most part of the shift, was unable to sleep and all pharmacological interventions were ineffective. Per the documentation, the resident was pacing in the day room and had two hours of sleep all night. A progress note dated August 25, 2024 revealed that at approximately 11:22 a.m., the licensed practical nurse (LPN/staff #85) was sitting at the nursing station when resident #5 was standing in the hallway, and resident #6 came into proximity with resident #5. As (LPN/staff #85) began to intervene, resident #6 reached around staff #85 and hit resident #5 in the face on the left side near his eye, unprovoked. The residents were separated, and redirected away from one another. Resident #5 followed staff to the nurse's station, with good affect. The Administrator and power of attorney were notified. The resident has a history of hitting others. The care plan dated August 26, 2024 revealed that the resident was at risk for psychosocial emotional distress related to resident to resident altercation. Interventions included to monitor for 72 hours for psychosocial emotional distress and allow the resident to verbalize any concerns related to this event. A psych note dated August 28, 2024 revealed the following information: -August 21, 2024 - The resident was pacing up and down the hall, and hitting staff and other residents; and, -August 22, 2024 - The resident was very aggressive and loud today, hitting anyone or anything in sight the entire shift and getting other residents to be aggressive. An interview was conducted on September 3, 2024 at 11:16 a.m. with a certified nursing assistant (CNA/staff #186), who stated that resident #25 can be aggressive with other residents and staff have to redirect him. She stated that he just heads for a resident and can also get upset when another resident was being loud. The CNA said that resident #25 gets irritated and angry with resident #6mwho was loud; and that, resident #25 would tell resident #6 to be quiet. Regarding resident #6, the CNA stated that the resident was non-verbal, hits and pulls staff hair all the time, also heads towards residents and tries to hit them, was tall and strong and cannot be redirected, so staff just get hit. She stated that resident #6 had a one-to-one staffing ratio because she hit a resident last week. The CNA further stated that it was difficult to watch the halls; and that, the facility have hospitality staff to help out in the unit, but the hospitality staff were not allowed to touch the residents. An interview was conducted on September 3, 2024 at 11:49 a.m. with a licensed practical nurse (LPN/staff #85), who stated that there had been a decline in the number of staff scheduled, so they did not have the ability to redirect residents as needed. She stated that she had seen an increase in the behaviors of the residents since the reduction in the number of staff. She stated that resident #25 does not like anyone in his space and will raise a closed fist to warn other residents; and that, resident #25 walks around and there was a possibility that he could hurt someone. Regarding resident #6, the LPN stated that resident #6 was very intrusive, fast, and strong; and that, staff never know if she was going to tap or hit. The LPN said that resident may tap and then hit a person. She stated that she heard the two residents had an altercation; and, when she came to work today, there were three CNAs assigned to the unit. The LPN said that one CNA may have been assigned as a one-to-one for one for residents #6 and #25. An interview was conducted on August 5, 2024 at 10:27 a.m. with the (DON/staff #200), who stated that all staff, including himself and the Administrator, have received training on abuse. He stated that abuse can be physical, verbal, sexual, fiduciary, neglect, and seclusion. He stated that all resident to resident incidents were documented in the change of condition form and the clinical team, which included himself. The administrator also said that the clinical team were responsible for reviewing the change of condition forms, so they were aware of the number of resident to resident incidents occurring on a daily basis. He also stated that the population that they serve was not able to understand when staff try to explain what they cannot do; and that, their facility assessment included that the facility was able to provide the supervision and care needed for the population that they serve. During an interview with the Administrator (staff #239) conducted on August 26, 2024 at 4:00 p.m., she stated that the facility provides adequate supervision for the residents. She stated that the regulation pertaining to supervision did not fit when you have wandering mentally ill residents in a skilled nursing facility (SNF). She stated that the facility was an institution where the resident carry out their last days and not a home. However, the administrator said that it was the facility's responsibility to protect the residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, resident/staff interviews, facility documentation and policy review and the State Agency (SA) complaint tracking system, the facility failed to report allegations of abuse to the State Agency (SA), Adult Protective Services (APS) and local law enforcement for three sampled residents (#40, #25 and #5). The deficient practice could result in abuse not identified and investigated and place all residents at risk for further abuse. Findings include: Resident #40 admitted on [DATE] with diagnoses including Alzheimer's disease, unspecified, dementia in other diseases classified elsewhere, unspecified severity, with agitation, with anxiety, dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, wandering in diseases classified elsewhere. A nurse note dated August 28, 2024 stated certified nurse assistant (CNA) found resident cornered outside with another resident (#49) who touched resident #40 inappropriately. Per the documentation, the CNA separated both residents,15-minute checks was initiated and the POA (power of attorney), DON (director of nursing) and physician were notified. A Psych Follow-Up Note dated August 28, 2024 included resident was seen for follow up after an incident where another resident (#49) grabbed the resident's breast. -Resident #49 was admitted on [DATE] with diagnoses of vascular dementia with other behavioral disturbance, major depressive disorder, recurrent, moderate and anxiety disorder. A behavior note dated August 28, 2024 included that resident #49 cornered and inappropriately touched another resident (#40) outside of his room; and that, the certified nurse assistant (CNA) intervened immediately. Per the documentation, resident #49 reported to the nurse that he was just messing around. It also included that the nurse notified management; and, change of condition and 15 minute checks were initiated for resident #49. A communication note dated August 28, 2024 revealed that the unit manager was notified about resident's sexual behavior towards another resident (#40); and that, both residents were place on every 15 minute checks. A Psych Follow-Up Note dated August 21, 2024 revealed that the last reported behavior reported by staff was on August 10, 2010. Per the documentation, prior behavior included sexual inappropriateness with staff and verbal behaviors were documented. Despite documentation that resident #49 grabbed the breast of resident #40, there was no evidence that this incident was reported to SA, APS and local law enforcement. An interview was conducted with the Administrator (staff #239) on September 4, 2024 at 9:48 a.m. The administrator said that a report on the incident dated August 8, 2024 had not been filed to the SA nor reported to the police because the administrator was not aware of it. In an interview with the administrator and the Director of Nursing (DON/staff #200) conducted on September 4, 2024 at 11:05 a.m., both staff stated that they had documentation regarding the incident involving residents #49 and #40 on August 8, 2024. The DON said that stated he had a text message regarding the incident and he had just interviewed the housekeeper. The DON said that resident #49 was sitting with his pants pulled down to his pelvic area and had his hands in his pants pleasuring himself and was sitting near the other resident (#40). The DON further stated that resident #40 did not have the capacity to be affected by what was being done in front of her; and that, resident #49's behavior was about the intent which was to self-gratify and not cause harm. The DON further stated how can this incident be sexual abuse or abuse when resident #40 did not even know what was happening because of her cognitive status. An interview with Director of Nursing (DON/staff #200) and the Administrator (staff #239) was conducted on September 4, 2024 at 12:33 p.m. Both staff stated that their process for implementing interventions for residents with behaviors was for staff to redirect the resident review the behavior to determine if the behavior affected others and come up with an intervention. The DON stated that interventions were determined based on a review of the resident's chart, medications and an interdisciplinary team meeting if needed; and, an appropriate intervention is put in place and the care plan is revised. The DON said that the interventions implemented are entered in the resident's electronic record, care plan and behavioral tracking on the units. Regarding resident #49, the DON said that the inappropriate behaviors of resident #49 was based on his intent behind the behavior. Both the DON and the administrator stated that they were the ones who make the decisions on whether or not information was to be shared with the state agency. An interview was conducted on September 4, 2024 at 3:23 p.m. with the housekeeper (staff #128) who stated that she was cleaning the dining room on the unit when she saw resident #49 walking into the dining area and sat down on one side of the dining room. She stated she continued cleaning in the dining room and then saw resident #49 sitting in the chair with his pants down, his penis exposed and making a jerking motion with his hand on his penis. The housekeepr said that resident #49 then got up and to a female resident (#40) who was seated upright in a recliner; and that, resident #49 touched the legs and arms of resident #40 and motioned resident #40 to look at his exposed penis. The housekeeper said that resident #40 looked over at resident #49 exposed penis twice. The housekeeper further stated that she immediately reported the incident to the staff that were in the area and moved on with her work. In an interview was conducted with an LPN (staff #158) conducted on September 4, 2024 at 4:01 p.m., the LPN stated she was familiar with residents #40 and #49. The LPN stated that she did not observe the incident herself; but, she was the assigned nurse on the unit and the housekeeper reported the incident to her. She stated the housekeeper told her that resident #49 was touching himself near another resident (#40) with his pants down; so, she immediately went into the dayroom. An interview was conducted September 5, 2024 at 10:27 a.m. with the administrator and the DON. The DON stated that residents had a right to privacy and personal space; and, the expectation was that residents that had cognitive capacity need for staff to respect the resident's space; and, there was no facility culpability for residents without the cognitive ability and capacity. The DON stated that wandering mentally ill residents does not fit in a skilled nursing facility, which is an institution and not the residents home. Further, the DON stated that the facility does not have sufficient staffing to prevent residents from entering and wandering into other resident's rooms and to prevent it from occurring. The DON stated that it felt like it was an expectation of perfection but, it was not; and that, the facility's current population does not have the cognitive ability to understand the consequences of their actions. -Resident #25 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with agitation, major depressive disorder, and an anxiety disorder. The care plan dated November 5, 2024 revealed that the resident had a behavior problem related to posturing, physical aggression, verbal aggression, sexually inappropriate gestures, intrusive wandering, and attempting to take peers food/items. Interventions included to administer medications as ordered, monitor and document for side effects and effectiveness, assist the resident to develop more appropriate methods of coping and interacting, and monitor behavior episodes and attempt to determine underlying cause, consider the location, time of day, persons involved, and situations. A progress note dated July 9, 2024 revealed that the resident continued to wander along the hallway, and to other residents' room; and that, the resident was redirected several times with a negative impact. A progress note dated July 12, 2024 revealed that the resident was pacing the hall, refusing care, and entering others rooms. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 3 indicating the resident had severe cognitive impairment. It also included that the resident exhibited physical and verbal behaviors towards others for 4- 6 days during the lookback period. A progress note dated August 15, 2024 revealed that resident #25 was found in another resident's room naked. A progress note dated August 16, 2024 at 5:48 a.m. revealed that resident #25 was touching a sleeping female's thighs; and that, the resident was physically aggressive towards staff (hitting). -Resident #36 was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD), dementia in other diseases classified elsewhere, severe, with agitation, and aphasia. The care plan dated January 31, 2024 revealed the resident had a behavior problem related to physical aggression with peers, impulsive, and restless. Interventions included to intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, remove from situation and take to alternate location. The MDS dated [DATE] included a staff assessment that the resident had a severe cognitive impairment. Review of a complaint filed in the SA dated September 3, 2024 included that resident #25 was found in another resident's (#36) room undressed. The report also included that resident #36 was asleep and had no knowledge of resident #25 being in the room; and that, the CNAs dressed resident #25 by the bathroom for privacy and dignity and took him out of the room in approximately 2 to 3 minutes. The clinical record revealed no documentation of behavior of resident #25 wandering and being found undressed in the bathroom of resident #36. Despite documentation of behaviors on August 15 and August 16, 2024, there was no evidence found that the facility self-reported the incidents on August 15 and August 16, 2024 to the SA, APS and local law enforcement. An interview was conducted on September 3, 2024 at 10:10 a.m. with the Director of Nursing (DON/staff #200), who stated that there had been some type of disconnect with the staff; and that, training was being completed this day and the following day with all staff regarding the difference between baseline behaviors and reportable events. He stated that he was going to explain that the behaviors of resident's that affect other residents was a reportable event. He stated that one staff had been spoken to multiple times about reporting events. He stated that he and the Administrator were not being notified by staff when an allegation/reportable event occurs; and, both he and the administrator need to receive this information to determine what should be done. An interview was conducted on August 3, 2024 at 2:53 p.m. with the Administrator (staff #239), who stated that she did not have any information regarding the incident on August 15, 2024 when resident #25 was found in another resident's room naked. The administrator then stated that one CNA reported that resident #25 was naked and another CNA reported that resident #25 was naked because he needed to use the bathroom. An interview was conducted on August 3, 2024 at approximately 3:00 p.m. with a certified nursing assistant (CNA/staff #226), who stated that she found resident #25 in the bathroom of resident #36. She stated that it was approximately 4:30 p.m. to 5:00 p.m. just before dinner time. She stated that resident #36 had his call-light on, so she went to see what he needed and she found resident #36 standing by his bed with his pants down around his ankles. She stated that he appeared distressed and she thought he was frustrated and irritated by his facial expressions. She stated that resident #36 was flinging his hands around and pointing to the bathroom, but she could not understand what he was saying, it sounded like gibberish. The CNA said that she then saw resident #25 come out of the bathroom; and that, she asked resident #25 what happened, but resident #25 did not answer and appeared confused. She observed that there were feces in the toilet and thought that resident #36 was going to the bathroom when resident #25 came in and startled resident #36. She stated that she went to get another staff to help redirect resident #25 and resident #36 did end up having a bowel movement. She reported the incident to the nurse, but she does not remember what the nurse told her. She stated that she has had training on abuse and resident rights, including the resident's right to privacy. An interview was conducted on September 4, 2024 at 9:11 a.m. with a licensed practical nurse (LPN/staff #92), who stated she had been told that she does not need to contact the Administrator or the Director of Nursing to report incidents if the behavior was a part of the resident's baseline behaviors. An interview was conducted on August 5, 2024 at 10:27 a.m. with the (DON/staff #200), who stated that all staff, including himself and the Administrator, have received training on abuse. He stated that abuse can be physical, verbal, sexual, fiduciary, neglect, and seclusion. He stated that all resident to resident incidents were documented in the change of condition form and the clinical team, which included himself. The administrator also said that the clinical team were responsible for reviewing the change of condition forms, so they were aware of the number of residents to resident incidents occurring on a daily basis. He also stated that the population that they serve was not able to understand when staff try to explain what they cannot do; and that, their facility assessment included that the facility was able to provide the supervision and care needed for the population that they serve. Review of the facility policy on Abuse, Neglect, Exploitation and Misappropriation Program with revision date of April 2021 included that all reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to ensure an allegation of abuse for two residents (#40 and #36) by another resident (#49 and #25) were thoroughly investigated. The deficient practice could result in appropriate corrective action not taken to prevent further abuse. Findings include: -Resident #40 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia in other diseases with agitation, with anxiety, other behavioral disturbance, wandering in diseases classified elsewhere. A nurse note dated August 28, 2024 stated certified nurse assistant (CNA) found resident cornered outside with another resident (#49) who touched resident #40 inappropriately. Per the documentation, the CNA separated both residents,15-minute checks were initiated and the POA (power of attorney), DON (director of nursing) and physician were notified. A Psych Follow-Up Note dated August 28, 2024 included resident was seen for follow up after an incident where another resident (#49) grabbed the resident's breast. -Resident #49 was admitted on [DATE] with diagnoses of vascular dementia with other behavioral disturbance, major depressive disorder, recurrent, moderate and anxiety disorder. A behavior note dated August 28, 2024 included that resident #49 cornered and inappropriately touched another resident (#40) outside of his room; and that, the certified nurse assistant (CNA) intervened immediately. Per the documentation, resident #49 reported to the nurse that he was just messing around. It also included that the nurse notified management; and, change of condition and 15 minute checks were initiated for resident #49. A communication note dated August 28, 2024 revealed that the unit manager was notified about resident's sexual behavior towards another resident (#40); and that, both residents were place on every 15 minute checks. A Psych Follow-Up Note dated August 21, 2024 revealed that the last reported behavior reported by staff was on August 10, 2010. Per the documentation, prior behavior included sexual inappropriateness with staff and verbal behaviors were documented. Despite documentation that resident #49 grabbed the breast of resident #40, there was no evidence that the facility conducted a thorough investigation to include observations, interviews with other residents, staff or witnesses to the incident, reporting of the incident to appropriate agencies, conclusion of the investigation and the corrective actions taken. An interview with the Administrator and the Director of Nursing (DON/staff #200) was conducted September 5, 2024 at 10:27 a.m. Both the administrator and the DON stated that reporting timelines were two hours. The DON said that this was global practice regardless of the allegation and four hours for all other allegations; and that, the timeline to complete investigation was five days. The DON stated that any staff with allegations were taken off the floor, cleared from any patient area, office area and responsible staff were notified. The DON stated that the reason for the removal of the alleged staff was to ensure the safety of the residents until completion of the investigation. The DON stated that residents had a right to privacy and personal space; and, the expectation was that residents that had cognitive capacity need for staff to respect the resident's space; and, there was no facility culpability for residents without the cognitive ability and capacity. -Resident #25 was admitted to the facility on [DATE] with diagnoses that included vascular dementia with agitation, major depressive disorder, and an anxiety disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status (BIMS) score of 3 indicating the resident had severe cognitive impairment. It also included that the resident exhibited physical and verbal behaviors towards others for 4- 6 days during the lookback period. A progress note dated August 15, 2024 revealed that resident #25 was found in another resident's room naked. A progress note dated August 16, 2024 at 5:48 a.m. revealed that resident #25 was touching a sleeping female's thighs; and that, the resident was physically aggressive towards staff (hitting). -Resident #36 was admitted to the facility on [DATE] with diagnoses of post-traumatic stress disorder (PTSD), dementia in other diseases classified elsewhere, severe, with agitation, and aphasia. The MDS dated [DATE] included a staff assessment that the resident had a severe cognitive impairment. Review of a complaint filed in the SA dated September 3, 2024 included that resident #25 was found in another resident's (#36) room undressed. The report also included that resident #36 was asleep and had no knowledge of resident #25 being in the room; and that, the CNAs dressed resident #25 by the bathroom for privacy and dignity and took him out of the room in approximately 2 to 3 minutes. There was no evidence that the facility conducted a thorough investigation to include observations, interviews with other residents, staff or witnesses to the incident, reporting of the incident to appropriate agencies, conclusion of the investigation and the corrective actions taken. An interview was conducted on September 3, 2024 at 10:10 a.m. with the Director of Nursing (DON/staff #200), who stated that there had been some type of disconnect with the staff; and that, training was being completed this day and the following day with all staff regarding the difference between baseline behaviors and reportable events. He stated that he was going to explain that the behaviors of resident's that affect other residents was a reportable event. He stated that one staff had been spoken to multiple times about reporting events. He stated that he and the Administrator were not being notified by staff when an allegation/reportable event occurs; and, both he and the administrator need to receive this information to determine what should be done. An interview was conducted on August 3, 2024 at 2:53 p.m. with the Administrator (staff #239), who stated that she did not have any information regarding the incident on August 15, 2024 when resident #25 was found in another resident's room naked. The administrator then stated that one CNA reported that resident #25 was naked and another CNA reported that resident #25 was naked because he needed to use the bathroom. An interview was conducted on August 3, 2024 at approximately 3:00 p.m. with a certified nursing assistant (CNA/staff #226), who stated that she found resident #25 in the bathroom of resident #36. She stated that it was approximately 4:30 p.m. to 5:00 p.m. just before dinner time. She stated that resident #36 had his call-light on, so she went to see what he needed and she found resident #36 standing by his bed with his pants down around his ankles. She stated that he appeared distressed and she thought he was frustrated and irritated by his facial expressions. She stated that resident #36 was flinging his hands around and pointing to the bathroom, but she could not understand what he was saying, it sounded like gibberish. The CNA said that she then saw resident #25 come out of the bathroom; and that, she asked resident #25 what happened, but resident #25 did not answer and appeared confused. She observed that there were feces in the toilet and thought that resident #36 was going to the bathroom when resident #25 came in and startled resident #36. She stated that she went to get another staff to help redirect resident #25 and resident #36 did end up having a bowel movement. She reported the incident to the nurse, but she does not remember what the nurse told her. She stated that she has had training on abuse and resident rights, including the resident's right to privacy. An interview was conducted on September 4, 2024 at 9:11 a.m. with a licensed practical nurse (LPN/staff #92), who stated she had been told that she does not need to contact the Administrator or the Director of Nursing to report incidents if the behavior was a part of the resident's baseline behaviors. An interview was conducted on August 5, 2024 at 10:27 a.m. with the (DON/staff #200), who stated that all staff, including himself and the Administrator, have received training on abuse. He stated that abuse can be physical, verbal, sexual, fiduciary, neglect, and seclusion. The DON said that allegations of sexual abuse are to be reported to the state agency within two hours and all other allegations are to be reported within four hours and the written investigation is to be completed within 5 days. In a facility policy entitled Abuse, Neglect, Exploitation and Misappropriation-Reporting and Investigating, last revised in April 2021 stated that the individual conducting the investigation as a minimum: a. Reviews the documentation and evidence; b. Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident; c. Observes the alleged victim, including his or her interactions with staff and other residents; d. Interviews the person(s) reporting the incident; e. Interviews any witnesses to the incident; f. Interviews the resident (as medically appropriate) or the resident's representative; g. Interviews the resident's attending physician, as needed, to determine the resident's condition; h. Interviews staff members (on all shifts as needed) who have had contact with the resident during the period of the alleged incident; i. Interviews the resident's roommate, family members, and visitors, j. Interviews other residents to whom the accused employee provides care or services; k. Reviews all events leading up to the alleged incident; and l. Documents the investigation completely and thoroughly

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure there was sufficient staffing to provide adequate supervision for multiple residents. The deficient practice could result in residents' not receiving the supervision needed to ensure resident safety. Findings include: -Resident #40 was admitted on [DATE] with diagnoses of Alzheimer's disease, dementia in other diseases with agitation, with anxiety, other behavioral disturbance, wandering in diseases classified elsewhere. A nurse note dated August 28, 2024 stated certified nurse assistant (CNA) found resident cornered outside with another resident (#49) who touched resident #40 inappropriately. Per the documentation, the CNA separated both residents,15-minute checks were initiated and the POA (power of attorney), DON (director of nursing) and physician were notified. A Psych Follow-Up Note dated August 28, 2024 included resident was seen for follow up after an incident where another resident (#49) grabbed the resident's breast. -Resident #49 was admitted on [DATE] with diagnoses of vascular dementia with other behavioral disturbance, major depressive disorder, recurrent, moderate and anxiety disorder. A behavior note dated August 8, 2024 revealed the housekeeper notified the nurse that resident #49 sitting next to resident #40 and was fondling her private parts. Per the documentation, both residents were immediately separated and the nurse instructed the CNAs to keep the two residents away; and that, plan of care was ongoing. A behavior note dated August 28, 2024 included that resident #49 cornered and inappropriately touched another resident (#40) outside of his room; and that, the certified nurse assistant (CNA) intervened immediately. Per the documentation, resident #49 reported to the nurse that he was just messing around. It also included that the nurse notified management; and, change of condition and 15 minute checks were initiated for resident #49. A communication note dated August 28, 2024 revealed that the unit manager was notified about resident's sexual behavior towards another resident (#40); and that, both residents were place on every 15 minute checks. A Psych Follow-Up Note dated August 21, 2024 revealed that the last reported behavior reported by staff was on August 10, 2010. Per the documentation, prior behavior included sexual inappropriateness with staff and verbal behaviors were documented. Review of the facility assessment, dated January 25, 2024, revealed that the facility had determined it needed 56 CNAs (8 hour shifts) working daily to meet residents' needs. The staff schedule for Wednesday, August 28, 2024 revealed that Licensed Practical Nurses (LPN) and Registered Nurse (RN) worked 12-hour shifts. Further review of the schedule revealed the following: -Day shift: 12 Certified Nursing Assistants (CNAs), 1 Restorative Nursing Assistant (RNA), 7 LPNs, one RN and, 1 Licensed Practical Nurses (LPN) on training; Evening Shift: 16 CNAs, 1 CNA orientee, 1 CNA providing 1:1, 3 LPNs and 2 RNs; and, Night shift: 12 CNAs and 1 CNA providing 1:1. An interview was conducted on September 3, 2024 at 9:17 a.m. with a certified nursing assistant (CNA/staff #186), who stated that the staffing ratios had been lowered and there were not enough staff to monitor all the residents. She stated that she was not able to get to the residents on time to prevent falls or to provide activities of daily living (ADLs) timely. She also stated that it was difficult to monitor the halls, and even though, they have hospitality staff to help, the hospitality staff were not allowed to touch the residents. An interview was conducted with a CNA (staff #246) on September 4, 2024 at 10:19 a.m. The CNA stated that the CNA's rely on the nurses to also monitor the residents; and that, there was a need for more staff for extra monitoring of the residents and the halls/unit. The CNA also said that more staff would give them more eyes and hands, because sometimes when both CNA's on shift were in a room assisting another resident, the nurse cannot always be there to watch the unit. An interview with the Administrator and the Director of Nursing (DON #200) was conducted September 5, 2024 at 10:27 a.m. The DON stated that he supervises the Staffing Coordinator (staff #225) who was provided training on scheduling by himself, the Administrator, and the prior Staffing Coordinator; and that, the staffing coordinate was receiving ongoing training on how to use the scheduling software. The DON said that the team makes the determination regarding staffing needs on each unit and was usually determined daily. He stated that staffing was based on current behaviors and the number of residents on each unit; and that, he communicates with the staff to determine their staffing needs and what they feel was needed for staffing, and acuity. The DON said that acuity includes the behaviors of the residents, the assistance needed for activities of daily living, and if one-to-one staffing was needed. He stated that if staff call to ask for one-to-one staffing, he helps to evaluate the need. The DON also said that the Staffing Coordinator completes the staffing schedule and he and the Administrator review the schedule and authorize it if they agreed. He stated that behaviors, the needs and concerns regarding the residents were discussed during the morning meeting and the information was used to determine the staffing needs, but the behaviors, needs, and concerns were not documented. The DON stated that residents had a right to privacy and personal space; and, the expectation was that residents that had cognitive capacity need for staff to respect the resident's space; and, there was no facility culpability for residents without the cognitive ability and capacity. The DON stated that residents had a right to privacy and personal space; and, the expectation was that residents that had cognitive capacity need for staff to respect the resident's space; and, there was no facility culpability for residents without the cognitive ability and capacity. An interview was conducted on September 3, 2024 at 11:49 with (CNA/staff #85), who stated that there had been a change in the staff to resident ratio. The CNA stated that she was no longer able to redirect residents as needed; and, there were not enough staff to provide care in pairs. She stated that two staff may be required depending the residents' behaviors and needs. She also stated since the number of staffs has decreased, she had seen an increase in the number of behaviors exhibited by the residents. She stated that she discussed the concern about staffing with the prior Administrator; but, the new Administrator and new Director of Nursing have not asked about staffing concerns. She stated that the CNAS were complaining daily about the low staffing ratios and they had too much to do. During an interview conducted on September 3, 2024 at 12:20 p.m. with the Administrator (staff #239), she reviewed the Facility Assessment Tool, Staffing Plan dated January 25, 2024 and stated that she has not had time to review or update the assessment and did not understand the staffing plan. An interview was conducted on September 3, 2024 at 12:59 p.m. with the Staffing Coordinator (staff #425), who stated that the facility did not use registry staff, does not offer incentives, and staff were not required to come into work if they were not scheduled to work. She stated that there were a lot of call-offs; and that, she had staff call off every day since she started working at the facility. She stated that when she was hired, she interviewed a few nurses and observed every unit for approximately 45 minutes except one unit was for 2 hours to determine staffing needs. She stated that she just goes off what the staff tell her about the residents and has not reviewed the clinical records to determine the needs of the residents. She stated that without knowing the behaviors of each resident and the incidents that were occurring, she was not able to accurately determine the number of staffs that is needed on each unit. During an interview with the Administrator (staff #239) conducted on August 26, 2024 at 4:00 p.m., she stated that the facility provides adequate supervision for the residents. She stated that the regulation pertaining to supervision did not fit when you have wandering mentally ill residents in a skilled nursing facility (SNF). She stated that the facility was an institution where the resident carries out their last days and not a home. However, the administrator said that it was the facility's responsibility to protect the residents. An interview with an LPN (staff #158) was conducted September 4, 2024 at 4:01 p.m. The LPN stated there was not enough staff, more specifically CNAs on the units to safely and effectively monitor the residents; and that, there were not enough CNA's to monitor the residents. The LPN said that the risks associated with not having sufficient staff to monitor the residents are neglect in their care, fall risks and might make a resident be vulnerable to sexual acts, because of residents not alert and oriented and the history of wandering. The LPN also said that there were two CNAs on the unit; and, sometimes a CNA providing 1:1 on the floor in the morning shift, but not in the evening shift. She further stated there was a need for more staff due to the behaviors on the unit and not being able to monitor the residents as they should be. Further, the LPN said that if the CNA's are providing care in pairs, she will at times step down and assist with resident care or help with monitoring, but it was not always possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure that one resident (#650) was free from abuse of another. The deficient practice could result in other residents being abused. Findings include: Resident #650 (alleged victim) was admitted to the facility on [DATE] with diagnoses that included bipolar disorder and mild cognitive impairment. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident is cognitively intact. The MDS also indicated that the resident had not exhibited psychosis, behavioral symptoms or wandering behavior during the assessment period. A care plan initiated on July 30, 2024 indicated that the resident is at risk for not meeting emotional, intellectual, physical, and social needs regarding bipolar disorder. Interventions included to ensure that activities resident attends are compatible with physical and mental capabilities, and to introduce resident to other residents with similar background, interests, and facilitate interaction. A care plan initiated on August 15, 2024 identified that the resident is at risk for psychosocial emotional distress related to resident to resident altercation. Interventions included to allow resident to answer question and verbalize feelings, perceptions, and fears; psych consult as needed; and room move to allow resident to be free from triggers. A physician's progress note dated August 8, 2024 documented that resident was transferred here for continued care following an altercation. His only complaint is redness in the rt(right) eye. Furthermore, the note indicated that the resident was involved in a resident-to-resident altercation but does not recall why, denies any pain/abrasions/swelling or concerns. Review of a behavior progress note dated August 8, 2024 documented that resident #650 told resident #625 to shut up while watching television in the day room. The note indicated that this angered resident #625 and led him to attack resident #650. According to the note, a nurse broke up the fight and resident #625 turned his anger on the nurse. The note documented that resident #625 squared up to the nurse, threatening, and spitting. However, the note did indicate that resident #625 was redirected and residents were separated. An interview with resident #650 was conducted on August 21, 2024 at 10:55 a.m. According to the resident, he has been in his current room for about 2-weeks. Resident #650 said that he has not had any issues in the facility. No one is mean or have tried to hurt him. During an interview with a Licensed Practical Nurse (LPN/staff #60) conducted on August 21, 2024 at 11:15 a.m., staff #60 stated that resident #650 transferred to the unit about a week ago. The LPN noted that they are not aware of why the resident was transferred to the unit, but that resident #650 was there when they returned to work. Staff #60 indicated that the transfer to the unit was not medical related. The LPN also stated that resident #650 is forgetful. According to staff #60 you can tell resident #650 something and the resident will quickly forget what was discussed. Resident #625 (alleged perpetrator) was admitted to the facility on [DATE] with diagnosis that included schizoaffective disorder, bipolar, dementia with agitation, and anxiety disorder. A behavior care plan initiated on April 9, 2018 and revised on August 23, 2021 indicated that resident may exhibit verbal aggression, being demanding, and psychotic thinking. Interventions included to administer medications as ordered, attempt to redirect behaviors, monitor resident for significant behavioral and medical changes to ensure proper placement, and psych follow-up as ordered. A care plan initiated on April 12, 2018 indicated that the resident has cognitive/communication deficits related to dementia with behaviors and schizoaffective disorder with delusions. Interventions included anticipate needs, encourage resident to participate in decision making, reality orientation, and verbal cues and reminders. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4 indicating that the resident has severe cognitive impairment. The MDS also indicated that the resident was negative for psychosis, behavior symptoms, rejection of care, and wandering. A psych follow-up progress note dated August 8, 2024 indicated that the resident was seen for routine psychiatric follow-up. The note indicated a recommendation for a follow-up in 2-weeks. However, the note instructed to reach out sooner with any urgent needs or status change. According to the note, the staff reported that the resident had been irritable, short-tempered, and threatening. Additionally, the note indicated that another resident in the unit has been triggering him. The note documented that at the time of it was written, no physical aggression had been observed from the resident. Review of a physician's progress note dated August 8, 2024 documented that resident was involved in a resident-to-resident altercation. The note stated that the resident could not recall what happened. A behavior progress note dated August 8, 2024 documented that resident #625 was observed assaulting resident #650. According to the note resident #650 told resident #625 to shut up while watching television in the day room. This angered resident #625 and he attacked resident #650. The note indicated that the nurse broke up the fight. Resident #625 then turned his anger on the nurse. According to the note, resident #625 squared up to the nurse, threatening, and spitting on him. The note also documented that the resident was redirected and both residents were separated. Review of eINTERACT progress note dated August 8 2024 documented that the resident was the physical aggressor in the altercation. The note stated that the resident# 625 did not sustain any injuries nor was he hit. The Primary Care Provider (PCP) Feedback section of the note indicated that the PCP did not have any recommendations, did not order any new testing, and did not order any new interventions. A care plan initiated on August 8, 2024 identified the resident's risk for psychosocial emotional distress regarding the resident to resident altercation. Interventions included psych evaluation as needed and to allow resident to verbalize and express any concerns regarding the incident. Review of a behavior note dated August 9, 2024 documented that resident continues to be demanding and exhibited aggressive tone. The resident was noted to ask multiple questions and argue with staff. The facility investigation report dated August 15, 2024 revealed that on August 8, 2024 residents #650 and #625 were involved in a resident-to-resident altercation. According to the report, resident #625 was in the day room when he became increasingly loud in response to what he was viewing on the television. Resident #650 who was sitting directly behind resident #625, told resident #625 to shut up. Resident #625 turned around in his wheelchair, approached resident #650 and punched resident #650 on the left shoulder. The investigation report concluded that the allegation of resident-to-resident allegation was substantiated. Further review of the facility investigation note dated August 15, 2024 revealed a screenshot of the nurse's text message which stated resident #650 told resident #625 to shut up which led to resident #625 turning around and assaulting resident #650. Additionally, the facility investigation dated August 15, 2024 included witness statements. A statement from a tech aide (staff #200) taken on August 8, 2024 revealed that resident #650 stated shut him up before I kill him referring to resident #625. Resident #650 then yelled at resident #625 to shut up. According to the statement this caused resident #625 to be upset and he ended up shoving/hitting resident #650 on the shoulder. Resident #625 was extremely upset that he tried to fight the nurse that was deescalating the situation. An interview with a Registered Nurse (RN/staff #110) was conducted on August 21, 2024 at 2:31 p.m. According to staff #110 the altercation started verbally due to resident #625 being riled up by what he was watching on the television and was told by resident #650 to shut up. Staff #110 said that this resulted in resident #625 hitting resident #650. The RN noted that there were no injuries to include skin tears on either resident when they were assessed. During an interview with a Licensed Practical Nurse (LPN/staff #60) conducted on August 21, 2024 at 11:15 a.m., staff #60 stated that the protocol following a resident-to-resident altercation is to ensure the residents are safe. The LPN said that they call the abuse coordinator/administrator to complete the steps for reporting. Staff #60 stated that residents are separated to ensure no contact, and then assessed. The LPN noted that it is the law so abuse allegations/incidents are reported. According to staff #60, any instance of abuse is terrible and leaves residents in fear. Additionally, the LPN said that it creates confusion for residents and leaves a mental impact on the victim. An interview with a Certified Nursing Assistant (CNA/staff #20) was conducted on August 21, 2024 at 12:31 p.m. According to staff #20 the protocol for a resident-to-resident altercation is to separate residents, have the nurse assess, and inform the administrator so the mandatory reporting and notification can be made. The CNA noted that they had heard about an incident involving resident #625. Staff #20 described resident #625 as mostly calm and minded his own business. The CNA said that they do abuse in-service and that they just did one last week. Staff #20 stated that it is important to protect residents from abuse because these people are someone's loved ones and you do not want them to be hurt. Furthermore, resident #20 said that abuse is a crime and no one wants to be around someone who is abusive. If a resident is not protected from abuse it will torment the resident and cause the resident to be scared and hurt. During an interview with the Director of Nursing (DON/staff #120) conducted on August 21, 2024 at 2:38 p.m., staff #120 stated that the expectation is that staff follow abuse policy and procedures, ensure the safety or residents, and report allegations/incidents of abuse to the abuse coordinator. The DON said that this is important in order to ensure allegations/incidents of abuse are investigated and keep residents safe. Staff #120 noted that residents could suffer from physical or psychosocial distress if they are not protected from abuse. The facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 indicated that resident have the right to be free from abuse. The facility policy titled Abuse and Neglect - Clinical Protocol revised March 2018 indicated that the physician and staff will help identify risk factors for abuse within the facility. Additionally, the policy stated that the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect.

Based on observations, staff interviews, facility documentation, review of the Centers for Disease Control (CDC) recommendations and policies and procedures, the facility failed to ensure infection control standards were followed by failing to ensure that Personal Protective Equipment (PPE) was donned. The deficient practice could result in the spread of infection, including COVID-19 to residents and staff. Findings include: Review of the COVID+ Residents facility bulletin board on the electronic record dashboard indicated that there were 12 residents that were COVID positive. The notice was posted on August 7, 2024 and listed the names of the residents and the date they tested positive. During sign-in at the front desk on August 19, 2024 at 10:56 a.m., an orange sign posted on the wall was observed. The sign read Attention! COVID-19 OUTBREAK. All visitors and staff are required to sign in at the kiosk located by the Reception Desk. All Staff are required to wear CDC recommended PPE including N95 Masks while in the Facility. However, during sign-in, the Concierge (staff #80) at the front desk was observed not wearing a mask. Furthermore, when the Concierge (staff #80) was asked if there is COVID, staff #80 noted that it was just on the East side of the facility so no mask needed inside the facility. Additionally, there were individuals in the reception area and hallway that were observed not wearing a mask. An entrance conference with the Director of Nursing (DON/staff #120) and Administrator (staff #215) was conducted on August 19, 2024 at 11:11 a.m., the DON noted that personnel and guests entering the resident area will have to wear a mask. However, the Administrator (staff#215) stated that the resident are out of isolation. During the entrance conducted on August 19, 2024 at 11:11, both the Administrator and the DON were observed entering the conference room with masks on. However, both of them took it off during the conference. During re-entry into the facility on August 21, 2024 at 8:50 a.m., the concierge was observed not wearing a mask. Signs stating COVID outbreak were present. However, guest, residents at the reception area were not wearing masks. An interview with the Concierge (staff #80) was conducted on August 21, 2024 at 10:40 a.m. Staff #80 noted that her job entails greeting people when they enter the facility, answering questions over the phone, transferring calls, and letting guests know if there is an outbreak in the unit and the specific unit. The Concierge stated that she offers masks. Staff #80 stated that the COVID outbreak sign has been up for about 2-weeks. The Concierge stated that staff have to wear mask on the skill side but not on the assisted living side. Staff #80 noted that as soon as staff enters the facility they have to wear a mask and that includes her. When asked why she was seen not wearing a mask during check-in this morning and the other day, she admitted that Honestly, I forgot. The Concierge noted that she was not used to wearing a mask anymore. Staff #80 said that the importance of wearing a mask s to protect themselves and residents. Additionally, she noted that wearing a mask stops the spread of disease such as COVID. During an interview with a Certified Nursing Assistant (CNA/staff #40) conducted on August 21, 2024 at 12:10 p.m., staff #40 stated that the signs for COVID outbreak as been up for about 2-3 weeks. The CNA noted that the process for staff prior to reporting to their assigned unit is to check-in, take their temperature, fill out COVID questionnaire, and then clock in. Staff #40 stated that if you work at the East unit, you have to get COVID tested 2-3 times a week due to the outbreak. The CNA noted that the last time she was tested was last week. Staff #40 said that staff is supposed to wear a mask as soon as they enter the building. The CNA stated that wearing a mask is important in order to not spread the disease. Staff #40 said that not following the protocol can lead to somebody getting sick and spreading COVID. An interview with a Certified Nursing Assistant (CNA/staff #20) was conducted on September 21, 2024 at 12:31 p.m. Staff #20 stated that the signs for COVID outbreak have been up for 3-weeks. The CNA noted that mostly the staff assigned to the East unit are not allowed to clock in or out and reports directly to the unit. Staff #20 said that if staff is not assigned to the East unit, then they mask up and use hand sanitizer. Temperature is checked every morning and if you are symptomatic then you have to get tested prior to going to the unit. The CNA also said that every morning staff completes a questionnaire that assesses if the member has a temperature or symptoms. Staff #20 said that this is important so they can stop the spread of COVID and protect everyone, especially those with a weak immune system. The CNA noted that not following the protocol can lead to the spread of COVID and not protecting others. An interview with the Infection Preventionist (IP/staff #100) was conducted on August 21, 2024 at 12:59 p.m. According to the IP it has been approximately 2-3 weeks since the outbreak in the facility began. Staff #100 noted that this coming Friday (8/23/24), they will test and it will be 10 days since the last positive. The IP said that staff used N95 masks on the first night of the outbreak, they did COVID testing and it was determined that the outbreak was limited to one unit. Since then the Director of Nursing (DON/staff #120) had taken over oversight for and implementation of infection control and prevention protocols for the outbreak. Staff #100 noted that when she was at the facility, the staff were wearing N95 masks. She said that she was last in the facility last week (Wednesday, 8/14/24). The IP indicated that due to the shared entry and the Assisted Living (AL) side being owned by another company, she can understand the potential concern of cross-contamination and guests not necessarily being able to identify or know that the people are not their facility's staff. The IP indicated that she had their staff wear N95 masks-they especially had to have one while at the East unit. Staff working at the East unit went straight to East and they treated the entire East unit as a hot zone. Staff #100 noted that the receptionist at the shared front desk is not their employee but the AL's staff. The receptionist works at the desk. Although, they expect her to mask up, it is hard to enforce since she is not their staff. The receptionist is supposed to provide education and provide mask to guests. The IP acknowledged that having two companies operating in the shared space can be problematic when it comes to identifying staff and residents that should be masking up. Staff #100 stated that she understands the concern about the staff from two companies intermingling and can see the concern of spreading, and cross-contaminating. This is the reason why they do testing and also there is multiple ways to get to the unit. Although, the dining room is one that both companies' staff can pass through, they do discourage their staff from doing so since there are multiple-ways to get to the units. During an interview with a Registered Nurse (RN/staff #110) conducted on August 21, 2024 at 2:31 p.m., staff #110 noted that they have had a COVID outbreak for approximately 2-weeks. The RN stated that as soon as staff step into the building they are required to wear a mask. In an interview with the Director of Nursing (DON/staff #120) conducted on August 21, 2024 at 2:38 p.m., staff #120 stated that staff have been educated about current policy and protocols and are expected to follow them while on shift. The DON stated that current staff use questionnaire and get their temps taken and don N95 when walking to the units. He stated he would like for them to wear the mask before they enter the unit so there is isolation supplies handy. The DON stated that it is important to prevent the spread of bacteria since it can be passed to anyone. If infection control protocols are not followed then there can be a spread of infection/disease. Staff #120 noted that the receptionist has the responsibility to educate visitor and there is signage and provide PPE (personal protective equipment). It is up to the guest to comply. When asked why the receptionist did not provide the surveyor a brief on the status of the building regarding COVID, he responded that the surveyor is not a guest, the surveyor is a surveyor. Per the Center for Clinical Standards and Quality/Survey & Certification Group Red: QSO-20-39 -NH regarding Nursing Home Visitation - COVID-19 revised May 8, 2023. On April 10, 2023, the President signed legislation that ended the COVID-19 national emergency. On May 11, 2023, the COVID-19 public health emergency (PHE) is expected to expire. While the PHE will end, CMS still expects facilities to adhere to infection prevention and control recommendations in accordance with accepted national standards. The facility policy titled Policies and Practices - Infection Control dated October 2018 indicated that the facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of diseases and infections. Additionally, the policy stated that the objective of the policy is to maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public.

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a closed record review, staff interviews, review of facility documentation, policy and procedures, the facility failed to ensure that a resident's representative was notified of an injury for one resident (#7). The deficient practice could result in resident representatives not being aware of the resident's injuries. Findings include: Resident #7 was admitted on [DATE] with diagnosis including dementia, hypertension, type 2 diabetes mellitus, post-traumatic stress disorder, atherosclerotic heart disease, hyperlipidemia, dysphagia and a personal history of traumatic brain injury and transient ischemic attacks. A review of the electronic health record revealed progress note entries noting that the resident #7 would wander and take other resident's belongings. It was noted that the resident required frequent redirection. The progress notes further revealed that the resident #7 sustained an injury to his left lower leg on March 19, 2024; however, the progress notes revealed no documentation that family had been notified subsequent to the injury. A review of the MDS (minimum data set) dated June 3, 2024 revealed a BIMS (brief interview of mental status) score of 6, suggesting severe cognitive impairment. An interview was conducted on July 11, 2024 at 9:54 A.M. with the former resident's sister, individual #200. Individual #200 stated that the resident had been injured at the facility and that she had received no notification. An interview was conducted on July 11, 2024 at 10:33 A.M. with a LPN (licensed practical nurse/ staff #152). Staff #152 stated that if a resident sustains an injury residing at the facility, then notifications to the doctor, case manager and family would take place. She stated that per facility guidelines, these notifications are required. A telephonic interview was conducted on July 11, 2024 at 10:45 A.M. with another LPN (staff #151). Staff #151 stated that change of condition, falls and injuries would all warrant notifications to the POA (power of attorney), DON (director of nursing), administrator, doctor, social worker and corporate nurse. Staff #151 stated that she was familiar with resident #7 and did not recall any falls associated with this resident. Staff #151 stated that she did recall an injury that resident #7 had incurred on March 19, 2024. She stated that the resident did not hit the ground but had bumped into another resident's wheelchair which resulted in a wound to his lower leg. Staff #151 was unable to recall which leg. She stated that she wasn't sure if the injury to the leg would require notifications to the POA/family. She stated that she is new and did not know whether family should have been notified. She stated that she did not recall if she notified the family of the injury. She stated that she always documents the notifications when they occur; however, the electronic health record revealed no evidence that a notification to the family had occurred. An interview was conducted on July 11, 2024 at 10:51 A.M. with staff #83 (DON/ Director of Nursing). Staff #83 stated that when a resident sustains an injury, the expectation is that family would be notified and that this would be documented in the electronic health record. Staff #83 reviewed the record for resident #7 and was unable to locate any evidence that the family had been notified of the injury that resident #7 sustained. The DON stated that she would further review the record to see if perhaps someone else had conducted the notification to the family. On July 11, 2024 at 12:12 P.M., staff #83 returned and stated that she was unable to find evidence that anyone had contacted the family regarding injury of resident #7. The DON stated that the risk for not notifying the family and documenting the notification could include the family not being aware of what had occurred as well as other staff not being aware that the notification had occurred. A review of the facility policy entitled accidents and incidents-investigating and reporting, revised July 2017 revealed that the nurse supervisor/ charge nurse and or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. The policy further revealed that documentation includes the date and time that the person's family was notified and by whom; however, facility documentation revealed no evidence that the family of resident #7 had been notified for the injury incurred on March 19, 2024.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, staff interviews, and review of facility policy and procedures, the facility failed to ensure one resident (#1) was not abused by another resident (#2) The deficient practice could result in residents being physically and psychologically harmed. Findings include: Regarding resident #1: Resident #1 was admitted to the facility on [DATE] with diagnoses of Dementia, Post Traumatic Stress Disorder (PTSD), and Adjustment Disorder with Mixed Disturbance of Emotions and Conduct. The annual Minimum Data Set (MDS) dated , January 22, 2024 revealed that the resident was not able to complete the Brief Interview for Mental Status (BIMS). However, staff were able to complete the Staff Assessment for Mental Status and it was determined that resident #1 had both short-term and long-term memory problems. The assessment also indicated the resident's Cognitive Skills for Daily Decision making was moderately impaired. Regarding resident #2: Resident #2 was admitted to the facility on [DATE] with diagnoses of Dementia, PTSD, and Major Depressive Disorder. The quarterly MDS dated , January 2, 2024 revealed resident #2 had a BIMS score of 03 which indicated the resident was severely cognitively impaired with behaviors. Review of resident #1's progress notes revealed a note dated February 27, 2024 at 8:33 PM. The note indicated resident # 1 was standing outside near a sliding glass door entry way yelling. Resident #2 was standing on the inside of the entry way. Resident #2 then slapped resident #1. The note indicated the nurse and the CNA (Certified Nursing Assistant) then separated the resident and did a skin assessment on resident #2 which revealed no injuries on the resident's face and chest. Review of resident #2's progress notes revealed a psych follow-up note dated February 28, 2024 at 7:00 AM. The provider indicated they assessed the resident and determined the current risk to be low. The note also indicated that a safety plan was not required for the resident. Further review of both resident's progress notes indicated staff continued to monitor each resident's behavior, via 15-minute checks through February 29, 2024. Review of both residents' care plan revealed there were no changes made to the care plan after this incident. Review of both residents' census revealed both residents continued to live in the same unit after the incident. Review of resident #1's progress notes revealed a note dated April 18, 2024 at 7:20 PM. The progress note indicated it was a late entry for an incident that occurred at 10:30 AM that same day. The progress note continues to reveal that resident #1 was yelling at resident #2 as they walked past resident #1. Resident #2 then hits resident #1 with an open hand. The noted stated resident #1 received a superficial scratch to left forehead. A review of resident #2's progress note revealed an Alert Note dated April 18, 2024 at 7:46 PM. The note indicated that a psychological evaluation was ordered due to increased aggression. The noted revealed that the resident #2 was put on 15-minute checks and was moved to another unit for the safety of the other resident. A review of resident #2's care plan revealed it was updated on April 25, 2024 to include triggers that causes some behavior issues. Triggers were identified as loud noises/shouting. Interventions to address those triggers were to move the resident away from the situation and to identify the cause of the trigger and address it to resolve the issue. An interview was conducted on May 6, 2024 with a Licensed Practical Nurse (LPN/Staff #5) at 1:13 PM. Staff #5 indicated they receive training on abuse annually. They also receive refreshers throughout the year during staff meetings. Staff #5 indicated that resident-to-resident abuse does not happen frequently so they remember the incident that took place between resident #1 and #2. Staff #5 pointed out that they were not present during the altercations but remembers being briefed on it. They stated that the residents were getting into altercations so both residents were moved to different units. An interview was conducted on May 6, 2024 at 2:20 PM with the facility administrator (Staff #16). Staff #16 indicated that the MDS coordinator along with the Director of Nursing is responsible to update the care plan. When asked about how the care plan is updated when there is a change in condition, staff #16 indicated they would have to look at the policy since they had only been working at the facility for a month. When asked what would be a reasonable expectation for the updating of the care plan, staff #16 stated in my judgement, as soon as possible but within 72 hours. Staff #16 also was not able to explain why both residents were not separated or placed in different units after the first altercation took place on February 27, 2024. An interview was conducted on May 6, 2024 at 3:00 PM with Social Services (Staff #24). Staff #24 was not able to identify why resident #2's care plan was not updated in February to include interventions to address the physical behaviors of the resident. Staff #24 indicated they were not the primary person investigating the incident as it was the previous Social Services Director who is no longer with the facility. They did state that it was tough to follow-up with both residents because neither of the residents were able to remember either incidents due to their Dementia diagnosis. Staff #24 also indicated that the wife of resident #2 alerted the facility that a possible trigger was yelling and it was when they discovered this information, the care plan was updated to include it.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to ensure one resident (#26) was free from abuse of another. The deficient practice could result in other residents being abused. Findings include: -Resident #28 was admitted on [DATE] with diagnoses of Alzheimer's disease, vascular dementia, behavioral disturbance, dementia, and anxiety disorder. Review of a care plan initiated October 16, 2014 revealed the resident had diagnosis of dementia with behaviors; and that confusion and history of disorganized thinking cause him to display behaviors that interfere with his participation. Interventions included to administer medications as ordered, attempt to determine cause, attempt to redirect behaviors, follow the resident specific behavior plan per the clinical director, monitor resident for significant behavioral and medical changes to ensure proper placement of resident, and psych follow up as ordered. A behavioral care plan reviewed and updated on August 19, 2021 revealed the resident had primary target behaviors that included physical aggression towards peers and staff, verbal aggression towards peers and staff, elopement risk, and suicidal ideation/behaviors. Per the documentation, the resident gets very agitated by loud noises and had become physically aggressive to peers when he is near others who yell out or make loud noises; and that, staff should do their best to keep resident #28 in a quieter setting. The ADL (activities of daily living) care plan revised on September 22, 2021 included that changes in cognition was related to dementia and cause the resident to be non-compliant with care at times; and that altered mood due to being upset with environmental noise and peers' behaviors limit his social interaction with peers. Interventions included to administer medications as ordered. Review of the quarterly MDS assessment dated [DATE] revealed a BIMS score of 10 indicating that the resident has moderate cognitive impairment. The MDS also included the resident have not exhibited psychosis or behavioral symptoms during the assessment period. The behavior note dated December 9, 2021 included the resident was compliant with care with no behaviors reported during the shift. A behavior note dated December 10, 2021 revealed that resident exhibited the following behaviors from November 29 through December 5, 2021: visual hallucinations and physical restlessness. Per the documentation, staff implemented behavioral treatment plan interventions to prevent/limit physical aggression to peers and staff, elopement risk and inappropriate toileting. A behavior note dated December 11, 2021 included the resident was in good spirits, smiling and was joking during the interaction; had no inappropriate voiding; and speech and behavior were appropriate for the situation. The behavior note dated December 17, 2023 included the resident displayed the following behaviors from previous week (December 6 through 12, 2021): physically restless. Per the documentation no other behaviors were observed. Review of the behavior note dated December 23, 2021 revealed that another resident (#26) was observed coming from the resident's room; and that, the other resident (#26) had blood and laceration to the center of the forehead that measured 1.5 cm (centimeter) x 0.2 cm. Per the documentation, it appeared that the other resident (#26) entered and would not leave the resident's room; and that, resident #28 appeared to have sustained a self-inflicted hematoma to the left side of forehead while guarding his face. The documentation also included that both residents were separated and assessed. A behavior note dated December 24, 2021 included staff continued monitoring resident #28 following an altercation with another resident (#26). Per the documentation, resident #28 kept away from the other resident (#26); and, behavior plan was used effectively. A behavioral care plan reviewed and updated on December 24, 2021 to include a staff approach to keep resident #28 a significant distance from resident #26; and that their rooms should be a significant distance apart. The nursing progress note dated December 26, 2021 revealed the resident remained on change of condition for recent altercation; and that, a medium-sized bump and dark purple bruise at various stages of healing were observed to the left side of his forehead. -Resident #26 was re-admitted on [DATE] with diagnoses of delusional disorders, dementia with behavioral and psychosis symptoms. The behavior care plan initiated on November 29, 2016 revealed the resident had diagnosis of dementia with behaviors and had behaviors such as having sexual behaviors towards peers and staff, psychotic thinking and being demanding. Interventions included to administer medication as ordered, attempt to determine cause, attempt to redirect behaviors and to monitor resident for significant behavioral and medical changes to ensure proper placement. The cognition care plan revised on May 12, 2017 included the resident had impaired cognition related to dementia with behaviors, had impaired decision-making skills and had history of physical and verbal aggression. Interventions included to administer medications as ordered, anticipate needs and use of verbal cues and reminders. The care plan initiated revised on October 29, 2019 included resident had deficit related to altered cognition with behavior symptoms and preferred 1:1 activity. The wandering risk evaluation dated November 30, 2021 included a score of 4 indicating the resident was low risk for wandering. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS assessment indicated that at the resident was negative for psychosis, behavioral symptoms, rejection of care, and wandering. The care conference summary dated December 3, 2021 included the resident was alert and oriented x 3, was able to make all needs known, continued to display behaviors of interfering with the care of peers, repetitive demands and psychotic thinking; and was being monitored by psychiatric providers and nursing staff. A behavior note dated December 11, 2021 included resident was experiencing delusional thoughts; and that, the resident was asking the nurse to touch his head as he believed the injury was recent and was not treated. Per the documentation, the resident was redirected easily; and that, resident went back to bed after some time. A behavior note dated December 14, 2021 revealed the resident kept leaving his room and bed but could not tell staff why. Per the documentation, the resident became aggressive with staff when they tried to redirect him back to bed; and that, behavior plan was used with little effect. The nursing note dated December 14, 2021 included the resident was yelling and was found outside the gate but not outside of the secured unit. Per the documentation, the resident became upset when asked to go out of the dining room after eating dinner so that other residents could come and eat. A behavior note dated December 15, 2021 included the resident kept on leaving his room for the dayroom; and, staff tried to redirect him back to his room but resident refused or returned back to the dayroom. The documentation included that staff offered snack which resident accepted; and that, behavior plan was used with some good effect. The behavior note dated December 16, 2021 revealed the resident left his room and entered the dayroom; and that, staff tried multiple times to redirect him back to this room but resident refused. Per the documentation, behavior plan used but was not effective; and that, resident became a little verbally aggressive with staff. Review of the behavior note dated December 17, 2021 revealed resident displayed the following behaviors from December 6 through 12, 2021: interfering with care of peers, repetitive demands, psychotic thinking and fall risk. Per the documentation, staff implemented behavior plan interventions to prevent and greatly limit disruptive yelling. The behavior note dated December 20, 2021 included resident was propelling wheelchair near another resident; and when he was redirected, resident #26 became increasingly upset, refused to eat breakfast and went back to his room. Per the documentation, resident later noted with inappropriate behavior towards another resident who did not understand the gesture. The documentation included that the two residents were separated; and, resident #26 was visibly angered with threatening posture. The behavior note dated December 23, 2021 revealed resident woke up, left his room for the dayroom and had displayed some psychotic thinking; and that, behavior plan was used with little effect. In another behavior note dated December 23, 2021 it included that resident #26 came from another resident's (#28) room with blood and laceration noted to the center of the forehead that measured 1.5 cm (centimeters) x 0.2 cm. Per the documentation, it appeared that resident #26 entered and would not leave the room of the other resident (#28) who hit resident #26 with a television remote. The documentation included that resident #26 was noted with increased confusion repeating the phrase save the girls. It also included that both residents were separated, assessed; and resident #26 was moved to another room as in immediate intervention. Review of the behavioral care plan reviewed and updated on December 24, 2021 included the resident had the following primary target behaviors were identified: interfering with care of peers, disruptive yelling, repetitive demands, physical aggression to peers, sexual behavior to peers, resistive/combative with care, psychotic thinking, and sexual comments to staff. Staff approaches included that staff should be aware of resident's whereabout on the unit at all times; and that, the resident was not allowed to go into other resident rooms. Further, it included that whenever the resident #26 goes into another resident room, staff should escort him away from the other resident/room and distract his attention away from the situation. Review of the facility incident report dated December 24, 2021 revealed resident #26 was observed coming from resident #28's room with blood and laceration to the center of his forehead that measured 1.5 cm (centimeters) x 0.2 cm. Per the documentation, it appeared that resident #26 entered and would not leave the room of the other resident (#28) who hit resident #26 with a television remote. The documentation included that resident #26 was noted with increased confusion repeating the phrase save the girls. It also included that resident #28 sustained hematoma to the left side of the forehead likely self-inflicted while guarding his face. It also included that both residents were separated and head to toe assessment was conducted. Further, the report included that resident #26 was moved to another room as in immediate intervention. The report also included that there were no witnesses to the incident. An interview with a certified nursing assistant (CNA/staff #70) was conducted on May 18, 2023 at 8:44 a.m. The CNA stated that staff are provided training on abuse identification, prevention, and reporting; and that, any incidents or allegations of abuse and/or resident-to-resident altercation will be reported immediately to the nurse and executive director (staff #143). The CNA also said that when a resident-to-resident altercation occurs, staff would immediately separate the residents; and that, part of separating the residents sometimes mean moving resident to another room depending on their room locations. The CNA said that staff would monitor the residents; and that, the facility would investigate the incident. The CNA stated that the facility would conduct witness interviews and determine who was around when the incident occurred; and, would also notify the police. The CNA said that she was not familiar with the incident between residents #26 and #28. In an interview with a licensed practical nurse (LPN/staff #142) conducted on May 18, 2023 at 9:27 a.m., the LPN stated that when a resident-to-resident altercation occurs, the residents involved are immediately separated, assessed for injuries; and the incident is reported to the executive director and the police. The LPN said that the management team and resident family/ POA (power of attorney), Director of Nursing (DON), and physician are also notified. The LPN said that the main objective was to take care of the residents then notify everyone that needs to be notified. Further, The LPN stated that she was not employed at the facility at the time of the incident; and was not familiar with resident #26. A phone interview with two LPNs (staffs #145 and #146) who were the nurse on duty at the time of the incident was attempted on May 18, 2023 at 10:40 a.m. but was unsuccessful. A phone interview with former Social Services/Case Manager (staff #147) was conducted on May 18, 2023 at 10:44 a.m.; however, staff #147 declined answer questions during the interview. During an interview with the Director of Nursing (DON/staff #5) conducted on May 18, 2023 at 10:58 a.m., the DON stated that the expectation was that all allegations of abuse is reported; and that, staff were provided abuse training on how to identify and report allegations of abuse. The DON said that depending on the allegation, the Executive Director (ED/staff #143) normally takes the lead on the investigation; and that, part of investigation was to interview the individuals involved, residents on the unit, and the staff members working during the timeframe of the incident. The DON also said that the incident is reported to the ED, physician, family/POA, APS (Adult Protective Services) and the SA (State Agency). Regarding the incident between resident #26 and #28, the DON said that he did not have any recollection of the incident because he was not working with them in that unit and he was not the DON at that time. Review of the undated facility policy Resident Rights: Abuse & Neglect revealed a purpose to establish an appropriate, consistent means to identify, report and document cases of suspected abuse and neglect in compliance with reporting requirements and respect for patient rights. The policy included that all employees adhered to the rights of their resident and treat each resident with dignity and respect; and that, the facility does not allow or condone abuse, and as such, were dedicated to assuring that each resident is kept free from abuse and neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of facility documentation, policy and procedures, the facility failed to implement their policy on abuse investigation for an allegation of abuse for one resident (#26). The deficient practice could result in abuse not identified and investigated. Findings include: -Resident #28 was admitted on [DATE] with diagnoses of Alzheimer's disease, vascular dementia, behavioral disturbance, dementia, and anxiety disorder. -Resident #26 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included delusional disorders and dementia with behavioral and psychosis symptoms. Review of the SA Complaint/Incidents Tracking System revealed that the facility submitted a self-report regarding the incident between residents #26 and #28 on December 23, 2021 at 9:47 p.m. The facility incident report dated December 24, 2021 revealed resident #26 was observed coming from resident #28's room with blood and laceration to the center of his forehead that measured 1.5 cm (centimeters) x 0.2 cm. Per the documentation, it appeared that resident #26 entered and would not leave the room of the other resident (#28) who hit resident #26 with a television remote. The documentation included that resident #26 was noted with increased confusion repeating the phrase save the girls. It also included that resident #28 sustained hematoma to the left side of the forehead likely self-inflicted while guarding his face. It also included that both residents were separated and head to toe assessment was conducted. Further, the report included that resident #26 was moved to another room as in immediate intervention. The report also included that there were no witnesses to the incident. Continued review of the incident report included the incident was reported to APS (Adult Protective Services) and SA (State Agency) on December 24, 2021 at 8:43 p.m. However, the report did not include documentation of interviews conducted with involved residents and/or staff, other residents and/or staff that may be affected or have knowledge and any other evidence that will uncover facts that will lead to facility conclusion. There was no evidence found in facility documentation and the SA Complaint /Incident Tracking that the facility provided a complete and thorough documentation of their investigation of the incident; and that, investigation was submitted to the SA within the required timeframe. An interview with a certified nursing assistant (CNA/staff #70) was conducted on May 18, 2023 at 8:44 a.m. The CNA stated that staff are provided training on abuse identification, prevention, and reporting; and that, any incidents or allegations of abuse and/or resident-to-resident altercation will be reported immediately to the nurse and executive director (staff #143). The CNA also said that when a resident-to-resident altercation occurs, staff would immediately separate the residents; and that, part of separating the residents sometimes mean moving resident to another room depending on their room locations. The CNA said that staff would monitor the residents; and that, the facility would investigate the incident. The CNA stated that the facility would conduct witness interviews and determine who was around when the incident occurred; and, would also notify the police. In an interview with a licensed practical nurse (LPN/staff #142) conducted on May 18, 2023 at 9:27 a.m., the LPN stated that when a resident-to-resident altercation occurs, the residents involved are immediately separated, assessed for injuries; and the incident is reported to the executive director and the police. The LPN said that the management team and resident family/ POA (power of attorney), Director of Nursing (DON), and physician are also notified. The LPN said that the main objective was to take care of the residents then notify everyone that needs to be notified. During an interview with the Director of Nursing (DON/staff #5) conducted on May 18, 2023 at 10:58 a.m., the DON stated that the expectation was that all allegations of abuse is reported; and that, staff were provided abuse training on how to identify and report allegations of abuse. The DON said that depending on the allegation, the Executive Director (ED/staff #143) normally takes the lead on the investigation; and that, part of investigation was to interview the individuals involved, residents on the unit, and the staff members working during the timeframe of the incident. The DON also said that the incident is reported to the ED, physician, family/POA, APS (Adult Protective Services) and the SA (State Agency). Regarding the incident between resident #26 and #28, the DON said that he did not have any recollection of the incident because he was not working with them in that unit and he was not the DON at that time. During the complaint exit conference conducted with the Executive Director (ED/staff #143) on May 18, 2023 at 11:25 a.m., the ED stated that since she was not employed at the time of the incident, she cannot account for how the incident was investigated. However, she stated that they do education of their staff on identification and reporting so that allegations of abuse can be thoroughly investigated. Review of the undated facility policy titled Resident Rights: Abuse & Neglect stated that their residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility noted that the investigation process begins when the administrator or the DON receives information that abuse have taken place. The receipt of this information triggers process for acting to protect residents and employees and collecting information to determine facts. The Administrator and/or the Director of Nursing will take a lead role in coordinating fact-finding investigation. The investigator will collect any physical, demonstrative, or documentary evidence related to the incident. The investigator much also collects statements from the individual bringing the allegation, alleged victim, other persons to include residents with knowledge or potential knowledge of the incidents, and the individual accused of abuse or neglect. Furthermore, a full report of the completed investigation shall also be sent to the Department of Health, APS, Ombudsman, Scottsdale PD, and State Board of Nursing (if applicable) within 5 working days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, review of facility documentation, policy and procedures, the facility failed to ensure a thorough investigation was completed for an allegation of abuse for one resident (#26). The deficient practice could result in appropriate corrective actions not taken. Findings include: -Resident #28 was admitted on [DATE] with diagnoses of Alzheimer's disease, vascular dementia, behavioral disturbance, dementia, and anxiety disorder. -Resident #26 was initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included delusional disorders and dementia with behavioral and psychosis symptoms. Review of the facility incident report dated December 24, 2021 revealed resident #26 was observed coming from resident #28's room with blood and laceration to the center of his forehead that measured 1.5 cm (centimeters) x 0.2 cm. Per the documentation, it appeared that resident #26 entered and would not leave the room of the other resident (#28) who hit resident #26 with a television remote. The documentation included that resident #26 was noted with increased confusion repeating the phrase save the girls. It also included that resident #28 sustained hematoma to the left side of the forehead likely self-inflicted while guarding his face. It also included that both residents were separated and head to toe assessment was conducted. Further, the report included that resident #26 was moved to another room as in immediate intervention. The report also included that there were no witnesses to the incident. Continued review of the incident report included that the incident was reported to APS (Adult Protective Services) and SA (State Agency) on December 24, 2021 at 8:43 p.m. However, the report did not include documentation of interviews conducted with involved residents and/or staff, other residents and/or staff that may be affected or have knowledge and any other evidence that will uncover facts that will lead to facility conclusion. There was no evidence found in facility documentation and the SA Complaint /Incident Tracking that the facility provided a complete and thorough documentation of their investigation of the incident; and that, investigation was submitted to the SA within the required timeframe. An interview with a certified nursing assistant (CNA/staff #70) was conducted on May 18, 2023 at 8:44 a.m. The CNA stated that staff are provided training on abuse identification, prevention, and reporting; and that, any incidents or allegations of abuse and/or resident-to-resident altercation will be reported immediately to the nurse and executive director (staff #143). The CNA also said that when a resident-to-resident altercation occurs, staff would immediately separate the residents; and that, part of separating the residents sometimes mean moving resident to another room depending on their room locations. The CNA said that staff would monitor the residents; and that, the facility would investigate the incident. The CNA stated that the facility would conduct witness interviews and determine who was around when the incident occurred; and, would also notify the police. In an interview with a licensed practical nurse (LPN/staff #142) conducted on May 18, 2023 at 9:27 a.m., the LPN stated that when a resident-to-resident altercation occurs, the residents involved are immediately separated, assessed for injuries; and the incident is reported to the executive director and the police. The LPN said that the management team and resident family/ POA (power of attorney), Director of Nursing (DON), and physician are also notified. The LPN said that the main objective was to take care of the residents then notify everyone that needs to be notified. During an interview with the Director of Nursing (DON/staff #5) conducted on May 18, 2023 at 10:58 a.m., the DON stated that the expectation was that all allegations of abuse is reported; and that, staff were provided abuse training on how to identify and report allegations of abuse. The DON said that depending on the allegation, the Executive Director (ED/staff #143) normally takes the lead on the investigation; and that, part of investigation was to interview the individuals involved, residents on the unit, and the staff members working during the timeframe of the incident. The DON also said that the incident is reported to the ED, physician, family/POA, APS (Adult Protective Services) and the SA (State Agency). Regarding the incident between resident #26 and #28, the DON said that he did not have any recollection of the incident because he was not working with them in that unit and he was not the DON at that time. During the complaint exit conference conducted with the Executive Director (ED/staff #143) on May 18, 2023 at 11:25 a.m., the ED stated that since she was not employed at the time of the incident, she cannot account for how the incident was investigated. However, she stated that they do education of their staff on identification and reporting so that allegations of abuse can be thoroughly investigated. Review of the undated facility policy titled Resident Rights: Abuse & Neglect stated that their residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. The facility noted that the investigation process begins when the administrator or the DON receives information that abuse have taken place. The receipt of this information triggers process for acting to protect residents and employees and collecting information to determine facts. The Administrator and/or the Director of Nursing will take a lead role in coordinating fact-finding investigation. The investigator will collect any physical, demonstrative, or documentary evidence related to the incident. The investigator much also collects statements from the individual bringing the allegation, alleged victim, other persons to include residents with knowledge or potential knowledge of the incidents, and the individual accused of abuse or neglect. Furthermore, a full report of the completed investigation shall also be sent to the Department of Health, APS, Ombudsman, Scottsdale PD, and State Board of Nursing (if applicable) within 5 working days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility documentation, staff interviews, and facility policy and procedures, the facility failed to ensure one resident (#2) was not abused by another resident (#21) and one resident (#38) was not abused by another resident (#27). The deficient practice could result in residents being physically and psychologically harmed. Findings include: Regarding Resident #2: Resident #2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, unspecified psychosis, and an anxiety disorder. The Minimum Data Set (MDS) dated [DATE] revealed that the resident was not able to complete the brief interview for mental status. It also included that the resident requires one-person assist with ambulation and uses a wheelchair. Review of a progress note dated January 14, 2023 at 4:24 p.m. revealed that resident #2 sat down on another resident's chair and refused to move when asked by the other resident. The note stated resident #2 started cursing and yelling at the other resident, which caused a disturbance in the day room and caused the other resident to lunge for resident #2's hair. The note stated then the other resident along with another female resident threw water at resident 2's face and these residents were separated by the staff around them. Review of a progress note dated March 3, 2023 at 6:10 p.m. revealed that resident #2 had been screaming for almost an hour. The note stated that resident #2 was given liquid Lorazepam but her yelling and screaming kept triggering another resident, had others yell at her and one tried to fight her as he was angered at her screaming. The care plan dated April 3, 2023 revealed that resident #2 has an activities of daily living (ADLs) deficit related to confusion. Interventions included to breakdown ADL and mobility tasks and encourage resident to participate in activities. The care plan dated April 13, 2023 revealed that resident #2 has behavior problems as evidenced by other behaviors related to dementia with behaviors diagnosis. Interventions included to administer medications as ordered and monitor for effectiveness of medication usage, attempt to redirect behaviors, and staff will attempt to keep resident #2 away from close proximity to 2 other named residents at all times. Review of a behavioral care plan updated April 14, 2023 states that resident #2 has a history of physical and verbal aggression towards peers and resident #2 should never be near resident #21. Review of a progress note dated April 15, 2023 at 6:13 p.m. revealed that the Executive Director was notified of a resident to resident altercation. The residents were separated and an investigation was initiated. All parties were notified. Review of a progress note dated April 15, 2023 at 7:01 p.m. revealed that resident #2 had an altercation with another peer after they had an exchange of words and was punched on the left side of the face. The note stated staff was quick to separate the residents and deescalated the situation amid the fighting and too late. The note stated the licensed practical nurse (LPN/staff #78) did a skin assessment and all parties notified. The note also included that resident #2's vitals were within limits and other peer was removed from the room to his room. Regarding Resident #21: -Resident (#21) was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, schizophrenia, dementia in other diseases classified elsewhere, anxiety disorder, and major depression. The care plan dated October 13, 2022 revealed that resident #21 is at risk in ADL performance related to dementia and needs staff oversight. He needs assistance to complete some daily tasks and mobility safety. Interventions included to breakdown ADL and mobility tasks and encourage resident to participate in activities. The care plan dated October 13, 2022 revealed that resident #21 has a diagnosis of dementia with behaviors, and was admitted with increased symptoms of sexually inappropriate comments and actions directed at peers and staff. Interventions included to administer medications as ordered and monitor effectiveness of medication usage. Resident #21 did not have a care plan for physical aggression toward residents. The MDS dated [DATE] revealed that resident #21 exhibited physical behavioral symptoms directed towards others, such as hitting, kicking, pushing, scratching, grabbing, and abusing others sexually daily during the 7-day look-back period. The MDS dated [DATE] included a brief interview for mental status score of 4 indicating the resident has a severe cognitive impairment. It also included that resident #21 uses a wheelchair for ambulation. A progress note dated April 15, 2023 at 6:19 p.m. revealed that the Executive Director was notified of a resident to resident altercation. The note stated the residents were separated, an investigation was initiated and all parties were notified. A progress note dated April 15, 2023 at 7:10 p.m. revealed that resident #21 had an altercation with a peer. The note stated resident #21 wheeled himself to where the resident was sitting and punched her on the left side of the face. The note stated staff was quick to separate them and resident #21 was taken to his room. Review of a behavioral care plan updated April 17, 2023 states that resident #21 gets very agitated by loud noises. and becomes physically aggressive to peers when he is near others who yell or make loud noise. The care plan stated staff should do their best to keep resident #21 in quieter settings and the resident should be kept a significant distance from a named female peer. Review of the facility investigation dated April 19, 2023 revealed that on April 15, 2023 at around 5:45 p.m., resident #21 was in the dining room and shouting at resident #2 to shut up. Before a certified nursing assistant (CNA) could reach resident #21, he slapped resident #2 on the left side of her face. Resident #2 was assessed for injuries and no injuries were noted. An interview was conducted on May 4, 2023 at 9:20 a.m. with (CNA/staff #236), who stated that he was not present when resident #21 hit resident #2 because one of the other residents had thrown water on the floor and after he cleaned it up, he left the dining room to put the wet towel in the utility room. He stated when he came back, there was another CNA standing between resident #21 and resident #2 and resident #2 was screaming that resident #21 punched her and hurt her. He stated resident #21 was saying that he hit resident #2 because she was screaming. On May 4, 2023 at 9:40 a.m. an interview was conducted with a charge nurse (staff #78), who stated that she was doing work at the nurse's station and was not facing the residents. She stated that resident #2 was sitting at a table in the middle of the dining room and resident #21 sitting in his wheelchair up against the wall by the door. She stated that there were three CNAs in the room, one was a regular staff and the other two CNAs were from an agency and there are always supposed to be 3 CNAs in the dining room at meal time. She stated that one of the residents threw her food and drink on the floor and one of the CNAs was cleaning it up when staff #78 left the dining room and went down the hall to fax a medication orders. When she was faxing, the female CNA came to tell her that she was going to lunch and staff #78 asked the CNA to wait and directed the CNA to go back to the dining room and monitor the residents. When staff #78 returned to the dining room, a male CNA reported that he was emptying a plate of food into the trash and when he turned around, he saw resident #21 hit resident #2 on the left cheek with a closed fist. Staff #78 stated that she assessed resident #2's cheek and there was no mark, but the resident said it hurt when staff #78 touched the cheek. She stated that resident #21 said he hit resident #2 because she kept yelling. An interview was conducted on May 4, 2023 at 12:56 p.m. with the (DON/staff #67), who stated that abuse is when there is any unwelcome contact from staff or another resident. He stated that there doesn't need to be a physical injury because the resident may state that it hurt even if there is no physical mark. He stated that all staff should be in the dining room during meal time and there is a two-to-one ratio during meal time. He stated that if one CNA leaves the dining room, there should be communication between staff, so another staff can fill in. He stated that he reviewed the 5-day report and did not think abuse had occurred because he felt that it was more neglect than abuse. He stated that resident #21 did hit resident #2, but felt it was neglect by staff because staff did not monitor appropriately. Regarding Resident #38: -Resident #38 was admitted to the facility on [DATE] with diagnoses the included conduct disorder unspecified, unspecified convulsions, and unspecified psychosis. The minimum data set (MDS) dated [DATE] include a staff interview for mental status score of 3 indicating a severe cognitive impairment. A progress note dated February 27, 2023 at 10:38 a.m. revealed that resident was sitting in the dining room, when peer came into the day room as he does and didn't show any signs of aggression and hit resident #38 in the right side of her face. The note stated that the CNAs immediately intervened and redirected peer out of the day room and into his room. The note stated resident #38's right eyebrow was slightly swollen; no other injuries were noted. A progress note dated February 27, 2023 at 12:44 p.m. revealed that the Executive Director was notified of resident to resident altercation. Investigation initiated and completed. Review of a behavior plan dated February 27, 2023 revealed that resident #38 is not allowed to be within arm's length of resident #27 at any time. Regarding Resident #27: -Resident #27 was admitted to the facility on [DATE] with diagnoses that included Parkinson's Disease, chronic obstruction pulmonary disease, and dementia in other diseases elsewhere, unspecified severity with agitation. The MDS dated [DATE] did not include a brief interview for mental status. It did include that resident #27 was physically and verbally abusive towards others 1 to 3 days during the look-back period and has an active diagnosis of adjustment disorder with mixed disturbance of emotions and conduct, and a psychotic disorder with delusions and hallucinations due to a known physiological condition. A progress note dated February 27, 2023 revealed that resident #27 came into the dining room and didn't show any signs of aggression and hit resident #38 in the right side of her face. The note stated that the CNAs immediately intervened and redirected resident #27 out of the dining room into his bedroom. It stated the Executive Director, DON, and behavioral manager were notified of the incident. The POA(Power of Attorney) was notified and had some concerns of why resident #27 was so aggressive lately. The care plan dated February 27, 2023 stated the resident has a behavior problem as evidenced by physically and verbally aggressive with staff and peers. Interventions included to monitor resident in common areas around his peers. The behavior plan updated on May 3, 2023 included that resident #27 is never to be near resident #38 or resident #61 even if he was calm. An interview was conducted on May 4, 2023 at 11:55 a.m. with (CNA/staff #111), who stated that she was doing an activity with a male resident in the dining room, a second CNA was helping another male resident with an activity, and the third CNA was helping another resident when resident #27 walked into the dining room by resident #38. Staff #111 stated that she didn't see resident #27 hit resident #38, but one of the other CNAs saw him. Following the interview with staff #111, another CNA (staff #87) joined the interview and stated that she was in the dining room assisting another resident and saw resident #27 come in and hit resident #38 with a closed fist. She stated that resident #27 has to be watched at all times. Staff #111 stated that resident #27 was really aggressive and sometimes he walked by staff and hit staff. She stated that resident #27 hit her in the stomach this morning. An interview was conducted on May 4, 2023 at 12:56 p.m. with the DON (staff #67), who stated that he reviewed the 5-day report for resident #27 and resident #38. He stated that it was abuse by resident #27, however, there are times when things are unpredictable, so he stated there was no finding regarding staff. Staff #67 stated that resident #27 hit resident #38 and one other resident after the incident with resident #38. The facility's policy, Resident Rights: Abuse and Neglect, states that physical abuse includes violence or rough treatment, even if it does not leave an injury. A push that might not hurt a younger person can be very harmful to an older person.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interviews, and policy and procedures, the facility failed to ensure that an allegation of abuse involving two residents (#2 and #21) was investigated. The deficient practice could result in allegations of abuse not being accurately investigated. Findings include: -Resident #2 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's Disease, unspecified psychosis, and an anxiety disorder. -Resident (#21) was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, schizophrenia, dementia in other diseases classified elsewhere, anxiety disorder, and major depression. Review of the facility investigation dated April 19, 2023 revealed that on April 15, 2023 at around 5:45 p.m., resident #21 was in the dining room and shouting at resident #2 to shut up; and that, before a certified nursing assistant (CNA) could reach resident #21, he slapped resident #2 on the left side of her face. It also included that resident #2 was assessed for injuries and no injuries were noted. The investigation did not include any staff interviews. An interview was conducted on May 4, 2023 at 9:20 a.m. with (CNA/staff #236), who stated that he was not present when resident #21 hit resident #2 because one of the other residents had thrown water on the floor and after he cleaned it up, he left the dining room to put the wet towel in the utility room. When he came back, he stated there was another CNA standing between resident #21 and resident #2 and resident #2 was screaming that resident #21 punched her and hurt her. Resident #21 was saying that he hit resident #2 because she was screaming. On May 4, 2023 at 9:40 a.m. an interview was conducted with a charge nurse (staff #78), who stated that she was doing work at the nurse's station and was not facing the residents. She stated that resident #2 was sitting at a table in the middle of the dining room and resident #21 sitting in his wheelchair up against the wall by the door. She stated that there were three CNAs in the room, one was a regular staff and the other two CNAs were from an agency and there are always supposed to be 3 CNAs in the dining room at meal time. She stated that one of the residents threw her food and drink on the floor and one of the CNAs was cleaning it up when staff #78 left the dining room and went down the hall to fax a medication orders. When she was faxing, she stated the female CNA came to tell her that she was going to lunch and staff #78 asked the CNA to wait and directed the CNA to go back to the dining room and monitor the residents. When staff #78 returned to the dining room, she stated a male CNA reported that he was emptying a plate of food into the trash and when he turned around, he saw resident #21 hit resident #2 on the left cheek with a closed fist. Staff #78 stated that she assessed resident #2's cheek and there was no mark, but the resident said it hurt when staff #78 touched the cheek. She stated that resident #21 said he hit resident #2 because she kept yelling. An interview was conducted on May 4, 2023 at 12:56 p.m. with the (DON/staff #67), who stated that a thorough investigation typically includes finding out which staff and residents were involved. Also, he stated everyone involved should be interviewed verbally and the interview should be documented by the person conducting the interview. He stated that if you don't interview everyone involved, it opens up for more incidents to occur. The facility's policy, Resident Rights: Abuse and Neglect, states that a preliminary review of the situation will be conducted to identify possible witnesses, either staff, patients, family members. The investigator must also try to collect statements from the individual bringing the allegation, the alleged victim, other persons (including residents) with knowledge or potential knowledge of the incident and the individual accused of abuse or neglect.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to complete a comprehensive Minimum Data Set (MDS) assessment within the required timeframe for one resident (#9). The census was 91 residents. The deficient practice could result in delayed identification of potential risks and care needs. Findings include: Resident #9 was re-admitted to the facility on [DATE] with diagnoses that included Post Traumatic Stress Disorder (PTSD), Parkinson's disease, and dementia without behavioral disturbance. Review of the resident's MDS assessments revealed that an annual assessment was not conducted in March 2022, but one was dated April 7, 2022 that was not signed as complete by the RN assessment coordinator and showed as in progress as of April 28, 2022. A phone interview was attempted on April 28, 2022 at 2:05 PM with the MDS nurse (staff #161). A voicemail message was left. A second phone interview was attempted at 2:38 PM. A second voicemail message was left. An interview was conducted on April 28, 2022 at 2:40 PM with the Executive Director (ED/staff #68). She stated that the Director of Nursing (DON) was out of the facility on this date. She said that the previous MDS nurse was no longer working in the facility and had been gone for about a month or so. She stated that they had hired an outside nurse to work on the MDS assessments who has been attempting to complete the assessments as best she can. She stated that the facility is aware that MDS assessments are not being completely timely. She stated that the MDS assessments are important because they show an overall picture of the resident and the care that they require and they also drive payment. She stated they have been working hard to get them caught up as there are about 25% of them that are not completed. Further, she stated that she understands that the assessments should be completed timely so they can be transmitted within 14 days of completion. She said that she has reviewed many of the assessments and noted that they show as in progress which indicates they are being worked on and have not been completed or submitted yet. Review of the facility's MDS completion and submission timeframes policy, revised July 2017, revealed that the facility will conduct and submit resident assessments in accordance with federal and state submission timeframes. The policy implementation included that the assessment coordinator or designee is responsible for ensure that resident assessments are submitted to the Center for Medicare and Medicaid Services (CMS) assessment submission and processing system in accordance with current federal and state guidelines. This includes the current requirements published in the RAI manual. Review of the RAI manual, dated October 2019, revealed that the primary purpose of the MDS assessment tool is to identify resident care problems that are addressed in an individualized care plan. The manual included that the MDS completion date must be no later than 14 days after the Assessment Reference Date (ARD), and there can be no more than 366 days between comprehensive assessments.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and facility documentation and policy, the facility failed to ensure that one resident (#28) received adequate and consistent showers. The sample size was two residents. The deficient practice could result in residents' personal hygiene and grooming needs not being met. Findings include: Resident #28 was admitted to the facility on [DATE] with diagnoses that included borderline personality disorder, bipolar disorder, morbid (severe) obesity due to excessive calories, and chronic pain. Review of the resident's Activities of Daily Living (ADL) care plan, initiated on July 13, 2016, revealed the resident received physical assistance with ADL care, required a mechanical lift for transfers, and used an electric scooter for mobility. The goal was to meet the resident's daily care needs. An intervention included two person assist for all care. The care plan included showers and bed baths as being the resident's preferences. The resident's quarterly Minimum Data Set (MDS) assessment, dated January 24, 2022, revealed that the resident had a Brief Interview for Mental Status (BIMS) of 15 indicating she was cognitively intact. The assessment indicated that the resident was totally dependent upon staff and required two people for physical assistance with bathing. The shower schedule for the unit the resident resided on included a schedule organized by room, bed number, and shift. This resident was to receive showers on the evening shift on Tuesdays and Fridays. Review of bathing documentation for April 2022 revealed a single entry on April 15 at 10:48 PM that the resident received a bed bath. There were no other entries in the bathing documentation to show that the resident received any further showers or bed baths. The rest of the entries were coded to show that the activity did not occur. Review of the nursing progress notes did not reveal any documentation that the resident received or refused showers or bed baths beyond the one documented on April 15, 2022. Review of shower sheet documentation revealed no evidence the resident received any further showers or bed baths in April 2022. An interview was conducted with the resident on April 25, 2022 at approximately 10:00 AM. She stated that she had not received two bed baths last week. During an interview with a Licensed Practical Nurse (LPN/staff #73) on April 28, 2022 at approximately 10:12 AM, he stated that the resident is scheduled to receive showers or bed baths on Tuesdays and Fridays on the evening shift for a total of two per week. He said that bathing is documented in the clinical record under the bathing documentation. He said they are also documented on paper shower sheets. He said that he knew the resident well and she requires two person physical assistance for showers. He reviewed the shower documentation in the clinical record and said he only saw one bed bath documented on April 15, 2022. In an interview with the Assistant Director of Nursing (ADON/staff #38) on April 28, 2022 at approximately 1:50 PM, she said that the Director of Nursing (DON) is not in the building on this date. She further stated that residents receive showers (or bed baths) twice weekly at a minimum unless they refuse this care. She said that the shower documentation is recorded in the resident's clinical record. She said that she was familiar with this resident and she reviewed the clinical record. She said that there was only one bed bath documented for April 2022. She said she was not able to provide any other documentation to show that the resident received any additional showers or bed baths in April 2022. Review of the facility's shower policy, revised February 2018, revealed the purpose was to promote cleanliness, provide comfort to the resident, and observe the condition of the resident's skin. The policy noted that documentation of showers (or bed baths) should include the date and time the shower was performed, if the resident refused, the reason why, and the intervention taken. The policy included to notify the supervisor if a resident refuses showers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that one resident (#28) was provided adequate care and treatment related to bowel care. The sample size was two residents. The deficient practice could result in residents having discomfort and difficulty having a bowel movement. Findings include: Resident #28 was admitted to the facility on [DATE] with diagnoses that included borderline personality disorder, bipolar disorder, morbid (severe) obesity due to excessive calories, chronic pain, and osteoarthritis. Review of the resident's active incontinence care plan revealed the resident had bowel incontinence related to immobility and behavior and the resident was noted to be at risk for constipation related to medications. The goals included to anticipate the resident's needs, the resident will not experience complications related to incontinence, and the resident will have bowel movements at least every 3 days. Interventions included incontinence care briefs, monitor for complications, skin treatments as ordered, medications as ordered, follow facility bowel protocol for bowel management, and keep physician informed of any problems. Review of the quarterly Minimum Data Set (MDS) assessment, dated January 24, 2022, revealed that the resident has a BIMS (Brief Interview for Mental Status) of 15 indicating she was cognitively intact. The assessment included that the resident always had bowel incontinence. Review of the recapitulation of physician's orders for April 2022 revealed the following orders for bowel care: -Miralax powder, give 17 grams by mouth every day for bowel care. -Bisacodyl tablet 5 mg, give 1 tablet every day for bowel care. -Milk of Magnesia (MOM) suspension 400 mg/5 ml, give 30 ml by mouth every 72 hours as needed for bowel care if no bowel movements. -Dulcolax suppository 10 milligrams (mg) insert rectally as needed for bowel care if no results from MOM in 8 hours -Fleet enema 7-19 gm/118 milliliter (ml), insert 1 unit rectally every 72 hours as needed for bowel care if no results from suppository in 8 hours, check for bowel sounds, palpate abdomen and notify the physician. Toileting documentation was reviewed from April 2022. There was no documentation that the resident had a bowel movement from April 15 through 22 which is 8 days. Review of the Medication Administration Record (MAR) for April 2022 revealed the daily bowel medications were administered as ordered, however, no as needed medication for bowel care was administered from April 15, 2022 through April 22, 2022. Review of the clinical record revealed no evidence that the resident had any bowel movements or received bowel care between April 15 through 22. On 4/28/22 at 10:04 AM, an interview was conducted with a Licensed Practical Nurse (LPN/staff #73). He stated that the residents are evaluated for bowel protocol based on the physician's orders upon admission. He said the facility protocol is that when a resident has not had a bowel movement in 3 days, they will administer as needed bowel medication and the outcome is monitored. If the medication is not effective, then they will follow the physician's orders for the next step. He said that he is familiar with this resident and her required level of care related to bowel incontinence. He reviewed the clinical record and said that the resident did not have a documented bowel movements for some time and that there were no as needed medications documented as administered during that time. He said that he could not locate any further information on this matter. An interview was conducted with the Assistant Director of Nursing (ADON/staff #38) on April 28, 2022 at approximately 2:05 PM. She said that the Director of Nursing (DON) was not in the facility on this date. She said that the facility has standing orders that are used when a resident requires as needed bowel medication. She said that the protocol goes into effect after the resident has not had a bowel movement after 3 days. She said that if medications are administered, this is documented on the MAR. She reviewed the resident's clinical record and said there was no documentation of a bowel movement between April 15 and 22, 2022 and no as needed bowel protocol medications were administered. She said that she did not know for sure what happened and that it is possible that the resident's bowel movements were not documented. She said that there is no other information regarding this available in the resident's clinical record. The facility bowel care protocol policy, revised January 19, 2021, revealed the facility's bowel protocol included MOM by mouth one time daily and if ineffective after 8 hours, give bisacodyl suppository rectally if needed. If that is ineffective after 8 hours, give fleet enema rectally. The policy included to notify the physician if the resident remains constipated.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that one resident (#37) consistently received care to prevent pressure ulcers and was consistently provided pressure ulcer treatment. The sample size was 3. The deficient practice could result in the development of pressure ulcers, and delayed wound healing or worsening of a pressure ulcer. Findings include: Resident #37 was admitted to the facility on [DATE] with diagnoses of Unspecified Dementia with Behavioral Disturbance and Type 2 Diabetes Mellitus with Unspecified Diabetic Retinopathy Without Macular Edema. Review of the care plan initiated on August 10, 2020 revealed the resident was at risk for development of pressure ulcer and impaired skin integrity. Intervention included monitoring for changes in skin integrity, repositioning every 2 hours and as needed, and weekly skin evaluation per protocol. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident's cognitive skills for daily decision making were severely impaired. The assessment included the resident was at risk for developing pressure ulcers and did not have any pressure ulcers, and had an infection of the foot. Skin and ulcer treatments included a pressure reducing device for the bed and application of dressings to the feet. Regarding heel protectors and offloading heels Physician orders dated January 11, 2022 included offloading the resident's heels for wound prevention, placing heel protectors when the resident is in bed, and applying skin prep twice a day to the left heel and toes. Review of the Treatment Administration Record (TAR) for March 2022 revealed no evidence that the treatment for heel protectors to be placed while in bed was done on March 24, & 25, and 28 & 29. Continued review of the TAR for March 2022 revealed no evidence the resident's heels were offloaded on March 2, 4, 12, and 15 on the day shift, on March 24, 25, 28, and 29 on the evening shift, and on March 25 & 29 on the night shift. A review of the TAR for April 2022 revealed no evidence that heel protectors were placed while the resident was in bed on April 7. Review of TAR for April 2022 revealed no evidence that the resident's heels were offloaded on April 6 on the night shift, all shifts on April 7, and the day shift on April 26. Regarding the right heel ulcer Nursing progress notes dated January 12, 2022 stated that the ulcer to right heel was unchanged from yesterday. No signs of pain or discomfort at the site. Physician aware of finding and the resident is on change of condition for monitoring of skin. The notes also included there was a new order for the right heel ulcer, place betadine on the wound every shift and leave it open to air. Review of the at risk for development of pressure ulcer and impaired skin integrity care plan was updated to include the resident has a right heel ulcer dated January 12, 2022. The goal was that the right heel ulcer will resolve. Interventions included treatment as ordered. A wound physician progress note dated January 13, 2022 revealed that resident #37 had a new wound to the right heel. The note stated the right heel is an unstageable pressure ulcer with obscured full-thickness skin and tissue loss that measured 2.3 centimeters (cm) x 1.9 cm, no drainage and the wound bed had 76-100% eschar. The dressings/recommendation plan included skin prep, open to air, float heel(s) in bed, and reposition per facility protocol. The note also revealed the plan of care was discussed with the resident and/or family, and the nursing staff. A physician order dated January 13, 2022 stated to cleanse the right heel with NS, pat then apply skin prep leave open to air every evening shift. A quarterly MDS assessment dated [DATE] revealed that the resident cognitive skills for daily decision making were severely impaired. The assessment also included the resident had an infection of the foot. A physician order dated March 22, 2022 stated to cleanse the right heel with normal saline, pat dry, apply Bactroban, cover with Allevyn 2 x 2 dressing one time a day for deep tissue injury for 21 days. Review of the nursing skin/wound note dated April 6, 2022 revealed the right heel has a stage 3 pressure ulcer that measured 1.3 cm x 1.3 cm x 0.2 cm, with scant amount of yellow drainage, wound bed has 1-25% epithelialization, 1-25% eschar, 26-50% pink granulation. The TAR for April 2022 revealed no evidence that Bactroban treatment to the right heel was performed on April 7. The TAR also revealed the resident refused the treatment on April 9, 2022. An interview conducted with the Infection Preventionist (IP/staff #98) on April 28, 2022 at 10:50 AM. The IP stated that once a pressure ulcer has been identified, they notify the provider. He stated there is no wound nurse in the facility and that the wound physician rounds weekly. He stated interventions in place for resident #37 include offloading the heels, heel protectors, and a special mattress. The IP stated the treatment was being provided, it just was not documented. During an interview conducted with the Assistant Director of Nursing (ADON/staff #38) on April 28, 2022 at 12:41 PM, she stated that if a resident has a wound, the nurses will notify the IP. The IP also stated that treatments are expected to be provided as ordered and that she would not expect a gap in the treatments. Review of the facility's policy Dressing, Dry and Clean revised September 2013 stated the purpose is to provide guidelines for the application of dry, clean dressing. Verify that there is a physician order and check the treatment record. The policy stated that after providing the treatment the following information should be recorded in the resident's medical record, treatment sheet or designated wound form: the date and time the dressing was changed, the wound appearance, the name and title of the individual changing the dressing, and the signature or initials of the person recording the data. If the resident refuses the treatment, document the reason for the refusal and the resident's response to the explanation of the risk of refusing the procedure, the benefits of accepting an available alternative. The policy also stated to document that the family and physician was notified of the refusal.

Based on facility assessment review, personnel record reviews, staff interviews, and facility policy, the facility failed to provide dementia training for three staff members (#49, #72, and #5) and failed to provide resident rights training for one staff member (#5). The sample size was ten staff members. The deficient practice could result in inadequate care for the residents in the facility. Findings include: Regarding Dementia Training: Review of the facility assessment, revised February 18, 2022, revealed that common diagnoses or conditions the facility cared for included: Parkinson's disease, Alzheimer's disease, non-Alzheimer's dementia, Huntington's disease, depression, bipolar disorder, schizophrenia, Post Traumatic Stress Disorder (PTSD), anxiety disorder, behaviors that require interventions, and mood disorders. The facility assessment included that one of the nursing units was designated for residents with dementia and two other nursing units were designated for residents that have dementia with behaviors. -Review of the personnel record for a social services coordinator (staff #49) revealed a hire date of Februaury 1, 2018. The personnel record did not reveal evidence of training for dementia care. -Review of personnel record for a Certified Nursing Assistant (CNA/staff #72) revealed a hire date February 1, 2018. The personnel record did not reveal evidence of training for dementia care. -Review of the personnel record for a Licensed Practical Nurse (LPN/staff #5) revealed a hire date of November 24, 2020. The personnel record contained a form titled Skills Blitz Competency Fair Checklist dated February 24, 2022. The checklist included abuse and neglect, infection prevention, and de-escalation/managing behaviors. Further review of the personnel record did not reveal any evidence of training for dementia care. During an interview conducted on April 26, 2022 at 3:22 p.m. with the Executive Director (ED/staff #68), she stated that she has been reviewing the training provided by the facility and there is no training for dementia being done. An interview was conducted on April 27, 2022 at 9:14 a.m. with the Assistant Director of Nursing (ADON/staff #38), who stated that annual training is required for resident rights, dementia, abuse and infection control and all nursing staff are required to attend. She said that the ED, DON, and/or Human Resources (HR) let her know who is due for annual training, but there has been a change in staffing, leadership, and in HR, so training for dementia may have been missed. Review of the facility's, Skills Blitz Competency Fair Checklist, which is used for the annual in-service training, did not reveal training for dementia care. Review of the facility's general orientation documentation revealed that an orientation packet must be completed on or before the date of hire. Alzheimer's/Dementia training was included in this as part of the packet. Review of the Registered Nurse (RN)/LPN Orientation Checklist did not reveal dementia training. Review of the Certified Nursing assistant Skills Competency Checklist did not reveal dementia training. Regarding Resident Rights Training: -Review of the personnel record for a LPN (staff #5) revealed a hire date of November 24, 2020. The personnel record contained a form titled Skills Blitz Competency Fair Checklist dated February 24, 2022. The checklist included abuse and neglect, infection prevention, and de-escalation/managing behaviors. Further review of the personnel record did not reveal any evidence of training regarding resident rights. Review of the sign-in sheet for resident rights training that occurred on February 9, 2022 did not reveal a signature for staff #5. During an interview on April 27, 2022 at 9:14 a.m. with the Assistant Director of Nursing (ADON/staff #38), she reviewed the in-service training binder and the Resident Rights training sign-in sheet conducted on February 9, 2022 and stated that staff #5 did not receive training. She said that resident rights training is required annually and all nurse staff must attend. She stated that the Executive Director, DON, or HR will let her know who is due for annual training. Review of the facility's Skills Blitz Competency Fair Checklist, which is used for the annual in-service training, did not reveal training for resident rights. Review of the facility's general orientation documentation revealed that and orientation packet must be completed in its entirety on or before the date of hire. Resident rights training was included in this packet. Review of the RN/LPN Orientation Checklist did not reveal resident rights training.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, and staff interviews, the facility failed to ensure that pharmacist reported irregularities were reviewed and acted upon for 2 residents (#49 and #37). The sample size was 5 residents. The deficient practice could result in medication irregularities that go unnoticed or are not acted upon. Findings include: -Resident #49 was admitted to the facility on [DATE] with diagnoses that included dementia with behavioral disturbance and major depressive disorder. Review of the physician's orders revealed the following orders dated 8/20/2021 for antidepressant medications: -Mirtazapine 15 milligrams (mg) at bedtime. -Citalopram hydrobromide 20 mg per day. Review of the resident's psychoactive drug use care plan, initiated on 8/20/2021, revealed the resident used antidepressant medications. Interventions included to monitor the resident closely for adverse side effects, monitor mood/behaviors as indicated, and to evaluate for gradual dose reduction routinely. A physician's order dated 8/23/2021 revealed monitoring for self isolation every shift. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 15 on the Brief Interview for Mental Status (BIMS) indicating she was cognitively intact. The resident scored a 0 on the mood assessment indicating no mood problems and was coded as having received antidepressant medication daily. The Medication Administration Record (MAR) for 8/23/2021 through 12/6/2021 revealed the medications were given as ordered and behavioral monitoring was being completed every shift. Review of the physician's orders revealed the following orders dated 12/7/2021 for antidepressant medications: -The original citalopram order was discontinued. -citalopram hydrobromide 10 milligrams (mg) per day, Instructions included to be given with 20 mg dose to make 30 mg total. -citalopram tablet 20 mg. Instructions included to give with the 10 mg dose to make a total of 30 mg. Review of the MAR for 12/7/2021 through 2/2/2022 revealed the resident received all antidepressant medications as ordered. Also noted, no behaviors of self isolation were noted during this timeframe. Review of a pharmacy recommendation dated 2/2/2022 revealed the pharmacist noted that the resident was receiving the two antidepressant medications and that the dosage for the citalopram had increased. The recommendation noted that the resident had not exhibited self-isolation in the past quarter according to the facility's behavioral monitoring and had scored zeros on the Patient Health Questionnaire (PHQ9) since admission which measures severity of depression. The recommendation included that the resident may benefit from a dose reduction of the mirtazapine to 7 mg. There was no signature from the provider that the form was received and no response from the provider was noted. Review of the clinical record revealed no evidence that the provider had acknowledged the recommendation and no medication order changes were noted. Review of the MAR from 2/3/2022 to 4/28/2022 revealed that the resident continued to receive the antidepressant medications as ordered. During an interview with the Assistant Director of Nursing (ADON/staff #38) on 4/28/2022 at approximately 12:50 PM, she stated that she had no documentation to show that the medication review was seen or acted upon. She said that this means that it was no acted upon. An interview with the Executive Director (ED/staff #68) was conducted on 4/28/2022 at approximately 1:47 PM. She said that she did not have any evidence that the resident's physician reviewed or acted upon the pharmacy recommendation from 2/2/2022. -Resident #37 was admitted to the facility on [DATE] with diagnoses of unspecified dementia with behavioral disturbance, type 2 diabetes mellitus with unspecified diabetic retinopathy, and rheumatoid arthritis. A quarterly MDS dated [DATE] revealed that the resident had short-term and long-term memory problems and was severely cognitively impaired. Review of the physician's orders revealed an order dated 7/28/2020 for hydroxychloroquine 200 milligrams (mg) twice a day for rheumatoid arthritis. The MAR for 1/2022 through 3/9/2022 revealed the resident received the medication as ordered. Review of a pharmacy recommendation, dated 3/9/2022, revealed that due to the resident being on hydroxychloroquine for the long term, an Electrocardiogram (ECG) should be done periodically. The recommendation included checking the resident's ECG. There was no signature from the provider that the form was received and no response from the provider was noted. Review of the clinical record revealed no evidence that the provider had acknowledged the recommendation and no order changes were noted. Review of the MAR from 3/9/2022 through 4/28/2022 revealed the resident received the medication as per orders. An interview was conducted with the ADON (staff #38) on 4/28/2022 at approximately 12:50 PM. She said she had no documentation to reflect that the medication review for the resident was reviewed or that the physician had responded to it. She said that since the physician response line was blank, she said that the recommendations were not acted upon.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility documentation, the facility failed to ensure one resident's (#76) clinical record was complete regarding patient therapy records and Preadmission Screening and Resident Review (PASRR). The census was 91 residents. The deficient practice may result in residents' clinical records not being complete and accurate. Findings include: Resident #76 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, major depressive disorder with psychotic symptoms, Parkinson's disease, and Cerebral Vascular Accident (CVA). Regarding therapy records: The resident's CVA care plan, dated January 4, 2022 revealed a goal that the resident would maintain her current level of functioning. An intervention included rehabilitation (rehab) as ordered. Review of a Physical Therapy (PT) evaluation dated February 8, 2022 revealed the plan of therapy treatment was 1-3 times per week for 8 weeks. The certification period was from February 8, 2022 to April 4, 2022. PT notes revealed documentation of therapy for February 8, 11, and 22. There was no documentation to show the resident received PT on any other dates. A physician's order dated February 22, 2022 revealed for an Occupational Therapy (OT) evaluation and treat as directed. An OT evaluation dated February 22, 2022 stated that the plan of therapy treatment was to be 1-2 times per week for 60 day. The certification period was February 22, 2022 to April 4, 2022. Review of the OT notes indicated that the resident had received OT on February 22 and 28. There was no documentation to show the resident received OT on any other dates. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed that the resident's Brief Interview for Mental Status (BIMS) score was 14 which indicated the resident was cognitively intact. An interview was conducted on April 28, 2022 at 11:15 AM with the Executive Director (ED/staff#68). She stated that the facility had a previous contract with a company that provided PT and OT services and that they are no longer contracted in the facility. She said they utilized specific rehab software which is separate from the electronic medical records used in the facility. She said that is why the records are not in the resident's chart. She said that they are unable to provide the therapy documentation for the resident. She said she reached out to the former director of rehab (staff #160) for the documentation, however, she was only provided a few notes. She said that since the provider is no longer contracted with the facility, she is not able to access the records. A phone interview was conducted with the former director of rehab (staff #160) on April 28, 2022 at 12:30 PM. She said that she was familiar with the resident and that PT had completed an evaluation with the plan to treat the resident 1-3 times per week. She said that all treatment sessions were documented in their software. She said that all of the resident's records were archived with the facility and that they should have access to the archived records. She said she is sure that the DON, social services, and other staff in the facility have access to the rehab records. She said that the facility has never mentioned not having the records or any issues with obtaining access to the the therapy records. She further said that she would be able to review the records and share the details but the facility would have to provide the physical copies. During an interview with the ED (staff #68) on April 28, 2022 at 12:55 PM, she said that the facility does not have a policy that specifically addresses the components of complete and accurate medical records. She did provide a document checklist used by the facility. Review of facility documentation revealed a medical record document checklist. This checklist included that therapy documentation should be included in the medical record. Regarding PASRR documentation: Review of the level one PASRR dated December 29, 2021 revealed that while much of the form was completed, section D which included whether a level 2 PASRR was necessary or not was left blank. An interview was conducted with the Social Services Coordinator (staff #4) on April 28, 2022 at 10:55 AM. She said that the facility completes a level one PASRR prior to admission. She said that once the level one is complete, there would be a determination if the resident requires further screening with a level 2 PASRR. She stated that she has been trained to complete the form or review it if it was completed by the hospital. She said the purpose of the level one PASRR is to see if the resident is going to be placed in the proper unit of the facility or if they need additional services such as psych care. She reviewed the level one PASRR for the resident and said that it was filled out, however, she must have forgotten to complete the section which indicates if a level 2 PASRR is required or not. She said even though it was left blank, the resident did not need a level 2 PASRR referral. An interview was conducted on April 28, 2022 at 11:15 AM with the Executive Director (ED/staff#68). The ED stated that she expected that a level one PASRR should be obtained prior to admission or completed within 7 days. The ED explained that a PASRR should be completed to determine that residents were placed in the appropriate areas in the facility. The ED reviewed the level one PASRR for resident #76 and stated that there was no determination of whether a level 2 PASRR was needed. During an interview with the ED (staff #68) on April 28, 2022 at 12:55 PM, she said that the facility does not have a policy that specifically addresses the components of complete and accurate medical records. She did provide a document checklist used by the facility. Review of facility documentation revealed a medical record document checklist. This checklist included that PASRR documentation should be included in the medical record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, and facility policy, the facility failed to ensure that one resident (#76) was provided education regarding the risks and benefits of pneumococcal immunization and failed to ensure the resident was offered the pneumococcal vaccine. The sample size was 5 residents. The deficient practice could result in residents not being informed of risks and benefits of pneumococcal immunization and could result in residents not being offered the vaccine. Findings include: Resident #76 was admitted to the facility on [DATE] with diagnoses of dementia, schizophrenia, depression, and cerebrovascular accident. Review of the resident's admission paperwork revealed a blank pneumococcal vaccine request in the chart. The document was not signed and there was no information to show if the resident consented or declined the vaccination or if the resident was explained the risks and benefits of the vaccination. The resident's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored a 14 on the Brief Interview for Mental Status (BIMS) indicating she was cognitively intact. The assessment noted the resident's pneumococcal vaccination was not up to date and that it was not offered. The resident's clinical record did not include any other information regarding if the resident was educated on the risks and benefits of pneumococcal immunization. There was no documentation in the record to indicate if the resident received the pneumococcal immunization. An interview was conducted on 4/27/2022 at 3:19 PM with the infection preventionist (IP/staff #98). He said that the pneumococcal paperwork was in the chart but was not signed by the resident and/or the resident's representative upon admission. During an interview with the medical records director (staff #97) on 4/28/22 at 11:30 AM, he said that all consent paperwork should be completed during the admission process to ensure residents and/or resident representatives are present to sign and ensure the initial work is complete. He said that he has been in the role for about 2 months. He said that due to turnover and changes in the position, not all admission paperwork was being completed upon admission. He said that the previous person in the role was noted to put information directly into the medical record without having residents and/or resident representatives sign any consents for the documents. He said this has been identified by the quality team and they are working to fix this issue. Review of the facility's immunization and vaccination policy, revised October 2019, revealed that prior to or upon admission, residents will be assessed for eligibility to receive the pneumococcal vaccine series, and when indicated, will be offered the vaccine series within 30 days of admission to the facility unless medically contraindicated or the resident has already been vaccinated. Assessments of the pneumococcal vaccination status will be conducted within five working days of the resident's admission, if not conducted prior to admission. The policy noted that before receiving a pneumococcal vaccine, the resident or legal representative shall receive information and education regarding the benefits and potential side effects of the pneumococcal vaccine. Provision of such education shall be documented in the resident's medical record.

Based on personnel record reviews, interviews, facility policy, and Centers for Medicare and Medicaid Services (CMS) interim final rule requirements, the facility failed to ensure 3 staff members (staff #17, #130, and #10) were vaccinated for COVID-19 or had approved exemptions. The census was 91 residents. The deficient practice could result in the spread of COVID-19 in the facility. Findings include: Review of personnel health records revealed that two Licensed Practical Nurses (LPNs/staff #17 and #130) and a Certified Nursing Assistant (CNA/staff #10) were listed as not vaccinated and had COVID-19 vaccine exemptions. Their files revealed no evidence of approved exemptions. An interview was conducted with the Executive Director (ED/staff #68) on 4/27/2022 at approximately 12:00 PM. She said that she could not locate the COVID-19 vaccination exemptions for staff #17, #130, and #10. An interview was conducted with the business office manager (staff #36) on 4/28/22 at 8:49 PM. She stated that she organizes staff member's COVID-19 exemptions in their medical record which is stored alongside their personnel files. She said she had only been in the role for about a month and that the missing paperwork was missing when she got here. She said that she did not know where the documents for the exemptions for the three staff members were. The facility's COVID-19 staff vaccination policy, dated November 2021, revealed that all staff are required to be fully vaccinated or have a recognized medical or religious exemption. The policy included that the infection preventionist maintains a tracking worksheet of staff members and their vaccination status. Documentation for each facility employee is kept in a confidential and secure health file. Review of CMS interim final rule requirements regarding health care staff vaccination for COVID-19, dated January 14, 2022, revealed that all facility staff are to have received the appropriate number of doses of COVID-19, unless exempted as required by law. Within 60 days of issuance of the memorandum, 100% of staff should have received the necessary doses to complete the vaccine series (i.e., one dose of a single-dose vaccine or all doses of a multiple vaccine series) or have been granted a qualifying exemption, or are identified as having a temporary delay as recommended by the Centers for Disease Control (CDC) to remain in compliance. The rule indicates that facility staff vaccination rates under 100% constitute non-compliance under the rule. The rule defines staff as individuals who provide care, treatment, or other services for the facility and/or its residents, including employees, licensed practitioners; adult students, trainees, and volunteers; and individuals who provide care, treatment, or other services for the facility and/or its residents, under contract or by other arrangements.

Based on personnel record review, a staff interview, and facility documentation, the facility failed to provide abuse training for one staff member (staff #49). The sample size was 10 staff members. The deficient practice could result in staff not being knowledgeable of how to prevent, identify, investigate, and report allegations of abuse. Findings include: Review of the personnel record for a Social Services Coordinator (staff #49) revealed a hire date of February 1, 2018. The personnel record did not reveal evidence of training for abuse and neglect prevention. An interview was conducted on April 27, 2022 at 9:14 a.m. with the Assistant Director of Nursing (ADON/staff #38), who stated that annual training for staff members is required for resident rights, dementia, abuse prevention, and infection control. She said that the administrator, the Director of Nursing (DON), and/or Human Resources (HR) notify her when annual training is required for staff members. She reviewed the in-service documentation and said that she could not find documentation that staff #49 attended training for abuse and neglect prevention. Review of the facility's annual competency checklist revealed that training for abuse and neglect was included. Review of the facility's general orientation documentation revealed instructions that the packet must be completed in its entirety on or before date of hire. The orientation included abuse and neglect/Elder Abuse Act policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, the Resident Assessment Instrument (RAI) manual, and facility policy, the facility failed to complete quarterly Minimum Data Set (MDS) assessments within the required timeframes for 5 residents (#1, #3, #4, #5, and #8). The census was 91 residents. The deficient practice could result in delayed identification of potential risks and care needs. Findings include: -Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included delusional disorder, Peripheral Vascular Disease (PVD), and mood disorder. Review of the resident's MDS assessments revealed the following: -An annual MDS had been completed on June 2, 2021. -There was no quarterly MDS completed in September 2021, but one was done on November 30, 2021. -There was no quarterly MDS completed from December 2021 through February 2022, but one was completed on March 16, 2022. -Resident #3 was admitted to the facility on [DATE] with diagnoses that included unspecified psychosis, major depressive disorder, and Parkinson's disease. Review of the resident's MDS assessments revealed the following: -An admission assessment was completed on December 7, 2021. -A quarterly assessment was not completed in March 2022, but one was noted with a date of April 14, 2022, however, it was not signed as complete by the RN assessment coordinator and showed as in progress as of April 28, 2022. -Resident #4 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia with behavioral disturbance, and personality change due to a known psychological condition. Review of the resident's MDS assessments revealed the following: -A quarterly assessment was completed on December 2, 2021. -A quarterly assessment was not completed in March 2021, but one was dated April 15, 2022, but was not signed by the RN assessment coordinator as complete, and showed as in progress as of April 28, 2022. -Resident #5 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, and hyperlipidemia. Review of the resident's MDS assessments revealed the following: -A quarterly assessment was completed on December 2, 2021. -A quarterly assessment was not completed in March 2022, but one was dated April 14, 2022, but was not signed by the RN assessment coordinator as complete, and showed as in progress as of April 28, 2022. -Resident #8 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbance, hypothyroidism, and hyperlipidemia. Review of the resident's MDS assessments revealed the following: -An admission assessment was completed on December 2, 2021. -A quarterly assessment was not completed in March 2022, but one was dated April 14, 2022, however, it was not signed by the RN assessment coordinator as complete and showed as in progress as of April 28, 2022. A phone interview was attempted on April 28, 2022 at 2:05 PM with the MDS coordinator (staff #161). A voicemail message was left. A second phone interview was attempted at 2:38 PM. A second voicemail message was left. An interview was conducted on April 28, 2022 at 2:40 PM with the Executive Director (ED/staff #68). She stated that the Director of Nursing (DON) was out of the facility on this date. She said that the previous MDS nurse was no longer working in the facility and had been gone for about a month or so. She stated that they had hired an outside nurse to work on the assessments who has been attempting to complete the assessments as best she can. She stated that the facility is aware that MDS assessments are not being completely timely. She stated that the MDS assessments are important because they show an overall picture of the resident and the care that they require and they also drive payment. She stated they have been working hard to get them caught up as there are about 25% of them that are not completed. Further, she stated that she understands that the assessments should be completed timely so they can be transmitted within 14 days of completion. She said that she has reviewed many of the assessments and noted that they show as in progress which indicates they are being worked on and have not been completed or submitted yet. Review of the facility's MDS completion and submission timeframes policy, revised July 2017, revealed that the facility will conduct and submit resident assessments in accordance with federal and state submission timeframes. The policy implementation included that the assessment coordinator or designee is responsible for ensure that resident assessments are submitted to the Center for Medicare and Medicaid Services (CMS) assessment submission and processing system in accordance with current federal and state guidelines. This includes the current requirements published in the RAI manual. Review of the RAI manual, dated October 2019, revealed that the primary purpose of the MDS assessment tool is to identify resident care problems that are addressed in an individualized care plan. The quarterly Assessment Reference Date (ARD) is no later than the ARD of the previous OBRA assessment + 92 days and the completion date is no later than the ARD + 14 calendar days.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to ensure that Minimum Data Set (MDS) assessments for six residents (#1, #3, #4, #5, #8, and #9) were transmitted to the Centers for Medicare and Medicaid Services (CMS) system within 14 days of completion. The deficient practice could result in resident specific MDS data for payment and quality measure purposes not being submitted as required. Findings include: -Resident #1 was re-admitted to the facility on [DATE] with diagnoses that included delusional disorder, Peripheral Vascular Disease (PVD), and mood disorder. Review of the resident's MDS assessments revealed the following: -An annual MDS had been completed on June 2, 2021. -There was no quarterly MDS completed/transmitted in September 2021, but one was done on November 30, 2021. -There was no quarterly MDS completed/transmitted from December 2021 through February 2022, but one was completed on March 16, 2022. -Resident #3 was admitted to the facility on [DATE] with diagnoses that included unspecified psychosis, major depressive disorder, and Parkinson's disease. Review of the resident's MDS assessments revealed the following: -An admission assessment was completed on December 7, 2021. -A quarterly assessment was not completed/transmitted in March 2022, but one was noted with a date of April 14, 2022, however, it was not signed as complete by the RN assessment coordinator and showed as in progress as of April 28, 2022. -Resident #4 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, dementia with behavioral disturbance, and personality change due to a known psychological condition. Review of the resident's MDS assessments revealed the following: -A quarterly assessment was completed on December 2, 2021. -A quarterly assessment was not completed/transmitted in March 2021, but one was dated April 15, 2022, but was not signed by the RN assessment coordinator as complete, and showed as in progress as of April 28, 2022. -Resident #5 was admitted to the facility on [DATE] with diagnoses that included Alzheimer's disease, anxiety disorder, and hyperlipidemia. Review of the resident's MDS assessments revealed the following: -A quarterly assessment was completed on December 2, 2021. -A quarterly assessment was not completed/transmitted in March 2022, but one was dated April 14, 2022, but was not signed by the RN assessment coordinator as complete, and showed as in progress as of April 28, 2022. -Resident #8 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia with behavioral disturbance, hypothyroidism, and hyperlipidemia. Review of the resident's MDS assessments revealed the following: -An admission assessment was completed on December 2, 2021. -A quarterly assessment was not completed/transmitted in March 2022, but one was dated April 14, 2022, however, it was not signed by the RN assessment coordinator as complete and showed as in progress as of April 28, 2022. -Resident #9 was re-admitted to the facility on [DATE] with diagnoses that included Post Traumatic Stress Disorder (PTSD), Parkinson's disease, and dementia without behavioral disturbance. Review of the resident's MDS assessments revealed that an annual assessment was not conducted in March 2022, but one was dated April 7, 2022 that was not signed as complete by the RN assessment coordinator and showed as in progress as of April 28, 2022. A phone interview was attempted on April 28, 2022 at 2:05 PM with the MDS coordinator (staff #161). A voicemail message was left. A second phone interview was attempted at 2:38 PM. A second voicemail message was left. An interview was conducted on April 28, 2022 at 2:40 PM with the Executive Director (ED/staff #68). She stated that the Director of Nursing (DON) was out of the facility on this date. She said that the previous MDS nurse was no longer working in the facility and had been gone for about a month or so. She stated that they had hired an outside nurse to work on the assessments who has been attempting to complete the assessments as best she can. She stated that the facility is aware that MDS assessments are not being completely timely. She stated that the MDS assessments are important because they show an overall picture of the resident and the care that they require and they also drive payment. She stated they have been working hard to get them caught up as there are about 25% of them that are not completed. Further, she stated that she understands that the assessments should be completed timely so they can be transmitted within 14 days of completion. She said that she has reviewed many of the assessments and noted that they show as in progress which indicates they are being worked on and have not been completed or submitted yet. Review of the facility's MDS completion and submission timeframes policy, revised July 2017, revealed that the facility will conduct and submit resident assessments in accordance with federal and state submission timeframes. The policy implementation included that the assessment coordinator or designee is responsible for ensure that resident assessments are submitted to the CMS assessment submission and processing system in accordance with current federal and state guidelines. This includes the current requirements published in the RAI manual. Review of the RAI manual, dated October 2019, revealed that MDS assessments must be submitted within 14 days after the MDS assessment completion date to the CMS system.

Based on facility documentation, staff interviews, and facility policy, the facility failed to ensure that quality control testing was performed for one multi-use glucometer. The deficient practice could result in glucometers that do not function properly and therefore provide inaccurate glucose level results. Findings include: Review of the April 2022 glucometer daily quality control record for the 300 station revealed that there were more than 20 days where the glucometer quality control solution checks were not documented. During an interview with a Licensed Practical Nurse (LPN/staff #73) on 4/26/2022 at 8:30 AM, he said that the glucometer quality control testing is done daily by the night shift and should be documented on the glucometer control check records daily. He said that the purpose of calibrating the glucometer is to verify that it is giving accurate readings. He said that failing to do this could result in inaccurate monitoring. He added that the missing days on the control chart sheet indicated that it may have been overlooked by night shift or they failed to document the readings. An interview was conducted with the Director of Nursing (DON/staff #7) on 4/26/22 at 11:42 AM. She stated that glucometer control testing should be done every night during the night shift. She said that this needs to be done to ensure the glucometers are reading blood sugar levels accurately. She said that it is her expectation that the testing be done and documented every night shift. She said that it is her responsibility to ensure the testing is being done. Review of the facility's glucose quality control testing, dated April 2019, revealed that the control testing should be done daily. The policy included that in order to ensure accurate monitoring functions, the control testing must be completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #84 was admitted on [DATE] with diagnoses that included schizoaffective disorder, unspecified, epilepsy and extrapyramidal and movement disorder. A behavior care plan related to schizoaffective disorder was initiated on September 5, 2019. A goal was to have fewer symptoms. Interventions were to redirect behaviors, follow behavior plan and psychiatric follow up as ordered. The admission MDS assessment dated [DATE] revealed the resident scored 11 on the Brief Interview for Mental Status, indicating the resident had moderate cognitive impairment. The resident's behaviors included delusions and verbal behavioral symptoms for 1-3 days out of 7. The MDS indicated the resident was currently considered by the state level II Preadmission Screening and Resident Review (PASRR) to have serious mental illness (SMI). A nursing progress note dated October 8, 2019 at 8:00 a.m. revealed that at approximately 7:30 a.m., resident #84 and resident #54 had been arguing in the dining room during breakfast. Resident #54 was taken to her room. At approximately 7:50 a.m., resident #54 came out of her room and was self-propelling herself towards the day room as resident #84 came out of the day room. Resident #84 started yelling when she saw resident #54. Once she was close enough, resident #84 began to posture at resident #54. The note stated that resident #54 lifted her leg up from a seated position in her wheelchair, and kicked resident #84 in the abdomen. Before staff approached, resident #84 punched resident #54 on the right side of her face with a closed fist. Resident #54 sustained a bruise under her right eye and a scratch to the right side of her face. A physicians' order was received to have both residents eat in their rooms for the rest of the day and to keep them separated for 24 hours. -Resident #54 was admitted on [DATE] with diagnoses that included schizoaffective disorder, bipolar type, borderline personality disorder and anxiety disorder. A behavioral care plan related to bipolar disorder included a target behavior of physical aggression to peers. Staff approaches included at the first sign of being upset towards a peer they are to be immediately separated, if persists, the resident is to be removed for a minimum of 30 minutes, if the resident acts physically aggressive to anyone, she is to go to her room for a minimum of 2 hours, with all special privileges suspended, if at mealtime, she may return after peers are done to finish her meal and may come out of her room after two hours, once she is visibly calm. A behavior care plan related to bipolar disorder/psychosis, traumatic brain injury, borderline personality disorder and schizoaffective disorder included a goal to have fewer symptoms. Interventions included to attempt to redirect behaviors, follow behavior plan and psychiatric follow-up as ordered. The quarterly MDS assessment dated [DATE] revealed the resident scored a 15 on the BIMS assessment, indicating she was cognitively intact. The MDS included the resident required set-up and supervision of one person physical assistance for activities of daily life (ADLs). The behaviors included delusions and verbal behaviors directed toward others (1-3 days out of 7). A nursing progress note dated October 8, 2019 included the physical altercation between resident #54 and resident #84. An interview was conducted on January 6, 2020 at 1:37 p.m., with a restorative nursing assistant/certified nursing assistant (staff #52 ). She stated that her process for redirecting residents during an altercation would include separating them and giving them both a verbal warning to calm down. After that, she would implement their care plans. She stated that she would tell the nurse immediately after the residents had been separated. She said when residents begin to be aggressive verbally, staff keep an eye on them for the whole day. She said she doesn't know exactly what is written in the residents' behavioral care plans, but she knows they are supposed to be separated. On January 6 2020 at 1:43 p.m., an interview was conducted with a Licensed Practical Nurse (LPN/staff #184 ). She stated her process would be to separate the residents. She stated that normally, they would be separated until they are calm. She stated that either a CNA or nurse would monitor the resident(s) to ensure they were calm before they would be allowed to come back into the general population. As she understands, that is what the residents' behavioral care plans say. She said staff can tell by the resident's demeanor and tone whether or not the residents are calm. She said if the residents are still posturing, then they are probably not calm enough to return. She stated that when both residents are agitated, they make it known and nursing staff should be able to tell. On January 6, 2020 at 1:51 p.m., an interview was conducted with the Director of Nursing (DON). She said that her expectation is to immediately separate and distract the residents. She said that some of the residents have behavioral plans that specify exactly what staff are supposed to do. She said the goal would be to diffuse and deter any aggression. She stated that her expectation would be for the residents to be separated for at least 30 minutes, per their behavior plan. Review of a policy titled, Abuse & Neglect revealed the facility is committed to protecting residents from abuse by anyone, including other residents. A policy titled Behavioral Assessment, Intervention and Monitoring stated the interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice. The care plan will include, at a minimum, a description of the behavioral symptoms, targeted and individualized interventions for the behavioral and/or psychosocial symptoms, and how the staff will monitor for effectiveness of the interventions. According to a policy titled, Safety and Supervision of Residents, 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. Based on clinical record reviews, facility documentation, staff interviews and policy review, the facility failed to ensure that one resident (#23) was free from physical abuse by resident (#87), and that two residents (#54 and #84) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse. Findings Include: -Resident #23 was admitted to the facility on [DATE], with diagnoses that include paranoid schizophrenia, vascular dementia and bipolar disorder. Review of the clinical record revealed that resident #23 resided on the high acuity Behavioral Unit. A behavioral care plan included the resident had physical and verbal behaviors with staff. A goal included for a decrease in symptoms. Interventions included determining the cause of the behaviors, redirection, and encourage the resident to attend activities. Review of a quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident had no cognitive impairment. The MDS included the resident required limited assistance with ADL's (activities of daily living). -Resident #87 was admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar disorder and dementia. Review of the clinical record revealed resident #87 resided on the high acuity Behavioral Unit. A behavioral care plan included the resident had a history of physical aggression with staff. A goal included for a decrease in symptoms. Interventions included determining the cause of the behaviors, redirection, and encourage the resident to attend activities. Review of a quarterly MDS assessment dated [DATE] revealed a BIMS score of 9, which indicated the resident had moderate cognitive impairment. The MDS included that the resident required supervision with most ADL's. Review of the facility's Investigative report revealed that on the afternoon of October 8, 2019, resident #87 was walking past resident #23 in the day room, and stopped to yell at resident #23. Resident #87 then hit resident #23 on the right arm with a hairbrush. Resident #87 then attempted to hit resident #23 a second time, but the strike was blocked by resident #23's raised right arm. The residents were separated, and escorted back to their rooms. Both residents quickly calmed down. Resident #87 was found to have two very small lacerations to her right hand with scant blood. Resident #23 was not injured. An interview was conducted on 1/3/2020 at 1:21 p.m. with a certified nursing assistant (CNA/staff #92). Staff #92 stated that she witnessed the incident that happened on October 9, 2019. She stated that she heard resident #87 yell something at resident #23, and soon both residents were yelling at each other. Staff #92 stated that she saw resident #87 hit resident #23 on her right arm with a hairbrush. She said that resident #87 attempted to hit resident #23 a second time, but her arm was blocked by resident #23. An interview was conducted with a Licensed Practical Nurse (staff #224) on 1/3/2020 at 1:27 p.m. Staff #224 stated that she witnessed the altercation between resident #87 and #23. She added that resident #87 yelled at resident #23 and hit her on her right arm with a hairbrush. She said that resident #87 did swing the hairbrush a second time at resident #23, but #23 was able to block the hairbrush. Staff #224 said she did find two small scratches on resident #87's right hand and that she assumes the scratches were caused by the blocking motion of resident #23.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, interviews and policy review, the facility failed to ensure an allegation of abuse involving two of seven sampled residents (#60 and #72) was immediately reported to the Administrator and reported to the State Agency (SA) within 2 hours after the allegation was made. The deficient practice could result in further abuse incidents not being identified timely and corrective action implemented and reported to the SA. Findings include: -Resident #72 was admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia, quadriplegia and anxiety disorder. -Resident #60 was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, insomnia and anxiety disorder. An Interdisciplinary Team (IDT) note dated October 11, 2019 included that today at 10:30 a.m., a family member of resident #72 reported to the social services coordinator (staff #40) that resident #72's roommate (resident #60) hit resident #72 on purpose on the head, on the right side temple area on the night of October 6, 2019. Resident #72 reported that he and resident #60 were not arguing and did not have a conflict. He reported that he was sitting in his wheelchair, when resident #60 came over and hit him in the head. Resident #72 stated it did not hurt and he asked resident #60 why he did that and resident #60 did not respond. Resident #60 was interviewed and denied hitting or having any altercation with his roommate, resident #72. Review of the facility's investigative report dated October 18, 2019 included that a resident to resident incident took place on October 6, 2019. The report included that resident #72 reported that his roommate, resident #60, hit him twice on the side of his head in their room, which was unprovoked. The report included that the incident was unwitnessed and there were no physical indications that this occurred. Further, the report revealed resident #60 was interviewed and denied the allegation. Further review of the investigative report revealed an interview with a Licensed Practical Nurse (LPN/staff #27) dated October 11, 2019, which included the social service coordinator (staff #40) reported that a family member of resident #72 spoke to him on the phone and he mentioned that on October 6, 2019, his roommate, resident #60 punched him in the head, while he was in his room. The report also included an interview dated October 11, 2019, with a LPN (staff #231). She reported that resident #72 did tell her that his roommate hit him in the head for no reason. She reported that resident #72 told her that the night shift nurse (LPN/staff #27) was aware. The report also included an interview dated October 11, 2019, with the nurse who worked the night shift on October 6, 2019, LPN (staff #143). She stated this incident was not reported to her on her shift on October 6. In addition, the investigative documentation was completed on October 11, 2019, and the State Agency (SA) report was not completed online until 2:32 p.m. In an interview with staff #231 on January 6, 2020 at 10:44 a.m., she stated that she was coming on shift in the morning when resident #72 reported to her that resident #60 hit him in the head. She stated that she asked resident #72 if he had reported this to the night shift nurse and he said he had. She stated she did not remember who the night shift nurse was but at the time, she assumed the night shift nurse reported it to the proper people. An interview was conduced on January 7, 2020 at 8:40 a.m. with the Director of Nursing (staff #96). She said if there is an allegation of abuse, the first thing to do is to ensure the resident(s) safety and to assess for injury. She stated if it is a resident to resident incident, the residents are separated immediately. She said the allegation should be reported immediately to the charge nurse and/or DON and then it needs to be reported to the SA within 2 hours. She stated with this incident, the social services coordinator (staff #40) reported it to her, and the LPN (staff #231) did not report it because she thought the night nurse (staff #27) had reported it and taken care of everything. Review of facility policy titled, Abuse & Neglect dated October 2016 included the investigation process begins when the Administrator or the Director of Nursing receives information that abuse or neglect may have taken place. Information may come from a staff member, a resident, visitor, or family member, a resident advocate, another agency, or other sources. Information may be received orally, in writing or via electronic communications .All alleged or suspected violations involving mistreatment, neglect or abuse including injuries of unknown origin, involuntary seclusion and misappropriation of elder property are to be reported immediately to the Unit Manager or Charge Nurse. The policy also included that the SA requires 24 hour notification of abuse allegations. However, the regulation states that allegations of abuse/neglect are to be reported to the SA within 2 hours after the allegation is made.

Based on observations, clinical record review, staff interviews and policy review, the facility failed to ensure the care plan for one (#39) of 19 sampled residents was revised regarding hearing status. Findings include: Review of the the clinical record for resident #39 revealed a physician orders dated 1/1/2020 for bilateral hearing aides to be applied each morning and taken out each evening. A care plan indicated the resident had moderate hearing loss, with a goal that needs will be anticipated. Interventions included to apply bilateral hearing aids in the morning, remove at bedtime, and store at nurses station. An observation was conducted on 1/2/2020 at 10:49 a.m., of resident #39 sitting in a wheelchair in the dayroom of the nursing unit. Resident #39 was yelling loudly and incoherently and was not interviewable. The resident was not wearing any hearing aides. During an interview with a Licensed Practical Nurse (LPN)/staff #62) on 1/2/2020, he stated that resident #39 does not like to wear the hearing aides. An observation was conducted on 1/6/20 at 8:15 a.m. and resident #39 was not wearing any hearing aides. A CNA (staff #70) stated that resident #39 refuses to wear hearing aides. When asked where her hearing aides were she stated that she did not know. Staff #70 looked in resident #39's room and was unable to find her hearing aides. Review of Certified Nursing Assistant task list for the week of 1/6/2020 revealed to apply hearing aides bilaterally in the morning and remove at bedtime for the resident. Each day the task was recorded as completed for the first week in January. During an interview with a CNA (staff #108) on 1/6/20 at 8:24 a.m., she said that she had cared for resident #39 the previous week and that the resident does not have hearing aides. During an interview with a LPN (staff #62) on 1/6/2020 at 9:00 a.m., he stated that resident #39's hearing aides were not in the nursing station or in the resident's room. During an interview with the unit manager LPN (staff #119) on 1/6/2020 at 10:26 a.m., she reviewed the clinical record and confirmed there were current physician's orders for hearing aides and there was a current care plan for hearing aides. She also confirmed that the CNA's were documenting putting in and removing the hearing aides. In an interview with the Director of Nursing (DON/staff #96) on 1/6/2020 at 10:45 a.m., she stated the family had taken the hearing aides home, as resident #39 would not wear them. She confirmed there was a current physician's order for the hearing aides and a current careplan for the hearing aides. She said that they should have updated the orders and the care plan. According to a facility policy and procedure, assessments of residents are on going and care plans are revised as information about residents or condition changes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record reviews, staff interviews, and review of policy and procedures, the facility failed to ensure 4 residents (#'s 16, 23, 94 and 72) received education regarding the risks, benefits and potential side effects of the influenza vaccination. The deficient practice could result in residents not being fully informed, which could affect their decisions regarding treatments. Findings include: -Resident #16 was initially admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar type, Alzheimer's disease and primary hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 11 on the Brief Interview for Mental Status (BIMS) assessment, indicating he had moderate cognitive impairment. Review of an immunization audit report revealed that on September 24, 2019, the resident had consented for and had received an influenza immunization. However, the report indicated that no immunization education regarding risks and benefits of the vaccine was provided to the resident. Further review of the clinical record did not reveal that a signed consent had been obtained prior to administration of the immunization. -Resident #23 was admitted on [DATE] with diagnoses that included schizoaffective disorder, bipolar disorder and unspecified dementia with behavioral disturbance. The quarterly MDS assessment dated [DATE] revealed the resident scored 11 on the BIMS assessment, indicating she had moderate cognitive impairment. A immunization audit report stated that on September 23, 2019 the resident had consented for and had received, an influenza immunization. The document indicated that no immunization education regarding risks and benefits of the vaccine was provided to the resident. Further review of the clinical record did not reveal that a signed consent had been obtained prior to administration of the immunization. -Resident #94 was admitted on [DATE] with diagnoses that included vascular dementia with behavioral disturbance, chronic kidney disease stage 3 and primary hypertension. The quarterly MDS assessment dated [DATE] revealed the resident scored 11 on the BIMS assessment, indicating she had moderate cognitive impairment. An immunization audit report stated that on September 26, 2019 the resident had consented for and had received, an influenza immunization. The document indicated that no immunization education regarding risks and benefits of the vaccine was provided to the resident. Further review of the clinical record revealed that a signed consent had not been obtained prior to administration of the immunization. -Resident #72 was admitted on [DATE] with diagnoses that included paranoid schizophrenia, unspecified voice and resonance disorder and bipolar disorder. The annual MDS assessment dated [DATE] revealed the resident scored 12 on the BIMS assessment, indicating he had moderate cognitive impairment. A immunization audit report stated that on September 24, 2019 the resident had consented for and had received, an influenza immunization. The document indicated that no immunization education regarding risks and benefits of the vaccine was provided to the resident. Further review of the clinical record revealed no evidence that a signed consent had been obtained prior to administration of the immunization. On January 7, 2020 at 2:13 p.m., an interview was conducted with the Director of Nursing (DON/staff #96). She stated that nursing provides education regarding the risks and benefits of influenza vaccines upon admission to the facility. She stated that an informed consent is obtained at that time. She stated that the education and informed consent are sufficient for the resident's stay. An interview was conducted on January 7, 2020 at 2:38 p.m. with a Licensed Practical Nurse (LPN/staff #224). She stated that her process is to provide information sheets regarding the risks and benefits of vaccines to the resident's representative upon admission. She stated an informed consent would be obtained at that time. She said she would have to look to see if education needed to be provided every year. A facility policy titled, Influenza Vaccine included that the facility shall provide pertinent information about the significant risks and benefits of vaccines to residents (or the resident's legal representatives). The policy stated that prior to the vaccination, the resident (or the resident's legal representative) will be provided information and education regarding the benefits and potential side effects of the influenza vaccine. Provision of such education shall be documented in the resident's medical record.