According to observation, record review, and interview the facility failed to ensure residents were free from abuse with continuous altercations of verbal abuse and physical abuse between two residents (Resident #47 and Resident #54). This failed practice had the potential to affect all 66 residents currently in the facility to psychosocial harm from repeated resident to resident abuse altercations. It was determined the facility's non-compliance with one or more requirements of participation had caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.25 (Quality of Care) at a scope and severity of J. The IJ began on 03/12/2024 at 12:30 PM, when Resident #47 and Resident #54 had an altercation in the dining room. The altercation from witness statements began when Resident #54 was impatient at the coffee area and rammed into Resident #47, which caused an argument between the two residents. A few minutes later after separation Resident #47 bumped into Resident #54's wheelchair and another argument began in the dining area. The Administrator and Nurse Consultant were notified of the IJ on 05/03/2024 at 11:00 AM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 05/03/2024 at 05:32 PM. The IJ was removed after the survey team performed onsite verification that the Removal Plan had been implemented. Noncompliance for F600 remained at the lower scope and severity of no actual harm with an isolated potential for more than minimal harm that was not immediate jeopardy: These were our findings: A review of the Care Plan indicates that Resident #47 had diagnoses of chronic inflammatory demyelinating polyneuritis, cerebral palsy, bipolar disorder, major depressive disorder, and post-traumatic stress syndrome (PTSD). A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/22/2024 documented the resident scored 15 (13-15 indicates cognitively intact) on a Brief Interview for Mental Status. A review of the Care Plan indicated Resident #47 makes false accusations against staff, yells at other residents without provocation, and will argue with others and get in their personal space. A review of the quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 03/28/2024 indicated Resident #54 had a score of 7 (0-7 indicates moderate cognitive impairment) on a Brief Interview of Mental Status. A review of the order summary indicated Resident #54 had diagnoses of Down Syndrome, generalized anxiety disorder, and unspecified intellectual disabilities. A review of the medication administration record indicates no charting for behavioral symptoms. A review of the Care Plan indicated on 03/12/2024 a revision was made that stated, [Resident #54] is obsessed with certain other resident's and becomes physically and verbally aggressive towards them. placed on male secured unit for decreased stimuli . A review of the Care Plan with an initiated date of 05/04/23 and a revision date of 04/23/2024 indicated, .[Resident #54] can be disruptive. Yelling at other residents and staff, will throw food, plastic wrappers, other items on the floor. Also, will throw food on the walls. Sits in wheelchair in the middle of the hallway and watches television. Wants other residents doors closed. Grabs other residents. Goes into other residents rooms and yells at them, physically aggressive, agitated, frustration/anger at others, makes disruptive sounds, threatens others, anxious, exit seeking behaviors. Refuses bath. Scratches others .' A review of documentation from a care plan conference held on 03/19/2024 for Resident #54 stated, Care plan conference regarding behaviors - possible room change per family [the resident] perceives that somebody will take his stuff. Had a psych [psychological] eval which recommends [Facility Name]. [Resident #54] is going to return to regular room on 400 hall. Family does not want [Facility Name] placement. On 05/02/2024 at 10:55 AM, the Surveyor heard a commotion in the hallways, while walking toward the dining room on the 300 Hall side could hear raised voices. There were several staff members standing at the entrance, ten residents were in the dining room and residents around the nurse ' s station were looking around confused at where the raised voices were coming from. Two residents down the 300 Hall were in the hallway looking down the hall towards the dining room. Staff were standing around Resident #47. The Dietary Manager had a hold of Resident #47's wheelchair handles, the resident was saying if, [Resident #54] wants to [expletive] fight [Resident #54] can [expletive] fight, [Resident #54] said [Resident #54] was going to kill him. Resident #47 then stated, [Resident #54] kicked me, [Resident #54] kicked me I am telling you [Resident #54] kicked me. The Surveyor observed Resident #47 kept yelling as the Dietary Manager wheeled the resident over to a table to calm the resident down. Resident #47 was stating that [Resident #54] kicked me, and I did not do [expletive] to [Resident #54] him. The Surveyor observed Resident #54 was nowhere in sight. The Surveyor then observed Resident #47 wheeling over to the 400 Hall stating over and over again, I am going to [expletive] kill [Resident #54], if [Resident #54] wants to go, I will go. I am going to beat [Resident #54's] [expletives]. The Surveyor observed Resident #47 was red in the face, spit was flying from the resident's mouth, legs straight, and visibly shaking threatening to go down the hall to Resident #54's room with staff attempting to calm the resident down. The Surveyor heard Resident #54 yelling back down the hall threatening Resident #47. The Surveyor walked with Licensed Practical Nurse (LPN) #2 to Resident #54's room. LPN #2 asked what happened. The Surveyor heard Resident #54 stating, I am not going to lie, I kicked [Resident #47]. LPN #2 asked if [Resident #54] was good, the resident was calm. Resident #54 said yes and asked about the resident's cokes. LPN #2 said [Resident #54] was getting two boxes this afternoon. Resident #54 then started complaining about how cold the room was and wanting the vents closed. LPN #2 said what are we going to do when we see [Resident #47] again today. Resident #54 stated, I will beat [Resident #47's] [expletive]. LPN #2 said no we will not engage again. LPN #2 asked if the resident was good, [Resident #54] was calm. Resident #54 then said yes and started complaining about the vents being cold. LPN #2 asked if [Resident #54] wanted to stay in the resident's room to calm down for a while if maintenance will close the vents, and Resident #54 started rubbing the resident's stomach to ask for a snack being agreeable with staying in the resident's room as long as they closed the vents. On 05/02/2024 at 11:00 AM, Dietary Aide #2 stated, This happens all the time, it's only the two of them. The Surveyor asked what happened with today's altercation. Dietary Aide #2 stated, [Resident #54] was getting a cup of coffee and [Resident #47] wheeled into the dining room. When [Resident #54] saw [Resident #47], [Resident #54] pointed the resident's finger at [Resident #47] and yelled, I am going to kill you. Resident #54 then ran the resident's wheelchair into [Resident #47] and then kicked the resident in the left leg. On 05/02/2024 at 12:09 PM, the Surveyor interviewed Resident #9 and Resident #1 in the resident's room. The Surveyor asked if any interaction or incidents of yelling between residents has happened before. Resident #9 laughs and said, All the time. Constant hollering between Resident #54 and Resident #23 a lot of times they say they want to kill each other and cursing. I have never heard such filthy talking men. I don't go for that kind of stuff and when you say anything they say nothing they can do. The Surveyor asked who have you told, whoever is around, staff. Resident #9 said, yes, they holler and wake you out of a sound sleep. It is disturbing. I would not let a child do that in my home, it was never allowed. I'm told they can't help it. I hate when they start as you are falling off to sleep. I don't know the resident's name, but is handicapped and, in a wheelchair, and they hit the resident, and the resident's words are bad. The Surveyor asked how often the incidents occur. Resident #9 said off and on all the time and early afternoon and night too. The Surveyor asked what has been done to prevent the negative interactions. Resident #9 stated they try to keep them apart and it lasts maybe 2 minutes. The Surveyor asked does this ever involve or happen to other residents. Resident #9 said usually at the dining table and whoever is at the table. That is why [Resident #1] and I eat in here. (In room) I don't want to get in on that. The Surveyor asked do you feel safe here. Resident #9 said I do not feel safe here. I am teetering on my feet and now in a wheelchair. The Surveyor asked Resident #1 if there had been any incidents of yelling. Resident #1 said yes. It happens all the time, but I grew up in a house full of kids, so noise doesn ' t bother me. I hear [Resident #23] all the time. The Surveyor asked is that why you don't go to the dining room. Resident #1 said I don't ever leave my room. I don't feel good. The Surveyor asked do you feel safe here. Resident #1 said yes, I feel safe here. On 05/02/2024 at 12:30 PM, the Surveyor interviewed the Assistant Director of Nursing (ADON). The Surveyor asked if the interaction/incidents between Resident #47 and Resident #54 happened before. The ADON stated yes. The Surveyor asked how often has these incidents occurred. The ADON said April and March maybe. I would have to check. The Surveyor asked what has been done to prevent the negative interactions. The ADON said immediately separated, medication reviews, and psych visits for each. The Surveyor asked that is after the fact, what was done to prevent the incidents. The ADON said one intervention was to put coffee machine up front as Resident #54 usually eats in the resident's room. The Surveyor asked does this ever involve or happen to other residents. The ADON said just those two. The Surveyor asked if any other residents have complained. The ADON said yes in the dining room and a grievance was done from someone in a room. On 05/02/2024 at 1:23 PM, Certified Nursing Assistant (CNA) #3 had worked in the facility almost 1 month on the 7:00 AM to 3:00 PM shift. The Surveyor asked if interaction/incidents between Resident #47 and Resident # 54 had happened before. CNA #3 said yes, every other week. We try to keep them separated. The Surveyor asked what has been done to prevent negative interactions with these residents. CNA #3 said we keep an eye on Resident #54, was on monitor sheet for every 15 minutes. The Surveyor asked does this ever involves or happens to other residents. CNA #3 said Resident #47 is sweet to everybody else so is Resident #54. Resident #54 was yelling at Resident #44 his roommate that is dependent on care. Resident #47 and Resident #54 had an altercation on my second day here. They said they usually do that. The Surveyor asked who said they usually do that. CNA #3 said the other staff, Resident #54 usually doesn't eat in the dining room. The Surveyor asked has any resident told you they were tired of hearing the two of them. CNA #3 said no. On 05/02/2024 at 01:30 PM, during an interview with Dietary Manager, the Surveyor asked if this interaction between Resident #47 and Resident #54 had happened before. The Dietary Manager said yes. The Surveyor asked how often the incidents occur. The Dietary Manager stated it used to happen every other day. I talk to Resident #47 a lot and talk about the values the resident has, common sense, and calm the resident and redirect the resident. The Surveyor asked what has been done to prevent the negative interaction. The Dietary Manager said we put a coffee pot up front for Resident #54 to go get coffee. I ask Resident #47 to ignore Resident #54 when the resident points and makes noises. Resident #54 was at one point on the unit. Resident #47 wanted to go to another facility and referrals were sent out. The Surveyor asked who the aggressor was. The Dietary Manger stated, When I see them, it is usually [Resident #54] with finger pointing and words. The Surveyor asked why was Resident #54 taken off the unit. The Dietary Manager said I do not know why. The Surveyor asked does this ever involve or happen to other residents. The Dietary Manger said yes. Resident #23 and Resident #54. One gets loud and the other starts getting loud. I don't remember Resident #47 having physical issues with anyone else. Just verbal between Resident #54 and Resident #23. On 05/02/2024 at 1:30 PM, the Surveyor interviewed residents in the facility: The Surveyor asked Resident #19, have you heard any yelling and fighting. Resident #19 stated yes, three or four times a day. The Surveyor asked do you know their names. Resident #19 said no I do not. The Surveyor asked do you feel safe. Resident #19 responded yes; I do. The Surveyor asked when you saw the fighting, did you tell anyone. Resident #19 said no I have not. The Surveyor asked Resident #26 have you heard any yelling and fighting, Resident #26 said yes. The Surveyor asked how often does it happen. Resident #26 said every day, I think. The Surveyor asked do you know their names. The resident indicated no. The Surveyor asked, have you told anyone? Resident #26 said no they have never asked me. The Surveyor asked do you feel safe. Resident #26 said yes. The Surveyor asked Resident #12 if the resident had heard any yelling and fighting, Resident #12 said in the dining room. The Surveyor asked how often this happens. Resident #12 said every day, it keeps me up and I can ' t sleep. The Surveyor asked do you know their names. Resident #12 said no I do not but its men and women. The Surveyor asked, have you told anyone. Resident #12 said yes, I tell the Certified Nursing Assistants and it makes me feel like they do not care for me as they cannot make them go to bed or to their room that is what they said. The Surveyor asked do you feel safe. Resident #12 said yes, I think I do. The Surveyor interviewed Resident #42, who had been in the facility 6 months and was Resident Council President. The Surveyor asked has there been any interactions or incidents with residents. Resident #42 said at lunch today Resident #23, and Resident #14 hollered during the meal and Resident #47 got in the wheelchair got a little loud. No peace or quiet while eating here. The Surveyor asked do you feel safe here. Resident #42 said sure. The Surveyor asked what has been done to prevent the negative interactions. Resident #42 said nothing. It needs something done. The Surveyor interviewed Resident # 24 who stated he had heard a resident named (Resident #54) and a resident named (Resident #47) that yell and cuss at each other. That I've heard, but I've never seen it happen and 2 males that yell and cuss each other. Resident #24 was asked what the staff does when this happens. Resident #24 stated, Staff separate them. Resident #24 denied feeling afraid to be here in the facility, and no resident has cussed him or hit him. Resident #24 said this happens every other day. On 05/02/2024 at 2:58 PM, the Administrator was asked about [Facility Name] placement. She said no referral, it was just a suggestion in the care plan meeting that was shut down by the family. The Administrator was asked about why Resident #54 was placed on the unit then taken out. She stated it was to see if a decrease in stimuli would help. (Resident #54) ended up getting hit back there, so it was not helping. We ended up placing him back in the hall. The Administrator was asked what do you feel is the underlying cause of these altercations. The Administrator said they had a time frame and it usually occurred in the dining room but was not sure what the underlying issue was. The Administrator was asked what they were doing to protect the other residents. The Administrator said that they redirect and separate during altercations and that no other residents have been involved. The Administrator was asked what they were doing to protect Resident #54's vulnerable roommate. The Administrator said, I do not know of any issue or incident with his roommate. The Surveyor informed the Administrator that during interviews, a CNA said that they have witnessed Resident #54 yelling at their roommate. The Administrator said I was not informed of this and will look into it. Dates and Times of the Incidents: 03/11/2024 at 12:30 PM, the Witness Statement completed by Dietary Aide #3 stated, [Resident #54] got mad at [Resident #47] cause [Resident #47] was at the coffee table getting coffee. [Resident #54] rammed [the residents] wheelchair into [Resident #47] wheelchair. This is when the argument started between them. The facility then in-serviced on managing behaviors, filled out witness statements, separated, and redirected the residents. 04/10/2024 at 12:45 PM, the Witness Statement completed by Restorative CNA (RCNA) stated, [Resident #54] started to enter dining room. I stopped [Resident#54] to remind [the resident] to be nice. I turned away to help assist a resident eating. [Resident#54] entered the dining room, wheeled .up to [Resident #47], the two started to argue. The resident, [Resident #47] hit [Resident #54]. [Resident #54] kicked [Resident #47], me, and other staff member separated the two. The facility then in-serviced on managing behaviors, filled out witness statements, separated, and redirected the residents. 04/12/2024 at 10:45 AM, the Witness Statement completed by Medication Attendant Certified #1 stated, [Resident #54] was getting coffee while [Resident #47] was coming in from smoking. [Resident #54] did not say anything to [Resident #47], but [Resident #47] said Do you have a problem to [Resident #54]. That is when [Resident #47] started wheeling towards [Resident #54] as I was taking [Resident #54] out of the dining room I asked [Resident #47] to please stop yelling and [the resident] would not. [Resident #54] then started to yell back stating, I kill [Resident #47]. I removed [Resident #54] away from [Resident #47]. A facility policy titled, Abuse, Neglect and Maltreatment Investigation and Reporting stated, The facility will endeavor to protect Resident/Elders from maltreatment, which means adult abuse, exploitation, neglect, physical abuse, sexual abuse, neglect, and the misappropriation of Resident/Elder property. such maltreatment is strictly prohibited' This policy recognizes Resident/Elder rights to be free from physical or mental abuse, corporal punishment, involuntary seclusion, and any chemical and physical restraints. Removal Plan: 1. On 5/2/2024, Resident #47 was placed on 1 on 1 observation by nursing staff for verbal altercation that occurred in the dining room at 11:00 a.m. 2. On 5/2/2024, Resident #54 was placed on 1 on 1 observation by nursing staff for verbal altercation that occurred in the dining room at 11:00 a.m. 3. On 5/2/2024 at 5:04 p.m., Resident #47 was transported to [local hospital] for medical clearance to be evaluated and treated for behavioral health. 4. Nurse consultant in-serviced Administrator, Assistant Administrator, and the Assistant Director of Nursing (ADON) on ensuring any resident-to-resident altercation and any residents that witness the altercation are assessed for psychosocial affects and offered Mental Health Services if needed. This was completed 5/3/2024 at 11:40 p.m. 5. Assistant Administrator in-serviced all staff on duty on Resident-to-Resident altercations, to stop the altercation immediately, and protect the resident involved. This includes any resident that witnessed the altercation to ensure an assessment is completed to ensure their psychosocial wellbeing is addressed and any Mental Health issues are assessed. Assistant administrator will in-service all oncoming employees before starting assigned shifts. This was completed 05/03/2024 at 3:40 p.m. 6. On 05/03/2024, the Assistant Administrator interviewed all residents that are interviewable for any psychosocial distress and offered mental health care as needed. There were no negative findings noted. This was completed on 05/03/2024 at 3:45p.m. 7. On 05/03/2024, at 12:15 p.m., the Nurse consultant contacted our behavioral health provider to immediately see any residents that have been negatively affected and were available as needed. There were no negative findings and Mental Health services provider was notified 3:48 p.m. on 5/3/2024. Onsite Verification: On 05/06/2024 between 9:30 AM and 2:00 PM, the Surveyor was in the facility for verification of removal of Immediate Jeopardy. 1. Record Review of Resident #47's 1 on 1 monitoring log began 05/02/2024 at 11:00 AM and ended at 4:45 after other resident sent out at 5:04 PM. 11:00 AM, resident crying, upset. 11:15 AM calm. no other documentation of emotional upset. 2. Record Review of Resident #54's 1 on 1 log sheet that began on 05/02/2024 at 11:00 AM and ended at 5:04 PM with documentation that Resident #54 was sent out. 3. Record Review of Resident #54's Discharge Instructions & Summary; Sent to local emergency department for medical clearance, then to be transferred to behavioral health facility. Resident #54 continued to have explosive behaviors and is at risk for self-injury and injury to others. All appropriate notifications made. 4.Record review of inservice education provided by Nurse Consultant included: If a resident-to-resident altercation occurs any resident that witnesses or is a part of the altercation should be assessed for any psychosocial injury. If the resident-to-resident altercation occurs with the same resident repeatedly, effective interventions should be implemented to protect the resident. signed by Administrator, Director Of Nursing, Assistant Administrator. 5. Record Review of facility staff in-service conducted on 05/03/2024, the education included: Stop altercation, protect residents involved in altercation as well as residents that may have witnessed altercation for psychosocial well-being, and notify charge nurse, Director of Nursing, and/or Administrator. Reviewed staff audit of all staff inserviced. Between 11:00 AM and 1:00 PM, interviewed the Staff that work various shifts, who confirmed they received inservice training related to resident-to-resident altercation and were able to verbalize understanding of separating/stopping, protecting residents involved as well as any resident that may have witnessed altercation that could affect their psychosocial wellbeing, notify charge nurse, Director of Nursing or Administrator of altercation. Nine Certified Nursing Assistants, 6 Licensed Practical Nurses, 1 Registered Nurse, 2 Medication Assistants, 3 Housekeeping staff, the Activity Director and occupational therapist were the staff interviewed. 6. Reviewed residents interviewed for psychosocial effect of Resident to Resident altercation, documented no negative effects, residents clamed no affect. Between 1:00 PM and 1:40 PM, interviewed 7 alert and oriented residents who reported being aware of or witnessed altercations between residents. They were asked if they were upset, worried, or felt fearful due to witnessing the altercations. All residents verbalized feeling safe now that the resident is no longer in the facility. 7. Reviewed Nurse Consultant note on 05/03/2024, contacted our Behavioral health Provider to be available for possible Telemed Psychosocial eval and treatment for any resident that may have been affected negatively by any Resident-to-Resident altercation. After Resident interviews, there were no noted negative findings. Behavior Health Providers were notified that there were no negative findings from Resident interviews. At 1:06 PM, the Nurse Consultant reported education was provided to all staff through audit to ensure all staff had received inservice, confirmed the Mental Health Consultants were notified of possible need to have residents referred for evaluation and treatment. At 11:58 AM, the Assistant Administrator confirmed that all staff were inserviced and that she participated in the resident audit to ensure all residents were evaluated for psychosocial effects. At 12:57 PM, the Administrator was interviewed and confirmed any altercation between residents are to be reported, all residents are to be protected and assessed for any effect and referred to Mental Health consultants for evaluation and treatment. The Administrator and the Regional Nurse Consultant were informed of the Immediate Jeopardy Plan of Removal with a completion date of 05/03/2024, verified removal on 05/06/2024 at 2:00 PM.