**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#15) of one resident reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 41 sample residents. Resident #15 was admitted to the facility on [DATE]. His admission weight on 9/30/19 was188.4 pounds (lbs). The resident maintained a weight between 180 lbs to 200 lbs between January 2022 and June 2023. The resident was hospitalized in July 2023. When he returned to the facility, the facility failed to weigh the resident until August 2023. The facility did not attempt to weigh the resident after he refused one weight. The registered dietitian (RD) recommended weekly weights in July 2023 and no weights were obtained. Per staff interviews, the resident was not eating, refusing meals and often skipped breakfast and no preventative measures were implemented to address his eating patterns to ensure his intake was adequate. Due to the facility's failure to implement nutritional interventions, Resident #15 sustained a severe weight loss of 32.8 pound weight loss or a 17.09 percent weight loss in 60 days. Findings include: I. Facility policy The Food and Nutrition Services policy, revised October 2017, was provided by the corporate nurse consultant (CNC) #1 on 10/25/23 at 11:05 a.m. It read in pertinent part: Each resident is provided with a nourishing, palatable, well balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each diet. The multidisciplinary staff will assess each resident's nutritional needs, as well as physical, functional, and psychosocial factors that affect eating and nutritional intake and utilization. A resident-centered diet and nutrition plan will be based on this assessment. II. Resident #15 A. Resident status Resident #15, age [AGE] years old, was admitted on [DATE]. According to the October 2023 computerized physician orders (CPO), the diagnoses included dementia, schizophrenia, chronic obstructive pulmonary disease (COPD), cognitive communication deficit, psychotic disturbance, psychosis, hypertension, hypertensive chronic kidney disease and osteoarthritis. The 7/19/23 minimum data set (MDS) assessment documented that the resident was unable to complete the brief interview for mental status (BIMS). The staff assessment for mental status was completed. It documented the resident had a memory problem and was moderately impaired, made poor decisions and supervision or cues was required. The resident required supervision with bed mobility and transfers. He required one person assistance with toileting, grooming and personal hygiene. The assessment documented the resident required set up assistance with eating and the resident had not experienced any weight loss. His height was 5 foot 8 inches. B. Record review Resident #15's medical record revealed he experienced a significant unplanned weight loss of 23 pounds; 11.93 percent in six months, from April 2023 to 10/17/23. The resident was discharged on 7/12/23 and was readmitted on [DATE]. Prior to the discharge, the resident was in the secured memory unit. When the resident returned, the resident was moved to the secured behavioral unit. The facility attempted to weigh the resident one time at readmission but the resident refused and the staff did not reattempt a weight despite the resident being known to be at risk for weight loss. According to the hospital documentation on 7/12/23, the resident weight was 195 lbs. 1. Resident #15 nutritional status The unintended weight changed care plan, initiated on 9/30/19 and revised 8/4/23, documented the resident had potential for unplanned weight loss related to dementia, psychotropic medication, variable meal intakes, declining health status secondary to numerous comorbidities. Interventions included a health supplement shake due to the resident skipping breakfast; monitor weight weekly; and monitor for significant changes. The cognitive care plan, initiated on 11/16/19 and revised on 10/8/21, documented the resident had impaired cognitive function/dementia or impaired thought processes related to disease process. The activities of daily living (ADL) care plan, initiated on 10/3/19 and revised on 3/8/23, documented the resident had a self-care performance. It documented the resident did not require supervision and he was independent with eating. 2. Resident #15 weight loss history revealed significant weight loss as follows: -On 4/19/23, the resident weighed 195.3 pounds -On 5/3/23, the resident weighed 195.4 pounds -On 6/2/23, the resident weighed 195.4 pounds -The facility failed to obtain a weight for July 2023 -On 8/1/23, the resident weighed 162.6 pounds, a 32.8 pound weight loss or a 17.09 percent weight loss in 60 days -On 8/4/23, the resident weighed 165.8 pounds -On 8/18/23, the resident weighed 168.4 pounds -On 8/22/23, the resident weighed 172.8 pounds -On 9/1/23, the resident weighed 168.8 pounds -On 9/5/23, the resident weighed 175.2 pounds -On 9/12/23, the resident weighed 176.6 pounds -On 9/16/23, the resident weighed 173 pounds -On 9/19/23, the resident weighed 176.4 pounds -On 9/26/23, the resident weighed 171.8 pounds -On 10/3/23, the resident weighed 175.2 pounds -On 10/14/23, the resident weighed 168.6 pounds -On 10/17/23, the resident weighted 172 pounds -On 10/21/23, the resident weighed 168.2 pounds -On 10/24/23, the resident weighed 168.6 pounds The 7/14/23 readmission nutritional assessment, completed by a registered dietitian (RD), documented Resident #15 was on a regular diet with a regular texture and a thin liquid diet. It indicated the resident weighed 195.4 pounds on 6/2/23. The RD documentd the resident's intake was erratic at meals with refusals and skipped breakfast due to sleeping. The RD recommended monitoring intake and to obtain weekly weights. -However, the RD did not add any measures for his meal refusals and skipping breakfast. In addition, the RD was aware the resident was not eating prior to hospitalization in July 2023 and losing weight and no preventative measures were put in place to address his nutritional risk. In addition, the resident was not weighed weekly as the RD recommended to help monitor his nutritional status. The 8/4/23 interdisciplinary team weight variance assessment revealed that the resident had a 15.1 percent weight loss in eight weeks. A new intervention was to add mighty shakes in the morning. It revealed that potential medical factors were a recent illness within 30 days, recent significant changes in medication and psychotropic medications. The summary revealed that a nurse on the secure memory unit said the resident stopped eating prior to his hospitalization due to increased behaviors and aggression. -A supplement was added after the resident sustained a 32.8 pound weight loss with no preventative measures in place. The August 2023 CPO documented the following physician order for mighty shake one time a day for weight loss. Provide once the resident wakes up. The start date was 8/5/23. The September 2023 CPO documented the mighty shake was discontinued on 9/8/23. The 10/14/23 interdisciplinary team weight variance assessment revealed that the resident had a 13.7 percent weight loss in six months. The summary revealed the resident intake improved and mostly consumes 76-100 percent of meals. It documented with the weight trending down, mighty shakes were added. The October 2023 CPO documented the following physician order for mighty shake one time a day. The start date was 10/17/23. The October 2023 meal intake records documented the resident consumed the following from 9/20/23 to 10/19/23 the records revealed the resident ate 76-100 percent on 49 occasions; 51-75 percent on two occasions; 26-50 percent on four occasions; and, refused meals on six occasions (10/1/23, 10/3/23, 10/4/23, 10/5/23, 10/8/23 and 10/10/23). Additionally, the resident had less than three meals in a day recorded for several days between 9/20/23 to 10/19/23. The record revealed the resident ate only two meals on three days (9/23/23, 10/15/23 and 10/16//23); and only one meal on two days (9/26/23 and 9/30/23). III. Observations On 10/23/23 from 12:05 p.m. to 12:35 p.m., Resident #15's lunch meal was observed. Registered nurse (RN #1)and an unidentified certified nurse assistant (CNA) delivered the lunch meal tray and beverages to residents who ate meals in their room. The nurse went into Resident #15's room at 12:05 p.m., to deliver his lunch, the resident was lying on his bed and looked asleep. She asked him if he was hungry and he said no; she told him she would come back. The nurse went back at 12:15 p.m. to set up his meal. The nurse cut up the resident's chicken and left the food for him. The resident was lying on his bed and still looked asleep. At 12:35 p.m., Resident #15 did not start to eat his food. Resident #15 was interviewed on 10/23/23 at 1:35 p.m. The resident was unable to communicate why he did not eat his meal or even if he received a lunch time meal. The scales in all units were observed on 10/24/23 between 1:00 p.m. and 1:30 p.m. The secured memory unit had a commercial scale that a resident could stand on, in their television room. The non secured unit had a commercial scale in a locked scale room. It was a scale for residents who could not stand independently. The secured behavioral unit scale had a regular scale. IV. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 10/24/23 at 12:51 p.m. LPN #2 said the resident lost weight because he liked to sleep in instead of getting up for breakfast. LPN #2 showed the scale that was used to weigh residents on the unit. It was a home weight scale and was not a medical weight scale. The RD was interviewed on 10/24/23 at 10:05 a.m. She was familiar with Resident #15. She said the resident stopped eating completely prior to the resident's hospitalization and lost a lot of weight. Upon the resident's return and throughout August 2023, the resident lost a significant amount of weight. The physician ordered a mighty shake nutritional supplement then by September 2023 the resident started to gain some weight and the mighty shakes were discontinued so the resident did not gain too much weight. The resident was prescribed mighty shakes again in October 2023. The RD said the scale in the secured behavioral unit was not as accurate as the scale in the secured memory unit. She weighed herself in both units and said the difference was approximately five pounds and found that the scale in the secured memory care unit was more accurate. The RD said she would add interventions if a resident lost five percent in three months and 10 percent in six months. -However, nutritional interventions should be proactively added and not when the resident sustains a significant weight loss. The intervention would depend upon the resident individualized needs. She said if a resident was not weighed on the day of readmission, then the facility should weigh the resident within three days. She said it was important to have an accurate weight so she could complete an accurate nutritional assessment. She said all residents should be weighed monthly to ensure the resident was not losing weight and to provide a complete nutritional picture of the residents nutritional needs. Resident #15 who had a significant weight loss should have been weighed weekly. The director of nursing (DON) was interviewed on 10/24/23 at 2:00 p.m. She was familiar with Resident #15. The DON said Resident #15's dementia was progressing in addition to his mental illness which both contributed to his weight loss. Additionally, Resident #15 was a picky eater and did not have a hunger drive. The DON said Resident #15 refused to be weighed in July 2023 when he returned from the hospital. The DON said when a resident refused to be weighed the nursing staff should attempt to weigh the resident within three days and document the results. The DON said residents should be weighed weekly for the first weeks after admission and then monthly thereafter. She said there would be times the resident would not be weighed monthly based on the RD's recommendation. She said it was important to weigh resident's monthly because it was indicative of other things that happened to the resident. Monthly weight history helped with the whole picture of the resident health and could trigger concern for other care areas like medication review. The DON said the CNAs weighed the resident and reported to the nurse who would record and report any weight concerns. The DON said the facility offered Resident #15 meal alternatives, like a supplement shake to help with the resident's weight loss; and would recommend adding additional interventions if the resident lost five percent of his weight in three months and 10 percent in six months. The DON said that a two month gap of no weights for a resident would be too long. If the resident refused to be weighed, she would follow up with the interdisciplinary team to develop other interventions. The DON said she placed an order for a medical weight scale to be placed in the resident's unit to reduce weight discrepancies.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to keep two residents (#1 and #2) free from resident to resident physical abuse of five sample residents. The facility failed to protect Resident #2 from resident to resident physical abuse from Resident #1 and then failed to protect approximately one hour later, Resident #1 from retaliatory physical abuse from Resident #2 on 4/19/23. During the first altercation, Resident #1 tapped Resident #2 on the shoulder and put up his balled fists. Resident #2 lunged at Resident #1, put his hands on Resident #1's neck and a fight began which required nursing staff to separate the two men. The police were called to come to the facility due to the first altercation. Within approximately one hour after the first altercation, Resident #2 left his room and walked to the dining room where he found Resident #1. Resident #2 then began another fight with Resident #1 and the nursing staff separated the men again. After the first altercation both men had documented that the facility staff checked on them every 15 minutes. The nursing home administrator (NHA) in an email (see facility follow-up) wrote that because police were in the building staff had their physical presence and attention removed from the residents and the retaliatory incident happened as a result. Resident #1 and Resident #2 both lived in a secured unit, and both men had histories of verbal and physical aggression. Findings include: I. Resident census and conditions demographic The Resident Census and Condition was provided by the nursing home administrator (NHA) on 5/4/23 at 3:15 p.m. It revealed that 90 residents resided in the facility. The form further documented that 47 residents had a psychiatric diagnosis, 44 had dementia, and 18 had behavioral healthcare needs. The facility had two secured units. The secured unit called Legacy was where Resident #1 and Resident #2 lived. II. Professional reference According to the Centers for Disease Control (CDC) website, Preventing Elder Abuse https://www.cdc.gov/violenceprevention/elderabuse/fastfact.html 6/2/21, (Retrieved 5/9/23), Elder abuse is an intentional act or failure to act that causes or creates a risk of harm to an older adult. Common types of elder abuse include: physical abuse, sexual abuse, emotional or psychological abuse, neglect and financial abuse. Physical abuse is when an elder experiences illness, pain, injury, functional impairment, distress, or death as a result of the intentional use of physical force and includes acts such as hitting, kicking, pushing, slapping, and burning. III. Facility policies and procedures Three different abuse policies were provided by the nursing home administrator (NHA) on 5/4/23 at 3:00 p.m. Each policy contained pertinent information. The Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 revealed in pertinent part, Residents have the right to be free from abuse. This includes physical abuse. The resident abuse, neglect, and exploitation prevention program consists of a facility wide commitment and resource allocation to support the following objectives: Protect residents from abuse by anyone including, other residents. Develop and implement policies and protocols to prevent and identify: abuse or mistreatment of residents. Protect residents from further harm during investigations. The Abuse, Neglect, Exploitation or Misappropriation Reporting and Investigation policy, September 2022, revealed in pertinent part, The administrator ensures that the resident and the person(s) reporting violation are protected from retaliation or reprisal by the alleged perpetrator, or by anyone associated with the facility. The Abuse and Neglect Clinical Protocol, March 2018, revealed in pertinent part, Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. IV. Resident to resident physical abuses between Resident #1 and Resident #2 on 4/19/23 at approximately 4:00 p.m and on 4/19/23 approximately one hour later. The 4/19/23 facility incident report which involved Resident #1 and Resident #2 was provided by the NHA on 5/4/23 at 10:00 a.m. It revealed in pertinent part, On 4/19/23 at approximately 4:00 p.m. Resident #1 walked up to Resident #2 and tapped him on the back of his shoulder and put his hands up with balled fists. Resident #2 then lunged at Resident #1 and the two men began striking each other. Staff responded and put the two men on 15 minute checks for monitoring. Within approximately one hour Resident #2 came out of his room and found Resident #1 who was in a common area and slapped him. The facility put Resident #1 on one-to-one monitoring at that time (See social services assistant interview below that there was no one-to-one tracking documentation from this monitoring). Resident #1 had slight redness and a small abrasion to his arm. Resident #2 had slight redness to his neck which was no longer visible within a few hours (The report did not say how many hours until the redness was gone). The facility staff said they heard the two men yelling, and observed Resident #1 strike Resident #2, and Resident #2 put his hands on Resident #1's neck. The staff said about an hour later Resident #2 entered a common area where Resident #1 was seated and struck him with an open hand. Resident #1 was placed on one-to-one monitoring and Resident #2 was redirected to his room. The incident report documented the video footage was reviewed which revealed Resident #1 tapped Resident #2 on the shoulder. Resident #1 put up balled fists at Resident #2 who responded by hitting Resident #1. Then about one hour later Resident #2 struck Resident #1. Resident #1 was placed on every 15 minute monitoring which progressed to one-to-one care by staff. -The facility documented 15 minute checks for both men but not one-to-one care for Resident #1 as was documented in the medical records. The facility concluded there was insufficient evidence to substantiate resident to resident physical abuse because there was no willful infliction of injury including physical harm, pain, or mental anguish. The facility documented willful was characterized by an awareness of consequences which Resident #1 was unable to understand due to dementia with severe agitation and a traumatic brain injury (TBI). There was nothing in the facility's conclusion about Resident #2 who retaliated and was the aggressor in the second incident. Agency staff were interviewed on the day of the investigation which revealed, Agency LPN (licensed practical nurse) said she saw Resident #1 choking Resident #2 but did not see the event leading up to it. She separated the two residents immediately. She said about one hour later Resident #2 approached Resident #1 who was in the dining room and slapped him from behind. The agency certified nurse aide (CNA) said she saw the first altercation when Resident #1 put his fists up and then Resident #2 started to hit Resident #1. The documentation of 15 minute checks was provided by the NHA on 5/4/23 at 3:30 p.m. which revealed, -Resident #1 was placed on 15 minute checks at 4:00 p.m. During this time the second incident occurred. The initials which verified he was observed every 15 minutes were not clear enough to determine who signed the 15 minute checks. The NHA said the initials did not look like the agency LPN that was on duty that day. The NHA said he would look at the employee time cards and verify the initials. -The facility did not provide who the initials represented for facility staff who did the 15 minute checks. The facility documented Resident #1 was on 15 minute checks for the next three days but did not have any documentation of Resident #1 with a one-to-one person or sitter. -Resident #2 was put on 15 minute checks which began at 3:00 p.m. according to the documentation, which was an hour before the altercation. The initials were the same on the staff checks as with Resident #1, which was not verified as to who initialed the 15 minute checks for the next several hours. The 4/19/23 nursing progress note revealed that Resident #1 approached Resident #2 when he raised his fists and hit Resident #2 in the chest. Before the nurse could intervene to separate the two men Resident #2 responded with physical violence by a swing which hit Resident #1. Then Resident #1 began to choke Resident #2. The nurse was able to get Resident #1 to release his hand grip from around Resident #2's neck. At 5:09 p.m. Resident #2 hit Resident #1 in the face. The NHA notified that the resident was to be put on one-to-one care. One of the residents said, He hit me, he shouldn't have hit me. I'll beat his (expletive). The social services assistant (SSA) video camera footage description was provided by the SSA on 5/4/23 at 4:05 p.m. It revealed that the SSA watched the video footage of the incident. It was observed Resident #1 walked up to Resident #2 in the hallway, tap him on the shoulder, and put up his balled fists. Resident #2 lunged at Resident #1 and started to hit him, leaving visible scratches on Resident #1's arm. She documented Resident #2 said Resident #1 choked him. The SSA told the staff on the unit to place the two residents on 15 minute checks. Resident #2 said he hit Resident #1 because he was mouthing off. The SSA was notified of the second incident at 5:20 p.m. Resident #1 was to be placed on one-to-ones with an agency nurse. V. Resident #1 A. Resident status (perpetrator in the first incident and victim in the second incident) Resident #1, age under 65, was admitted on [DATE] and readmitted on [DATE]. According to the May 2023 computerized physician orders (CPO) the diagnoses included unspecified dementia, severe, with agitation, traumatic brain injury (TBI), cognitive communication deficit, chronic obstructive pulmonary disease (COPD) and altered mental status. The 3/8/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of three out of 15. He had disorganized thinking. He did not reject care from staff. He required supervision with bed mobility, transfers, walking in his room and in the corridors, dressing, eating, toilet use, and personal hygiene. B. Record review The 7/18/22 suicide homicide risk evaluation for Resident #1 revealed the resident had made homicidal remarks. (See social service assistant was unaware of the note in the electronic medical records EMR). The resident reported I am going to kill someone. Social service interviewed him and he said he was not going to hurt anyone. He said he made statements like this when joking. The comprehensive care plan on 3/20/22 and revised on 8/29/22 revealed in pertinent part, Focus: The resident had impaired cognitive function/dementia or impaired thought process with dementia. The resident had dementia with behavioral disturbances. The resident had physically aggressive behaviors. -Resident had a history of being verbally aggressive towards peers and staff. Also history of antagonizing peers. At times resident makes threatening statements and balls fists though reports he was joking. -Resident had a history of hitting other residents. Goal: Resident will not harm self or others through the review date. (Revised on 4/10/23, nine days before the incident) He will verbalize the need to control physical aggressive behaviors through the review date. Interventions: Behavior monitoring revised on 2/18/23. Identify/document potential causative factors and eliminate/resolve where possible. Analyze key times, places, circumstances, triggers, and what de-escalates behavior and document. Staff will redirect if (the) resident becomes verbally aggressive. The behavior progress notes documented, -On 3/22/23 the resident was on frequent checks due to a recent altercation with another resident. -On 4/7/23 the resident threatened to hit another resident two times on the same day while walking past the resident. -On 4/19/23 the resident made (a) physical altercation with another resident in the hallway, obtained bruising/abrasion to lower left arm and above the elbow. Resident was to remain on one-to-one supervision with staff until he could be evaluated the next morning. (See interviews below that the resident was not placed on one to one supervision) The April 2023 treatment administration record (TAR) documented a daily tracking of the following: -Target behavior (physical aggression, strikes out) at the end of each shift, mark frequency how often behavior occurred and intensity. How (the) resident responded to redirection. Intensity code: zero equaled did not occur, one equaled easily altered, and two equaled difficult to redirect every shift. -On 4/19/23 the day of the altercation, the facility did not record any intensity codes on the TAR about behaviors for physical aggression. The nurse practitioner (NP) progress note on 4/15/23 (four days before the physical abuse incident) revealed in pertinent part that staff reported he had a history of seeking out more vulnerable residents and physically assaulting/attempting to physically assault them. The nurse practitioner (NP) progress note on 4/20/23 revealed in pertinent part, the resident had an altercation with another resident on 4/19/23 and had a bruise and abrasion to the left lower arm above the elbow. The NP documented the resident was in another skilled nursing facility and went to the hospital on [DATE] where he was aggressive and required restraints. The resident previously had heavy alcohol use and he used crack cocaine. VI. Resident #2 A. Resident status (victim in the first incident, and perpetrator in the second incident) Resident #2, age [AGE], was admitted on [DATE]. According to the May 2023 computerized physician orders (CPO), the diagnoses included unspecified dementia, moderate, without mood disturbances, cerebral infarction (stroke), hypertension (high blood pressure), stage 4 chronic kidney disease, anxiety disorders, alcohol abuse in remission, depression, cognitive communication deficit and difficulty in walking. The 3/13/23 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of five out of 15. The resident had verbal behavioral symptoms directed toward others. The resident did not reject care from staff. The resident required supervision with bed mobility, transfers, walking in his room and corridors, dressing, eating, and toilet use. He needed limited assistance with personal hygiene. B. Record review The comprehensive care plan 4/11/23 revealed in pertinent part, Focus: Resident had a history of being verbally aggressive. Had a potential for injury to self or others which was manifested by constant yelling, kicking, verbal outbursts, and delusional behaviors. Interventions: Monitor/record occurrences of target behavior symptoms, inappropriate response to verbal communication, violence/aggression towards staff/others, and document per facility protocol. The April 2023 TAR documented a daily tracking of the following: -Target behavior (physical aggression, strikes out) at the end of each shift, mark frequency how often behavior occurred and intensity. How (the) resident responded to redirection. Intensity code: zero equaled did not occur, one equaled easily altered, and two equaled difficult to redirect every shift. -On 4/19/23 the day of the altercation, the facility did not record any intensity codes on the TAR about behaviors for physical aggression. The NP progress note on 4/20/23 revealed in pertinent part, the resident (had) fingerprint markings on his neck from an altercation with another resident on 4/19/23. The NP documented when the resident went to a hospital on 2/24/23 he punched a security guard in the face. The behavior progress note on 4/20/23 documented Resident #2 said That guy is dangerous. -The note did not document whom the resident said was dangerous. (See SSA interview below) VII. Staff interviews LPN #1 was interviewed on 5/4/23 at 12:10 p.m. She said she worked on the Legacy unit where Resident #1 and Resident #2 lived. She said she had complained prior about the agency nurses that were on the unit the day of the incident. She said the agency CNA the day of the incident had prior told her that she did not get involved with fights between residents. She said if the men were being watched after the first altercation there would not have been a second altercation. She said Resident #2 may not remember the incident but he still gets nervous and agitated when he sees Resident #1 in the hallway. She said the staff tried to keep Resident #2 from seeing Resident #1 but it was difficult on a small secured unit. The SSA was interviewed on 5/4/23 at 4:00 p.m. The SSA said she said she was the social worker responsible for the Legacy unit. She said after the second incident she told the agency nurse on the unit to start one-to-one staff supervision with Resident #1. She said she had no documentation that she told the nurse and there was no documentation any staff had provided one-to-one supervision with Resident #1. She said he needed to be watched 24/7 by nursing staff until he could be medically evaluated the next day. She was unaware only 15 minute checks were done for three days. She said Resident #1 had altercations with others prior to the incident. She said because Resident #2 had not had altercations with others prior to the incident he was not put on one-to-one supervision. She said she was unaware that there was a homicide/suicide evaluation done for Resident #1 in the electronic medical records (EMR). She said after the first incident with Resident #1, Resident #2 retaliated. She said she did not know why the staff on the unit did not notice Resident #2 had left his room to go to the dining room to seek out Resident #1. She said Resident #2's intervention after the incident was to be discharged to another state to go live with his former wife. She said she was unaware of a note in the medical record on 4/20/23 the day after the incident which documented Resident #2 had said that guy was dangerous. The social service director (SSD) was interviewed on 5/4/23 at 4:10 p.m. She said Resident #1 had other altercations with other residents on the unit. She said Resident #1 balled up his fists at others to be funny. She said some residents understand his humor and others hit him. She said after the first altercation the two men were separated. She said Resident #2 came out of his room and found Resident #1 and retaliated for what happened about an hour prior. She said she did not know what other interventions could have been put in place to protect the two residents except 15 minute checks because that usually worked. She did not know how the two men were not watched closely enough that a second incident happened. The NHA was interviewed on 5/4/23 at 4:20 p.m. He said he would read the employee time cards and if he found who initialed the 15 minute checks for Resident #1 and Resident #2 and he would provide the documentation. -No documentation was provided during or after the survey on 5/5/23. He said there was no documentation that Resident #1 was put on one-to-one care after the second incident. He said the nurse on duty documented the events in the resident's medical records. He said he was not sure the agency nurse that day viewed the altercation correctly. VIII. Facility follow-up On 5/5/23 at 4:34 p.m. the NHA emailed the following information. Resident #1 had aggressive behaviors in the past, and the facility had tried with no success to refer him to get accepted by other facilities to care for his needs. After the first altercation on 4/19/23 police were called and refused to transport Resident #1 on assault charges. The NHA said after viewing the video footage of the first incident he felt the nurse on duty that day had her back to the residents and did not see the incident correctly. The NHA requested the police department who responded to the event in the facility to send their report and a copy of the video footage. The facility had not received a response from the police department as of 5/5/23 (16 days after the incident). The NHA also wrote that when the police were in the building within an hour of the first altercation, the staff had removed their physical presence and attention to monitoring that would have otherwise been in place. The presence of the police and the proximity of the residents during the police interviews led to the retaliatory incident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** III. Failure to ensure an assessment was completed by an registered nurse (RN) following a fall A. Facility policy and procedure The Fall Documentation policy and procedure, revised 11/26/19, was provided by the nursing home administrator (NHA) on 9/15/22 at 5:30 p.m. It revealed in pertinent part, Documentation of care delivered to residents who have fallen, or who have preventative interventions in place to prevent a fall includes, but is not limited to the following: the initial nursing note/assessment following a fall should contain the following and include a description of what was done: vital signs, to include neurological assessment if indicated, where the resident was observed and the time of the day, first on scene, describe the resident's location, appearance and mental status, if visible injury, identify any assessment that was performed, document all attempts to notify the physician and family and document immediate interventions implemented to prevent another fall. B. Resident #27 1. Resident status Resident #27, age [AGE], was admitted on [DATE]. According to the August 2022 CPOs, the diagnoses included alcohol dependence with alcohol induced persisting dementia, major depressive disorder, hypothyroidism (decrease in thyroid function), and dysphagia (difficulty swallowing). The 6/22/22 MDS assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of 10 out of 15. She required one person physical assistance with bed mobility, transfers, dressing, personal hygiene and toileting. 2. Record review The 4/24/22 nursing progress note documented a certified nurse aide (CNA) witnessed the resident self-transfer from the wheelchair to the bed. The resident fell to her knees between the bed and the wheelchair. -The progress note was completed by a licensed practical nurse (LPN). A review of the resident's medical record on 9/15/22 at 2:30 p.m. did not reveal documentation an RN assessment had been completed following the fall sustained by Resident #27 on 4/24/22. D. Staff interviews LPN #6 was interviewed on 9/15/22 at 1:22 p.m. She said when a resident sustained a fall, the RN should be notified immediately to conduct an assessment of the resident. She said the RN would assess the resident for any injuries. She said she was unable to perform an assessment because it was outside of her scope of practice. The director of nursing (DON) was interviewed on 9/15/22 at 4:10 p.m. She said the RN should complete an assessment of the resident immediately following a fall. She said an LPN was unable to perform an assessment because it was outside of their scope of practice. She said the RN assessment should be documented in the resident's medical record. Based on record review, observations and interviews, the facility failed to ensure three (#60, #41 and #27) of four residents received adequate supervision to prevent accidents out of 31 sample residents reviewed. Specifically, the facility failed to develop and implement a person-centered care plan that identified the resident's current medical status, fall risk status and put effective interventions into place to reduce falls and prevent injury for Resident #60. Resident #60, who was admitted to the facility on [DATE], was an identified to be at high risk for falls upon admission due to a recent fall at another facility, which resulted in a subdural hematoma (blood collection on the brain). The facility failed to implement effective person-centered interventions, which considered the resident's compromised medical status to prevent further falls and major injuries. Since the resident's admission to the facility, he experienced seven falls on 7/9/22 with two falls, 7/10/22 with two falls, 7/15/22, 7/16/22 and 7/17/22, two of which resulted in a major injury (7/10/22 with a distal nasal fracture and 7/17/22 with multiple rib fractures). Resident #60's care plan was put into place on 6/20/22 but not revised until 7/11/22 (after the resident had fallen at the facility four times).The facility failed to identify the resident's pattern of weakness related to self-care upon admission, evaluate interventions already in place for effectiveness, identify the resident's pattern of cognitive impairment and initiate effective interventions to prevent the resident from sustaining major injuries from falls. Additionally, the facility failed to: -Ensure an assessment was completed by a registered nurse (RN) following a fall sustained by Resident #27; and, -Ensure medications were not left on the counter for Resident #41 to consume without supervision. Findings include: I. Facility policy and procedure The Fall Management policy and procedure, revised on 9/10/19, was provided by the nursing home administrator (NHA) on 9/15/22 at 3:30 pm. It revealed, in pertinent part, The purpose of this fall management policy is to modify or eliminate risk factors as applicable and thereby attempt to reduce the likelihood of falls with significant injury. A fall reduction program will be established and maintained to assess all residents to determine their risk for falls. A plan of care will be implemented based on the resident's assessed needs. Research has shown that a structured fall reduction program can substantially reduce the rate of falls and related injuries in nursing facilities; however falls may likely occur. Identify risk factors, followed by timely and appropriate interventions, is the key to a successful program. Risk factors that are internal to the resident include the resident's physical health and functional status. External risk factors include medication side effects, the use of appliances, and environmental conditions. To be effective, a reduction program is characterized by four components: fall risk evaluation, care planning and implementation of interventions, ongoing evaluation process Quality Assurance Performance Improvement (QAPI) and a commitment by caregivers to make it work. Individualized care plan interventions will be implemented for those residents found to be at high risk for falls. Resident and resident representatives will be invited to all care plan meetings. Please note interventions are to be re-evaluated when a resident falls. The following interventions are to be initiated and or considered: a physical therapy (PT) evaluation and/or screen should be initiated; medications will also be reviewed; evaluate physical health status - have pertinent laboratory test been performed; assess the environment and make appropriate changes; offer frequent toileting or follow individualized toileting schedule; assess the need for a potential room change; positioning devices; protective devices; restorative nursing; always assess for the least restrictive devices; notify Quality Improvement Specialist (QIS) consultant with frequent fallers and falls resulting in significant injury; and complete a thorough analysis of the fall - time of day, location of the fall, causative factors, identify whether the interventions were in place at the time of the fall. Falls review will include the following: Review the IDT risk management incident to ensure complete and appropriate interventions have been implemented, review that a care plan has been initiated, provide revision to the plan of care as necessary after falls. II. Failure to ensure effective interventions were in place to prevent falls with a major injury A. Resident #60 1. Resident status Resident #60, age [AGE], was admitted to the facility on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnosis included a history of falls, encephalopathy (a disease in which the functioning of the brain is affected by some agent or condition), cerebral infarction due to embolism of left middle cerebral artery (a stroke that occurs when a blood clot that forms elsewhere in the body breaks loose and travels to the brain by the bloodstream), and seizures. The 7/27/22 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status score of nine out of 15. He required limited assistance of one person assistance with transfers, locomotion on and off the unit, dressing, toileting and personal hygiene. It indicated the resident had not sustained any falls since the resident's readmission to the facility. 2. Observations On 9/14/22 at 10:01 a.m. Resident #60 was observed moving about his room without the use of an assistive device. The resident had removed all his personal items off the walls and around the room and placed them in his wheelchair and on top of his bed. Resident #60 said he was confused about where he was and why he was there. A sign, directing the resident to call for assistance before walking or to use an assistive device for walking, was not found in the resident's room (an intervention documented as put into place following the fall the resident sustained on 7/16/22). 3. Record review a. Resident #60's status upon admission The 6/20/22 physician progress note documented the resident was admitted to the facility that day. The resident was recently hospitalized for a prolonged period of time due to seizures and was discharged to a subacute facility, where he experienced falls which led to another hospitalization. It indicated the resident was having falls at the previous skilled nursing facility, likely due to poor safety awareness, the lactulose medication being reduced and his ammonia level was very high. The physician documented the resident had poor memory. The 6/20/22 nursing progress note documented the resident was a new admission to the facility with a prior history of frequent falls and weakness with his activities of daily living (ADLs). It indicated the resident had numerous falls at many different facilities and the resident's responsible party was concerned. It indicated the resident had poor cognition, poor safety awareness, poor memory and poor self-awareness of his physical abilities. The fall care plan initiated on 6/20/22, documented the resident was at risk for falls, had poor self awareness of his physical ability, seizures, a history of falls, would spontaneously get out of bed or up from the wheelchair, and was forgetful with poor cognition. The interventions, upon admission, included: anticipating and meeting the resident's needs, ensuring the resident's call light was within reach, encouraging the resident to use the call light for assistance, encouraging rest periods when signs of fatigue were noted, encouraging the resident to be compliant with seizure medications, encouraging the resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, ensuring adequate lighting and visual aids are in place on admission, ensuring appropriate positioning in the center of the bed, ensuring the resident wore non-skid footwear when ambulating or mobilizing in the wheelchair, ensure the resident's environment was uncluttered and personal items were within reach, and review information on past falls and attempt to determine the cause of the falls and remove any potential causes. The fall care plan did not identify the causes of any previous falls sustained at other facilities or attempt to provide person-centered approaches to prevent falls and potential major injuries. The activities of daily living (ADL) care plan, initiated on 6/20/22, documented the resident had an ADL self-care performance deficit related to weakness, a history of falls, poor cognition, and needed reminders and supervision. It indicated the resident required the use of a wheelchair for mobility, side-by assistance for ambulation, and supervision from the facility staff to move between surfaces. The interventions included encouraging the resident to use the call light for assistance. The cognitive care plan, initiated on 6/20/22, documented the resident had impaired cognitive function/dementia or impared thought processes related to dementia and had difficulty making decisions. The interventions included: ensuring the resident's call light was within reach, encouraging the resident to use the call light for assistance as needed, encouraging the resident to use the wheelchair for ambulation and toileting, ensuring resident is wearing non-skid footwear when ambulating or mobilizing in wheelchair, and ensuring a fall mat was beside the bed. b. Fall incidents on 7/9/22 - witnessed The 7/9/22 nursing progress note documented at approximately 1:54 p.m. the RN was alerted to come to the resident's room by the certified nurse aide (CNA). The CNA said the resident had fallen, but did not hit his head. The resident told the nurse that he got light headed and fell into the wall. The RN completed an assessment and provided education to the resident to use his call light when he needed assistance. -At 3:30 p.m. the resident sustained another witnessed fall. The resident fell against the door in his room. It indicated the resident was assisted by three staff members to stand. The resident had on slippery socks and was provided non-skid socks by the facility staff. It indicated the resident's lab work had shown a high ammonia level of 130. The 7/11/22 interdisciplinary team (IDT) risk management review note documented the resident sustained two witnessed falls on 7/9/22. For the first fall, on 7/9/22, the root cause was determined to be poor safety awareness related to encephalopathy with an intervention of non-skid socks and re-education provided to the resident to use the call light to ask for assistance. -However, the intervention of non-skid socks was put into place upon the resident's admission on [DATE]. For the second fall, on 7/9/22, the root cause was determined to be poor safety awareness, the resident's history of falls and the resident had complained of feeling dizzy. The lab results showed high ammonia levels with an intervention of diagnostic orders from the physician. The review of the incident did not show the facility had evaluated the resident's history along with his current medical status, other than the lab work ordered by the physician. The facility identified the resident had cognitive impairment and continued to get up without assistance in his weakened state, but continued with the intervention to educate the resident to use the call light for assistance. The 7/9/22 x-ray imaging report documented the resident sustained an acute, minimally depressed distal nasal bone fracture. c. Fall incidents on 7/10/22 - unwitnessed with a nasal fracture The 7/10/22 nursing progress note documented at approximately 6:10 a.m. the RN was called to Resident #60's room by the licensed practical nurse (LPN). The RN found the resident sitting in the wheelchair bleeding from the left side of his nose. The CNA reported she found Resident #60 in his bed, lying on his left side, bleeding. Resident #60 was observed with swelling above the left eye with a slight abrasion and a swollen area to the right side and middle of his nose. It indicated the resident was confused and weak. The nurse applied a cold pack and called the physician for an x-ray of the resident's facial bones. The 7/10/22 nursing progress note documented she informed the physician the x-ray had revealed the resident had sustained a nasal bone fracture and bleeding from the right nostril. -At 8:58 p.m. the nurse documented the resident was being helped to the bathroom. During the transfer, the resident's legs became weak and was lowered to the ground. It indicated the resident was confused during the transfer, however did not sustain any injuries. The nurse contacted the physician and the resident's responsible party and placed the resident on 15 minute safety checks. The 7/11/22 physician progress note documented the resident had multiple falls at another skilled nursing facility and continued to fall at this facility. It indicated the resident had poor memory and poor safety awareness. It indicated the resident had fallen that weekend and sustained a distal nasal bone fracture. The 7/11/22 IDT risk management review note documented the resident was assisted to the floor by staff members because he became weak and was unable to ambulate. The interventions included for the resident to use a wheelchair for ambulation. -However, based on the resident's continued impulsive behavior of getting up without using the call light and without asking for assistance, the facility failed to implement an effective intervention that actually had the potential to reduce future falls for the resident. The facility failed to actively evaluate interventions put into place to determine their effectiveness. d. Fall incident on 7/15/22 - unwitnessed The 7/15/22 nursing progress note documented Resident #60 was sitting on the bathroom floor with his hands clasped to the toilet grab bars. There was diarrhea covering the wall behind the resident and the resident was incoherently cursing himself. The resident was provided incontinence care and assisted back to bed with two staff members. It did not indicate the previous interventions had been reviewed for effectiveness or a new intervention put into place. e. Fall incident on 7/16/22 - unwitnessed The 7/16/22 nursing progress note documented the call light in the bathroom was activated and Resident #60 was found, by the CNA, kneeling on one knee in front of the bathroom commode. The resident had bare feet and was ambulating to the bathroom without assistance. Resident #60 said he went to the bathroom and got weak when he was trying to get up. The RN performed an assessment with no injury noted. It indicated the resident was provided education on proper footwear and using the call light before getting out of bed. It did not indicate any additional interventions were put into place. f. Fall incident on 7/17/22 - unwitnessed with a major injury The 7/17/22 nursing progress note documented the CNA found the resident kneeling on the floor in the bathroom in front of the commode. The wheelchair was in the bathroom with the resident, but the brakes were not engaged. Resident #60 said he was trying to stand up and slipped and fell to the ground. It indicated the CNA had checked on the resident 20 minutes prior and the resident was in bed, asleep. The resident was assisted back to the wheelchair and then back to bed. A small abrasion was noted to his left knee. The nurse reminded the resident to use the call light for assistance with transfers and going to the bathroom. -At approximately 2:30 a.m., during a neurological check, Resident #60's left pupil was dilated and was nonreactive to light. He said his left eye was blurry and said he hit his head when he fell earlier. The physician was contacted and ordered for the resident to be sent to the hospital for an evaluation. The 7/17/22 hospital physician consultation notes documented the resident sustained a fall at the facility of unknown cause. It indicated the resident was confused and ordered imaging of the resident's brain. The physician documented the resident's chronic left sided weakness, from his history of a fall with a subdural hematoma, was what made him off balance and was likely why he fell. It indicated the resident sustained an acute to subacute fracture of the 10th and 11th rib based on the physician's assessment, the resident's complaint of acute abdominal pain and imaging. The 7/17/22 radiology study for a CT (computerized tomography) of the resident's chest, abdomen and pelvis, with contrast, revealed bilateral lower medial rib fractures and a correlation with point tenderness was needed to evaluate for an acute fracture. The 7/21/22 physician progress note documented the resident was readmitted to the facility on [DATE] from a fall sustained at the facility. While at the hospital, the resident was found to have right 10th and 11th rib fractures. It indicated the resident was placed on hospice services on 7/20/22 due to multiple falls, cognition, poor safety awareness and not using the call light. The 7/25/22 IDT risk management review note documented the resident had an unwitnessed fall and the resident continued to transfer and toilet himself despite nursing education to use the call light for assistance. It indicated the resident was placed on frequent checks and re-educated to call for assistance as needed. III. Staff interviews CNA #2 was interviewed on 9/15/22 at 8:33 a.m. She said there were pictures of leaves on the resident's room door that identified if the resident was considered a fall risk. She said each resident group assignment had a staff sheet that included information about each resident and any special needs they required. She said the report sheet indicated whether or not a resident was on frequent checks because they were considered a high fall risk. She said the restorative aide was responsible to update the report sheet and ensure it was current. CNA #1 was interviewed on 9/15/22 at 8:46 a.m. She said the leaf picture on the outside of a resident's door was just a decoration and did not have any meaning. She said point click care (PCC, the electronic charting system) contained a sheet that indicated if a resident was at risk for falls. She said any frequent checks were documented on the sheet in PCC. She said she provided care to Resident #60. She said the staff would encourage him to use his wheelchair. She said Resident #60 was not on frequent checks. The NHA and the director of nursing (DON) was interviewed on 9/15/22 at 9:15 a.m. The DON said the facility IDT reviewed each fall, discussed the circumstances around the fall and tried to determine the root cause. She said the IDT would review the immediate intervention put into place by the nurse and determine if that intervention was effective and should be continued moving forward. She said the IDT was responsible for updating the care plan with the new interventions. She said all interventions should be reviewed quarterly and with any change of condition to determine their effectiveness. The NHA said the facility could not prevent falls, but attempted to prevent major injuries. The DON said Resident #60 was admitted to the facility with a significant history of falls at the hospital and at another facility. She said he was not medically stable and had recently been discontinued from hospice to receive physical therapy services. She said the physician ordered lab and medication monitoring to stabilize the resident's ammonia levels. She said Resident #60 had cognitive impairment and was impulsive. She said the resident constantly got up and ambulated around his room and to the bathroom without calling for assistance. She said Resident #60 was not placed on frequent checks during the time when he sustained seven falls at the facility. She said during that time, the resident was impulsive and made poor decisions. She said she was unsure if the intervention to provide the resident with education, which was documented on multiple falls, was an effective intervention due to his cognitive status. IV. Failure to ensure medication was consumed by Resident #41 A. Facility policy The Medication Management policy for the nursing department, revised 11/26/19, was provided by the nursing home administrator (NHA) on 9/15/22 at 5:30 p.m. It revealed in pertinent part, Residents' medications are administered in an accurate, safe, timely, and sanitary manner. Observe that the resident swallows oral drugs. Do not leave medications with the resident. Residents are allowed to self administer medication when specifically authorized by the attending physician and in accordance with the guidelines for self administration of medication. B. Resident status Resident #41, age [AGE], was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included paranoid schizophrenia, vascular dementia, heart failure, chronic obstructive pulmonary disease and hypertension (high blood pressure). The 6/11/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) of 13 out of 15. The resident was independent with mobility and with his activities of daily living. He needed assistance with medication management and administration. He was on oxygen therapy. C. Observations On 9/13/22 at 10:02 a.m., Resident #41 was observed standing at the nurses station window located on the behavioral unit. The window was open and a cup of water and approximately eight oral medications in a clear cup was sitting on the ledge of the window. Resident #41 was standing at the window and was observed taking his cup of medications and swallowing with a cup of water. Licensed practical nurse (LPN) #3 placed the cup of oral medications on the window ledge and proceeded to enter the bathroom in the nurses station. When Resident #41 was observed to take his medications, LPN #3 was in the bathroom with the door closed. There were two certified nurses assistants at the nurses station, however there was not a licensed nurse observing the resident at the time he took his medications. Resident #41 finished taking the medication and threw the empty clear cup and cup of water into the trash receptacle behind the window inside the nurses station and proceeded to walk away. LPN #3 exited the bathroom and sat down at the computer at the nurses station. There were approximately three other residents in the dining room area and multiple residents outside in the smoking courtyard during observation time. The dining room was connected to the nurses station and the courtyard was within close proximity to the medication window. D. Record review A review of the residents medication administration record (MAR) on 9/13/22 at 10:43 a.m. revealed the resident received the following morning medications at 10:00 a.m. to include; -Finasteride 5 milligram (MG) tab for benign prostatic hyperplasia; -Lasix 20 mg tab for congestive heart failure; -Metoprolol succinate 100 mg tab for hypertension; -Metoprolol succinate 50 mg tab for hypertension; -Potassium chloride 750 mg tab for hypertension; -Eliquis 5 mg for afibrillation; -Senna plus 8.6-50 mg tab for bowel care; and, -Acetaminophen 650 mg tab for back pain. A review of the residents care plan revised on 6/28/22 revealed the resident was on psychotropic medications and had a history of poor compliance with medications. The intervention in place was to have nursing staff administer medications as ordered by the physician. Staff will offer assistance with medication monitoring and prompting to take medications and will reapproach after 15 minutes if the resident refuses to take the medication. -Review of the resident's medical record revealed no self administration assessment for the resident to independently administer his medications. E. Interviews Licensed practical nurse (LPN) #3 was interviewed on 9/13/22 at 10:05 p.m. He said Resident #41 just completed taking all of his scheduled physician ordered morning oral medications. LPN #3 said Resident #41 did not have an order to self administer his medications and he should have been observed to swallow all of his medications. LPN #3 said the resident did not have a history of refusing his medications and he was compliant with medication administration. -However, according to the resident's care plan he had a history of poor compliance with medication. LPN #3 said although he did not have concerns about Resident #41 taking his medication, he should have been observed during the entire medication administration process. He said he should not have left the cup of medications on the window ledge with the resident while he went to the bathroom. He said he did not observe the resident swallow the medications and that was against the medication administration protocol. LPN #4 was interviewed on 9/15/22 at 12:56 p.m. He said all the residents on the behavioral unit needed the nurse to administer their medications. He said he administered all the medications during his shift which included administering and observing the resident swallow or take their medication. He said he would not leave the resident alone with the medications because that was against the medication administration policy. He said there was a risk that some residents might pocket their medications and not swallow them or potentially another resident could get ahold of the medication if the nurse did not complete the medication administration process. The director of nursing (DON) was interviewed on 9/15/22 at 3:40 p.m. She said the medication administration protocol was the same on every unit in the facility. She said the nurse should be following the same process which would include administering the medication and observing the resident swallow or take the medication. She said Resident #41 should have been observed during the medication administration process. She said LPN #3 was trained in the medication administration process and should have watched the entire process. She said he should not have gone to the bathroom and left the cup of medications on the window ledge of the nurses station. She said leaving the medication on the window ledge unattended did have the potential of putting residents at risk.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#6) of three residents reviewed received the care and services necessary to meet their nutrition needs and maintain their highest physical well-being level out of 31 sample residents. Specifically, the facility failed to consistently monitor weights, identify significant weight loss, and timely address Resident #6's nutritional needs. Resident #6 experienced a significant, unplanned weight loss of 13% in six months. The facility failed to implement appropriate interventions timely to address Resident #6's significant weight loss. Findings include: I. Facility policy and procedure The Weight Management policy and procedure, revised on 1/17/2020, was provided by the nursing home administrator (NHA) on 9/15/22 at 5:30 p.m. It revealed in pertinent part, Residents are monitored per physician order for significant weight changes regularly. The results are reviewed and analyzed by the facility for intervention as appropriate. Residents identified with significant weight change will be assessed by the IDT (interdisciplinary team). Further interventions will be implemented to minimize the risk of additional weight change and promote weight stability. Residents will be screened for the risk for weight change on admission quarterly, annually, and with a significant change of condition with completion of the MDS. Weigh all residents upon admission, then monthly or indicated as physicians order. Document the results in the medical record. Residents with weight variance loss or gain are reweighed. A significant weight variance is a 3% (percent) weight loss/gain in one month. Residents identified at risk for weight change and will have interventions implemented to minimize the risk for additional weight change included in their plan of care. This may include supplements, RD (registered dietitian) evaluation, assisted dining, etc. The nurse identifying the weight variance (loss or gain) will record findings on the 24 hour report. The following categories of residents should be weighed weekly unless otherwise indicated. Residents with significant weight change until weight is stabilized as defined in the Policy. As determined by the physician, Director of Nursing, or IDT team direction. The IDT meets weekly to review the resident with identified weight change, develops a plan, implements, evaluates, and reevaluates interventions to minimize the risk for weight change. Nursing staff is responsible to communicate weight changes to the attending physician and resident's family. The nurse documents the notification in the medical record. Nursing staff is to notify food and nutrition services and the RD of a resident weight change. The RD further assesses the resident and makes recommendations as indicated to reduce or stabilize the weight change. Nursing staff are to notify the speech therapist if swallowing problems are suspected. The Director of Nursing or designee will analyze results for trends and patterns in residents identified with weight changes and report findings to the QA(quality assurance) committee for review and recommendations. II. Resident #6 A. Resident status Resident #6, over the age of 65, was admitted on [DATE]. According to the September 2022 computerized physician orders (CPO), the diagnoses included dementia without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, schizophrenia, and dysphagia (difficulty swallowing). The 8/24/22 minimum data set (MDS) assessment documented that the resident had short-term and long-term memory impairment and had difficulty in a new situation of making decisions for daily life. She required supervision with bed mobility, and extensive assistance of two people with transfers, toileting, grooming and personal hygiene. It indicated the resident required supervision with setup assistance with eating. It indicated the resident had not experienced any weight loss, however, according to record review, the resident had lost 15 pounds (lbs) since April 2022. B. Record review Resident #6's record revealed she experienced a significant, unplanned weight loss of 19.2 lbs , 13.06 % in six months, from March 2022 to 9/6/22. 1. Resident #6's nutritional status on April 2022 The cognitive care plan, initiated on 9/10/15 and revised on 12/6/19, documented that the resident had a cognitive loss. It indicated the resident was able to communicate her needs verbally. The interventions included encouraging the resident to participate and attend any activities of hobbies she enjoyed and provide positive mental stimulation as well as increased socialization and community participation. The assessment for mental status completed on 8/24/22 documented that the resident had memory problems and has modified independence with making decisions about tasks of daily living. The activities of daily living (ADL) care plan, initiated on 9/15/15 and revised on 3/3/22, documented the resident had a self-care performance deficit related to limited mobility, impaired balance and cognitive impairment. It indicated the resident required supervision and set up assistance with eating. The nutritional care plan, initiated on 6/18/19 and revised on 12/14/21, documented the resident had potential for unintended weight loss related to advanced age with associated decreased intake. It indicated the resident required an altered textured diet related to a dysphagia diagnosis, the resident preferred to have her meals in bowls and the resident was provided double portions of oatmeal and soup to assist with meal intake (initiated on 6/27/19 and revised on 11/1/21). The interventions included providing adaptive equipment at meals as the resident preferred her food in bowls, monitoring the residents weights as ordered, monitoring for significant weight changes, obtaining the resident's food preferences, offering food alternates of equal nutritional value, providing and serving supplements as ordered and evaluations and changes to the resident's diet per RD recommendations. According to the comprehensive care plan, changes or updates to the nutritional interventions had not been made since 10/18/21. 2. Resident #6's significant weight loss Resident #6's weights were documented as follows: -The facility failed to obtain a weight for the resident for March 2022. -On 4/7/22, the resident weighed 147 lbs, -On 4/14/22, the resident weighed 146 lbs. -On 4/28/22, the resident weighed 142.2 lbs, a 4.8 lbs (3.27%) weight loss in 21 days. -The facility failed to obtain a weight for the resident in May 2022. -On 6/14/22, the resident weighed 138.2 lbs, an 8.8 lb (5.99%) weight loss since 4/7/22. -On 7/21/22, the resident weighed 132.4 lbs, a 14.6 lb (9.93%) weight loss in three months. -On 8/4/22, the resident weighed 132 lbs. -On 9/6/22, the resident weighed 127.8 lbs, a 19.2 lb (13.06%) weight loss since 4/7/22. The June 2022 CPO documented the following physician order: -Boost Plus one time per day for weight management-ordered 6/1/22. The 6/3/22 nutritional assessment, completed by the RD, documented Resident #6 was on a regular diet with a diet texture of mechanical soft with thin liquids. The resident had a physician ordered supplement of Boost Plus one time per day. -It indicated the resident weighed 142.2 pounds. It did not document that the weight was from 4/28/22 and the facility had not documented a recent weight for Resident #6 for the month of May 2022or for the RD to complete an accurate nutritional assessment. The 6/3/22 assessment further documented the resident required setup assistance with meals. The nutritional interventions included: providing the resident her food in bowls per her preference, monitoring the resident's weights as ordered, monthly, and monitoring any significant weight change. The RD documented the goal was for the resident to maintain sufficient nutritional status by maintaining a weight within 5% of 142 lbs and consuming at least 50% of at least two meals daily. It indicated the RD attempted to visit the resident, however she was sleeping. The RD requested a more recent weight be obtained for the resident. The 8/24/22 nutritional assessment, completed by the dietary manager, documented the resident's weight was 132 lbs, down 8.71% in 180 days. It indicated the resident liked the food, but did not eat much. -The assessment did not include any nutritional interventions to address the resident's weight loss of 15 lbs since April 2022. The September 2022 meal intake records documented that the resident consumed the following from 9/1/22 - 9/14/22: -75-100% of meals on 22 occasions; -51-75% of meals on nine occasions; -26-50% on six occasions; and, -refused on one occasion. The September 2022 (9/1/22-9/12/22) snack intake records documented that the resident consumed a snack on six occasions and refused on three occasions out of 12 occasions. The September 2022 (9/1/22-9/14/22) medication administration record (MAR) documented that Resident #6 refused the Boost Plus supplement on 9/1/22, 9/2/22, 9/5/22, 9/6/22, 9/7/22 and 9/14/22. III. Staff interviews Certified nurse aide (CNA) #7 was interviewed on 9/15/22 at 10:00 a.m. She said Resident #6 was independent with eating her meals. She said the resident ate in her room. She said the facility did not have a restorative program for meal assistance. CNA #8 was interviewed on 9/15/22 at 2:40 p.m. She said Resident #6 required total assistance with her ADL care. She said Resident #6 ate alone in her room and did not require any assistance or supervision with meals. The RD was interviewed on 9/14/22 at 3:19 p.m. She said weights should be obtained on every resident at least once per month. She said the facility had decided to place every resident on weekly weights, however it had been difficult for the CNAs to obtain the weights. She said when the weights were obtained, she entered the weights into each resident's medical record. She said she reviewed every resident's weight at the facility. She said all residents with weight loss or weight gain were reviewed every Thursday during the clinical meeting. She said the IDT would discuss any weight changes and potential nutritional interventions. She said she would conduct an assessment for any resident who had experienced significant weight loss and put intervention into place to address the weight loss. She said she was familiar with Resident #6, however, would like to review her notes regarding her weight loss. The RD was interviewed again on 9/14/22 at 4:34 p.m. She said she attempted to get a reweigh on the resident that day (9/14/22, during the survey process). She said the resident had consumed her meals pretty well in the past 14 days. She confirmed the resident's medical record had shown the resident consistently losing weight since June 2022. She said she was aware the facility did not obtain a weight for Resident #6 for March 2022. She said the computer system did not trigger the resident as having a significant weight loss. She said she would have had to calculate it by hand. She confirmed it was her responsibility to monitor each resident's weight, whether the computer triggered it as a significant weight loss. She confirmed the resident experienced a significant weight loss. She confirmed the nutritional intervention put into place was Boost Plus on 6/1/22. She said she did not put any other interventions into place to combat the resident's continued weight loss. The director of nursing (DON) was interviewed on 9/15/22 at 3:40 p.m. She said each resident's weight should be obtained every week. She said the CNAs were responsible for obtaining weekly weights. She said getting weekly weights on all residents had been a challenge because of staffing issues. She said she was aware the facility was having difficulty obtaining weights on residents for a few months. She said the RD was responsible to review all weights for weight loss, weight gain and provide direction on nutritional interventions. She said the RD was responsible to conduct an assessment, provide nutritional interventions and update the care plan for all residents who experienced weight loss or weight gain. She said nutritional interventions should be put into place immediately following an identified weight loss. She confirmed the weight loss for Resident #6 was not identified until the survey process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure that residents were free from abuse, neglect, and exploitation for four (#46, #30, #36 and #31) out of eight residents reviewed for facility-reported incidents of abuse out of 38 sample residents. Specifically, the facility failed to recognize and prevent resident-to-resident altercations involving verbal and physical aggression between Resident #46 and #30 and Resident #36 and #31. As a result of the 5/1/21 resident to resident altercation between resident #46 and Resident #30; Resident #46 suffered psychosocial harm causing distress for three days following the incident. Resident #46 experienced behavioral changes resulting in decreased participation in normal activities; increased anxiety and anger; and he seemed fearful and watchful of others. In addition to mood and behavior changes Resident #46 experience hip pain after being pushed to the floor by Resident #30. Resident #30 experienced mild change in mood following the resident to resident altercation and showed increased irritation for one day following the incident. The facility was aware that Resident #46 had a tendency to become agitated when other residents got too close to him and did not have sufficient interventions in place to prevent this alteration from occurring. It was not until after this third resident to resident altercation initiated by resident #46 that the facility began to assess the resident behaviors and implemented more effective interventions. Findings include: Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 6/6/21 to 6/10/2, resulting in the deficiency being cited at past non-compliance with a correction date of 5/6/21. I. Facility policy The Abuse policy, revised 10/28/2020, was provided by the nursing home administration (NHA) on 6/6/21 at 7:30 p.m. The policy read in pertinent part, The facility does not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members, other residents . -Every resident has the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, and involuntary seclusion. -Standards: Providing a safe environment for the resident is one of the most basic and essential duties of our facility. -Resident abuse is defined as the willful infliction of injury .Verbal abuse is defined as the use of oral, written, or gestured language that includes disparaging or derogatory terms to residents or their families, or within their hearing distance, regardless of their ability to comprehend, or disability. -If a resident experiences a behavior change resulting in aggression toward other residents, the facility conducts further assessment and arranges for appropriate psychiatric evaluation for further screening. The resident's care plan is revised to include new approaches to reduce or eliminate any further chance of abuse. II. Resident to resident altercation between Resident #46 and #30 Facility reported incident investigation dated 5/1/21 for an allegation of resident-to-resident physical abuse was provided by the social services director (SSD) on 6/8/21 at 12:13 p.m. The investigation revealed the allegation of physical abuse between Resident #46 and #30 was substantiated by the facility based on video surveillance evidence. Staff did not witness the incident but video surveillance revealed Resident #46 became agitated when Resident #30 walked close to where he was standing in the hallway. Video surveillance revealed the two residents exchanged words; however, the recording did not have audio so what was said was unknown. Resident #46 raised his walker with a threatening motion towards Resident #30. Resident #30 turned his back towards Resident #46 and started to walk away. Resident #46 picked up his walker and hit Resident #30 in his lower back and back of the legs with the walker two times. Resident #30 turned back facing Resident #46 and with both hands pushed Resident #46 in his chest. Resident #46 lost his balance and fell backwards to the floor, landing on his back and buttocks. Resident #46 complained of right hip pain; Resident #30 did not complain of pain after the incident. A mobile x-ray revealed Resident #46 had no fractures. The two residents were immediately separated and placed on increased monitoring. Immediately following the incident, Resident #30 said Resident #46 came after him. Resident #46 was not able to verbalize what happened. Per the investigative report, neither resident was able to explain what had happened the day after the incident when the investigator interviewed them. Following the 5/1/21 facility reported incident allegation of physical abuse between resident #46 and #30, non-interviewable resident observations were conducted to monitor the residents for changes in condition. Observation notes of the non-interviewable resident revealed the following changes in the resident's baseline mood and behavior following the incident: Resident #46 -On the evening and through the night of 5/1/21, Resident #46 presented with a decrease in participation in completing activities of daily care, recreational activities, was more anxious, and slept less. -On 5/2/21, Resident #46 ate his meals in his room instead of the dining room, was more irritable with others, more anxious, seemed angrier, and seemed fearful (not wanting to be alone and/or was more watchful of others). -On 5/3/21 Resident #46 was isolating, agitated, anxious and angrier during the day. By nighttime, Resident #46 was at baseline. Resident #46 showed signs and symptoms of mood change in the three days following the incident. In addition to mood and behavior changes, the resident also expressed physical pain in his hips and elbows in the three days following the incident for which prescribed tylenol was effective. Resident #30: -On 5/2/21 Resident #30 was more irritable. -On 5/3/21 Resident #30 was at baseline. A. Resident #46 1. Resident status Resident #46, age [AGE], was admitted on [DATE]. According to the June 2021 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, traumatic brain injury, cognitive communication deficit, and bipolar disorder. The 4/18/21 minimum data set (MDS) assessment revealed the resident had severely impaired cognition with a score of four out of 15 on the brief interview for mental status (BIMS). The resident had difficulty communicating some words or finishing thoughts but was able, if prompted and given time, to make himself understood but missed some intent or parts of communication from others. The resident did not reject care or exhibit any behaviors during the time of the assessment. The resident's balance was not steady but was able to walk with the assistance of a front wheeled walker. 2. Record review Resident #46's comprehensive care plan revealed a care focus for behavior; the care focus was initiated 3/11/21 and was revised 5/5/21. The behavioral care focus revealed Resident #46 had poor impulse control and a potential to be physically aggressive with peers, when they got too close to his personal space. -Resident #46 can become physically aggressive with peers displaying behaviors such as slapping, punching and slamming his walker into peers. Resident #46 has a difficult time recognizing his needs and verbalizing them. At times Resident #46 will use non-verbal communication; for example, when he is angry he will raise his fist in the air. When he is happy, he smiles and nods his head. Interventions initiated 3/11/21 included: -Document observed behavior and attempted interventions in behavior log. -Administer medications as ordered. Monitor and 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 etc. -Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of staff members when agitated. -Give the resident as many choices as possible about care and activities. -Modify the environment to decrease stimuli and provide resident with space when the resident becomes agitated. -Monitor, document and report any signs and symptoms of resident posing danger to self and others. -Offer and document non-pharmacological interventions prior to administering medication. Additional interventions initiated on 5/6/21, following the 5/1/21 resident-to-resident altercation included: -Allow compassionate care visits with his sister on a regular basis when she is available. -Resident #46 will meet with activities for one to one therapeutic support. -The social services director will meet with Resident #46 one time a week for therapeutic check-ins. The medical record confirmed interventions were initiated and both the social worker and activities staff were providing the resident with additional support. A review of Resident #46's medical record revealed that Resident #46 had a history of aggression towards his peers going back to March 2021. -On 3/9/21 Resident #46 became aggressive towards a female peer as she tried to enter the television room he was blocking her entry. Video footage showed Resident #46 was standing in the doorway blocking the female resident from entering. The female resident tugged at his shirt then tried to enter. Resident #46 reached out to slap at the female resident and the two residents began to punch at each other. Resident #46 ended up elbowing the female resident in the face four to five times causing her to sustain a swollen right lip. Resident #46 ended up with a scratch on his right arm. The residents were separated and placed on 15-minute monitoring checks. -On 3/15/21 Resident #46 became aggressive towards his roommate when the roommate got too close to his side of the room by Resident #46's bed. When the roommate would not leave his bedside Resident #46 pushed the roommate in the chest area. Staff walked in on this incident and separated the two residents immediately and neither was injured. Progress notes revealed the facility contacted Resident #46's physician and power of attorney; the interdisciplinary treatment team began to assess the resident for underlying causes of aggression and implemented interventions to prevent future resident to resident altercations initiated by Resident #46 form reoccurring. These events showed that Resident #46 had a potential for aggression directed towards his peers without incitement; the facility had an obligation to provide oversight and monitoring to prevent further incidents until they could be sure the interventions were effective to prevent future recurrence. Progress notes revealed that while the facility developed interventions after the first resident-to-resident altercation on 3/9/21 and were working on interventions, none were fully effective until the interdisciplinary team (IDT) and physician initiated additional interventions on 5/6/21 as documented above, and made adjustments in the resident's psychotropic medications (see documentation of progress notes below for more information). Progress notes documented the following information: -The physician/medical provider note dated 3/10/21 at 2:12 p.m., read in pertinent part: Resident seen acutely for dementia with increased agitation .Psychological: angry: positive .Plan: resident with advanced dementia. Nursing reporting increased agitation over the last few days. Agitated again today. He takes Risperdal 0.25 milligrams (mg) at bedtime. Agree that benefits of decreased aggression outweigh potential side effects. Plan: increase Risperdal to 0.5 mg daily at bedtime. -Incident note dated 3/15/21 at 7:02 a.m., read in part: Resident's roommate encroached on resident personal space (and) this made him upset. Resident pushed his roommate. -Incident note dated 4/2/21 at 10:53 p.m., read in part: Staff heard two walkers clang together and a resident say 'hey what was that for;' when investigated, Resident #46 was hitting another resident's walker angrily and stopping them from going around him. He shoved the walker against the other resident's walker. No physical contact happened and no injuries were noted. -The physician/medical provider note dated 4/15/21 at 11:45 a.m., read in pertinent part: Reason for visit: follow up on dementia with behaviors .Resident was reviewed at psych-pharmacology meeting earlier in the week and due to his frequent behaviors of striking other residents (has happened multiple times), to make medication change to decrease his dangerous behavior .Has been combative with other residents consistently since his transfer to the facility. Was on Risperdal but had no notable effect. Recommended by psych-pharmacology to trial Zyprexa at 2.5 mg and titrate up to 5 mg Zyprexa (olanzapine)- allows for increased overall well being, increased participation in activities and happiness. Benefits of this med regimen at this time, outweigh potential risks of, but not limited to agitation, depression and hallucinations as listed in clinical pharmacology. -Nursing note dated 4/25/21 at 10:47 p.m. read: Resident asleep and resting well, with no adverse reaction to being on Zyprexa, no behavior concerns at present time. -Nursing note dated 5/1/21 at 5:44 p.m. read in part: At 2:22 p.m., nurse heard two raised male voices in the hall and ran to find this resident laying on the floor with his walker tipped on its side next to him. Resident #30 was walking away from this resident. Nurse asked what happened and Resident #30 pointed at this resident and stated, 'he came after me'! Resident #46 was assessed .Both residents were placed on frequent checks for safety. Video footage viewed for this incident: Resident #46 became agitated when resident #30 walked close to where he was standing in the hallway. Resident #46 picked up his walker and threatened resident #30 with it. Resident #30 turned his back and began walking away. Resident #46 picked up his walker and struck Resident #30 in the lower back and back of thighs with his walker. Resident #30 then pushed this resident by the chest, which caused him to fall down onto the floor . -Nursing note dated 5/2/21 at 4:21 a.m., read: X-ray results, no fracture or dislocation. -Nursing note dated 5/10/21 at 11:06 a.m. Order dated on 5/7/21 discontinue Zyprexa 2.5 mg at bedtime; start Zyprexa 5 mg every morning for dementia with behavioral disturbance. Residents with a known recent history of aggression towards peers were able to initiate another resident-to-resident altercation on 5/1/21 as documented above. The resident's medical record failed to document a full assessment of care-planned interventions for effectiveness in preventing resident-to-resident altercations and physical aggression or need for temporary intervention until the newly prescribed Zyprexia was titrated to full dose and assessed for effectiveness. B. Resident #30 1. Resident status Resident #30, age [AGE], was admitted on [DATE]. According to the June 2021 CPO, diagnoses included Alzheimer's disease, dementia without behavioral disturbance, and cognitive communication deficit. The 4/1/21 MDS assessment revealed the resident had severely impaired cognition as evidenced by a score of seven out of 15 on the BIMS. The resident was able to make himself understood and was able to understand communication. The resident did not reject care or exhibit any behaviors during the time of the assessment. The resident was steady at times and used a four-wheeled walker to walk and get around the unit. 2. Record review Resident #46's comprehensive care plan reviewed care focus for behavior: The care focus was initiated 5/7/21. The behavioral care focus revealed Resident #30 had the potential to be physically aggressive with peers when they hit him. Progress notes reviewed one note regarding physical aggression towards a peer. -Nursing note dated 5/1/21 at 5:55 p.m., read in part: At 2:22 p.m., nurse heard two raised male voices in the hall and ran to find Resident #46 laying on the floor with his walker tipped on its side next to him. Resident #30 was walking away from Resident #46. Nurse asked what happened and Resident #30 pointed at Resident #46 and said, he came after me! C. Interviews Resident #46 was interviewed on 6/6/21 at 5:30 p.m. Resident #46 was nonverbal and answered with hand and facial gestures. When asked how things were going he gestured with a wide smile, eyebrows raised and hand movement with his pointer finger at his temple making a swirling circular motion. He was unable to express his thoughts in words. Resident #30 was interviewed on 6/7/21 at 9:10 a.m. Resident #30 was not very talkative, but did give some short answers to questions. When asked if everyone was getting along he said most of the time. He did not name any one in particular with whom he might have had concerns about and diverted his attention back to his television show. Registered nurse (RN) #2 was interviewed on 6/9/21 at 3:01 p.m. RN #2 said no staff witnessed the resident to resident altercation between Resident #46 an Resident #30 but they were able to get a sense of what happened from the hallway video surveillance. Based on the video footage Resident #46 became aggressive towards Resident #30 as he was walking past. Resident #46 was known to get agitated with peers who got too close to his personal space. When Resident #30 walk past Resident #46 raised his walker and threw it towards Resident #30 hitting Resident #30 on the back of his body as he was walking away with the walker; Resident #30 turned around and raised his hands in response and pushed Resident #46 backwards. Resident #46 fell back and hit his hip on the floor. It all happened very quickly. Both Residents were separated and examined for possible injury and placed on increased supervision. Resident #46 was wearing hipsters at the time and had no broken bones. Since this altercation, Resident #46 was placed on 15-minute checks at all times to ensure he kept a distance from his peers to prevent aggressive behavior. The goal was to ensure a safe environment. Resident #46 showed a decline in the past month; he was now using a manual wheelchair to get around the unit. Since a medication change to from Risperdal to Zyprexa Resident #46's behavioral aggressions had decreased. He is less aggressive with peers. III. Resident to resident altercation between Resident #36 and #31 Facility reported incident investigation dated 4/13/21 for an allegation of resident-to-resident physical abuse was provided by the SSD on 6/8/21 at 12:13 p.m. The investigation revealed the allegation of physical abuse between Resident #36 and #31 was not substantiated by the facility despite a staff witness describing Resident #31's actions as being purposeful. -After this review of the investigative report, supporting evidence and staff interviews, this allegation was substantiated. The investigative summary documented: on 4/13/21 at approximately 5:44 p.m. Resident #36 requested to call his wife. Staff were busy helping other residents with dinner service and asked Resident #36 to wait until they were available to assist him with the call. Resident #36 became very aggressive and agitated and upset with staff because he was not able to call his wife when he asked. Resident started to call the staff names and when that did not get his desired result, Resident #36 purposefully ran his wheelchair into Resident #31, who was sitting in the hall in her wheelchair. Staff intervened and separated Resident #36 and #31 and placed the two on 15 minute monitoring checks to ensure safety. Behavior tracking for Resident #36 revealed: On 4/13/21 at 6:30 p.m. CNA #4 observed Resident #36, being physically and verbally aggressive, and attempted to bump into the nurse and other resident. In response to the resident behavior staff offered one to one validation, verbal redirection, and distraction. After the interventions, Resident #36 appeared to be better. The investigation and witness interview did not start until 4/19/21. By that time, the video footage of the occurrence had been recorded over and was no longer accessible and one of the staff witnesses was on vacation and was not interviewed. The residents involved were interviewed by the licensed practical nurse (LPN) on duty the day after the resident-to-resident altercation. Resident #31 was not able to recall the altercation. When the LPN asked Resident, #36 why he had been so upset to hit another resident and told Resident #36 that it was not ok to hit another resident; Resident #36's recorded response was I don't care. The interview report failed to document Resident #36's response to the first question asked about why he was so upset. It was unclear if the resident recalled the event that next day or if he was indifferent to the questioning. There were other residents in the area when this incident occurred but the witnessing resident interviews were not conducted until 4/19/21, six days after the incident. None of the residents present were able to recall the altercation. Staff interviews were not obtained until 4/19/21. Certified nurse aide (CNA) #4 reported witnessing Resident #36 run his wheelchair into Resident #31 but gave no detail as to how hard or how many times he hit Resident #31 with his chair or if he hit any part of her body. After running into Resident #31, Resident #36 ran his chair into staff once, was told to stop, and he did. CNA #5 was on vacation at the time staff interviews were conducted and a witness statement was not obtained from CNA #5. The LPN on duty gave a witness statement but gave no additional insight into the incident. Video surveillance, which is only maintained for a limited number of days, was no longer available at the time of the investigation to view as evidence. Following the 4/13/21 facility reported incident allegation of physical abuse between resident #36 an #31, non-interviewable resident observations were conducted but not started until three days after the incident on 4/16/21 and only completed for Resident #31. The documentation revealed the following changes in the resident's baseline mood and behavior following the incident: Resident #36: -On 4/19/21 Resident #36 was at baseline -There was no documented observation of Resident #36's mood and behavior in the first couple of days after the incident from 6/13/21 and 6/18/21. There was no assessment of the Resident #36's mood and behavior following the 4/13/21 resident to resident altercation. Resident #31: -On 4/16/21 Resident #31 was displaying increased signs of agitation; was sleeping less; was out of her room more; and was more fearful (not wanting to be left alone, or was watchful of others). -On 4/17/21 Resident #31 was displaying increased signs of agitation; was sleeping less; and was more fearful (not wanting to be left alone, or was watchful of others). -On 4/18/21 Resident was at baseline. -There was no documented observation of Resident #31's mood and behavior in the first couple of days after the incident from 6/13/21 and 6/15/21. Because there was no documentation of the resident's mood and behavior immediately after the incident there was no way to determine how severely the incident affected the resident's psychosocial demeanor. The resident did have some mood and behavioral changes in the days after this event, based on documentation as described above, which may have been a response to the altercation she had with Resident #36 on 4/13/21. A. Resident #36 1. Resident status Resident #36, age [AGE], was admitted on [DATE]. According to the June 2021 CPO, diagnoses included dementia with behavioral disturbance, Parkinson's disease and anxiety disorder. The 4/18/21 MDS assessment revealed the resident had moderately impaired cognition as evidenced by a score of 10 out of 15 on the BIMS. The resident was able to communicate needs and make himself understood. The resident did not reject care or exhibit any behaviors during the time of the assessment. The resident used a manual wheelchair as a primary mode of transportation. 2. Record review Resident #36's comprehensive care plan reviewed care focus for behavior: The care focus was initiated 4/16/21 and was revised 4/20/21 and 5/26/21. The behavioral care focus revealed Resident #36 had a history of verbal aggression towards staff with the potential to be verbally aggressive towards his peers. Resident #36's behavioral symptoms included name calling, cursing at and threatening staff. Resident #36 also displayed physical aggression with using his wheelchair as a tool of aggression towards his peers and staff. Interventions included: -Behavioral monitoring. -Conduct 15-minute checks for safety. -Assist the resident with making the phone call when he requests, no matter time or day. -Anticipate and meet the resident's needs. -Assist the resident to develop more appropriate methods of coping and interacting (specify:) No interventions were specified. -Caregivers to provide opportunity for positive interaction, attention. Stop and talk with him as passing by. -Encourage the resident to express feelings appropriately. -Explain all procedures to the resident before starting and allow the resident to adjust to changes. -If reasonable, discuss the resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable. -Monitor behavior episodes and attempt to determine underlying cause. Consider location, time of day, persons involved, and situations. Document behavior and potential causes. -When behaviors occur, intervene as necessary to protect the rights and safety of others. Approach and speak in a calm manner. Divert attention. Remove from the situation and take to alternate location as needed. Progress notes revealed: -Nursing note dated 4/13/21 at 5:57 p.m., read in part: Resident has increased agitation because he dislikes the telephone schedule that was placed by his wife. Resident called several staff members disrespectful names, raised his hand to a staff member in anger as if going to hit them, ran into a resident with his wheelchair 3-4 times while I was helping to protect another resident from being hit. -Nursing note dated 4/16/21 at 2:49 p.m., read in part: The SSD and NHA contacted resident's wife to discuss facility's plan of care for Resident #36 regarding his behaviors. Resident is on 15 minute checks and we cannot tell him he cannot call her, as this causes the behaviors. The SSD asked the resident's wife, if it was ok with her, we would like for her to ignore the call if he calls and she is busy so it eliminates behaviors. The resident's wife was in agreement to this and stated she would answer on the times she can. The resident's wife understands that Resident #36 can be tough sometimes and is willing to do what she needs to make his stay here better. The SSD and NHA also discussed compassionate care visits. The resident's wife loved the idea of being able to visit in person. The resident's wife thinks this could help him and hopefully make him happier. - Nursing note dated 4/21/21 at 9:16 a.m., read in part: Resident is upset that I can no longer call his wife at this time. He has called her three times and his wife is hanging up on him. When I spoke with his wife before she stated that the resident accuses her of cheating and so she will hang up on him when he does this. The resident is becoming very agitated and will sit at the nurse station and call staff names if not able to call his wife over and over for him. -Physician/medical provider note dated 4/21/21 at 5:03 p.m., read in pertinent part: Medical necessity of visit: request to be seen, by nursing, wife and social worker. Chief complaint: patient is being seen to address dementia with behaviors. History of present illness: increasing behavior that are causing him distress .agitation, physically and verbally abusive hallucinations and paranoid delusions .Assessment and plan: consulted the geriatric psychiatrist who recommends discontinuing Sinemet as this can cause psychosis and hallucinations. I will also check labs to rule out organic causes. If the labs are normal and he is still having behaviors .Staff will monitor and keep providers up to date on behaviors. -Physician/medical provider note dated 4/26/21 at 4:52 p.m., read in pertinent part: Date of encounter: 4/26/21. Request to be seen by nursing and family. Chief complaint: patient with uncontrolled diabetes and dementia with behaviors. History of present illness: Dementia with behaviors- patient is having increasing behaviors that are causing him distress. He is calling his wife constantly and will accuse her of cheating on him. This prompts her to hang up on him. If staff does not call her when he wants, he becomes agitated and physically and verbally abusive. He also is hallucinating about a family of owls outside in a tree near the patio. His paranoid delusions about his wife have increased recently .Assessment and plan: consulted with the geriatric psychiatrist who recommends starting patients on Zyprexa. Will start with 2.5 mg twice a day. Can increase dose if needed .Staff will monitor and keep providers up to date on behaviors. -Psychosocial note - late entry dated 5/24/21 at 2:45 p.m., read: SSD followed up with Resident #36 regarding the nursing note that was documented on 5/24/21. He reported he was agitated because he wanted to call his wife. SSD and resident called his wife together. Unfortunately, she did not answer. SSD did role-playing with resident and it seemed to help de-escalate the situation. SSD stated to resident since your wife did not answer, pretend I am your wife, say the things to me that you would say to your wife if she answered. Resident said I care about you a lot and would like to see you. SSD and Resident looked at pictures together of him and his wife. SSD asked resident to share some stories/memories of them together. Resident was able to share some memories with SSD. Resident was laughing and reminiscing about past events with his wife and children. At the end of our conversation, Resident was in a pleasant mood and did not seem to be in any distress. -Psychosocial progress note dated 6/6/21 at 8:45 p.m., read in pertinent part: Changes to medical status: Started on Zyprexa on 4/26/21. Had an increase in verbal/physical aggression directed at staff (due to his wife not answering the phone when he calls). Cognition and communication status BIMs eight out of 15, previous score 10. Resident is able to verbalize his needs. Mood and behaviors .documented behaviors in the quarter, (2/6/21-5/6/21): verbal aggression: five times; refusal of care: three times; disruptive or intrusive: one time; mood issues: one time; repetitive statements: one time and physical aggression: one time. Psychoactive medications: Zyprexa tablet 2.5 mg two times a day for dementia with behaviors . B. Resident #31 1. Resident status Resident #31, over the age of 85, was admitted on [DATE]. According to the June 2021 CPO, diagnoses included dementia with b[TRUNCATED]