**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, review of facility documentation, review of policy and staff interviews for 1 of 5 sampled residents (Resident # 60) reviewed for abuse, the facility failed to ensure the resident was free from abuse and failed to protect other residents following a resident-to-resident altercation resulting in the finding of Immediate Jeopardy and for 4 of 10 residents (Resident # 36, # 43, # 70, # 76), reviewed for abuse, the facility failed to ensure the residents were free from mistreatment. The findings included: An observation on 2/28/24 at 1:09 PM, in the dining room identified Resident #76 was standing over Resident #60 who was sitting in a wheelchair in front of her/him delivering three to four blows with a closed fist to the top of Resident #60's head while Recreational Staff #1 was attempting to stand between the two residents. Other staff members responded immediately, and the two residents were separated. Resident #60 was immediately removed from the area and staff stayed with Resident #76 who remained in the area still agitated and yelling but no longer physically aggressive. 1. Resident #60's diagnoses included dementia and cerebral infarction (stroke). The quarterly MDS assessment 12/6/23 identified Resident #60 required one person assist with bed mobility, transfers, ambulated with assist of one and a rolling walker or wheelchair. The Resident Care Plan (RCP) dated 12/19/23 identified Resident #60 had impaired cognitive function related to dementia and limited physical mobility related to cerebral vascular accident (CVA). Interventions directed to monitor and report changes in cognitive function and provide ADL assistance with mobility as needed. 2. Resident#76's diagnoses included depression and chronic kidney disease. The quarterly MDS assessment dated [DATE] identified Resident #76 as severely cognitively impaired, did not demonstrate physical behavior towards others and required supervision with ambulation. The RCP dated 10/15/23 identified Resident #76 as independent with ADL skills including ambulation and had a history of resident-to-resident physical altercations. Interventions directed to provide close and distant monitoring, psychosocial support and provide a calm, quiet environment. A video surveillance dated 2/28/24 at 1:14 PM identified after the resident-to-resident altercation at 1:09 PM on the same day, Resident #76 was escorted by Licensed Practical Nurse, LPN #4 through the lobby and back to his/her room. At 1:15 PM LPN #4 was observed entering the lobby area again alone. At 1:16 PM Resident #76 returned to the lobby area before making his/her way back towards the dining area at 1:17 PM. Resident #76 was then greeted by Social Worker, SW #2 and went to her office. Resident # 76 then exited SW # 2's office and was observed returning to the dining room where there were more than five residents remaining. Resident #76 sat down in a chair along the wall within 3 feet of two other residents without staff supervision which resulted in a finding of Immediate Jeopardy. Resident #60 's nurses note dated 2/28/23 at 10:05PM identified at 1:30PM the resident was heard yelling from the dining room where it was witnessed Resident #60 was yelling with another resident (Resident #76) and was hit multiple times in the head and arm by Resident #76. The two residents were separated immediately. Emergency Medical Services (EMS) were called, social worker, medical and police were notified. Resident #60 was escorted back to his/her room with staff until EMS arrived and subsequently transferred to the emergency room for an evaluation. A subsequent nurses' note dated 2/29/24 at 12:41 PM identified s/he returned from the hospital at approximately 11:55 PM skin warm to touch, no bruising noted, purpura to the back of right hand. Lung sounds clear to auscultation, drenched with urine with no swelling noted and no signs of discomfort. Resident #76's Advanced Practice Registered Nurse (APRN) progress note dated 2/28/24 identified Resident #76 was in the dining room and observed by staff in a verbal altercation with Resident # 60. Resident # 76 was observed striking Resident # 60 on his/her head and arm. The residents were immediately separated and returned to their rooms on different units. Resident #76 was placed on one-to-one continuous observation. A hospital Discharge summary dated [DATE] identified s/he was cleared by psychiatry before returning to the facility with no medication changes. Resident #76 was scheduled to be evaluated by psychiatry on 2/29/24. A subsequent nurses note dated 2/29/2024 at 1:09AM identified Resident #76 was back at the facility appeared to be calm and remained on 1:1 enhanced supervision. An interview with Recreational Staff #1 on 2/28/24 at 1:24 PM and 2: 21 PM identified residents in the dining area were involved in unstructured activities after lunch which did not require staff supervision. Resident #76 and Resident #60, both Spanish speaking and known to be friends, were sitting next to each other playing a game of Dominos. Recreational Staff #1 heard Resident #76 and Resident #60 conversing during the game while coming in and out of the room but did not understand what was being said. Recreational Staff #1 entered the room and observed Resident #60 push the dominos away from him/herself and Resident #76 and stood up from the chair and started yelling just as Recreational Staff #1 walked over to intervene, Resident #76 began delivering blows to the top of Resident #60's head who was sitting in a wheelchair. Recreational Staff #1 stated she stood between Resident #76 and Resident #60 to intervene and began calling out but was unable to prevent Resident #76 from continuing to deliver blows to Resident #1's head. Additional staff arrived to intervene, and the two residents were separated. Recreational Staff #1 removed Resident #60 from the area to receive medical attention. Recreational Staff #1 stated Resident #76 was known to have exhibited aggressive behavior towards other residents in the past while playing dominos and had reported the problem to the Recreation Director with no resolution. An interview with the Director of Nursing Services, DNS on 2/28/24 1:29 PM identified she had instructed LPN #4 to escort Resident # 76 back to h/her room and stay with h/her until EMS arrived. An interview with LPN #4 on 2/28/24 at 1:34 PM 2/29/24 at 10:48 AM identified she was directed by the DNS to bring Resident #76 back to h/her room following the altercation but needed to leave h/her to provide care to another resident on her assigned unit. LPN # 4 further indicated she left Resident #76 alone in h/her room following an altercation with Resident # 60. An interview with the Recreation Director on 2/28/24 at 2:56 PM identified Resident #76 loved playing Dominos and was competitive. There were times Resident #76 would yell at other residents while playing Dominos and that defusing and redirecting usually worked. If not, residents would be separated. The Director of Recreation stated Recreation Staff #1 did bring up the game of Dominos as a concern in the past, but the consensus was Resident #76 liked to play so dominos was provided without any additional intervention. A subsequent interview with the DNS on 2/28/24 at 3:07 PM identified she was aware of past resident to resident altercations centered around the game of Dominos and had set up additional rooms, purchased additional [NAME] games and indicated staff to be aware when Resident #76 was playing with Dominos. An interview with the Director of Maintenance on 2/28/24 at 4:01 PM identified he translated for Resident #76 when speaking with local law enforcement following the resident-to-resident altercation on 2/28/24. Resident #76 indicated he/she was playing Dominos with Resident #60 who began making moves in the game that made Resident #76 angry and was sworn at before slapping Resident #60. The facility failed to ensure a resident, Resident #60 was free from physical mistreatment resulting in a resident-to-resident altercation during a game where it was previously known to staff Resident #76 demonstrated increased aggressive behaviors while playing and had a previous resident altercation over the game and failed to protect other residents by providing enhanced supervision of Resident #76 until he was transferred to the Emergency Department for an evaluation following an assault of another resident. A review of the facility policy for Abuse directed that the facility maintains a zero-tolerance policy for any form of abuse including physical abuse defined as hitting, slapping, pinching kicking or controlling behavior through corporal punishment. The Administrator was presented with the Immediate Jeopardy Template on February 29, 2024, at 2:33 PM for F 600 Free from Abuse and Neglect. The facility submitted a removal plan on February 29, 2024, at 6:36 PM. The removal plan included the following: 1. The Interdisciplinary Team (IDT) will review daily the clinical record or observations to ensure no resident is exhibiting aggressive behavior or harm to another resident. 2. Staff will immediately separate any resident-to-resident altercations and remove both from area and de-escalate the situation. 3. Resident with be placed on frequent checks including but not limited to 1:1 until cleared by psychiatric services. 4. Ongoing assessment will include but not limited to offer or seek alternate placement as needed if determine that resident is still exhibiting behaviors that put other at risk. 5. Facility will continue to monitor Resident # 76 and any other resident for triggers that may cause harm or injuries from resident-to-resident altercations and provide safety interventions including but not limited to 1:1 and every 15-minute check of monitoring until behavior is safe. 6. Review and re-educate staff on abuse policy and revise as necessary 7. Staff will stay with the aggressor until additional interventions are implemented to ensure the safety of other residents. 8. Both the Social Worker and Director of Recreation are meeting with residents to ensure no other resident is harmed or fearful. 9. The IDT team will continue to have ongoing evaluations of residents to ensure no resident is susceptible to harm from another resident weekly times four and monthly thereafter. Additionally, noted the person responsible for monitoring the plan action was Administrator /Designee. 3. Resident #36's diagnoses included dementia, intellectual disability, and aphasia (difficulty communicating or understanding). The quarterly Minimum Data Set (MDS) assessment dated [DATE] identified Resident #36 as cognitively intact and independent with activities of daily living (ADL) including ambulation. The Resident Care Plan (RCP) dated 9/29/23 identified Resident #36 attended scheduled programs and expressed interest in more activities. Interventions directed to continue to invite and encourage participation in appropriate activities. An Advanced Practice Registered Nurse (APRN) note dated 11/7/23 at 1:03 PM identified Resident # 36 was involved in a resident-to-resident altercation with another resident, Resident #76 the evening prior at 4:15 PM in the resident dining room. Resident #36 was struck on the back of the neck by Resident #76 with no reported injuries. A Psychiatric Evaluation dated 11/7/23 identified Resident #36 had a recent altercation with another resident, Resident #76, was unclear of the details, appeared calm and cooperative with no new medication changes. Resident#76's diagnoses included depression and chronic kidney disease. The quarterly MDS assessment dated [DATE] identified Resident #76 as severely cognitively impaired, did not demonstrate physical behavior towards others and required supervision with ambulation. The RCP dated 10/15/23 identified Resident #76 as independent with ADL skills including ambulation and had a history of resident-to-resident physical altercations. Interventions directed to provide close and distant monitoring, psychosocial support and provide a calm, quiet environment. A nurse's note dated 11/7/23 at 8:11 PM identified a resident was heard in the dining area yelling in Spanish and being aggressive. Another resident, Resident #36 was assisting in cleaning a table when Resident #76 became agitated and hit h/her on the back of the neck. Two staff members were hit while attempting to separate the two residents. Resident #76 was moved to a separate area, emergency services activated, and Resident #76 was subsequently transferred to the emergency department for further evaluation. The hospital After Visit Summary dated 11/6/23 identified Resident #76 was psychiatrically cleared for return to the facility with no medication changes and recommendations to follow up with providers. A Psychiatric Evaluation dated 11/7/23 identified Resident #76 was sent to the hospital for physical aggression after hitting another resident. Resident #76 was prescribed an increase in Trazadone (medication used for the treatment of depression) and recommendations for a neurocognitive psychiatric evaluation. A Police Case/ Incident Report dated 11/7/23 at 8:09 PM identified on 11/6/23 at approximately 4:10 PM the police responded to the facility following a report of a resident to staff and resident to resident incident where Resident #76 was reportedly playing Dominos when a staff member told Resident #76 it was time for dinner. Resident #76 became upset and lashed out because s/he did not want to put away the game of Dominos. A facility Reportable Event Summary dated 11/10/23 identified on 11/6/23 at 4:15PM in the dining area, Resident # 36 was struck in the back by Resident #76 when attempting to clean up after a game of dominos. Resident #76 was transferred to the emergency room (ER) for further evaluation, returned to the facility following medical clearance and received medication adjustments on 11/7/23 after being evaluated by in-house psychiatry. Resident #36 and Resident #76 resided on separate units and the [NAME] activity was moved to another room to facilitate additional space for card playing prior to supper time. An interview with Recreational Staff #1 on 2/28/24 at 1:24 PM and at 2: 21 PM following a subsequent resident-to-resident incident during a game of Dominos identified Resident #76 was known to have exhibited aggressive behavior towards other residents in the past while playing dominos and had reported the problem to the Recreation Director with no resolution. An interview with the Director of Nursing on 2/28/24 at 3:07 PM and 3/4/24 at 11:35 AM identified Resident #76 was evaluated by psychiatry following the incident and was prescribed medication adjustments following the incident. Another room outside of the dining room where the incident had occurred was designated for use for Dominos, however residents were not required to use the room for that purpose. The DNS indicated she would expect residents to be free from abuse. 4. Resident #70's diagnoses included hemiplegia (weakness) and hemiparesis (paralysis) following a cerebral infarction (stroke). The quarterly MDS assessment dated [DATE] identified Resident #70 was cognitively intact, required extensive two person assist with bed mobility, transfers, one person assist with locomotion on the unit using a wheelchair. The Resident Care Plan (RCP) dated 4/11/23 identified Resident #70 had limited physical mobility and had a history of being verbally abusive and combative telling people to get out of the way so s/he can navigate the hallways. Interventions included providing assistance of two and analyze times, places, circumstances, triggers and what de-escalates the behavior and document. Resident #70 nurse's note dated 6/1/23 identified a resident-to-resident altercation had taken place between Resident #70 and Resident #26 and a police investigation was ongoing. 5. Resident #26' diagnoses included borderline personality disorder and anxiety. The quarterly MDS assessment dated [DATE] identified Resident #26 as cognitively intact, did not express any indicators of psychosis, required one person assist with bed mobility, transfers and was independent with locomotion with the use of a wheelchair. The RCP dated 5/22/23 identified Resident #26 had a history of loud outbursts, past resident to resident physical abuse and often threw things at staff. Interventions directed to approach with two staff members for loud outbursts, call police and address behavior and inappropriateness immediately with resident. Resident #26's nurse's note dated 6/1/23 at 7:55PM identified a resident-to-resident altercation that took place at 7:45 PM. Resident #26 reported Resident #70 ran over h/her right lower leg while trying to pass, doing it on purpose. Resident #70 reported Resident #26 was calling h/her names because s/he was unable to get by in the hallway calling Resident #70 a B and a MF. Resident #70 stated s/he accidentally hit Resident #26 with the wheelchair because s/he was close. The Director of Nursing was notified, and a skin check was completed. Resident #26 complained of pain in the right lower leg. The right leg was able to move without limitations. An x-ray was scheduled, and police notified. An investigation statement dated 6/1/23 completed by Maintenance Staff #1 (former staff) identified at approximately 7:40 PM, Resident #26 was observed asking Resident #70 to move h/her wheelchair so s/he could go down the hall. Resident #70 attempted to move the wheelchair so Resident #26 could pass but ran over Resident #26's foot by accident. Resident #26 screamed and began cursing at Resident #70 and then threw water on h/her. Radiological Results for Resident #26 dated 6/2/23 identified x-rays of the right tibia/fibula (lower leg bones) were negative. A facility Reportable Event Summary dated 6/8/23 identified on 6/1/23 at 7:40PM, Resident #70 and Resident #26 were both in the hallway trying to get by each other. Resident #70 was in an electric wheelchair and in the process of trying to move the wheelchair s/he accidentally hit Resident #26's leg. Resident #26 had a glass of water, in a medicine cup in h/her hand and threw it at Resident #70. No injuries were noted to either resident. The residents were separated immediately and would continue to be seen by medical, psychiatry, and social services. Resident #70 and Resident #26 were educated to offer space to others when ambulating in common areas. Staff were directed to monitor for inappropriate interactions or escalation of the residents and separate as necessary or deescalate. An interview with the Director of Nursing (DNS) on 3/4/24 at 11:35 AM identified she would expect residents to be free from abuse, the care plan updated to reflect the individualized need and the resident(s) to receive support from social services following the event. Efforts to interview the (former) Maintenance Staff #1 were unsuccessful. 6. Resident #43's diagnosis included depressive episodes and dementia. Resident #43's was admitted on [DATE] to the facility. Resident #43 was verbally appropriate, had adequate hearing and adequate vision with glasses. A Brief Interview for Mental Status (BIMS) dated 12/6/2024 indicated resident #43 had mild cognitive impairment. The baseline care plan from admission with no date of completion, indicated in part Resident #43 was admitted with depression, dementia and was sad/crying. 7. Resident # 250's diagnoses included diabetes mellitus, psychotic disorder, and schizophrenia. The quarterly MDS assessment dated [DATE] identified cognition intact and independence with ambulation. The facility Reportable Event (RE) form dated 12/8/22 at 9:20 AM indicated Resident #43 alleged Resident #250 came to the door of the resident's room and verbally threatened to cause sexual harm. A Reportable Event Report dated 12/8/22 at 9:20 AM indicated another Resident #29 accused Resident #250 of touching his/her thigh while making verbal sexual advances. The report further indicated the facility immediately initiated an hourly check on Resident #250, and staff were educated to be vigilant of any inappropriate behavior. The Reportable Event Report also indicated Resident #250 was seen by psychiatric services and provided counseling and police were notified and came in to talk with the resident. An interview with the DNS on 2/28/24 at 10:40AM indicated copies of the police report were not requested as Resident #250 did not return from the hospital. Although, the DNS indicated he/she found the abuse allegations against Resident #250 were unsubstantiated indicating Resident #43 most likely was repeating something else heard outside the room. The DNS indicated Resident #29's incident may have happened days before. The conclusion was made without the additional evidence of interviews conducted by the police. The DNS agreed to obtain copies of the police report (2 years later). The police reports incident date 12/8/2022 at 10:17AM, 1:47PM and 7:00PM obtained after surveyor inquiry indicated in part Resident #250 did touch Resident #29's shoulder in a platonic way as they were hanging out but did not touch Resident #29 or show an imprint of his/her genital area. The officer advised Resident #250 to leave Resident#29 alone and if he/she continued to speak to Resident # 29 he/she could be arrested for harassment. The reports further indicated Resident #250 admitted to the police officer he/she told Resident #43 he/she wanted to rape Resident #43. The report further indicated Resident #43 did not want to press charges. The social service note dated 12/9/22 at 2:33 PM identified the Social Worker (SW) did a follow up visit with resident to see how s/he was doing after the alleged allegation of one of her/his peers. Resident # 43 was informed that Resident # 250 was no longer in the facility, so s/he does not have to fear. Resident # 43 stated that she was very happy Resident # 250 gone and s/he does not have to listen to her/him. Additionally, the resident was seen by psychiatric APRN and assured all safety measures were in place. The facility policy labeled Resident Abuse and Neglect indicated in part a summary of the facts, actions taken, conclusions and specific plan of correction are documented on the Incident/Accident investigation in the medical record and ensure the outcome is completed within 5 working days. The dates of completion of the police reports indicated 12/10 22 at 9:11 AM, 9:59 AM, and 10:19 AM (within 5 working days (12/14/2022) and could have been requested by the facility for use in their investigation. Interview with the DNS on 3/4/24 at 2:30 PM identified to hourly checks were safety measures put in place to address the resident-to-resident incident. 8. Resident #76's diagnoses that included traumatic brain injury, major depressive disorder, and seizures. The annual MDS assessment dated [DATE] identified Resident #76 as moderately cognitively impaired and required set up or clean up assistance for eating and required partial assistance for toileting and showering. The assessment noted the resident was independent for mobility. The MDS assessment further identified Resident #76 had 1 occasion of verbal behavioral symptoms. 9. Resident # 61's diagnoses included high blood pressure, chronic kidney disease and dementia. The quarterly MDS assessment date 12/27/22 identified Resident #61 as severely cognitively impaired and required limited assistance of one for eating, toileting and personal hygiene and was independent for dressing. The MDS assessment further identified Resident #61 did not display any verbal or physical behavioral symptoms towards other residents. a. A review of the Accident and Incident Report (A & I) form dated 2/13/23 at 7:00 AM identified a possible physical altercation that happened between Resident #76 and Resident #61. Resident #76 had slight left eye bruising and discoloration and stated Resident #61 hit h/him. The incident was unwitnessed, and police were called. The police report dated 2/13/2023 at 8:34 AM indicated Resident #76 was attempting to go to sleep when Resident #61, who was also his/her roommate was watching TV, and Resident #76 states that s/he stood up to turn the TV off and when s/he did, s/he was struck in the eye, fell to the ground and kicked in the right rib area while on the ground. Resident #76 and Resident # 61 were separated. The attending officer indicated that he observed Resident #76 ' s bruised left eye and bruised right ribs. Resident #61 stated to officers that s/he did not recall the event. Although the facility investigation indicated no bruising to the right ribs, police identified it. A review of the Reportable Events page findings for the state agency dated 2/17/2023 at 12:00 AM indicated Resident #76 was upset because h/her roommates TV was loud early in the morning. An argument occurred and Resident #76 was hit in the face by Resident #61. Resident #61 was moved back to h/his original room, on another wing. Resident #76 was seen by medical, social work, and psychiatry. Resident #76 was offered ear plugs or headphones for when their roommate is watching TV. The event was identified as resident to resident abuse without injury. b. A review of the A & I formed dated 6/4/23 at 7:45 PM identified that an argument over the TV occurred where Resident #76 asked resident #7, their roommate to turn down the TV. It is unclear whether Resident #76 tried to take the remote or attempted to turn the TV down, when Resident #7 pushed Resident #76, and both residents were hitting/punching each other. The residents were separated from each other, and the police were called. A hematoma was noted on the eye of Resident #76. The police report dated 6/4/23 at 6:44 PM indicated Resident #76 was trying to sleep when Resident #7, who was their roommate, turned the TV on in the room. Resident #76 asked Resident #7 to turn the volume of the TV down and Resident #7 turned the volume up. Resident #76 stated s/he stood up to turn the TV off and was pushed by Resident #7. Resident #7 stated s/he tried to keep the remote away from Resident #76 when Resident #76 fell. Resident #7 indicated to officers that s/he did not mean to push Resident #76. No injuries were identified by officers. A review of the Reportable Events page findings for the state agency dated 6/8/23 at 12:00 AM indicated Resident #76 became mad when Resident #7 would not turn the TV down after being asked. Resident #76 and Resident #7 began to argue when Resident #76 was pushed by Resident #7, and they proceeded to hit each other in the face. No injuries were noted to either resident in the report. Resident #7 was moved to another room and wing. Education regarding space in common areas was given. Resident #76 plan directed to continue to be seen by medical, psychiatry, and social work. Staff were to monitor for inappropriate interactions or escalation of the resident and separate as necessary or deescalate. The event was identified as resident to resident abuse without injury. Interview on 2/29/24 at 11:24 AM with the DNS indicated after the 2/13/23 resident to resident altercation that the facility provided Resident #76 with earplugs and headphones to help with the noise. A review of the facility Resident Abuse and Neglect policy (no date) directs the facility to maintain a zero-tolerance policy for any forms abuse, neglect, and exploitation of a resident. It further states that all residents have the right to be free from abuse, neglect, and exploitation.