**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, hospital document review, staff interviews, family interviews, hospice documents, hospice agreement and facility policy review the facility failed to notify in a timely manner 1 of 3 resident's hospice provider when she had a fall with injury (Resident #1). On [DATE] at 8:30 AM the nurse was called to the resident's room by another staff member. Resident #1 was lying on the floor on her left side. The resident reported she was getting up to go to the bathroom and fell. An assessment was completed and found skin tears to her left arm and next to her left eye. Bruising was noted to start over her left eye. At 10:07 AM the hospice nurse was notified that the resident had a fall and sustained an injury. When the hospice nurse arrived to the facility at 11:38 AM she noted a large hematoma to her left eye and it was swollen shut. Various small lacerations to her bilateral upper extremities were also noted. She was later sent to the hospital and found to have a subarachnoid hemorrhage scattered throughout the brain, small amount of intraventricular hemorrhage, small intraparenchymal hemorrhage, and left sided scalp hematoma. On [DATE] at 12:28 PM Resident #1 expired at the facility. This resulted in an Immediate Jeopardy (IJ) to residents' health and safety The facility reported a census of 32 residents with 2 residents receiving hospice services. The facility was notified of the Immediate Jeopardy on [DATE] at 4:10 PM. The IJ was removed on [DATE] at 4:41 PM when the facility submitted an acceptable removal plan and the scope and severity was lowered from a J to a D. The facility's removal plan documented the following actions: 1) Change of condition or fall, hospice notification will occur in a timely manner 2) If nurses cannot reach the on-call hospice provider they will call the primary care provider (PCP). If they cannot reach the PCP, they will contact their third-party physician services to notify the Medical Director. 3) One on one training with the Director of Nursing (DON), Assistant Director of Nursing (ADON) and licensed nurses to notify hospice in a timely manner of a change of condition or fall. 4) Agency Orientation Checklist to be completed for all new agency staff members to review education. 5) Hospice Notification Audit created to be completed with each clinical morning meeting by DON or designee to ensure compliance. 6) Medical Director notified and reviewed through ADHOC QAPI [DATE] at 5:18 PM. 7) Information taken to QAPI monthly x 3 months. Findings include: The significant change Minimum Data Set (MDS) assessment dated [DATE] for Resident #1 identified a Brief Interview of Mental Status (BIMS) score of 14 out of 15 indicating no cognitive impairment. The MDS revealed she required extensive assistance of one staff for transfers and toilet use, and supervision of one staff for bed mobility and personal hygiene. The MDS listed the following diagnoses for Resident #1 to include chronic obstructive pulmonary disease (COPD), atrial fibrillation, CAD, heart failure, renal failure, diabetes mellitus, anxiety, depression, and morbid obesity. The care plan focus area dated [DATE] identified Resident #1 received hospice services effective [DATE] due to hypertensive disease with heart failure. The care plan indicated the facility will coordinate her care with her hospice team. The focus area dated [DATE] identified the resident at risk for falls. The care plan directed staff to ensure hourly rounding is completed on the resident to offer more frequent toileting and care needs. The care plan also directed staff to encourage and remind the resident to ask for assistance instead of getting up on her own. The care plan focus area dated [DATE] identified the resident needs staff assistance due to her right hip fracture and directed staff to provide two person assistance with routine toileting and all transfers. The care plan focus area dated [DATE] identified the resident as at risk for bleeding due to anticoagulant therapy. Review of Resident #1's Cardiopulmonary Resuscitation (CPR) Do Not Resuscitate (DNR) Declaration Form indicated she wanted CPR initiated and/or the Automated External Defibrillator (AED) used to prolong her life when biological death was imminent. Record review revealed an untitled document that indicated Hospice began serving Resident #1 on [DATE] with the primary diagnosis of congestive heart failure. Record review revealed an Interdisciplinary Group Meeting with hospice on [DATE] at 8:00 AM listed she was admitted to hospice on [DATE]. The hospice care plan documented Resident #1 required assist with transfers to her bed/chair, dressing but was able to self-propel while in her wheelchair. The meeting listed she received Clopidogrel 75mg once a day and she desired to receive CPR. Review of Resident #1's [DATE] Medication Administration Record (MAR) revealed she received clopidogrel (blood thinner) 75 milligram (mg), 1 tablet by mouth one time a day for blood clot prevention, with a start date of [DATE] and end date of [DATE]. The MAR also documented staff administered a PRN (as needed) order of Tylenol 500 milligrams (mg) every six hours as needed for pain on [DATE] and was documented as effective at 1:44 PM. The Progress Notes for Resident #1 documented the following: On [DATE] at 12:58 PM Hospice note documented the Social Worker visit completed. Facility charge nurse states the resident is a bit more confused from last week but no other concerns. On [DATE] at 2:39 PM Hospice note documented the Registered Nurse visit completed. Charge nurse, Staff A, reports resident a little more confused this morning. On [DATE] at 9:00 AM late entry documented Staff A called to the room at 8:30 AM, resident lying on the floor on her left side. Resident #1 stated she was getting up to go to the bathroom and fell. Assessment done, no noted extremity deformities, no pain in her arms or legs, active range of motion (AROM) was within normal limits. Skin tears noted on her left arm and next to her left eye. Bruising starting to develop over her left eye, attempts were made to apply ice to the area. Hospice called and nurse came and evaluated the resident. Staff A made calls to Resident #1's top two emergency contacts, no answer to either. On [DATE] at 11:38 AM Son here to see resident and very upset regarding her condition with injury to left eye from the fall. Son requested resident be sent to the emergency room (ER). Nurse contacted Hospice and spoke to the nurse. She stated she is almost to the facility to assess the resident. Currently no change to the resident, she denied pain, no change in level of consciousness and vitals stable. On [DATE] at 12:02 PM Hospice nurse here ans spoke to son and charge nurse regarding the resident. Son very upset about injury and resident having multiple falls. Charge nurse asked son to reach out to sister and brother and if they decide they want her sent out then the facility will send her out. On [DATE] at 1:44 PM Acetaminophen tablet 500mg administered as needed for pain. On [DATE] at 2:02 PM Hospice note documented the Hospice nurse received a call from Staff A at 10:07 AM that the resident had a fall with injury about an hour prior to notification and family had been notified. Upon arrival to facility at 11:38 AM observed resident sitting next to the nurse station. Large hematoma to left eye and is swollen shut. Various small lacerations to bilateral upper extremities. Vitals stable, neuro checks normal and patient denies pain at this time. Son at bedside and is upset that she was not sent out immediately to the ER. Hospice nurse advised that resident could be sent out per his request. He is awaiting his sister. At 4:29 PM Hospice nurse provided an update to son on resident with no changes. Daughter arrived to facility and she would like the resident sent out. At 4:58 PM verbal order received by physician to send resident out for evaluation. On [DATE] at 7:31 PM ER Nurse phoned and informed facility that resident had a brain scan and has several small brain bleeds for which there are no interventions and will be sent back to the facility on hospice and end of life care. On [DATE] at 7:40 PM Hospice Nurse phoned and informed facility that resident is returning to facility and she is still full code but they are going to work on changing that. On [DATE] at 8:30 PM Late entry documented resident returned to facility. Upon assessment resident lethargic. Significant swelling and bruising noted to left eye and left side of face. Dressings clean, dry and intact to skin tears on left arm. On [DATE] at 9:00 PM son and daughter arrived. Daughter at bedside and requested pain medications administered due to resident is twitching and grimacing in pain. Resident nods head when questioned about pain. As needed Morphine given. Review of the resident's clinical record revealed the resident's primary physician was not contacted by the facility staff of the incident that occured on [DATE] at 8:30 AM until notified by the Hospice Nurse at 4:58 PM. Review of the Major Injury Determination Form documented on [DATE] at 8:30 AM Resident #1 was found lying on the floor in her room. Noted a skin tear and bruising around her left eye. By the afternoon her left eye was swollen shut, was sent to the hospital and found to have several subarachnoid hemorrhages. Resident was confused, stated she was trying to go to the bathroom and fell. Resident passed away on [DATE]. At the time of the fall she was an assistance of two staff, pivot transfer to her wheelchair. The form was completed by the Director of Nursing (DON) on [DATE] at 1:30 PM. The A Registered Nurse Practitioner (ARNP) deemed injury as a major injury; signed and dated the form on [DATE] at 11:42 AM. Review of the emergency room (ER) Visit note dated [DATE] at 5:51 PM documented Resident #1 fell and had left periorbital (eye socket area) swelling. The resident was not sure how she fell and reported facial pain. She was not sure why she was in the nursing home or on hospice. Physical exam revealed left eye periorbital edema and ecchymosis (discoloration of the skin resulting from bleeding underneath). A head CT (computed tomography) scan showed: a subarachnoid hemorrhage scattered throughout the brain, small amount of intraventricular hemorrhage, small intraparenchymal hemorrhage within the medial left cerebellum, and a large left-sided scalp hematoma. Review of hospice call logs provided by the hospice company revealed Staff A called the hospice on-call number on [DATE] at 10:03 AM to report Resident #1 fell, hit her head and had a hematoma over her left eye. The message was marked as delivered to the on call hospice staff member on [DATE] at 10:06 AM. At 11:36 AM the Assistant Director of Nursing (ADON) called to report Resident #1's family was upset she did not go to the hospital after her fall. On [DATE] at 12:51 PM Resident #1's emergency contact #3 indicated when he came to visit his mom on [DATE] she was sitting up in her wheelchair behind the nurse's station. She had a softball sized raised area to her face, and that it was bad. Photo image provided of resident #1 revealed left eye swollen shut and swollen softball sized and purple with a laceration and dried blood down the left side of her face. Son feels like the facility should have sent her to the ER when it first happened. Review of Resident #1's certified death certificate with an issued date of [DATE] listed the immediate cause of death as subarachnoid hemorrhage. On [DATE] at 2:08 PM Staff B stated it was a busy morning on [DATE]. She went in to Resident #1's room about 8:05 AM to assist her roommate with getting up for breakfast. Resident #1 was still in bed sleeping which was normal because she stayed in bed during breakfast. After she was done assisting other residents she saw Resident #1 in her wheelchair about 8:30-8:35 AM with blood coming from her face. When asked if Resident #1 was in pain, she stated her whole side of her face hurt and it was swollen, it looked absolutely horrible. Resident #1 said it hurt pretty bad and they were putting ice packs on her face to try to keep her comfortable. Her knee and head were bleeding and she had a huge knot on her head with an open spot on her eyebrow. On [DATE] at 11:12 AM Staff C Certified Medication Aide (CMA)/Certified Nursing Assistant (CNA) stated it was a crazy day on [DATE]. She indicated after breakfast, the kitchen staff were passing room trays. That staff member called down the hall indicating she needed a nurse because Resident #1 was on the floor and bleeding. Herself and the nurse on duty that day went down to the resident's room. They found her lying on the floor, in front of the bathroom. There was a lot of blood on the floor which appeared to be coming from a laceration on her eyebrow. They applied dressing to the area and got ice to place on her head. She appeared to be in pain and said her eye hurt. Staff C did give her an as needed (PRN) Tylenol but that did not help and she reported this to the nurse on duty. The nurse indicated there was not much they could do, so they continued with the ice packs. On [DATE] at 2:31 PM the hospice nurse that was on call on [DATE] stated she got a call from Staff A about 10:00 AM or so that resident had a fall out of bed. When she asked if Resident #1 had injuries he indicated she did. She told him she was about one and half hours away, heading to the facility. She was probably about five minutes from the facility when the ADON called her to report the family was upset they did not send the resident out. She had observed a large bruise to her face and her eye was swollen shut. The hospice nurse indicated the first call she got that day about the resident falling and sustaining an injury was about 10:00 AM, which she called them back right away. She gave them her personal cell phone number to contact her after that if they needed. The next call she received was when she was about five minutes from the facility and that was from the ADON. The facility calls the on call number which the triage nurse takes the call and passes the message on to the hospice nurse on-call for that day. She denied the facility calling her twice before speaking with them. She indicated once she receives the message, she calls the facility right away. On [DATE] at 10:29 AM the ADON stated she arrived to the facility about 10:15-10:30 AM. She noted a large bruise over Resident #1's eye, a skin tear to one of her elbows. When she asked Resident #1 if she was in pain, she denied having pain. She did not believe a PRN was given since Resident #1 was denying any pain. Hospice was contacted and on their way in by the time she came to the facility herself. On [DATE] at 10:48 AM Staff A, Licensed Practical Nurse, stated about 8:15-8:20 AM a kitchen staff member was passing trays down the hall and saw Resident #1 on the floor in her room. He went down to the resident to assess her. After he completed his assessment they brought the resident up to the nurse's station in her wheelchair so he could continue to complete his neurological assessments while he passed medication, assisted with transfers and other tasks that needed done that morning. Resident #1 had reported she was getting up to go to the bathroom and she fell, this was normal for her to get up without assistance. He noted bruising on the left side of her forehead and swelling over her eye. Staff A indicated he called hospice twice before someone called him back after the third call. He could not remember if the call was dropped or he was hung up on. When asked if he could have called the doctor, he indicated the hospice nurse notifies their hospice provider when things like this happen. When asked if Resident #1 was in pain, he stated no not really. On [DATE] at 11:29 AM Staff D [NAME] stated she was delivering room trays that morning and noticed Resident #1 on the floor. She called for the nurse and CMA to assess the resident. Resident #1 complained of pain in the back of her head kind of by her ear. She noticed a large amount of blood and a gash near her eye, but she was not complaining of pain above her eye. She indicated after awhile the nurse attempted to call hospice but stated he could not get through. Staff D stated her eye continued to swell and the bruising was turning a dark purple/black color, she thought maybe the resident had a fracture or brain bleed by looking at her injuries. On [DATE] at 1:05 PM the Director of Nursing (DON) stated she was not on call when Resident #1 fell on [DATE]. She came in to assist with a community event at the facility. She arrived at the facility about 10:45 AM and saw Resident #1 sitting at the nurse's station. She noticed she had some bruising to her face and her eye was swollen. She asked her if she was in pain and she said no. Staff A indicated he called hospice and she was on her way. On [DATE] at 11:37 AM during an interview with Staff F, Registered Nurse, she stated she was not working at the time of Resident #1 fall. She stated the resident's injuries to her face were pretty swollen and were from her left eye. She stated the resident should have gone to the ER sooner. She stated if she was working and with this serious of injuries and being a full code and on a blood thinner she would have sent her out. She stated when a resident is Hospice they call them first. When asked if she could not get ahold of Hospice she stated she would call the resident's physician. The facility policy titled Change in a Resident's Conidition or Status with a revised date of February 2021 documented the following: Policy Statement: Our facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition and/or status. Policy Interpretation and Implementation: 1. The nurse will notify the resident's attending physician or physician on call when there has been an: a. accident or incident involving the resident; d. significant change in the resident's physical/emotional/mental condition; g. need to transfer the resident to a hospital/treatment center. 2. A significant change of condition is a major decline or improvement in the resident's status that: a. will not normally resolve itself without intervention by staff or by implementing interventions; b. impacts more than one area of the resident's health status; c. requires interdisciplinary review and/or revision to the care plan. 4. Unless otherwise instructed by the resident, a nurse will notify the resident's representative when: a. the resident is involved in an accident or incident that resulted in an injury. The facility policy titled Acute Condition Changes with a revised date of [DATE] documented the following: Policy Statement: 1. The facility shall use a defined protocol to evaluate and report changes in condition of its residents. 2. Physicians shall help identify and manage causes of acute changes of condition. Procedure: 5. The nursing staff will contact the physician based on the urgency of the situation. For emergencies, they will call or page the physician and request a prompt response (within approximately one-half hour or less). 6. The attending physician will respond in a timely manner to notification of problems or changes in condition and status. The nursing staff will contact the medical director for additional guidance and consultation if they do not receive a timely or appropriate response. The facility provided the following hospice agreement, dated [DATE], between the facility and hospice provider. The agreement indicated the facility shall immediately notify hospice if: a significant change in the hospice resident's physical, mental, social or emotional status occurs; a need arises to transfer a hospice resident and hospice will make arrangements for any necessary continuous care, acute inpatient care or skill nursing facility care necessary related to the terminal illness and related conditions. The facility shall designate a member of facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident by facility staff and hospice staff. The facility interdisciplinary team member must have a clinical background, function within her/his Iowa scope of practice act, and have the ability to assess the resident or have access to someone that has the skills and capabilities to assess the resident. The facility interdisciplinary team member is responsible for the following: a. Collaborating with the hospice representatives and coordinating facility staff participation in the hospice care planning process for those residents receiving these services. b. Communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family. c. Ensuring that the facility communicates with the hospice medical director, that patient's attending physician, and other practitioners participating in the provision of care to the patient as needed to coordinate the hospice care with the medical care provided by other physicians. d. Obtaining the following information from the hospice provider: (iv) names and contact information for hospice personnel involved in hospice are for each patient; (v) instructions on how to access hospice provider's 24 hour on-call system; and (vii) the hospice provider physician and attending physician (if any) orders specific to each patient. For Skilled Nursing Facility Care, the facility shall provide the 24 hour services of on-site professional nurses to render direct nursing services to hospice patients. Facility shall also ensure the patients are comfortable, clean, well-groomed, and protected from negligent and intentional damage, including but not limited to accident, injury and infection.

Based on record review, observation, resident and staff interviews and facility policy review the facility failed to keep a resident (Resident #27) from physically abusing other residents while living at the facility. Review of Resident #27 record revealed documentation in the past she has open handed slapped another resident in the face, hit a resident in the back of the head, and threw water at a resident. During the survey Resident #27 threw a full pop can at a resident causing mental anguish and pain. The facility was unable to produce documentation of nursing risk management incident report investigations potentially placing all residents at risk for resident to resident abuse due to failure to review incidents. The Iowa Department of Inspections and Appeals (DIA) informed the facility of the Immediate Jeopardy (IJ) that began as of December 14, 2022 on April 27, 2023 at 11:45 AM the Facility Staff removed the Immediate Jeopardy on April 27, 2023 through the following actions: a. Resident # 27 was placed on one to one supervision with staff for 24 hours a day, until further assessment and safety plan can be implemented. b. Resident #27 primary care physician has been notified of the alleged behavior. c. Resident #27 care plan will be revised according to the treatment plan. d. Facility staff and agency staff (prior to their next scheduled shift) have been/will be educated to: 1. Maintain a safe environment free from resident abuse by another resident who resided at the facility by placing them one to one until evaluated by the facilities interdisciplinary team involving facility management and the primary care physician, and family, if any, to determine if the need continues after a review of behavior trends with potential medication modification or placement elsewhere is determined with no observation and/or documentation of behavior. The duration of the one to one will be based on the individual and continued exhibition of the behavior and will continue. 2. To report all allegations of abuse including physical, mental, psychosocial, sexual, verbal, and misappropriation immediately to their supervisor. The facilities management has been educated to report to DIA and/or local law enforcement within two (2) hours if applicable. 3. To fully investigate allegations of abuse to prevent and protect residents from further potential abuse during the investigation. 4. Resident to resident altercation policy. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 37 residents. Findings include: The Minimum Data Set (MDS) for Resident #27 dated 2/28/2023 documented a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented no physical, verbal, or other behavioral symptoms directed towards others in the past 90 days. The MDS also documented she needs physical assistance of one person with transfers, dressing, walking, and locomotion. The MDS revealed diagnoses of depression, epilepsy (seizure disorder), and other neurological conditions. The MDS documented that she takes antipsychotic medication (a type of psychiatric medication used to treat psychosis) and antidepressant medication (a type of medication used for treatment of depression and anxiety disorders). Record review of a Progress Note dated 11/21/2022 at 3:40 AM for Resident #27 documented yelling throughout the shift for staff to come to her room and when they enter she yelled at them, she cursed at staff by calling them bitches or fagots. Each time she cursed at staff and used vulgar names, education was provided to her that it was rude to talk like that and ask her to please stop. The Progress Note also documented none of the interventions had been effective and she continued to yell. Record review of a Progress Note dated 12/2/22 at 5:44 AM for Resident #27 documented She was awake the majority of the shift, yelling out, cussing, and calling staff bitch redirections attempted and unsuccessful. Record review of Resident #27 Progress Note dated 12/14/22 at 5:43 PM documented another female resident was reaching across the table attempting to grab a book and Resident #27 became upset and repeatedly yelled at the other resident to stop. Resident #27 yelled, fucking bitch and the other resident yelled bitch. Resident #27 propelled her wheelchair around the table and open handed slapped the other female resident across the right side of the face hitting her glasses. The residents were separated and the Administrator was notified. Record review of Resident #27 Progress Note dated 12/23/22 at 3:39 PM documented she open handed hit another female resident in the back of the head because the other resident was singing. The Progress note documented the Administrator was notified and Resident #27 was moved to a different room for the safety of other residents at the facility and 30 minute checks on Resident #27 were started. The MDS for Resident #11 dated 3/30/23 documented a BIMS of 15 indicating no cognitive impairment. The MDS documented she needs supervision of one person with transfers, walking, and locomotion. The MDS revealed diagnoses of anxiety, depression, and bipolar disorder. The MDS documented that she takes antipsychotic and antidepressant medications. Record review of Resident #11 Progress Note dated 12/23/22 at 3:45 PM documented she was sitting in a chair in the dining room quietly singing to herself when another female resident came up behind her and open handed hit her in the back of the head. The residents were separated and no injuries found to the back of her head. She was crying out in pain. The Administrator was notified, emergency services, and waiting for an officer to come to the facility. Record review of Resident #11 Progress Note dated 12/23/2022 at 8:26 PM documented she was upset with the lack of consequences the other female received from the police officer today. She stated she is going to call the state, she informed she feels that something needs to be done, the nurse explained that she had the right to call the state and make a complaint. Resident #11 stated she felt better, but more needed to be done because she did not feel safe living here with someone who will hit her for no reason. Record review of Resident #24 Progress Note dated 3/5/2023 at 1:36 PM documented another resident threw a glass of water on him while he was in the dining room cleaning off the tables. Resident #24 stated the cup itself didn't hit him, just the water. Resident #24 denies being fearful of the other resident and stated he doesn't know what he did. Resident #27 was visibly wet and staff assisted him to change his clothes. Record review of Resident #27 Progress Note dated 3/5/2023 at 1:38 PM documented she was in the dining room and was trying to propel herself back to her room, but another male resident was in her way and didn't move so she threw her glass of water on him. He moved and she propelled herself back to her room. Record review of Resident #27 Progress Note dated 4/16/2023 at 4:02 AM, documented Resident #27 was cursing at staff and throwing objects at staff when they assisted her to get dressed and into her wheelchair. Record review of Resident #27 Progress Note dated 4/16/23 at 7:20 PM, documented she began having aggressive threatening verbal behaviors while the facility's Doctor was in the facility seeing other residents. Resident #27 behaviors escalated to her throwing a phone and other objects at other residents. At the time the facility's Doctor decided it was safest and best to have her sent out for psychiatric evaluation and review of medications. The facility placed a call to 911 and moved her to the chapel. Resident #27 calmed but continued to be very aggressive in threats and intent on what she would do to other residents. Emergency services arrived and she left the facility. During an interview on 4/25/23 at 9:37 AM with Resident #11 revealed another resident here at the facility, Resident #27, had hit her multiple times. She revealed she was scared to live here and the facility had done nothing about it. She further informed she was at the point where she felt so unsafe living here she can't eat or sleep at night, she informed she hadn't slept for months because she was scared Resident #27 would come into her room. Record review of Resident #27 Progress Note dated 4/25/23 at 3:26 PM, documented a late entry of Incident, Accident,Unusual Occurrence Note. The Progress Note revealed Resident #27 was in the dining room going to another resident's table. The other resident stated don't sit here. This resident (Resident #27) picked up a full can of soda and threw it at the other resident. This resident was immediately removed from the situation and taken to her room for a private interview of what happened. Resident #27 stated the other resident pissed her off and told her she couldn't sit at the table, and then stated fuck you, you stupid son of a bitch, nobody tells me what to do. The facility started 15 minute checks at 3:00 PM and the police were notified. During an interview on 4/25/2023 at 2:08 PM with the facilities Administrator revealed Resident #27 and Resident #11 just had a physical resident to resident altercation where Resident #27 threw a full pop can at Resident #11 shoulder. He revealed he is working on reporting it to the State Agency and the local police department. He then informed Resident #27 and Resident #11 have not had physical altercations in the past that he was aware of. He revealed they will occasionally have arguments, he stated they have a love/hate relationship for some reason. During an interview on 4/25/23 at 2:16 PM with Resident #11 revealed she was tired of the abuse by Resident #27 and something had to be done about it. She informed Resident #27 threw a full pop can at her shoulder about 15-20 minutes ago. She stated, I'm not a target, I am a human being, something has to get done. She revealed the facility had done nothing about the continued abuse besides removing her at the time of the abuse, but then it happens again. She asked the question: how do I know if I am going to be safe? And stated the facility does nothing and so this keeps happening. She then informed this past Saturday Resident #27 hit her in the left arm in the afternoon. Throughout the interview Resident #11 was observed to have redness throughout her face, shaking in her arms, difficulty forming sentences due to excessive crying, and nasal drainage (runny nose). During an interview on 4/26/23 at 1:25 PM Staff D, Certified Nurse Aide (CNA), revealed Resident #27 has had many incidents of aggression with other residents and staff here. He recalled the following incidents: a. Resident #27 threw a pop at Resident #11 b. Resident #27 punched Resident #11 in the face less than 2 months ago in the dining room c. Resident #27 slapped Resident #22 in the face He revealed when altercations happen between residents the residents are separated and both residents are then spoken with to get both sides of the story. He informed the nurse on and the next nurse on duty is notified of the incidents. He stated he does not remember the nurses names that were working during b and c resident to resident physical altercations he mentioned because the facility used agency nurse staffing at the time. During an interview on 04/27/2023 at 8:39 AM with the Assistant Director of Nursing (ADON) and the facilities Social Services Director revealed the facility did not investigate to identify and implement root cause analysis interventions for Resident #27 Care Plan for her resident to resident physical altercations that occurred on 12/14/2022 12/23/2022, and 3/5/2023. During the interview they also confirmed they do not have incident reports for the 12/14/22 and 12/23/22 incidents. During an interview on 5/1/23 at 10:20 AM with Resident #11 she stated, thank you, thank you, thank you, Resident #27 no longer lives here, I slept this weekend, I feel safe now and love my home now. I used to feel unsafe and now everything has changed. During an interview on 5/3/23 at 11:19 AM with the facilities Housekeeping Supervisor revealed she had worked here for about five (5) years and the incident between Resident #27 and Resident #11 that occurred on 4/25/23 is the first incident she had heard of regarding Resident #27 being in a physical altercation with another resident, she then informed the day after the incident Resident #11 showed her a bruise on her collarbone. She also revealed she attends the facilities daily morning meetings. During an interview on 5/3/23 at 2:16 PM with the facilities ADON revealed the facility has had three (3) DON's in the past five (5) months. She informed multiple of Resident #27 resident to resident incidents were not put into the facilities Risk Management system on their Electronic Health Record (EHR) and so the facility did not know about them. She revealed the facility is now reading a daily document called, 24 hour progress notes, in case anything is missed that should be in Risk Management. Record review of the facilities policy titled, Resident-to-Resident Altercations, last revised on 12/2016 instructed the following: 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator. 2. If two residents are involved in an altercation, staff will: a. Separate the residents, and institute measures to calm the situation; b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; c. Notify each resident's representative and Attending Physician of the incident; d. Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents; e. Consult with the Attending Physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem; f. Make any necessary changes in the care plan approaches to any or all of the involved individuals; g. Document in the resident's clinical record all interventions and their effectiveness; h. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team; i. Complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; j. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident; and k. Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. 3. Inquiries concerning resident-to-resident altercations should be referred to the Director of Nursing Services or to the Administrator.

Based on record review, resident and staff interviews, and facility policy review the facility failed to report continued resident to resident altercations for 1 of 3 residents reviewed to the State Agency (Iowa Department of Inspections and Appeals (DIA)), (Resident #27). The facility reported Resident #27 initial resident to resident physical altercation for an incident that occurred on 12/14/2022, however the facility failed to report subsequent resident to resident physical altercations by Resident #27 that occurred on 12/23/22 and 3/5/2023. During the facilities annual survey Resident #27 had an additional resident to resident physical incident that could of potentially been avoided if the State Agency would have been aware of Resident #27 continued aggression towards other residents. The State Agency (DIA) informed the facility of the Immediate Jeopardy (IJ) that began as of December 23, 2022 on April 27, 2023 at 11:45 AM the Facility Staff removed the Immediate Jeopardy on April 27, 2023 through the following actions: a. Resident # 27 was placed on one to one supervision with staff for 24 hours a day, until further assessment and safety plan can be implemented. b. Resident #27 primary care physician has been notified of the alleged behavior. c. Resident #27 care plan will be revised according to the treatment plan. d. Facility staff and agency staff (prior to their next scheduled shift) have been/will be educated to: 1. Maintain a safe environment free from resident abuse by another resident who resided at the facility by placing them one to one until evaluated by the facilities interdisciplinary team involving facility management and the primary care physician, and family, if any, to determine if the need continues after a review of behavior trends with potential medication modification or placement elsewhere is determined with no observation and or documentation of behavior. The duration of the one to one will be based on the individual and continued exhibition of the behavior and will continue. 2. To report all allegations of abuse including physical, mental, psychosocial, sexual, verbal, and misappropriation immediately to their supervisor. The facilities management has been educated to report to DIA and/or local law enforcement within two (2) hours if applicable. 3. To fully investigate allegations of abuse to prevent and protect residents from further potential abuse during the investigation. 4. Resident to resident altercation policy. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 37 residents. Findings include: The Minimum Data Set (MDS) for Resident #27 dated 2/28/2023 documented a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented no physical, verbal, or other behavioral symptoms directed towards others in the past 90 days. The MDS also documented she needed physical assistance of one person with transfers, dressing, walking, and locomotion. The MDS revealed diagnoses of depression, epilepsy (seizure disorder), and other neurological conditions. The MDS documented that she takes antipsychotic medication (a type of psychiatric medication used to treat psychosis) and antidepressant medication (a type of medication used for treatment of depression and anxiety disorders). Record review of a Progress Note dated 11/21/2022 at 3:40 AM for Resident #27 documented yelling throughout the shift for staff to come to her room and when they enter she yelled at them, she cursed at staff by calling them bitches or fagots. Each time she cursed at staff and used vulgar names, education was provided to her that it was rude to talk like that and ask her to please stop. The Progress Note also documented none of the interventions have been effective and she continued to yell. Record review of a Progress Note dated 12/2/22 at 5:44 AM for Resident #27 documented She was awake the majority of the shift, yelling out, cussing, and called staff bitch redirections attempted and unsuccessful. Record review of Resident #27 Progress Note dated 12/14/22 at 5:43 PM documented another female resident reached across the table attempting to grab a book and Resident #27 became upset and repeatedly yelled at the other resident to stop. Resident #27 yelled, fucking bitch and the other resident yelled bitch. Resident #27 propelled her wheelchair around the table and open handed slapped the other female resident across the right side of the face hitting her glasses. The residents were separated and the Administrator was notified. Record review of Resident #27 Progress Note dated 12/23/22 at 3:39 PM documented she open handed hit another female resident in the back of the head because the other resident was singing. The Progress note documented the Administrator was notified and Resident #27 was moved to a different room for the safety of other residents at the facility and 30 minute checks on Resident #27 were started. The MDS for Resident #11 dated 3/30/23 documented a BIMS of 15 indicating no cognitive impairment. The MDS documented she needed supervision of one person with transfers, walking, and locomotion. The MDS revealed diagnoses of anxiety, depression, and bipolar disorder. The MDS documented that she took antipsychotic and antidepressant medications. Record review of Resident #11 Progress Note dated 12/23/22 at 3:45 PM documented she sat in a chair in the dining room quietly singing to herself when another female resident came up behind her and open handed hit her in the back of the head. The residents were separated and no injuries found to the back of her head. She was crying out in pain. The Administrator was notified, emergency services, and waiting for an officer to come to the facility. Record review of Resident #11 Progress Note dated 12/23/2022 at 8:26 PM documented she was upset with the lack of consequences the other female received from the police officer today. She stated she was going to call the state, she informed she felt that something needed to be done, the nurse explained that she had the right to call the state and make a complaint. Resident #11 stated she felt better, but more needed to be done because she does not feel safe living here with someone who would hit her for no reason. Record review of Resident #24 Progress Note dated 3/5/2023 at 1:36 PM documented another resident threw a glass of water on him while he was in the dining room cleaning off the tables. Resident #24 stated the cup itself didn't hit him, just the water. Resident #24 denied being fearful of the other resident and stated he doesn't know what he did. Resident #27 was visibly wet and staff assisted him to change his clothes. Record review of Resident #27 Progress Note dated 3/5/2023 at 1:38 PM documented she was in the dining room and was trying to propel herself back to her room, but another male resident was in her way and didn't move so she threw her glass of water on him. He moved and she propelled herself back to her room. Record review of Resident #27 Progress Note dated 4/16/2023 at 4:02 AM, documented Resident #27 was cursing at staff and throwing objects at staff when assisting her to get dressed and into her wheelchair. Record review of Resident #27 Progress Note dated 4/16/23 at 7:20 PM, documented she began having aggressive threatening verbal behaviors while the facility's Doctor was in the facility seeing other residents. Resident #27 behaviors escalated to her throwing a phone and other objects at other residents. At the time the facility's Doctor decided it was safest and best to have her sent out for psychiatric evaluation and review of medications. The facility placed a call to 911 and moved her to the chapel. Resident #27 calmed but continued to be very aggressive in threats and intent on what she would do to other residents. Emergency services arrived and she left the facility. During an interview on 4/25/23 at 9:37 AM with Resident #11 revealed another resident here at the facility, Resident #27, had hit her multiple times. She revealed she was scared to live here and the facility had done nothing about it. She further informed she was at the point where she felt so unsafe living here she can't eat or sleep at night, she informed she hadn't slept for months because she was scared Resident #27 would come into her room. Record review of Resident #27 Progress Note dated 4/25/23 at 3:26 PM, documented a late entry of Incident, Accident,Unusual Occurrence Note. The Progress Note revealed Resident #27 was in the dining room going to another resident's table. The other resident stated don't sit here. This resident (Resident #27) picked up a full can of soda and threw it at the other resident. This resident was immediately removed from the situation and taken to her room for a private interview of what happened. Resident #27 stated the other resident pissed her off and told her she couldn't sit at the table, and then stated fuck you, you stupid son of a bitch, nobody tells me what to do. The facility started 15 minute checks at 3:00 PM and the police were notified. During an interview on 4/25/2023 at 2:08 PM with the facilities Administrator revealed Resident #27 and Resident #11 just had a physical resident to resident altercation where Resident #27 threw a full pop can at Resident #11 shoulder. He revealed he was working on reporting it to the State Agency and the local police department. He then informed Resident #27 and Resident #11 have not had physical altercations in the past that he was aware of. He revealed they would occasionally have arguments, he stated they had a love/hate relationship for some reason. During an interview on 4/25/23 at 2:16 PM with Resident #11 revealed she was tired of the abuse by Resident #27 and something had to be done about it. She informed Resident #27 threw a full pop can at her shoulder about 15-20 minutes ago. She stated, I'm not a target, I am a human being, something has to get done. She revealed the facility had done nothing about the continued abuse besides removing her at the time of the abuse, but then it happens again. She asked the question: how do I know if I am going to be safe? And stated the facility does nothing and so this keeps happening. She then informed this past Saturday Resident #27 hit her in the left arm in the afternoon. Throughout the interview Resident #11 was observed to have redness throughout her face, shaking in her arms, difficulty forming sentences due to excessive crying, and nasal drainage (runny nose). During an interview on 4/26/23 at 1:25 PM Staff D, Certified Nurse Aide (CNA), revealed Resident #27 has had many incidents of aggression with other residents and staff here. He recalled the following incidents: a. Resident #27 threw a pop at Resident #11 b. Resident #27 punched Resident #11 in the face less than 2 months ago in the dining room c. Resident #27 slapped Resident #22 in the face He revealed when altercations happen between residents the residents are separated and both residents are then spoken with to get both sides of the story. He informed the nurse on and the next nurse on duty is notified of the incidents. He stated he does not remember the nurses names that were working during b and c resident to resident physical altercations he mentioned because the facility used agency nurse staffing at the time. During an interview on 04/27/2023 at 8:39 AM with the Assistant Director of Nursing (ADON) and the facilities Social Services Director revealed the facility did not investigate to identify and implement root cause analysis interventions for Resident #27 Care Plan for her resident to resident physical altercations that occurred on 12/14/2022 12/23/2022, and 3/5/2023. During the interview they also confirmed they do not have incident reports for the 12/14/22 and 12/23/22 incidents. During an interview on 5/1/23 at 10:20 AM with Resident #11 she stated, thank you, thank you, thank you Resident #27 no longer lives here, I slept this weekend, I feel safe now and love my home now. I used to feel unsafe and now everything has changed. During an interview on 5/3/23 at 11:19 AM with the facilities Housekeeping Supervisor revealed she had worked here for about five (5) years and the incident between Resident #27 and Resident #11 that occurred on 4/25/23 was the first incident she had heard of regarding Resident #27 being in a physical altercation with another resident, she then informed the day after the incident Resident #11 showed her a bruise on her collarbone. She also revealed she attends the facilities daily morning meetings. During an interview on 5/3/23 at 2:16 PM with the facilities ADON revealed the facility has had three (3) DON's in the past five (5) months. She informed multiple of Resident #27 resident to resident incidents were not put into the facilities Risk Management system on their Electronic Health Record (EHR) and so the facility did not know about them. She revealed the facility was now reading a daily document called, 24 hour progress notes, in case anything is missed that should be in Risk Management. Record Review of a document titled Self Reports dated 4/26/23 of the facilities self reports to DIA documented the facility only self reported the incidents that occurred on 12/14/2022 and 4/25/2023 for Resident #27. Record review of the facilities policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 4/2021 instructed the following: Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. 5. Notices include, as appropriate: a. the resident's name; b. the resident's room number; c. the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.); d. the date and time the alleged incident occurred; e. the name(s) of all persons involved in the alleged incident; and f. what immediate action was taken by the facility. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.

Based on record review, resident and staff interviews, and facility policy review the facility failed to implement safety measures and interventions for Resident #27 to protect residents from her physical resident to resident altercations for 2 of 3 residents reviewed (Residents #11 and #24). The facility failed to identify the root cause and implement interventions for Resident #27 aggression towards other residents potentially placing all residents at risk. The Iowa Department of Inspections and Appeals (DIA) informed the facility of the Immediate Jeopardy (IJ) that began as of December 14, 2022 on April 27, 2023 at 11:45 AM the Facility Staff removed the Immediate Jeopardy on April 27, 2023 through the following actions: a. Resident # 27 was placed on one to one supervision with staff for 24 hours a day, until further assessment and safety plan can be implemented. b. Resident #27 primary care physician has been notified of the alleged behavior. c. Resident #27 care plan will be revised according to the treatment plan. d. Facility staff and agency staff (prior to their next scheduled shift) have been/will be educated to: 1. Maintain a safe environment free from resident abuse by another resident who resided at the facility by placing them one to one until evaluated by the facilities interdisciplinary team involving facility management and the primary care physician, and family, if any, to determine if the need continues after a review of behavior trends with potential medication modification or placement elsewhere is determined with no observation and or documentation of behavior. The duration of the one to one will be based on the individual and continued exhibition of the behavior and will continue. 2. To report all allegations of abuse including physical, mental, psychosocial, sexual, verbal, and misappropriation immediately to their supervisor. The facilities management has been educated to report to DIA and/or local law enforcement within two (2) hours if applicable. 3. To fully investigate allegations of abuse to prevent and protect residents from further potential abuse during the investigation. 4. Resident to resident altercation policy. The scope lowered from a J to D at the time of the survey after ensuring the facility implemented education and their policy and procedures. The facility identified a census of 37 residents. Findings include: The Minimum Data Set (MDS) for Resident #27 dated 2/28/2023 documented a Brief Interview of Mental Status (BIMS) of 15 indicating no cognitive impairment. The MDS documented no physical, verbal, or other behavioral symptoms directed towards others in the past 90 days. The MDS also documented she needed physical assistance of one person with transfers, dressing, walking, and locomotion. The MDS revealed diagnoses of depression, epilepsy (seizure disorder), and other neurological conditions. The MDS documented that she took antipsychotic medication (a type of psychiatric medication used to treat psychosis) and antidepressant medication (a type of medication used for treatment of depression and anxiety disorders). Record review of a Progress Note dated 11/21/2022 at 3:40 AM for Resident #27 documented yelling throughout the shift for staff to come to her room and when they entered she yelled at them, she cursed at staff by calling them bitches or fagots. Each time she cursed at staff and used vulgar names, education was provided to her that it was rude to talk like that and asked her to please stop. The Progress Note also documented none of the interventions had been effective and she continued to yell. Record review of a Progress Note dated 12/2/22 at 5:44 AM for Resident #27 documented She was awake the majority of the shift, yelling out, cussing, and calling staff bitch redirections attempted and unsuccessful. Record review of Resident #27 Progress Note dated 12/14/22 at 5:43 PM documented another female resident reached across the table attempting to grab a book and Resident #27 became upset and repeatedly yelled at the other resident to stop. Resident #27 yelled, fucking bitch and the other resident yelled bitch. Resident #27 propelled her wheelchair around the table and open handed slapped the other female resident across the right side of the face hitting her glasses. The residents were separated and the Administrator was notified. Record review of Resident #27 Progress Note dated 12/23/22 at 3:39 PM documented she open handed hit another female resident in the back of the head because the other resident was singing. The Progress note documented the Administrator was notified and Resident #27 was moved to a different room for the safety of other residents at the facility and 30 minute checks on Resident #27 be started. The MDS for Resident #11 dated 3/30/23 documented a BIMS of 15 indicating no cognitive impairment. The MDS documented she needed supervision of one person with transfers, walking, and locomotion. The MDS revealed diagnoses of anxiety, depression, and bipolar disorder. The MDS documented that she took antipsychotic and antidepressant medications. Record review of Resident #11 Progress Note dated 12/23/22 at 3:45 PM documented she was sitting in a chair in the dining room quietly singing to herself when another female resident came up behind her and open handed hit her in the back of the head. The residents were separated and no injuries found to the back of her head. She was crying out in pain. The Administrator was notified, emergency services, and waiting for an officer to come to the facility. Record review of Resident #11 Progress Note dated 12/23/2022 at 8:26 PM documented she was upset with the lack of consequences the other female received from the police officer today. She stated she was going to call the state, she informed she feels that something needed to be done, the nurse explained that she had the right to call the state and make a complaint. Resident #11 stated she felt better, but more needed to be done because she does not feel safe living here with someone who would hit her for no reason. Record review of Resident #24 Progress Note dated 3/5/2023 at 1:36 PM documented another resident threw a glass of water on him while he was in the dining room cleaning off the tables. Resident #24 stated the cup itself didn't hit him, just the water. Resident #24 denied being fearful of the other resident and stated he doesn't know what he did. Resident #27 was visibly wet and staff assisted him to change his clothes. Record review of Resident #27 Progress Note dated 3/5/2023 at 1:38 PM documented she was in the dining room and was trying to propel herself back to her room, but another male resident was in her way and didn't move so she threw her glass of water on him. He moved and she propelled herself back to her room. Record review of Resident #27 Progress Note dated 4/16/2023 at 4:02 AM, documented Resident #27 was cursing at staff and throwing objects at staff when assisting her to get dressed and into her wheelchair. Record review of Resident #27 Progress Note dated 4/16/23 at 7:20 PM, documented she began having aggressive threatening verbal behaviors while the facility's Doctor was in the facility seeing other residents. Resident #27 behaviors escalated to her throwing a phone and other objects at other residents. At the time the facility's Doctor decided it was safest and best to have her sent out for psychiatric evaluation and review of medications. The facility placed a call to 911 and moved her to the chapel. Resident #27 calmed but continued to be very aggressive in threats and intent on what she would do to other residents. Emergency services arrived and she left the facility. During an interview on 4/25/23 at 9:37 AM with Resident #11 revealed another resident here at the facility, Resident #27, had hit her multiple times. She revealed she was scared to live here and the facility had done nothing about it. She further informed she was at the point where she felt so unsafe living here she can't eat or sleep at night, she informed she hadn't slept for months because she was scared Resident #27 would come into her room. Record review of Resident #27 Progress Note dated 4/25/23 at 3:26 PM, documented a late entry of Incident, Accident,Unusual Occurrence Note. The Progress Note revealed Resident #27 was in the dining room going to another resident's table. The other resident stated don't sit here. This resident (Resident #27) picked up a full can of soda and threw it at the other resident. This resident was immediately removed from the situation and taken to her room for a private interview of what happened. Resident #27 stated the other resident pissed her off and told her she couldn't sit at the table, and then stated fuck you, you stupid son of a bitch, nobody tells me what to do. The facility started 15 minute checks at 3:00 PM and the police were notified. During an interview on 4/25/2023 at 2:08 PM with the facilities Administrator revealed Resident #27 and Resident #11 just had a physical resident to resident altercation where Resident #27 threw a full pop can at Resident #11 shoulder. He revealed he was working on reporting it to the State Agency and the local police department. He then informed Resident #27 and Resident #11 have not had physical altercations in the past that he was aware of. He revealed they will occasionally have arguments, he stated they had a love/hate relationship for some reason. During an interview on 4/25/23 at 2:16 PM with Resident #11 revealed she was tired of the abuse by Resident #27 and something had to be done about it. She informed Resident #27 threw a full pop can at her shoulder about 15-20 minutes ago. She stated, I'm not a target, I am a human being, something has to get done. She revealed the facility had done nothing about the continued abuse besides removing her at the time of the abuse, but then it happens again. She asked the question: how do I know if I am going to be safe? And stated the facility does nothing and so this keeps happening. She then informed this past Saturday Resident #27 hit her in the left arm in the afternoon. Throughout the interview Resident #11 was observed to have redness throughout her face, shaking in her arms, difficulty forming sentences due to excessive crying, and nasal drainage (runny nose). During an interview on 4/26/23 at 1:25 PM Staff D, Certified Nurse Aide (CNA), revealed Resident #27 has had many incidents of aggression with other residents and staff here. He recalled the following incidents: a. Resident #27 threw a pop at Resident #11 b. Resident #27 punched Resident #11 in the face less than 2 months ago in the dining room c. Resident #27 slapped Resident #22 in the face He revealed when altercations happen between residents the residents are separated and both residents are then spoken with to get both sides of the story. He informed the nurse on and the next nurse on duty is notified of the incidents. He stated he does not remember the nurses names that were working during b and c resident to resident physical altercations he mentioned because the facility used agency nurse staffing at the time. During an interview on 04/27/2023 at 8:39 AM with the Assistant Director of Nursing (ADON) and the facilities Social Services Director revealed the facility did not investigate to identify and implement root cause analysis interventions for Resident #27 Care Plan for her resident to resident physical altercations that occurred on 12/14/2022, 12/23/2022, and 3/5/2023. During the interview they also confirmed they do not have incident reports for the 12/14/22 and 12/23/22 incidents. During an interview on 5/1/23 at 10:20 AM with Resident #11 she stated, thank you, thank you, thank you Resident #27 no longer lives here, I slept this weekend, I feel safe now and love my home now. I used to feel unsafe and now everything has changed. During an interview on 5/3/23 at 11:19 AM with the facilities Housekeeping Supervisor revealed she had worked here for about five (5) years and the incident between Resident #27 and Resident #11 that occurred on 4/25/23 was the first incident she had heard of regarding Resident #27 being in a physical altercation with another resident, she then informed the day after the incident Resident #11 showed her a bruise on her collarbone. She also revealed she attended the facilities daily morning meetings. During an interview on 5/3/23 at 2:16 PM with the facilities ADON revealed the facility has had three (3) DON's in the past five (5) months. She informed multiple of Resident #27 resident to resident incidents were not put into the facilities Risk Management system on their Electronic Health Record (EHR) and so the facility did not know about them. She revealed the facility was now reading a daily document called, 24 hour progress notes, in case anything was missed that should be in Risk Management. Record review of the facilities policy titled, Resident-to-Resident Altercations, last revised on 12/2016 instructed the following: 1. Facility staff will monitor residents for aggressive/inappropriate behavior towards other residents, family members, visitors, or to the staff. Occurrences of such incidents shall be promptly reported to the Nurse Supervisor, Director of Nursing Services, and to the Administrator. 2. If two residents are involved in an altercation, staff will: a. Separate the residents, and institute measures to calm the situation; b. Identify what happened, including what might have led to aggressive conduct on the part of one or more of the individuals involved in the altercation; c. Notify each resident's representative and Attending Physician of the incident; d. Review the events with the Nursing Supervisor and Director of Nursing, and possible measures to try to prevent additional incidents; e. Consult with the Attending Physician to identify treatable conditions such as acute psychosis that may have caused or contributed to the problem; f. Make any necessary changes in the care plan approaches to any or all of the involved individuals; g. Document in the resident's clinical record all interventions and their effectiveness; h. Consult psychiatric services as needed for assistance in assessing the resident, identifying causes, and developing a care plan for intervention and management as necessary or as may be recommended by the Attending Physician or Interdisciplinary Care Planning Team; i. Complete a Report of Incident/Accident form and document the incident, findings, and any corrective measures taken in the resident's medical/clinical record; j. If, after carefully evaluating the situation, it is determined that care cannot be readily given within the facility, transfer the resident; and k. Report incidents, findings, and corrective measures to appropriate agencies as outlined in our facility's abuse reporting policy. 3. Inquiries concerning resident-to-resident altercations should be referred to the Director of Nursing Services or to the Administrator. Record Review of a document titled Self Reports dated 4/26/23 of the facilities self reports to DIA documented the facility only self reported the incidents that occurred on 12/14/2022 and 4/25/2023 for Resident #27. Record review of the facilities policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, revised 4/2021 instructed the following: Reporting Allegations to the Administrator and Authorities 1. If resident abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source is suspected, the suspicion must be reported immediately to the administrator and to other officials according to state law. 2. The administrator or the individual making the allegation immediately reports his or her suspicion to the following persons or agencies: a. The state licensing/certification agency responsible for surveying/licensing the facility; b. The local/state ombudsman; c. The resident's representative; d. Adult protective services (where state law provides jurisdiction in long-term care); e. Law enforcement officials; f. The resident's attending physician; and g. The facility medical director. 3. Immediately is defined as: a. within two hours of an allegation involving abuse or result in serious bodily injury; or b. within 24 hours of an allegation that does not involve abuse or result in serious bodily injury. 4. Verbal/written notices to agencies are submitted via special carrier, fax, e-mail, or by telephone. 5. Notices include, as appropriate: a. the resident's name; b. the resident's room number; c. the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.); d. the date and time the alleged incident occurred; e. the name(s) of all persons involved in the alleged incident; and f. what immediate action was taken by the facility. 6. Upon receiving any allegations of abuse, neglect, exploitation, misappropriation of resident property or injury of unknown source, the administrator is responsible for determining what actions (if any) are needed for the protection of residents.