**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review and policy review, the facility failed to protect 1 Resident (#12) out of a total sample of 27 residents from physical abuse from Resident (#34), who had known and well-documented aggressive tendencies, resulting in a fracture. Findings include: Review of facility policy titled OPS300 Abuse Prohibition, revised 5/1/22, indicated the following: *Policy: Centers prohibit abuse, mistreatment, neglect, misappropriation of resident/patient property and exploitation for all residents. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, injury, or mental anguish .Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. *Process: Actions to prevent abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of patient property, will include: -Identifying, correcting, and intervening in situations in which abuse, neglect, and/or misappropriation of patient property is more likely to occur -If the suspected abuse is patient to patient, the patient who has in any way threatened or attacked another will be removed from the setting or situation and an investigation will be completed. -The Center will provide adequate supervision when the risk of patient to patient altercation is suspected. -The Center is responsible for identifying patients who have a history of disruptive or intrusive interactions or who exhibit other behaviors that make them more likely to be involved in an altercation. Resident #12 was re-admitted to the facility in March 2019 with diagnoses including dementia and unspecified mood disorder. Review of Resident #12's Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she was moderately cognitively impaired and scored a 10 out of 15 on the Brief Interview for Mental Status. The MDS further indicated the Resident had behavioral symptoms directed towards others 1 to 3 days out of the previous 7 days, verbal behavioral symptoms 4 to 6 days out of the previous 7 days, other behaviors 1 to 3 days out of the previous 7 days, did not reject care, and requires extensive assistance with a one person physical assist for transfers and dressing as well as supervision with one person physical assistance for locomotion off the unit. Resident #34 was admitted to the facility in April 2021 with diagnoses including unspecified dementia with agitation and alcohol dependence. Review of Resident #34's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact and scored a 13 out of 15 on the Brief Interview for Mental Status Exam (BIMS). Further review of the MDS indicated the Resident had delusions, physical and verbal behaviors directed at others 1 to 3 days out of the previous 7 days, and was independent with bed mobility, transfers, walking in his/her room and in the corridor and locomotion on and off the unit. Review of Resident #12's medical record indicated the following: -An undated altercation investigation summary signed by the Director of Nursing which indicated the following: Incident: On 5/1/22, staff responded to yelling and found Resident #34 tagging back and forth with Resident #12. Resident #34 stated he/she was walking in hallway when Resident #12 backed into him/her with his/her wheelchair. Resident #12 was unable to state exactly what happened. Staff separated residents. No apparent injuries to residents. Physician, responsible parties and police notified. Investigation: Staff and residents were interviewed. Staff stated that they responded to the yelling and found residents tagging back and forth. Staff did not witness the beginning of the altercation and therefore did not know what triggered the incident. Resident #34 stated that Resident #12 backed into him/her with his/her wheelchair as Resident #34 was walking triggering the incident. Resident #12 denied backing into Resident #34 and was unable to state what happened. Conclusion: The residents got into an altercation due to some sort of misunderstanding. The minutes prior to the incident were unwitnessed. We are unable to verify Resident #34's account of events. Plan: Staff to keep residents separated. Social services to follow up with residents as needed. Review of an accident incident action team document dated as reviewed 5/2/22 indicated a new intervention to keep Resident #12 and Resident #34 separated. Review of Resident #12 risk for alteration in overall behavioral/psychosocial well-being care plan, revised 5/1/22, indicated a new intervention added 5/1/22 to keep Resident #12 separated from Resident #34 in the dining room. Review of Resident #34's medical record indicated the following: -A SBAR note for Resident #34 dated 5/1/22 which indicated that residents were fighting on the floor due to stated issue, they were removed from each other and appropriate action taken. -A care plan for Resident #34 initiated 4/8/21 for potential to demonstrate verbal/physical behaviors related to cognitive loss/ dementia. He/she has gotten physical with other residents, history of punching another resident in the face, recently responded to resident attack with physical response with a new intervention added 5/1/22 to keep Resident #34 separated from Resident #12. Further review of Resident #12's medical record indicated the following: -A late entry note dated 8/8/22 at 9:02 P.M. effective for 8/8/22 at 8:30 A.M. which indicated Resident #12 was pulled out of his/her wheelchair and thrown to the ground. The Resident's Health Care Proxy (HCP) and Nurse Practitioner notified. Seen by psych doctor, social services. Resident diagnosed with left distal fibula fracture. Seen by Nurse Practitioner. -A Nurse Practitioner (NP) encounter note dated 8/8/22: NP follow up resident to resident encounter, fracture. Resident was involved in the resident to resident encounter, he/she sustained a fall and was complaining of left ankle pain; X-ray shows acute oblique distal fibula (the outer bone between the knee and ankle joint) fracture (a fracture that occurs when the bone is broken at an angle); resident sent to ER (emergency room) by this provider. -A radiology report dated 8/8/22 which indicated a left acute oblique distal fibula fracture. -A hospital after visit summary dated 8/8/22 which indicated the reason for the visit was a leg injury and the diagnosis was a broken leg. Review of facility provided investigations for Resident #12 indicated the following: -A Resident to Resident report dated 8/8/22 which indicated that staff heard a loud noise in the dining room and quickly ran and found Resident #12 and Resident #34 lying on the floor beside each other. Resident #12 said he/she was in his/her wheelchair by the dining room door. Resident #34 asked him/her to move and Resident #12 was about to do so then Resident #34 swore at Resident #12 and called him/her 'stupid idiot'. Resident #12 swore at Resident #34 and Resident #34 then hit Resident #12 in the face. Resident #12 threw a bottle of soda at Resident #34 and then Resident #34 pulled Resident #12 out of his/her wheelchair and threw him/her on the ground. -An unsigned summary document dated 8/8/22 which indicated the following: At approximately 8:30 A.M. on 8/8/22 staff on the mental health and recovery unit heard shouting from the dining room. Upon arrival to the dining room staff observed Resident #12 and Resident #34 on the floor entangled in one another. Upon initial interview, Resident #12 stated that Resident #34 told him/her to move, he/she began to try to move his/her chair to the side of the hallway when Resident #34 attempted to punch him/her in the face. Resident #12 explained that he/she splashed a cup of soda at Resident #34 and Resident #34 dragged him/her onto the ground. Upon initial interview, Resident #34 stated that he/she told Resident #12 to move, Resident #12 did not move and Resident #12 tried to punch Resident #34. The residents were immediately separated and assessed for injury. Resident #12 complained of left hip, left leg and left ankle pain. As needed Tylenol (a pain reliever) was administered and a stat x-ray was called in. Resident #34 had no injuries. Upon initial interview of the staff, no staff witnessed the altercation initiate. The interviews revealed CNA was in room [ROOM NUMBER] W, which has a clear siteline into the dining room. Certified Nursing Assistant (CNA) observed Resident #34 pull Resident #12 out of his/her wheelchair onto the floor and responded to the incident and called for help. Upon arrival at the dining room, the resident was on the floor and staff separated them. Upon investigation of the incident the security footage was reviewed. Resident #34 is seen exiting the dining room past Resident #12 with no incident. The initiation of the altercation was not in clear view but Resident #34 is seen attempting to punch Resident #12, Resident #12 is seen putting his/her hands over his/her head. Resident #34 is seen wrapping his/her arms around Resident #12, pulling the Resident out of his/her wheelchair and both residents are seen on the ground. Resident #34 is seen attempting to kick Resident #12 as they are entangled on the ground. Staff come running into the room and separate the two residents. In conclusion, the center believes that Resident #34 initiated the resident to resident altercation. The center believes that the residents did have a verbal exchange where Resident #34 asked Resident #12 to move. The center believes that both residents swore at one another during the verbal exchange and Resident #34 initiated the physical altercation with Resident #12 .Resident #12 was sent to the ER for complaints of pain, x-rays were done and revealed a fracture of the left fibula. -A signed CNA statement dated 8/8/22 indicating the CNA was in the hallway and heard someone calling for help and the CNA ran to the dining room and saw the residents on the floor. -Two signed CNA statements dated 8/8/22 stating they heard one staff call for help, they ran and saw two residents on the floor. -A signed CNA statement dated 8/8/22 which indicated the CNA was in a resident's room and turned her head and saw Resident #34 grab Resident #12 and pull him/her on the floor and the CNA called for help. Further review of Resident #12 and Resident #34's records failed to indicate staff had kept the residents separated in accordance with their care plans after a previous resident to resident altercation, resulting in aresident to resident altercation and a leg fracture for Resident #12. During an interview on 1/19/23 at 10:34 A.M., Unit Manager #1 said she is familiar with both residents. Unit Manager #1 said Resident #34 has been in the facility for about 2 years and used to be on the dementia unit but was fighting with the vulnerable residents on that unit so he/she moved to the current unit. Unit Manager #1 said Resident #34 has a short fuse and doesn't always remember to get staff when he/she is frustrated. Unit Manager #1 said she was working the day of the resident to resident altercation in August and that it happened in the morning. Unit Manager #1 said she was sitting at the nurses station and she was alerted by another staff member saying there was an altercation between Resident #34 and Resident #12. Unit Manager #1 said when she arrived both residents were on the floor and she and a CNA separated them. Unit Manager #1 said that Resident #34 told her he/she wanted to use the bathroom and asked Resident #12 to move out of the way and he/she said the other resident tried to grab him/her so he/she had to defend him/herself. Unit Manager #1 said Resident #12 initially said he/she was fine but she could tell he/she wasn't. Unit Manager #1 said she checked on Resident #12 a bit after the altercation and he/she reported pain in his/her leg, and an x-ray was ordered which showed a fracture in the leg. Unit Manager #1 said the Residents had altercations prior to this. Unit Manager said there are many residents with behaviors on the unit and when in the dining room residents should be supervised and further said the Residents were not supervised when this occurred. Unit Manager #1 was unable to say why no staff were present to keep the Residents separated prior to the altercation, but said maybe staff was pulled from the dining room. Unit Manager #1 said the expectation is that care plan interventions will be adjusted and followed as written. Unit Manager #1 said in her opinion Resident #34 should be supervised when interacting with other residents because he/she is aggressive and can snap quickly without warning. During an interview on 1/19/23 at 11:33 A.M., Nurse #3 said she is familiar with Resident #34 and is explosive and hot tempered. Review of Resident #34's medical record indicated the following: -A therapy note for service date 7/8/22 (one month before the altercation in which Resident #12's leg was broken) which indicated that the Resident continues to bully other residents in the facility. -A therapy note for service date 7/22/22 (17 days before the altercation) which indicated the Resident continued his/her bullying activities within the larger group and that the Resident said he/she was not going to be a bully. -A therapy note for service date 7/29/22 (10 days before the altercation) which indicated the Resident was confronted about his/her bullying behavior within the unit and how he/she treats other residents. -A therapy note for service date 8/8/22 (the date of the altercation) which indicated the Resident started a fist fight with another resident who was in a wheelchair/ Resident #34 pulled the other Resident (Resident #12) out of his/her wheelchair, threw him/her on the ground, got on top of him/her and started punching him/her in the head and kicking him/her. Resident #34 denied having done all of these activities but everything was on video. During an interview on 1/19/23 at 4:05 P.M., Licensed Therapist #1 said he has worked with Resident #34 since admission to the facility. Licensed Therapist #1 said he worked with Resident #34 on the dementia unit briefly and said the Resident was violent and would antagonize other residents and try to start fights or get other residents riled up. Licensed Therapist #1 said Resident #34 was transferred down to the mental health unit. Licensed Therapist #1 said Resident #34 is far too violent and that when he/she gets violent he/she gets violent. Licensed Therapist #1 said that on 8/8/22 Resident #34 pulled Resident #12 out of his/her wheelchair and beat him/her 'like you would in a street fight'. Licensed Therapist #1 said Resident #34 will try to find someone he/she perceives as weaker than him/her and start a fight and that when asked about the Resident to Resident altercation in August Resident #34 said Resident #12 tried to fight him/her and that the surveillance video did not match with what Resident #34 had said happened. Licensed Therapist #1 said he couldn't remember details about the Resident to Resident altercation in May between Resident #34 and Resident #12 but said would check his notes. Licensed Therapist #1 said Resident #34 is a tough person to have in the facility and that Resident #34 would try to be tough around other residents and posturing, and acknowledged his notes indicated Resident #34 was observed with bullying behaviors prior to the altercation on 8/8/22. Licensed Therapist #1 said staff was aware of Resident #34's behaviors and some interventions included staff staying in the dining room to be a buffer between Resident #34 and other residents and said that about 90% of time there is supervision plus cameras. Licensed Therapist #1 said supervision in the dining room is best for safety. During an interview on 1/19/23 at 4:54 P.M. with the Director of Nursing, Administrator and Corporate Consultant #2, the Director of Nursing said Resident #34 has had a few resident to resident incidents and has a lot of triggers. The Director of Nursing said Resident #34 is triggered by other residents and by people getting in his/her way and that the Resident ambulates independently with a cane. The Director of Nursing acknowledged that interventions were listed in Resident #34 and Resident #12's care plans to keep them separated but said that the interventions were not meant to be permanent even though they were still listed as current interventions. The Director of Nursing said care plan interventions were in place to keep the Residents separated and it wasn't done. The Director of Nursing and the Administrator said they didn't recall Resident #34 being documented as a bully or that information being communicated to them by Licensed Therapist #1. During a follow up interview on 1/20/23 at 10:16 A.M., the Director of Nursing said Resident #34's most recent roommate was moved after getting feedback from the nursing staff about Resident #34 and his/her behaviors. The Director of Nursing said she was unaware of bully phrase being used in psych notes and said care plan interventions should be reviewed and updated if there is a change or a new issue or concern. The Director of Nursing acknowledged no interventions were added after Resident #34's return from hospitalization and Licensed Therapist #1 assessing the Resident as being a threat to other residents still. During an interview on 1/20/23 at 11:44 A.M., Licensed Therapist #1 said he met with Resident #34 this morning and there was a behavioral health round session with staff to try to identify potential triggers for the Resident and that the facility revised his/her care plan today with new interventions based on the identified triggers including: people going into his/her bathroom, placing a stop sign in front of his/her door, and managing the TV in the dining room. Licensed Therapist #1 said he was unaware of any care plan updates after Resident #34 was re-admitted to the facility in August and he identified that Resident #34 was still a threat. Licensed Therapist #1 said the expectation would be that his/her care plan would have interventions based on identified triggers.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5.) For Resident #55 the facility failed to implement a physician's order for right elbow brace and a right palm protector. Review of the facility policy titled, Person- Center Care Plan, dated as revised 10/24/22, indicated the Center must development and implement a care plan that will be communicated to appropriate staff. Resident #55 was admitted to the facility in December 2016 with diagnosis including persistent vegetative state, non-traumatic subdural hemorrhage and quadriplegia. Review of Resident #55's Annual Minimum Data Set Assessment, dated 12/17/22, indicated he/she was comatose (persistent vegetative state), he/she required total dependence of one for dressing and had functional limitation in range of motion impairments on both upper extremities. Review of the physician's order dated 6/15/21 indicated: Apply Right elbow brace daily as tolerated. Apply after morning care and remove before bedtime care. Monitor skin for redness/irritation daily. If brace unavailable, place rolled towel to right elbow Review of the Treatment Administration Record, dated January 2023, indicated the right elbow brace was applied as ordered on 1/17/23. Review of the physician's order dated 3/2/22 indicated: Apply palm protector to right hand as tolerated. May remove for daily hygiene and skin inspection to ensure no redness/skin breakdown. May use rolled towel as alternate if palm protector is not available. Review of the Treatment Administration Record, dated January 2023, indicated the palm protector was applied to right hand on 1/17/23 and 1/18/23. During observation's on 1/17/23 at 8:03 A.M., 1/17/23 at 1:42 P.M., 1/18/23 at 7:20 A.M., 1/18/23 at 11:30 A.M., and on 1/18/23 at 4:30 P.M., there was no brace or rolled towel to his/her right elbow and there was no palm protector or rolled towel to his/her right hand. During an interview on 1/18/23 at 11:07 A.M., Certified Nurse Aide (CNA) #1 said she was not aware that Resident #55 required a brace or rolled towel to his/her right elbow or a palm protector or rolled towel to his/her right hand. CNA #1 said that the nurse will apply them. During an interview on 1/18/23 at 11:23 A.M., CNA #2 she was not aware that Resident #55 required a brace or rolled towel to his/her right elbow or a palm protector or rolled towel to his/her right hand. CNA #2 said that the nurse will apply them. During an interview on 1/18/23 at 11:30 A.M., Nurse #1 said CNA's will apply braces and palm protectors during care. Nurse #1 she has not seen a brace or a palm protector for Resident #55. Nurse #1 accompanied the surveyor to Resident #55's room. Resident #55 was not wearing anything in his/her right hand or anything on his/her right elbow. Nurse #1 and the surveyor were able to locate a brace in a box in his/her room and Nurse #1 said she had never seen this brace. During an interview and observation on 1/18/23 at 4:30 P.M., CNA #3 and CNA #4 had just completed providing care to Resident #55. There was no brace or rolled towel to his/her right elbow or a palm protector or rolled towel to his/her right hand. During an interview on 1/18/23 at 4:34 P.M., Nurse #1 said she was going to apply a face cloth to Resident #55's right hand. During an observation on 1/18/23 at 4:44 P.M., the surveyor with the Director of Nursing and the Regional Nurse made observations of Resident #55. Resident was not wearing a right arm brace. During an interview on 1/18/23 at 4:08 P.M., the Director of Nursing said nursing should be applying the brace and right palm protector as ordered. During an interview and observation on 1/19/23 at 8:08 A.M., the Director of Nursing and Occupational Therapist #2 were in Resident #55's room observing his/her right elbow. The Director of Nursing said that the brace was on hold until further evaluation. During an interview on 1/19/23 at 3:11 P.M., Occupational Therapist #1 said that she made the recommendations for the brace and the palm protector. OT #1 said she implemented a functional maintenance plan and said that Resident #55 was able to tolerate these devices. OT #1 said that if Resident #55 was unable to tolerate his/her brace and palm protector, nursing should have made a referral for a revision to his/her plan of care. 2. For Resident #86 the facility failed to ensure sleeves ordered by the physician were worn by the Resident to prevent further injury. Review of the facility policy titled Skin Integrity and Wound Management, dated as revised 9/1/22, indicated the following: * POLICY: A comprehensive initial and ongoing nursing assessment of intrinsic and extrinsic factors that influence skin health, skin/wound impairment, and the ability of a wound to heal will be performed. The plan of care for the patient will be reflective of assessment findings from the comprehensive patient assessment and wound evaluation. Staff will continually observe and monitor patients for changes and implement revisions to the plan of care as needed. *6.7: Notify interdisciplinary team members for a comprehensive approach to care including prevention and wound treatments, as indicated. Resident #86 was admitted to the facility in August 2022, with diagnoses that include Alzheimer's disease and gout. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/16/22, indicated Resident #86 was assessed by staff to have had moderately impaired cognition. The MDS further indicated Resident #86 required extensive assistance from one to two staff with all aspects of his/her care, including dressing and hygiene care. During an observation on 1/17/23 at 8:29 A.M., Resident #86 was observed in bed. His/her skin was observed to be fragile with several scabs, and red marks on both arms. During a record review the following was indicated: *A physician's order, dated 12/22/22, Apply beige arm sleeves to bilateral arms. Remove for ADL care each shift. *An Activities of Daily Living (ADLs) care plan, dated as updated 10/14/22, with an intervention Assist too dependent with bathing, dressing and grooming. *A behavior care plan, updated 11/27/22, did not indicate Resident #86 refused to wear the bilateral arm sleeves. *The treatment Administration Record (TAR) indicated Resident #86 wore the arm sleeves every shift and failed to indicate he/she refused the application. During an observation on 1/18/23 at 7:08 A.M., Resident #86 was observed in bed and was not wearing bilateral arm sleeves, nor were they observed in the area. The TAR for this date indicated nursing staff had documented the sleeves were applied. During an observation on 1/18/23 at 8:19 A.M., Resident #86 was observed in bed and was not wearing bilateral arm sleeves, nor were they observed in the area. The TAR for this date indicated nursing staff had documented that the sleeves were applied. During an observation on 1/18/23 at 10:14 A.M., Resident #86 was observed in bed and was not wearing bilateral arm sleeves, nor were they observed in the area. Review of the TAR indicated nursing staff had documented the sleeves were applied. During an observation on 01/18/23 at 12:09 P.M., Resident #86 was observed in bed, dressed for the day, and was not wearing bilateral arm sleeves, nor were they observed in the area. Review of the TAR indicated nursing staff had documented that the sleeves were applied. During an interview with a Certified Nursing Assistant (CNA) #5 on 1/19/23 at 9:36 A.M., she said that Resident #86 required total care and wore bilateral sleeves because his/her skin was fragile. CNA #5 said Resident #86 did not refuse to wear the sleeves. During an interview with the Clinical Reimbursement Coordinator (CRC) Nurse and Director of Nursing (DON) on 1/19/23 at 9:48 A.M., the surveyor shared the daily observations of Resident #86 not wearing the bilateral arm sleeves. The DON said Resident #86 often refuses the sleeves and that it should be documented in the care plan and TAR. 3. For Resident #70 the facility failed to provide hand and nail hygiene during morning care, failed to ensure bilateral arm sleeves were worn as ordered and failed to ensure a padded tray table was provided. Resident #70 was admitted to the facility in March 2020 and had diagnoses that included dementia without behavioral disturbance. Review of the most recent Minimum Data Set (MDS) assessment, dated 11/8/22, indicated Resident #70 was assessed by staff to have moderately impaired cognition. The MDS further indicated Resident #70 did not have behavior of rejecting care and required extensive two-person physical assistance with all Activities of Daily Living (ADLs), including dressing and personal hygiene care. During an observation on 1/17/23 at 8:17 A.M., Resident #70 was observed in his/her room, receiving morning care from 2 Certified Nursing Assistants (CNAs). The surveyor continued to make the following observations: * At 8:27 A.M., the 2 CNAs exited Resident #70's room, and Resident #70 was dressed for the day. Resident #70's fingernails were visibly soiled with thick dark brown substance under the fingernails and brown and yellow substance covering his/her cuticles. He/she had been placed in a wheelchair in the middle of room with an unpadded bedside table in front of him/her During a record review the following was indicated: * A physician's order initiated 9/22/22: Apply beige arm sleeves to bilateral arms. Remove for ADL care, every shift. * An ADL care plan, revised 8/27/22, with an intervention that Resident #70 is dependent with bathing, dressing, grooming. * A skin and bruising care plan, with an intervention bedside table padded. * An investigation for a bruise of unknown origin, dated 10/13/22, indicated Resident #70 was found to have a bruise on his/her right forearm. The intervention at the conclusion of this investigation was the center has padded his/her overbed table and seat in the dining room to avoid future incidents of the resident accidentally banging his/her arm. During an observation on 1/18/23 at 7:07 A.M., Resident #70 was observed asleep in bed and was not wearing bilateral arm sleeves, nor were they observed in the area. Nursing staff had documented in the TAR that the sleeves were applied. During an observation on 1/18/23 at 8:18 A.M., Resident #70 was observed seated in bed, not wearing bilateral arm sleeves, with his/her arms resting on top of the unpadded bedside table that had been placed directly in front of him/her. During an observation on 1/19/23 at 8:17 A.M., Resident #70 was observed in a chair in his/her room. He/she appeared anxious and was wringing his/her hands and arms on the unpadded bedside table that had been placed directly in front of him/her. During an interview with a Certified Nursing Assistant (CNA) #5 on 1/19/23 at 9:34 A.M., she said Resident #70 requires total care, including hygiene care, and that included nail care. CNA #5 said Resident #70 wore arm sleeves because his/her skin was very fragile, but that she had never seen a padded bedside table. During an interview with the Clinical Reimbursement Coordinator (CRC) Nurse and Director of Nursing (DON) on 1/19/23 at 9:48 A.M., they said that Resident #70 was supposed to have a padded bedside table and that someone must have moved it. The CRC Nurse said that nail care was an expected part of daily ADL care. Based on observation, record review and interview the facility failed to ensure the facility developed and implemented plans of care for 6 Residents (#12, #34, #86, #70, #8 and #55) out of a total sample of 27 residents. Findings include: Review of facility policy titled 'Person- Centered Care plan', revised 10/24/22, indicated the following: *Policy: A comprehensive, individualized care plan will be developed within 7 days after completion of the comprehensive assessment (admission, annual, or significant change in status) and review and revise the care plan after each assessment. *Purpose: To attain or maintain the patient's highest practicable physical, mental and psychosocial well-being; to eliminate or mitigate triggers that may cause re-traumatization of the patient; to promote positive communication between patient, patient representative, and team to obtain the patient's and resident representative's input into the plan of care, ensure effective communication . -Care plans will be reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, and as needed to reflect the response to care and changing needs and goals; 1a. For Resident #12, the facility failed to implement the Resident's care plan to keep him/her separated from another Resident (Resident #34) while in the dining room, resulting in a resident to resident altercation which resulted in a fractured fibula. Resident #12 was re-admitted to the facility in March 2019 with diagnoses including dementia and unspecified mood disorder. Review of Resident #12's Minimum Data Set Assessment (MDS) dated [DATE] indicated he/she was moderately cognitively impaired and scored a 10 out of 15 on the Brief Interview for Mental Status. The MDS further indicated the Resident had behavioral symptoms directed towards others 1 to 3 days out of the previous 7 days, verbal behavioral symptoms 4 to 6 days out of the previous 7 days, other behaviors 1 to 3 days out of the previous 7 days, did not reject care, requires extensive assistance with a one person physical assist for transfers and dressing, supervision with one person physical assistance for locomotion off the unit. Review of Resident #12's medical record indicated the following: -A SBAR (Situation, Background, Assessment and Recommendation) note for Resident #12 dated 5/1/22 which indicated Resident #12 swore, pushed his/her wheelchair into another resident and fell. -A resident to resident report for Resident #12 dated 5/1/22 which indicated that staff heard a loud noise in the hallway and quickly went and found two residents (#12 and #34) lying on the floor beside each other. The other Resident stated he/she needed to use the toilet and Resident #12 was sitting in the doorway. Resident #34 asked Resident #12 to move, then he/she swore at Resident #34 and backed up his/her wheelchair on the Resident and he/she fell. The report indicated the immediate actions taken were helping the two residents off the floor, removed them immediately from each other, incident reported to police. Continue to keep residents separated. -An undated altercation investigation summary signed by the Director of Nursing which indicated the following: Incident: On 5/1/22, staff responded to yelling and found Resident #34 tagging back and forth with Resident #12. Resident #34 stated he/she was walking in hallway when Resident #12 backed into him/her with his/her wheelchair. Resident #12 was unable to state exactly what happened. Staff separated residents. No apparent injuries to residents. Physician, responsible parties and police notified. Investigation: Staff and residents were interviewed. Staff stated that hey responded to the yelling and found residents tagging back and forth. Staff did not witness the beginning of the altercation and therefore did not know what triggered the incident. Resident #34 stated that Resident #12 backed into him/her with his/her wheelchair as Resident #34 was walking triggering the incident. Resident #12 denied backing into Resident #34 and was unable to state what happened. Conclusion: The residents got into an altercation due to some sort of misunderstanding. The minutes prior to the incident were unwitnessed. We are unable to verify Resident #34's account of events. Plan: Staff to keep residents separated. Social services to follow up with residents as needed. -An accident incident action team document dated as reviewed 5/2/22 which indicated a new intervention to keep Resident #12 and Resident #34 separated. -A care plan for Resident #12 revised 5/1/22 for risk for alteration in overall behavioral/psychosocial well-being with a new intervention added 5/1/22 to keep Resident #12 separated from Resident #34 in the dining room. Further review of Resident #12's medical record indicated the following: -A late entry note dated 8/8/22 at 9:02 P.M. effective for 8/8/22 at 8:30 A.M. which indicated Resident #12 was pulled out of his/her wheelchair and thrown to the ground. The Resident's Health Care Proxy (HCP) and Nurse Practitioner notified. notified. Seen by psych doctor, social services. Resident diagnosed with left distal fibula fracture. Seen by Nurse Practitioner. -A Nurse Practitioner (NP) encounter note dated 8/8/22: NP follow up resident to resident encounter, fracture. Resident was involved in the resident to resident encounter, he/she sustained a fall and was complaining of left ankle pain; X-ray shows acute oblique distal fibula (the outer bone between the knee and ankle joint) fracture (a fracture that occurs when the bone is broken at an angle); resident sent to ER (emergency room) by this provider. -A radiology report dated 8/8/22 which indicated a left acute oblique distal fibula fracture. -A hospital after visit summary dated 8/8/22 which indicated the reason for the visit was a leg injury and the diagnosis was a broken leg. Review of facility provided investigations for Resident #12 indicated the following: -A Resident to Resident report dated 8/8/22 which indicated that staff heard a loud noise in the dining room and quickly ran and found Resident #12 and Resident #34 lying on the floor beside each other. Resident #12 said he/she was in his/her wheelchair by the dining room door. Resident #34 asked him/her to move and Resident #12 was about to do so then Resident #34 swore at Resident #12 and called him/her 'stupid idiot'. Resident #12 swore at Resident #34 and Resident #34 then hit Resident #12 in the face. Resident #12 threw a bottle of soda at Resident #34 and then Resident #34 pulled Resident #12 out of his/her wheelchair and threw him/her on the ground. -An unsigned summary document dated 8/8/22 which indicated the following: At approximately 8:30 A.M. on 8/8/22 staff on the mental health and recovery unit heard shouting from the dining room. Upon arrival to the dining room staff observed Resident #12 and Resident #34 on the floor entangled in one another. Upon initial interview, Resident #12 stated that Resident #34 told him/her to move, he/she began to try to move his/her chair to the side of the hallway when Resident #34 attempted to punch him/her in the face. Resident #12 explained that he/she splashed a cup of soda at Resident #34 and Resident #34 dragged him/her onto the ground. Upon initial interview, Resident #34 stated that he/she told Resident #12 to move, Resident #12 did not move and Resident #12 tried to punch Resident #34. The residents were immediately separated and assessed for injury. Resident #12 complained of left hip, left leg and left ankle pain. As needed Tylenol (a pain reliever) was administered and a stat x-ray was called in. Resident #34 had no injuries. Upon initial interview of the staff, no staff witnessed the altercation initiate .a Certified Nursing Assistant (CNA) observed Resident #34 pull Resident #12 out of his/her wheelchair onto the floor and responded to the incident and called for help. Upon arrival at the dining room, the resident was on the floor and staff separated them. Upon investigation of the incident the security footage was reviewed. Resident #34 is seen exiting the dining room past Resident #12 with no incident. The initiation of the altercation was not in clear view but Resident #34 is seen attempting to punch Resident #12, Resident #12 is seen putting his/her hands over his/her head. Resident #34 is seen wrapping his/her arms around Resident #12, pulling the Resident out of his/her wheelchair and both residents are seen on the ground. Resident #34 is seen attempting to kick Resident #12 as they are entangled on the ground. Staff come running into the room and separate the two residents. In conclusion, the center believes that Resident #34 initiated the resident to resident altercation. The center believes that the residents did have a verbal exchange where Resident #34 asked Resident #12 to move. The center believes that both residents swore at one another during the verbal exchange and Resident #34 initiated the physical altercation with Resident #12 .Resident #12 was sent to the ER for complaints of pain, x-rays were done and revealed a fracture of the left fibula. -A signed CNA statement dated 8/8/22 indicating the CNA was in the hallway and heard someone calling for help and the CNA ran to the dining room and saw the residents on the floor. -Two signed CNA statements dated 8/8/22 stating they heard one staff call for help, they ran and saw two residents on the floor. -A signed CNA statement dated 8/8/22 which indicated the CNA was in a resident's room and turned her head and saw Resident #34 grab Resident #12 and pull him/her on the floor and the CNA called for help. Further review of Resident #12 medical record failed to indicate staff had kept the Resident separated from Resident #34 in accordance with his/her care plan after a previous resident to resident altercation, resulting in an unwitnessed resident to resident altercation and a leg fracture for Resident #12. During an interview on 1/19/23 at 10:34 A.M., Unit Manager #1 said she is familiar with both residents. Unit Manager #1 said Resident #34 has a short fuse and doesn't always remember to get staff when he/she is frustrated. Unit Manager #1 said she was working the day of the resident to resident altercation in August and that it happened in the morning. Unit Manager #1 said she was sitting at the nurses station and she was alerted by another staff member saying there was an altercation between Resident #34 and Resident #12. Unit Manager #1 said the Residents had altercations prior to this. Unit Manager said there are many residents with behaviors on the unit and when in the dining room residents should be supervised and further said the Residents were not supervised when this occurred. Unit Manager #1 was unable to say why no staff were present to keep the Residents separated prior to the altercation, but said maybe staff was pulled from the dining room. Unit Manager #1 said the expectation is that care plan interventions will be adjusted and followed as written. Unit Manager #1 said in her opinion Resident #34 should be supervised when interacting with other residents because he/she is aggressive and can snap quickly without warning. During an interview on 1/19/23 at 4:05 P.M., Licensed Therapist #1 said staff was aware of Resident #34's behaviors and some interventions included staff staying in the dining room to be a buffer between Resident #34 and other residents and said that about 90% of time there is supervision plus cameras. Licensed Therapist #1 said supervision in the dining room is best for safety. During an interview on 1/19/23 at 4:54 P.M. with the Director of Nursing, Administrator and Corporate Consultant #2, the Director of Nursing said Resident #34 has had a few resident to resident incidents and has a lot of triggers. The Director of Nursing said Resident #34 is triggered by other residents and by people getting in his/her way and that the Resident ambulates independently with a cane. The Director of Nursing acknowledged that interventions were listed Resident #12's care plans to keep him/her separated from Resident #34 but said that the interventions were not meant to be permanent even though they were still listed as current interventions. The Director of Nursing said the care plan interventions were in place to keep the Residents separated and it wasn't done. 1b. For Resident #34, the facility failed to keep him/her separate from another Resident (#12) while in the dining room, resulting in a resident to resident altercation. Resident #34 was admitted to the facility in April 2021 with diagnoses including unspecified dementia with agitation and alcohol dependence. Review of Resident #34's Minimum Data Set Assessment (MDS) dated [DATE] indicated the Resident was cognitively intact and scored a 13 out of 15 on the Brief Interview for Mental Status Exam (BIMS). Further review of the MDS indicated the Resident had delusions, physical and verbal behaviors directed at others 1 to 3 days out of the previous 7 days, was independent with bed mobility, transfers, walking in his/her room and in the corridor and locomotion on and off the unit. Review of Resident #34's medical record indicated the following: -A SBAR note for Resident #34 dated 5/1/22 which indicated that residents were fighting on the floor due to stated issue, they were removed from each other and appropriate action taken. -A care plan for Resident #34 initiated 4/8/21 for potential to demonstrate verbal/physical behaviors related to cognitive loss/ dementia. He/she has gotten physical with other residents, history of punching another resident in the face, recently responded to resident attack with physical response with a new intervention added 5/1/22 to keep Resident #34 separated from Resident #12. Further review of Resident #34's medical record indicated the following: -A SBAR note dated 8/8/22 which indicated that staff heard loud noise from the dining room and quickly ran in to the dining room and found this Resident with another Resident laying on the floor kicking each other. When reviewing the camera they noticed this Resident was the aggressor. -A therapy note for service date 8/8/22 (the date of the altercation) which indicated the Resident started a fist fight with another resident who was in a wheelchair/ Resident #34 pulled the other Resident (Resident #12) out of his/her wheelchair, threw him/her on the ground, got on top of him/her and started punching him/her in the head and kicking him/her. Resident #34 denied having done all of these activities but everything was on video. Further review of the Resident's medical record failed to indicate staff had kept the Resident separated from Resident #12 in accordance with his/her care plan after a previous resident to resident altercation, resulting in an unwitnessed resident to resident altercation and a leg fracture for Resident #12. During an interview on 1/19/23 at 4:05 P.M., Licensed Therapist #1 said he has worked with Resident #34 since admission to the facility. Licensed Therapist #1 said Resident #34 will try to find someone he/she perceives as weaker than him/her and start a fight and that when asked about the Resident to Resident altercation in August Resident #34 said Resident #12 tried to fight him/her and that the surveillance video did not match with what Resident #34 had said happened. Licensed Therapist #1 said staff was aware of Resident #34's behaviors and some interventions included staff staying in the dining room to be a buffer between Resident #34 and other residents and said that about 90% of time there is supervision plus cameras. Licensed Therapist #1 said supervision in the dining room is best for safety. During an interview on 1/19/23 at 4:54 P.M. with the Director of Nursing, Administrator and Corporate Consultant #2, the Director of Nursing said Resident #34 has had a few resident to resident incidents and has a lot of triggers. The Director of Nursing said Resident #34 is triggered by other residents and by people getting in his/her way and that the Resident ambulates independently with a cane. The Director of Nursing acknowledged that interventions were listed in Resident #34 and Resident #12's care plans to keep them separated but said that the interventions were not meant to be permanent even though they were still listed as current interventions. The Director of Nursing said care plan interventions were in place to keep the Residents separated and it wasn't done. 4. For Resident #8 the facility failed to a. ensure the Resident wore a wander guard in accordance with the physician's orders, and b. failed to develop and implement a care plan for smoking. a. Resident #8 was admitted to the facility in October 2022 with diagnoses including dementia, schizophrenia, and a history of alcohol abuse. Review of the most recent minimum data set (MDS) completed in 1/10/2023 indicated a brief interview for mental status (BIMS) score of 9 out of a possible 15 indicating moderate impairment. On 1/8/23 at 11:14 A.M., and 1/19/23 at 8:45 A.M., Resident #8 was observed in his/her room without a wander guard on his/her left ankle. Review of Resident #8's January 2023 physician's orders indicated the following: *Wander guard left ankle, check placement qs, (each shift) check function with wand on 11-7 daily, exp 7/25. Review of the care plan dated October 2022 indicated Resident #8 is at risk for elopement related to exit seeking in the hospital. Review of the behavior flow sheets dated December 2022 and January 2023 indicated Resident #8 attempted to elope/exit seek on 12/3/22 (day shift), 12/11/22 (day shift), and 1/3/23 (night shift). During an interview with the Unit Manager (UM #1) on 1/18/23 at 12:49 P.M., she said the Resident should have a wander guard on his left leg as ordered by the physician. During an interview with the Regional Nurse (RN#1) on 1/18/23 at 3:09 P.M., he said staff should follow physician's orders and care plans in the medical record. b. The facility failed to develop and implement a smoking care plan for Resident #8. Review of the facility's Smoking Policy dated 11/4/19, indicated the following: *The admitting nurse will perform a smoking evaluation on each patient who chooses to smoke. *A patient's smoking status - independent, supervised, or not permitted to smoke - will be documented in the care plan *The care plan will be updated, as necessary. Review of the facility's grievance log indicated a grievance alleging that Resident #8 was smoking in his/her room on 12/12/22. Review of Resident #8's Smoking Evaluation dated 10/17/22 indicated that Resident #8 has a history of selling/sharing cigarettes and is unable to locate the smoking area and required supervision while smoking. Review of Resident #8's care plans failed to indicate a care plan for smoking. During an interview with UM #1 on 1/19/23 at 11:00 A.M., she said that Residents who smoke should have a care plan and acknowledged that Resident #8 did not have a smoking care plan.