**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #2(R2) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R2 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar disorder, dementia, post-traumatic stress disorder, major depressive disorder, hypertension (high blood pressure), chronic obstructive pulmonary disease, and muscle weakness. The MDS reflected R2 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with bed mobility, transfers, locomotion on unit, dressing, toileting, and two person physical assist with hygiene. The MDS reflected R2 had no behaviors including verbal or physical including discharge MDS, dated [DATE]. Resident #3(R3) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R3 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar disorder, traumatic brain injury, diabetes mellitus, congestive heart failure, anxiety disorder, hypertension (high blood pressure), chronic obstructive pulmonary disease, and lack of coordination. The MDS reflected R3 had a BIM (assessment tool) score of 8 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with transfers, walking, dressing, toileting, hygiene and bathing. Resident #10(R10) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R10 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included cerebral infarction, schizoaffective disorder, dementia, major depressive disorder, hypertension (high blood pressure), extrapyramidal and movement disorder. The MDS reflected R10 had a BIM (assessment tool) score of 00 which indicated her ability to make daily decisions was severely impaired, and she required two person physical assist with bed mobility, transfers, toileting, and hygiene and one person physical assist with locomotion on unit, dressing and showering. Continued review of the MDS reflected R10 vision was not impaired. The MDS reflected R10, dated 10/27/22, reflected death in facility. Review of the complaint, reported to the State Agency 10/20/22, reflected R2 had several bruises with unknown cause. Review of the witnessed Facility Reported Incident(FRI), dated 9/16/22 at 6:00 p.m., reflected R10 tightly grabbed R2 arm and dug nails into skin resulting in injuries that included bruising and two crescent shaped skin scratches. The FRI named R10 as the perpetrator. Review of the witnessed FRI, dated 10/14/22 at 6:40 a.m., reflected R2 and R3 had a verbal altercation that developed into physical altercation on the C hallway near the nurse's station. The FRI reflected named R3 as the perpetrator and indicated the incident was witnessed by Housekeeper (HK) M. The report reflected, type of alleged incident: Mistreatment . During an observation and interview on 12/6/22 at 11:25 a.m., C hall was noted to be a locked unit with one Nurse and one Certified Nurse Aid observed on the unit. Registered Nurse (RN) L, who was present, reported there was another CNA on break who was currently working on C hall. R3 was observed sitting in Dining Room with several other Residents and appeared anxious and asking why this surveyor was present. The medication cart was parked by entrance to Dining Room, across from Nurse Station door with items top of cart including heavy medal pill crusher, medication and drinking cups. Review of the requested FRI investigation, dated 10/14/22 at 6:40 a.m., reflected a witness statement written by HK M and signed by Nursing Home Administrator(NHA) A. The statement reflected, I was cleaning the C-hall dining room & [named R2] was sitting in a chair next to the med cart & [named R3] was sitting in the wheelchair near the door of the nurse's station. They were having some type of argument that I was not paying attention to, when thighs started to escalate. [Named R3] approached [named R2] and grabbed her by her feet & started hitting her & taking her shoes off. [Named R2] started kicking and flailing and ended up kicking [named R3] directly in the face. [Named R3] then grabbed a large metal object off the med cart and started hitting [named R2] with it. At this point I stepped in and tried to get them to stop & I took the metal object from [named R3] and set it back on the med cart. As soon as I turned around, they resumed fighting, which started with [named R3] grabbing at [named R2] breasts and squeezing & pulling tightly. When that happened I went to go find someone to help, which was [named Scheduler N]. They continued fighting until other arrived. Continued review of the same investigation indicated based on the dementia diagnosis and cognitive disabilities for the resident involved, they did not feel that it was willful and did not substantiate abuse. During an interview on 12/7/22 at 8:25 a.m., HK M witnessed resident to resident verbal and physical altercation on 10/14/22 at 6:40 a.m. HK M reported R3 and R2 were located by the C-hall nurse station and started yelling at each other and escalated to throwing punches. HK M reported did not recall who started verbal altercation and reported R3 had history of over reacting and R3 pushed R2 with hands and R2 started kicking then R3 picked up metal object from medication cart and hit R2 with it several times to front of left shoulder area. HK M reported no other staff present at the time and had to leave the locked unit to get help after failing to deescalate the situation. HK M reported Scheduler N was located at the Main Nurse Station, outside the locked c-hall, who assisted to separate R2 and R3. HK M reported both residents appeared upset. HK M verified witness statement. HK M reported did not recall nurse present on c-hall prior to altercation and reported was also working on d-hall at the time and reported was unsure who Certified Nurse was at the time. HK M reported usually worked the c-hall three to four times weekly. During an interview on 12/7/22 at 9:10 a.m., Scheduler N reported had worked at the facility for nine years and was currently the scheduler, medical records and also a CNA. Scheduler N verified assisted HK M separate R2 and R3 after a physical altercation on 10/14/22 on unit C. Scheduler N verified was sitting at the Main Nurse Station, outside of the locked c-hall, when HK M exited the unit and requested assistance. Scheduler N reported no other staff present at the time of the incident and verified residents were separated. During an interview on 12/7/22 at 9:15 a.m., HK M reported had worked at the facility for nine months after transferring from another facility in the area. HK M reported did not receive abuse training from current facility and was able to report 3 of 8 types of abuse. HK M reported not aware of any resources available to utilize. HK M reported 10/14/22 resident to resident altercation was an example of an allegation of abuse and was reported to management. During an interview on 12/7/22 at 9:25 a.m., Scheduler N reviewed the schedule and reported Unit Manager(UM) I was the nurse from 6:30 a.m. to 9:00 a.m. and CNA O was the aid on the C-hall. Scheduler N reported Director of Nursing (DON) B had been the night nurse for the entire facility until 6:30 a.m. and CNA P had been only night CNA on c-hall. During an interview on 12/7/22 at 9:35 a.m., UM I reported had worked at the facility for two months and verified worked 10/14/22 from 6:30 a.m. to 9:00 a.m. UM I reported was not aware of R2 and R3 verbal and physical altercation on c-hall at 6:40 a.m. UM I reported worked on d-hall from 6:30 a.m. to 9:00 a.m. and reported usually obtained two resident blood sugars around breakfast time on c-hall before breakfast. UM I reported unsure if she had been on c-hall prior to altercation and again reported had not knowledge of R2 and R3 physical altercation on 10/14/22 at 6:40 a.m. During an interview on 12/7/22 at 10:41 a.m., Payroll Staff (PR) Q provided missed punches for DON B on 10/13/22 at 6:30pm to 10/14/22 at 7:00am. PR Q provided missed punches for UM I on 10/14/22 at 6:30am to 10:50am. During a telephone interview on 12/7/22 at 10:52 a.m., CNA R reported was not involved in R2 and R3 altercation on 10/14/22 at 6:40 a.m. CNA R reported had worked d-hall night shift until 10/14/22 at 7:00 a.m. CNA R reported frequent resident altercation on, psych unit (hall c) that often occur in the morning hours and reported R3 had frequent history of provoking other residents. During a telephone interview on 12/7/22 at 11:12 a.m., CNA O reported was not present for R2 and R3 altercation on 10/14/22 at 6:40 a.m. CNA O reported had heard about incident after arriving for shift on 10/14/22 at 7:00 a.m. and did not recall any changes in interventions to prevent further altercations. During a telephone interview on 12/7/22 at 11:23 a.m., RN E reported was not working c-hall on 10/14/22 at the time of R2 an R3 altercation and recalled UM I present at Main Nurse Station who was just getting report related to a call in and reported was maybe her first day. RN E reported was present for day shift on another hall but had good rapport with R3 and assisted after the altercation with attempts to defuse R3. Review of R3 Electronic Medical Record, dated 5/28/22 to 10/14/22, reflected R3 had 10 documented physical altercations with other residents on c-hall. Review of R3 Care Plans, dated 5/28/22 to current(12/7/22), reflected, The resident has impaired cognition and difficulty making decisions r/t a TBI and Schizoaffective Disorder and Bipolar Disorder Revision on: 12/11/2020 . Cue, reorient and supervise as needed. Date Initiated: 12/11/2020 .The resident has potential to be physically aggressive or agitated r/t Anger, History of harm to others, Poor impulse control .Goal .The resident will not harm self or others through the review date. Date Initiated: 08/11/2021 Revision on: 04/05/2022 .Interventions .Resident given soft stuffed animal to hit with when upset. Date Initiated: 06/14/2022 . Continued review of the Care Plans reflected no evidence of revision of interventions or new interventions added with exception 6/14/22 intervention for R3's 11 documented physical altercations with other residents including R2 on 10/14/22. During a telephone interview on 12/7/22 at 4:06 p.m., R2 Case Worker(CW) S reported was R2 and R3 Case Worker for local mental health organization. CW S reported between her and another case worker they visit facility weekly. CW S reported they make several recommendations for residents but facility has had issues with no follow up related to implementing recommendations possibly related to staffing changes but continue to make recommendations. CW S reported activities for residents on c-hall had been a concern but getting slightly better. CW S reported aware of recent change in facility Social Worker and reported every consult visit sent to facility staff in PDF form after each visit. CW S verified 12 missing consult notes for R3 since September. R3 facility EMR reflected no evidence of (local mental health) consult since 9/7/22. During an observation on 12/8/22 from 8:20 a.m. to 10:00 a.m., on the locked c-hall, reflected one nurse, RN T and one aid, CNA D for day shift 6:30 a.m. to 2:30 p.m. Continued observation reflected UM/MDS H in and out of unit, Social Worker(SW) F in and out of unit, and male staff wearing street clothes assisted a resident back to room from Dining Room in wheelchair with no foot pedals at 8:35 a.m. and then exited unit. At 8:56 a.m. two residents noted wandering hall with one resident who appeared very anxious repeatedly asking if it was time to smoke. UM H, CNA D and RN T off the unit at that time for more than 5 minutes with SW F as only staff on the unit(not observed). CNA D returned to the unit at 9:03 a.m., Activity staff entered the unit at 9:04 a.m. with RN T and tended to resident who wanted to smoke. Housekeeping entered unit at 9:08 a.m. and UM H returned at about 9:25 a.m. During a telephone interview on 12/8/22 at 8:42 a.m., CNA P reported worked night shift 10/13/22 to 10/14/22 on c-hall as only cna staff and DON B was only nurse on night shift for entire facility. CNA P reported staff document behaviors in tasks. CNA P reported was unsure who she gave report to on the morning of 10/14/22 but was not present at time of R2 and R3 verbal and physical altercation. When ask how staff prevent resident to resident altercations CNA P reported she tried to keep residents apart and reported did not recall change in R2 or R3 interventions after 10/14/22. CNA P reported did care for R2 and R3 after the 10/14/22 altercation and reported R2 had scratches on chest. In review of the facility's 5-day investigation of an allegation of resident-to-resident sexual abuse that occurred on 10/12/22 at 12:10 PM; the facility was notified by staff that they had reason to believe male resident had touched R2 in her private areas; R2 was visibly upset afterward, anxious and required medication. Witness statement dated 10/12/22, indicated Certified Nurse Assistant (CNA) K witnessed male resident grab R2's vagina from behind. In review of R2's October 2022's Medication Administration Record, Ativan 0.5 milligrams (mg) was ordered every 8 hours, as needed (PRN), for 14 days on 10/05/22. R2 did not require PRN Ativan from 10/05/22 through 10/08/22 and did not need Ativan PRN on 10/10/22 and 10/11/22. R2 had used Ativan 2 times on 10/09/22 and at 4:35 AM on 10/12/22. Ativan was administered on 10/12/22 at 12:46 PM following the incident with male resident, 10/13/22 at 4:46 AM and again at 1:16 PM, 10/14/22 at 9:40 AM(after resident-to-resident physical altercation at 6:40 a.m.that day), 10/15/22 at 10:45 AM, 10/17/22 at 2:43 PM, 10/18/22 at 1:26 PM, and 10/19/22 at 7:18 PM. Review of R2 EMR, dated 10/14/22 through 10/18/22, reflected no evidence that SW assessed/address residual effects from the 10/14/22 incident including Progress Notes. Continued Review of EMR reflected no evidence of completed skin assessments between 10/14/22 and 10/17/22(included existing abnormal skin with no documentation). The EMR reflected no evidence of Pain assessment between 10/14/22 and 10/23/22(discharge). During an interview on 12/8/22 at 4:23 p.m., DON B reported had been DON at the facility for 18 months with three different Nursing Home Administrators. DON B reported behaviors reviewed daily Monday through Friday at morning meetings that consisted of clinical managers. DON B reported morning meetings were the same as IDT meetings and all events were reviewed and if any changes in immediate interventions were need they add IDT Progress Notes and add interventions including on Care Plans. DON B reported would expect interventions to be added to care plans and implemented after each altercation to prevent further altercations. This surveyor requested DON B provided evidence of what measures were taken by facility to prevent resident to resident altercation. DON B reported R3 had incentive program started but was unsure where it was documented with frequent changes. DON B would expect SW to follow up with residents after each allegation of abuse including resident to resident altercations for 72 hours and document in Progress Notes. DON B reported noticed yesterday SW had not completed 72 hour follow up assessments for residents after allegations of abuse when reviewing surveyor requested documents and education was provided to SW F. DON B reported SW F had worked at the facility for three months with no prior SW experience. DON B reported she was covering role of SW as well as DON with regional staff to cover behavior unit(c-hall). DON B verified had been working to relocate R3 per resident and POA request with documentation for at least past six months. Request for evidence of follow up. DON B reported would expect consulted mental health documents to be in resident EMR prior to next visit or 48 hours. DON B reported they have access to reports but had not educated new SW on how to obtain or if she knows she is responsible for obtaining records. DON B verified R3's last record of community mental health consult visit was 9/7/22 and reported R3 had been seen several times since then. DON B reported had provided all staff with Dementia training and would provide evidence. Review of provided Dementia Training Report, dated 12/8/22, reflected no evidence of Dementia Training for HK M. In review of the facility's 5-day investigation of an allegation of resident-to-resident physical abuse that occurred on 9/16/22 at 6:00 PM; R10 was moving through out the dining room and hall and R2 was sitting in the dining room who R10 rolled past R2 and then lounged and grabbed R2 arm. Skin and pain for R2 reflected pain of 4 to bilateral legs( residents normal pain) and R2 had 2 crest shaped scratches with bruising noted. Review of R2 Physician Progress Note, dated 9/19/22, reflected, CHIEF COMPLAINT: Resident-to-resident incident. HISTORY OF PRESENT ILLNESS: [AGE] year-old female here for long-term care, locked psych unit. Patient with known history of dementia, bipolar disorder, schizoaffective disorder, bipolar type, PTSD, major depressive disorder. Patient had a resident-to-resident incident, was grabbed on her right arm via fellow resident which gouged arm pretty hard. Patient does not remember incident occurring. Patient confused at baseline .Skin: Warm and dry. Patient does have deep nail marks from another resident on her right forearm .IMPRESSION AND PLAN: 1. Schizoaffective disorder, bipolar type. 2. Fingernail gouging. 3. Bipolar disorder. 4. Major depressive disorder. Patient with resident-to-resident incident, had fingernail gouging from another resident on right forearm. We will monitor the site closely . Review of R2 Physician Progress Notes, dated 9/21/2022 at 11:58 a.m., reflected, HISTORY OF PRESENT ILLNESS .Patient is with recent injury to right arm, had nails scratched from another resident. Skin appears more red and tender . IMPRESSION AND PLAN: 1. Skin infection right forearm .Patient did have recent injury to right forearm from another resident ' s nails appears infected. We will start doxycycline 100 mg b.i.d. and monitor. Site red, swollen, tender. Injury with human nails, high risk for infection. We will start antibiotic and monitor . Review of R2 Skin assessment, dated 9/16/22 through 10/20/22, reflected on 9/16/22 R2 had two new abnormal skin areas to right hand purple discoloration with scab near thumb and right posterior forearm with 2 crescent shaped skin tears and purple discoloration. The Skin Assessment, dated 9/17/22, 9/24/22, 10/6/22, 10/10/22, reflected no existing abnormal skin areas. The Skin Assessments, dated 10/1/22 and 10/12/22, reflected R2 had bruising and discoloration right arm. The Skin Assessments, dated 10/12/22, and 10/17/22 and 10/20/22 reflected existing abnormal skin areas with no documentation completed. The Skin Assessments did not reflect increased redness and tenderness or signs of infection as indicated in Physician assessment dated [DATE]. Review of the Physician Orders, dated 9/21/22, reflected, Doxycycline Hyclate Tablet 100 MG Give 1 tablet by mouth two times a day for Skin infection for 7 Days. During an interview on 12/9/22 at 12:05 p.m., Regional staff V reported had been at facility for two months and had reviewed all FRI and tracked and identified need for full time activity staff on c-hall. During a telephone interview on 12/8/22 at 12:26 p.m., CNA W reported R10 and R2 had a resident-to-resident altercation on 9/16/22 at 6:04 p.m. CNA W reported there was another CNA on c-hall that was in another resident room. CNA W reported had her back turned and heard R2 scream for help from the Dining Room, turned and saw R10 grabbing at R2 arms. CNA W attempted to separate residents with moderate about of bleeding from R2 right arm from R10 nails that had gouged into skin and had to pry one finger off at a time. CNA W reported Nurse not on the unit at the time of the incident. CNA W reported only intervention implemented was R10 nails trimmed after incident. CNA W reported had never observed 1:1 for any residents on c-hall. CNA W reported times when she had to work c-hall by alone and nurse had to splits with d-hall. CNA W reported very stressful for one person related to residents with behaviors on c-hall. Review of the Nursing Working Schedule, dated 9/16/22, reflected one nurse split between c-hall and d-hall at time of resident-to-resident physical altercation between R10 and R2. During an interview on 12/8/22 at 3:20 p.m., Regional staff V and UM H reported aware increased, frequent FRI and reviewed with plan to add full time activity staff for 2023. UM H reported after creating surveyor requested time line for R3 noticed times and locations of resident-to-resident altercations that occurred mostly during meal time and discussed with team possible interventions to implement and possible plan to use both common areas for two Dining Rooms on c-hall instead of one. During a telephone interview on 12/8/22 at 4:51 p.m., RN X reported several residents on c-hall have manipulative behaviors and reported 12-15 residents on unit will gang up on you. RN X reported not safe for one staff to control entire c-hall on own and resident-to-resident altercation occur when nurse staff split between C and D halls. RN X reported nurses had been told they did not have document abnormal exiting skin on weekly assessments if it had been documented prior, only new skin issues. During a telephone interview on 12/8/22 at 5:30 p.m., RN T reported verbal cussing every day on c-hall and staffing had improved over past 30 days, however, times with one cna and nurse spilt between C and D hall. RN T reported medical event and resident-to-resident altercation occur at same time on both halls and impossible for nurse to be in two places at one time. RN T reported R2 son had questioned her related bruises and marks on R2 arms and reported she reassured him reports had been completed related to resident-to-resident incidents including when R10 grabbed R2 arm and dug her nails into R2 arm that caused open wounds and bruising. Review of R2 EMR dated, 7/25/22 through 10/23/22(admission to discharge), reflected R2 had no evidence of monthly behavioral meeting notes. During an interview on 12/13/22 at 9:10 a.m. SW F reported had worked at the facility about three months. SW F reported was familiar with R3 and reported R3 had behaviors that included cussing, yelling and often difficult to redirect and occasionally able to redirect with calls to sister. SW F reported did not have any involvement with R2 and R10 resident-to-resident altercation on 9/16/22 or R2 and R3 resident-to-resident altercation on 10/14/22. SW F reported received training from prior part time SW. SW F reported was informed by DON B within past week, need to follow up with residents for three days after an allegation of abuse or resident-to-resident altercation and document in Progress Notes to assess for both emotional and physical residual of event. SW F reported was not aware of that requirement prior to last week. SW F reported if community mental health involved in resident care facility has a monthly behavior meeting and should be documented. SW F verified no behavior meeting notes for R2 and reported prior SW was part time between another facility and may not of had time to complete. When SW F was quarried what was was being done to protect other resident on c-hall from R3 on-going physical altercations, SW F reported plan to continue to focus on R3 and DPOA request to transfer to another facility because nothing else had worked. SW F reported c-hall was not a homelike environment related to daily yelling, cussing and repeat resident-to-resident events. During an interview on 12/13/22 at 11:20 a.m., NHA A reported had worked at the facility since 7/18/22 and was also the facility Abuse Coordinator. NHA A reported R3 FRI were not substantiated because investigations did not reflect evidence of contact including staff eye witness events and recording devices have not been functioning. NHA A reported they have cleared congestion in c-hall at nurses station into dining room by removing medication cart one month ago. NHA A they have implemented mental health training for all staff, re-educated all staff on abuse, and continue to work on activity engagement. NHA A reported monthly meetings with consulting mental health groups and reported would expect facility to implement consulting mental health recommendation and have records of consults in resident records within 7 to days post visits. NHA A reported did not think meetings were happening on regular basis with current plans to have SW F and Medical Records N responsible for that task moving forward. During an interview on 12/13/22 at 1:15 p.m. DON B reported skin assessments should be completed through including existing skin alteration. This citation pertains to intake MI00132648, MI00132380, MI00132653, MI00131631, MI00132101 and MI00132397. Based on observation, interview, and record review, the facility failed to protect the resident ' s right to be free from abuse including sexual abuse by another resident in one of 20 residents reviewed for abuse (R1, R2 R3, R10), , resulting in Resident #2 observed visibly upset, anxious and required anti-anxiety medication following the incident. Findings include: Resident #1 (R1) On 12/06/22 at 11:45 AM R1 was observed sitting in a wheelchair, wearing pajamas, hair not combed, and eating lunch in the dining room. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated he admitted to the facility on [DATE] and was re-admitted from a psychiatric hospital on [DATE]. The same MDS indicated R1's cognition was severely impaired, required limited assistance with eating and locomotion. Physician progress note dated 11/09/22 at 11:32 AM indicated R1 had a history of schizo-affective disorder (comination of symptoms), bipolar disorder, cognitive communication deficit, dementia, and anxiety. Resident #2 (R2) R2's admission MDS assessment dated [DATE] indicated she was admitted to the facility on [DATE] and had a Brief Interview for Mental Status for Mental Status (BIMS, a performance-based screening tool for cognition) score was 11 (08-12 indicated moderate impairment). Psychiatry notes dated 9/29/22 revealed R2 was seen for follow-up and the exam indicated she was alert, calm, attentive and not in acute distress. R2's judgement was impaired and was able to follow conversation. The assessment and plan included supportive therapy to help improve current mood and functioning. R2's MDS dated [DATE] revealed she was discharged to a community setting. Progress note dated 9/30/22 at 9:32 AM indicated R2 had diagnoses of schizo-affective disorder, bipolar, dementia, post-traumatic stress disorder (PTSD), and depression. In review of the facility's 5-day investigation of an allegation of resident-to-resident sexual abuse that occurred on 10/12/22 at 12:10 PM; the facility was notified by staff that they had reason to believe R1 had touched R2 in her private areas; R2 was visibly upset afterward, anxious and required medication. Witness statement dated 10/12/22, indicated Certified Nurse Assistant (CNA) K witnessed R1 grab R2's vagina from behind. In an interview on 12/06/22 at 2:20 PM, CNA K stated she witnessed the incident that occurred between R1 and R2 on 10/12/22. R2 was standing, facing the nurses' station; R1 came up behind R2 and grabbed her over her clothing and between her legs. R1 was re-directed and let go of R2. R2 was visibly upset. CNA K stated before this event, on a different day, she had witnessed R2 sitting on R1's lap, but the incident on 10/12/22 had taken her by surprise. In review of R1's progress notes dated 10/12/22, he was transferred to the hospital following the incident. Social Services Progress Note dated 10/13/22 at 2:45 PM indicated R2 was seen in follow-up to incident with another resident on the unit the day before. The same note indicated R2 was anxious on the same day as the note and was exit seeking. Ativan was administered by the nurse at 1:15 PM to help with anxiety. The same note revealed R2 was .unable to express appropriately to any great extent but just says it's not a good day. Plan was to refer to psychiatric services to address needs. There were no Social Services progress notes in R2's record to assess/address residual effects from the 10/12/22 incident on 10/14/22 or 10/15/22. Nurses' Notes dated 10/17/22 at 10:31 AM, revealed R2 was asked to use walker or take a seat for safety and R2 threw the walker against the wall. In review of R2's October 2022's Medication Administration Record, Ativan 0.5 milligrams (mg) was ordered every 8 hours, as needed (PRN), for 14 days on 10/05/22. R2 did not require PRN Ativan from 10/05/22 through 10/08/22 and did not need Ativan PRN on 10/10/22 and 10/11/22. Prior to the 10/12/22 incident R2 had used Ativan 2 times on 10/09/22 and at 4:35 AM on 10/12/22. Ativan was administered on 10/12/22 at 12:46 PM following the incident with R1, 10/13/22 at 4:46 AM and again at 1:16 PM, 10/14/22 at 9:40 AM, 10/15/22 at 10:45 AM, 10/17/22 at 2:43 PM, 10/18/22 at 1:26 PM, and 10/19/22 at 7:18 PM. Social Services Progress Note was dated 10/20/22 at 9:28 AM, indicated the Guardian requested R2 to be discharged the following Sunday. Facility investigation of incident that occurred on 10/12/22 at 10:10 PM, revealed R1 was sent to the hospital for a neuropsychiatric care. The same investigation indicated based on R1's dementia diagnosis and cognitive disabilities, they did not feel that it was willful and did not substantiate abuse. Director of Nursing (DON) B was interviewed on 12/06/22 at 2:15 PM and stated they were not able to review camera footage of the 10/12/22 incident between R1 and R2, because the cameras were not able to record and had needed to be fixed since July 2022. Nursing Home Administrator (NHA) A was interviewed on 12/13/22 at 11:19 AM and stated residents were followed for 72 hours after an incident for any behaviors and psychosocial distress and documentation was expected.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #2(R2) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R2 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar disorder, dementia, post-traumatic stress disorder, major depressive disorder, hypertension (high blood pressure), chronic obstructive pulmonary disease, and muscle weakness. The MDS reflected R2 had a BIM (assessment tool) score of 11 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with bed mobility, transfers, locomotion on unit, dressing, toileting, and two person physical assist with hygiene. The MDS reflected R2 had no behaviors including verbal or physical including discharge MDS, dated [DATE]. Resident #3(R3) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R3 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar disorder, traumatic brain injury, diabetes mellitus, congestive heart failure, anxiety disorder, hypertension (high blood pressure), chronic obstructive pulmonary disease, and lack of coordination. The MDS reflected R3 had a BIM (assessment tool) score of 8 which indicated her ability to make daily decisions was moderately impaired, and she required one person physical assist with transfers, walking, dressing, toileting, hygiene and bathing. Resident #10(R10) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R10 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included cerebral infarction, schizoaffective disorder, dementia, major depressive disorder, hypertension (high blood pressure), extrapyramidal and movement disorder. The MDS reflected R10 had a BIM (assessment tool) score of 00 which indicated her ability to make daily decisions was severely impaired, and she required two person physical assist with bed mobility, transfers, toileting, and hygiene and one person physical assist with locomotion on unit, dressing and showering. Continued review of the MDS reflected R10 vision was not impaired. The MDS reflected R10, dated 10/27/22, reflected death in facility. Resident #16(R16) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R16 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included dysphagia, aphasia, stroke, anoxic brain damage, vascular dementia, hypertension, and major depressive disorder. The MDS reflected R16 had a BIM (assessment tool) score of 6 which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with transfers, dressing, toileting, hygiene and bathing. Resident #17(R17) Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE], reflected R17 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses that included schizoaffective disorder, bipolar disorder, kidney disease, congenital malformation of brain, hypertension, major depressive disorder' The MDS reflected R17 had a BIM (assessment tool) score which indicated her ability to make daily decisions was severely impaired, and she required one person physical assist with transfers, locomotion, dressing, toileting, hygiene and bathing. Continued review of the MDS assessments reflected R17 was transferred to the hospital 11/22/22. Review of the witnessed Facility Reported Incident, date 7/5/22 at 10:00a.m., reflected R3 and R17 had been verbally arguing all morning including call each other names. Physical contact was made when R3 struck R17 in head with closed fist. Review of the witnessed Facility Reported Incident(FRI), dated 9/16/22 at 6:00 p.m., reflected R10 tightly grabbed R2 arm and dug nails into skin resulting in injuries that included bruising and two crescent shaped skin scratches. The FRI named R10 as the perpetrator. Review of the witnessed FRI, dated 10/14/22 at 6:40 a.m., reflected R2 and R3 had a verbal altercation that developed into physical altercation on the C hallway near the nurse's station. The FRI reflected named R3 as the perpetrator and indicated the incident was witnessed by Housekeeper (HK) M. The report reflected, type of alleged incident: Mistreatment . Review of R3 Electronic Medical Record(EMR) and requested incident reports for R3, dated 5/28/22 to 11/22/22, reflected R3 had 14 documented physical altercations with other residents on the c-hall. Continued review of the EMR reflected three of the physical altercations occurred with R16 that included; 9/16/22 at 2:30 p.m. when payroll staff observed R3 hitting R16 leg with hand near nurse station; 10/25/22 at 11:00a.m. when two staff from housekeeping/cota observed R3 strick R16 at least three timed with closed fists in arm and call names. The investigation reflected nurse was not on the unit at the time and was working both c and d hall; 11/22/22 at 535 p.m. when staff observed R3 punching R16 in back three to 4 times during the meal. Continued review reflected no Social work follow up after 14 of 14 resident-to-resident physical altercations. During an observation and interview on 12/6/22 at 11:25 a.m., C hall was noted to be a locked unit with one Nurse and one Certified Nurse Aid observed on the unit. Registered Nurse (RN) L, who was present, reported there was another CNA on break who was currently working on C hall. R3 was observed sitting in Dining Room with several other Residents and appeared anxious and asking why this surveyor was present. The medication cart was parked by entrance to Dining Room, across from Nurse Station door with items top of cart including heavy medal pill crusher, medication and drinking cups. During a telephone interview and record review 12/8/22 at 9:34 a.m., Prior DON U reported witnessed physical altercation between R3 and R17 on 7/5/22 and was reported as Facility Reported Incident because R3 made physical contact with R17's head with closed fist. Prior DON U reported immediate interventions was to separate residents and redirect and unable to recall if interventions added. Prior DON U reported they would attempt to separate residents and involve in activities and reported no activites at the time and R3 very impulsive. The facility incident report reflected action as residents educated and seeking activity staff. Review of the facility Working Schedule, dated 7/5/22, reflected one CNA on c-hall and one Nurse split between C and D hall at time of the resident-to-resident event. Review of the requested FRI investigation, dated 10/14/22 at 6:40 a.m., reflected a witness statement written by HK M and signed by Nursing Home Administrator(NHA) A. The statement reflected, I was cleaning the C-hall dining room & [named R2] was sitting in a chair next to the med cart & [named R3] was sitting in the wheelchair near the door of the nurse's station. They were having some type of argument that I was not paying attention to, when thighs started to escalate. [Named R3] approached [named R2] and grabbed her by her feet & started hitting her & taking her shoes off. [Named R2] started kicking and flailing and ended up kicking [named R3] directly in the face. [Named R3] then grabbed a large metal object off the med cart and started hitting [named R2] with it. At this point I stepped in and tried to get them to stop & I took the metal object from [named R3] and set it back on the med cart. As soon as I turned around, they resumed fighting, which started with [named R3] grabbing at [named R2] breasts and squeezing & pulling tightly. When that happened I went to go find someone to help, which was [named Scheduler N]. They continued fighting until other arrived. Continued review of the same investigation indicated based on the dementia diagnosis and cognitive disabilities for the resident involved, they did not feel that it was willful and did not substantiate abuse. During an interview on 12/7/22 at 8:25 a.m., HK M witnessed resident to resident verbal and physical altercation on 10/14/22 at 6:40 a.m. HK M reported R3 and R2 were located by the C-hall nurse station and started yelling at each other and escalated to throwing punches. HK M reported did not recall who started verbal altercation and reported R3 had history of over reacting and R3 pushed R2 with hands and R2 started kicking then R3 picked up metal object from medication cart and hit R2 with it several times to front of left shoulder area. HK M reported no other staff present at the time and had to leave the locked unit to get help after failing to deescalate the situation. HK M reported Scheduler N was located at the Main Nurse Station, outside the locked c-hall, who assisted to separate R2 and R3. HK M reported both residents appeared upset. HK M verified witness statement. HK M reported did not recall nurse present on c-hall prior to altercation and reported was also working on d-hall at the time and reported was unsure who Certified Nurse was at the time. HK M reported usually worked the c-hall three to four times weekly. During an interview on 12/7/22 at 9:10 a.m., Scheduler N reported had worked at the facility for nine years and was currently the scheduler, medical records and also a CNA. Scheduler N verified assisted HK M separate R2 and R3 after a physical altercation on 10/14/22 on unit C. Scheduler N verified was sitting at the Main Nurse Station, outside of the locked c-hall, when HK M exited the unit and requested assistance. Scheduler N reported no other staff present at the time of the incident and verified residents were separated. During an interview on 12/7/22 at 9:15 a.m., HK M reported had worked at the facility for nine months after transferring from another facility in the area. HK M reported did not receive abuse training from current facility and was able to report 3 of 8 types of abuse. HK M reported not aware of any resources available to utilize. HK M reported 10/14/22 resident to resident altercation was an example of an allegation of abuse and was reported to management. During an interview on 12/7/22 at 9:25 a.m., Scheduler N reviewed the schedule and reported Unit Manager(UM) I was the nurse from 6:30 a.m. to 9:00 a.m. and CNA O was the aid on the C-hall. Scheduler N reported Director of Nursing (DON) B had been the night nurse for the entire facility until 6:30 a.m. and CNA P had been only night CNA on c-hall. During an interview on 12/7/22 at 9:35 a.m., UM I reported had worked at the facility for two months and verified worked 10/14/22 from 6:30 a.m. to 9:00 a.m. UM I reported was not aware of R2 and R3 verbal and physical altercation on c-hall at 6:40 a.m. UM I reported worked on d-hall from 6:30 a.m. to 9:00 a.m. and reported usually obtained two resident blood sugars around breakfast time on c-hall before breakfast. UM I reported unsure if she had been on c-hall prior to altercation and again reported had not knowledge of R2 and R3 physical altercation on 10/14/22 at 6:40 a.m. During an interview on 12/7/22 at 10:41 a.m., Payroll Staff (PR) Q provided missed punches for DON B on 10/13/22 at 6:30pm to 10/14/22 at 7:00am. PR Q provided missed punches for UM I on 10/14/22 at 6:30am to 10:50am. During a telephone interview on 12/7/22 at 10:52 a.m., CNA R reported was not involved in R2 and R3 altercation on 10/14/22 at 6:40 a.m. CNA R reported had worked d-hall night shift until 10/14/22 at 7:00 a.m. CNA R reported frequent resident altercation on, psych unit (hall c) that often occur in the morning hours and reported R3 had frequent history of provoking other residents. During a telephone interview on 12/7/22 at 11:12 a.m., CNA O reported was not present for R2 and R3 altercation on 10/14/22 at 6:40 a.m. CNA O reported had heard about incident after arriving for shift on 10/14/22 at 7:00 a.m. and did not recall any changes in interventions to prevent further altercations. During a telephone interview on 12/7/22 at 11:23 a.m., RN E reported was not working c-hall on 10/14/22 at the time of R2 an R3 altercation and recalled UM I present at Main Nurse Station who was just getting report related to a call in and reported was maybe her first day. RN E reported was present for day shift on another hall but had good rapport with R3 and assisted after the altercation with attempts to defuse R3. Review of R3 Care Plans, dated 5/28/22 to current(12/7/22), reflected, The resident has impaired cognition and difficulty making decisions r/t a TBI and Schizoaffective Disorder and Bipolar Disorder Revision on: 12/11/2020 . Cue, reorient and supervise as needed. Date Initiated: 12/11/2020 .The resident has potential to be physically aggressive or agitated r/t Anger, History of harm to others, Poor impulse control .Goal .The resident will not harm self or others through the review date. Date Initiated: 08/11/2021 Revision on: 04/05/2022 .Interventions .Resident given soft stuffed animal to hit with when upset. Date Initiated: 06/14/2022 . Continued review of the Care Plans reflected no evidence of revision of interventions or new interventions added with exception 6/14/22 intervention for R3's 11 documented physical altercations with other residents including R2 on 10/14/22. During a telephone interview and record review on 12/7/22 at 4:06 p.m., R2 Case Worker(CW) S reported was R2 and R3 Case Worker for local mental health organization. CW S reported between her and another case worker they visit facility weekly. CW S reported they make several recommendations for residents but facility has had issues with no follow up related to implementing recommendations possibly related to staffing changes but continue to make recommendations. CW S reported activities for residents on c-hall had been a concern but getting slightly better. CW S reported aware of recent change in facility Social Worker and reported every consult visit sent to facility staff in PDF form after each visit. CW S verified 12 missing consult notes for R3 since September. R3 facility EMR reflected no evidence of (local mental health) consult since 9/7/22. During an observation on 12/8/22 from 8:20 a.m. to 10:00 a.m., on the locked c-hall, reflected one nurse, RN T and one aid, CNA D for day shift 6:30 a.m. to 2:30 p.m. Continued observation reflected UM/MDS H in and out of unit, Social Worker(SW) F in and out of unit, and male staff wearing street clothes assisted a resident back to room from Dining Room in wheelchair with no foot pedals at 8:35 a.m. and then exited unit. At 8:56 a.m. two residents noted wandering hall with one resident who appeared very anxious repeatedly asking if it was time to smoke. UM H, CNA D and RN T off the unit at that time for more than 5 minutes with SW F as only staff on the unit(not observed). CNA D returned to the unit at 9:03 a.m., Activity staff entered the unit at 9:04 a.m. with RN T and tended to resident who wanted to smoke. Housekeeping entered unit at 9:08 a.m. and UM H returned at about 9:25 a.m. During a telephone interview on 12/8/22 at 8:42 a.m., CNA P reported worked night shift 10/13/22 to 10/14/22 on c-hall as only cna staff and DON B was only nurse on night shift for entire facility. CNA P reported staff document behaviors in tasks. CNA P reported was unsure who she gave report to on the morning of 10/14/22 but was not present at time of R2 and R3 verbal and physical altercation. When ask how staff prevent resident to resident altercations CNA P reported she tried to keep residents apart and reported did not recall change in R2 or R3 interventions after 10/14/22. CNA P reported did care for R2 and R3 after the 10/14/22 altercation and reported R2 had scratches on chest. In review of the facility's 5-day investigation of an allegation of resident-to-resident sexual abuse that occurred on 10/12/22 at 12:10 PM; the facility was notified by staff that they had reason to believe male resident had touched R2 in her private areas; R2 was visibly upset afterward, anxious and required medication. Witness statement dated 10/12/22, indicated Certified Nurse Assistant (CNA) K witnessed male resident grab R2's vagina from behind. Review of R2 EMR, dated 10/14/22 through 10/18/22, reflected no evidence that SW assessed/address residual effects from the 10/14/22 incident including Progress Notes. Continued Review of EMR reflected no evidence of completed skin assessments between 10/14/22 and 10/17/22(included existing abnormal skin with no documentation). The EMR reflected no evidence of Pain assessment between 10/14/22 and 10/23/22(discharge). During an interview on 12/8/22 at 4:23 p.m., DON B reported had been DON at the facility for 18 months with three different Nursing Home Administrators. DON B reported behaviors reviewed daily Monday through Friday at morning meetings that consisted of clinical managers. DON B reported morning meetings were the same as IDT meetings and all events were reviewed and if any changes in immediate interventions were need they add IDT Progress Notes and add interventions including on Care Plans. DON B reported would expect interventions to be added to care plans and implemented after each altercation to prevent further altercations. This surveyor requested DON B provided evidence of what measures were taken by facility to prevent resident to resident altercation. DON B reported R3 had incentive program started but was unsure where it was documented with frequent changes. DON B would expect SW to follow up with residents after each allegation of abuse including resident to resident altercations for 72 hours and document in Progress Notes. DON B reported noticed yesterday SW had not completed 72 hour follow up assessments for residents after allegations of abuse when reviewing surveyor requested documents and education was provided to SW F. DON B reported SW F had worked at the facility for three months with no prior SW experience. DON B reported she was covering role of SW as well as DON with regional staff to cover behavior unit(c-hall). DON B verified had been working to relocate R3 per resident and POA request with documentation for at least past six months. Request for evidence of follow up. DON B reported would expect consulted mental health documents to be in resident EMR prior to next visit or 48 hours. DON B reported they have access to reports but had not educated new SW on how to obtain or if she knows she is responsible for obtaining records. DON B verified R3's last record of community mental health consult visit was 9/7/22 and reported R3 had been seen several times since then. DON B reported had provided all staff with Dementia training and would provide evidence. Review of provided Dementia Training Report, dated 12/8/22, reflected no evidence of Dementia Training for HK M. In review of the facility's 5-day investigation of an allegation of resident-to-resident physical abuse that occurred on 9/16/22 at 6:00 PM; R10 was moving through out the dining room and hall and R2 was sitting in the dining room who R10 rolled past R2 and then lounged and grabbed R2 arm. Skin and pain for R2 reflected pain of 4 to bilateral legs( residents normal pain) and R2 had 2 crest shaped scratches with bruising noted. Review of R2 Physician Progress Note, dated 9/19/22, reflected, CHIEF COMPLAINT: Resident-to-resident incident. HISTORY OF PRESENT ILLNESS: [AGE] year-old female here for long-term care, locked psych unit. Patient with known history of dementia, bipolar disorder, schizoaffective disorder, bipolar type, PTSD, major depressive disorder. Patient had a resident-to-resident incident, was grabbed on her right arm via fellow resident which gouged arm pretty hard. Patient does not remember incident occurring. Patient confused at baseline .Skin: Warm and dry. Patient does have deep nail marks from another resident on her right forearm .IMPRESSION AND PLAN: 1. Schizoaffective disorder, bipolar type. 2. Fingernail gouging. 3. Bipolar disorder. 4. Major depressive disorder. Patient with resident-to-resident incident, had fingernail gouging from another resident on right forearm. We will monitor the site closely . Review of R2 Physician Progress Notes, dated 9/21/2022 at 11:58 a.m., reflected, HISTORY OF PRESENT ILLNESS .Patient is with recent injury to right arm, had nails scratched from another resident. Skin appears more red and tender . IMPRESSION AND PLAN: 1. Skin infection right forearm .Patient did have recent injury to right forearm from another resident ' s nails appears infected. We will start doxycycline 100 mg b.i.d. and monitor. Site red, swollen, tender. Injury with human nails, high risk for infection. We will start antibiotic and monitor . Review of R2 Skin assessment, dated 9/16/22 through 10/20/22, reflected on 9/16/22 R2 had two new abnormal skin areas to right hand purple discoloration with scab near thumb and right posterior forearm with 2 crescent shaped skin tears and purple discoloration. The Skin Assessment, dated 9/17/22, 9/24/22, 10/6/22, 10/10/22, reflected no existing abnormal skin areas. The Skin Assessments, dated 10/1/22 and 10/12/22, reflected R2 had bruising and discoloration right arm. The Skin Assessments, dated 10/12/22, and 10/17/22 and 10/20/22 reflected existing abnormal skin areas with no documentation completed. The Skin Assessments did not reflect increased redness and tenderness or signs of infection as indicated in Physician assessment dated [DATE]. Review of the Physician Orders, dated 9/21/22, reflected, Doxycycline Hyclate Tablet 100 MG Give 1 tablet by mouth two times a day for Skin infection for 7 Days. During an interview on 12/9/22 at 12:05 p.m., Regional staff V reported had been at facility for two months and had reviewed all FRI and tracked and identified need for full time activity staff on c-hall. During a telephone interview on 12/8/22 at 12:26 p.m., CNA W reported R10 and R2 had a resident-to-resident altercation on 9/16/22 at 6:04 p.m. CNA W reported there was another CNA on c-hall that was in another resident room. CNA W reported had her back turned and heard R2 scream for help from the Dining Room, turned and saw R10 grabbing at R2 arms. CNA W attempted to separate residents with moderate about of bleeding from R2 right arm from R10 nails that had gouged into skin and had to pry one finger off at a time. CNA W reported Nurse not on the unit at the time of the incident. CNA W reported only intervention implemented was R10 nails trimmed after incident. CNA W reported had never observed 1:1 for any residents on c-hall. CNA W reported times when she had to work c-hall by alone and nurse had to splits with d-hall. CNA W reported very stressful for one person related to residents with behaviors on c-hall. Review of the Nursing Working Schedule, dated 9/16/22, reflected one nurse split between c-hall and d-hall at time of resident-to-resident physical altercation between R10 and R2. During an interview on 12/8/22 at 3:20 p.m., Regional staff V and UM H reported aware increased, frequent FRI and reviewed with plan to add full time activity staff for 2023. UM H reported after creating surveyor requested time line for R3 noticed times and locations of resident-to-resident altercations that occurred mostly during meal time and discussed with team possible interventions to implement and possible plan to use both common areas for two Dining Rooms on c-hall instead of one. During a telephone interview on 12/8/22 at 4:51 p.m., RN X reported several residents on c-hall have manipulative behaviors and reported 12-15 residents on unit will gang up on you. RN X reported not safe for one staff to control entire c-hall on own and resident-to-resident altercation occur when nurse staff split between C and D halls. During a telephone interview on 12/8/22 at 5:30 p.m., RN T reported verbal cussing every day on c-hall and staffing had improved over past 30 days, however, times with one cna and nurse spilt between C and D hall. RN T reported medical event and resident-to-resident altercation occur at same time on both halls and impossible for nurse to be in two places at one time. RN T reported R2 son had questioned her related bruises and marks on R2 arms and reported she reassured him reports had been completed related to resident-to-resident incidents including when R10 grabbed R2 arm and dug her nails into R2 arm that caused open wounds and bruising. Review of R2 EMR dated, 7/25/22 through 10/23/22(admission to discharge), reflected R2 had no evidence of monthly behavioral meeting notes. During an interview on 12/13/22 at 9:10 a.m. SW F reported had worked at the facility about three months. SW F reported was familiar with R3 and reported R3 had behaviors that included cussing, yelling and often difficult to redirect and occasionally able to redirect with calls to sister. SW F reported did not have any involvement with R2 and R10 resident-to-resident altercation on 9/16/22 or R2 and R3 resident-to-resident altercation on 10/14/22. SW F reported received training from prior part time SW. SW F reported was informed by DON B within past week, need to follow up with residents for three days after an allegation of abuse or resident-to-resident altercation and document in Progress Notes to assess for both emotional and physical residual of event. SW F reported was not aware of that requirement prior to last week. SW F reported if community mental health involved in resident care facility has a monthly behavior meeting and should be documented. SW F verified no behavior meeting notes for R2 and reported prior SW was part time between another facility and may not of had time to complete. When SW F was quarried what was was being done to protect other resident on c-hall from R3 on-going physical altercations, SW F reported plan to continue to focus on R3 and DPOA request to transfer to another facility because nothing else had worked. SW F reported c-hall was not a homelike environment related to daily yelling, cussing and repeat resident-to-resident events. During an interview on 12/13/22 at 11:20 a.m., NHA A reported had worked at the facility since 7/18/22 and was also the facility Abuse Coordinator. NHA A reported R3 FRI were not substantiated because investigations did not reflect evidence of contact including staff eye witness events and recording devices have not been functioning. NHA A reported they have cleared congestion in c-hall at nurses station into dining room by removing medication cart one month ago. NHA A they have implemented mental health training for all staff, re-educated all staff on abuse, and continue to work on activity engagement. NHA A reported monthly meetings with consulting mental health groups and reported would expect facility to implement consulting mental health recommendation and have records of consults in resident records within 7 to days post visits. NHA A reported did not think meetings were happening on regular basis with current plans to have SW F and Medical Records N responsible for that task moving forward. During an interview on 12/13/22 at 1:15 p.m. DON B reported skin assessments should be completed through including existing skin alteration. This citation pertains to intakes MI00132318, MI00132309, MI00130769, MI00130733, MI00132653, MI00131631, MI00132101 and MI00130749. Based on observation, interview, and record review the facility failed to effectively supervise residents and implement effective interventions in 6 of 20 residents reviewed for abuse (Resident #1, #2, #3, #5, #10, #16, #17), resulting in continued resident to resident altercations. Findings include: Resident #1 (R1) On 12/06/22 at 11:45 AM R1 was observed sitting in a wheelchair, wearing pajamas, hair not combed, and eating lunch in the dining room. R1's significant change Minimum Data Set (MDS) dated [DATE] indicated he admitted to the facility on [DATE] and was re-admitted from a psychiatric hospital on [DATE]. The same MDS indicated R1's cognition was severely impaired, required limited assistance with eating and locomotion. Physician progress note dated 11/09/22 at 11:32 AM indicated R1 had a history of schizo-affective disorder (combination of symptoms), bipolar disorder, cognitive communication deficit, dementia, and anxiety. Resident #2 (R2) R2's admission MDS assessment dated [DATE] indicated she was admitted to the facility on [DATE] and had a Brief Interview for Mental Status (BIMS, a performance-based screening tool for cognition) score of 08 (08-12 Moderate Impairment). Progress note dated 9/30/22 at 9:32 AM indicated R2 had diagnoses of schizo-affective disorder, bipolar, dementia, post-traumatic stress disorder (PTSD), and depression. Investigation summary dated 8/13/22 at 3:24 PM indicated R1 [NAME] a glass of iced tea at R2, hitting her on the left side of her head. Resident #3 (R3) R3's MDS dated [DATE] revealed a BIMS score of 08 (08-12 Moderate Impairment). According to the facility 5-day investigation, date of incident 10/07/22 at 5:50 PM, R3 had diagnoses of schizoaffective disorder-bipolar Type, traumatic brain Injury, and generalized anxiety disorder. The same investigation revealed R1 hit R3 on top of her head at approximately 5:50 PM on 10/07/22 in the hallway, and there were not any witnesses. The same investigation indicated the nurse had responded to residents yelling. The incident report dated 10/07/22 at 5:50 PM, indicated predisposing environmental factors included crowding. Resident #5 (R5) R5's MDS dated [DATE] revealed she had a BIMS score of 08 (08-12 moderate cognitive impairment). Witness statement dated 10/11/22 indicated R5 yelled at R1 and R1 threw juice in R5's face. In review of R5's progress notes, there were no social services daily follow-up notes for 72 hours following the altercation. R5 was interviewed on 12/07/22 at 3:45PM and she recalled juice thrown in her face and stated there was a mean guy there. R5 became tearful and stated her nerves could not take much more. Resident #16 (R16) R16's MDS dated [DATE] revealed a BIMS score of 06 (00-07 severely impaired cognition). According to witness statement dated 12/01/22 at 9:30 AM, the nurse walked up to the nurse's station and was informed by residents, that R1 hit R16. The same statement indicated the nurse asked R16 she had been hit, and she replied yes and started crying. The same statement indicated R1 and R16 began kicki[TRUNCATED]