Based on the South Dakota Department of Health (SD DOH) complaint intake review, interview, observation, record review, and policy review, the provider failed to communicate with staff and implement fall prevention interventions, which potentially contributed to at least six falls (four of which resulted in injuries) from 2/1/25 to 7/6/25 for one of two sampled residents (1).Findings include: 1. Review of the SD DOH complaint intake received on 4/7/25 revealed:*An anonymous community member called to express their concerns about resident falls at the facility.*They specifically mentioned resident 1's falls which had resulted in issues.-They did not explain what those issues were. 2. Review of resident 1's electronic medical record (EMR) revealed:*Her 6/10/25 Brief Interview for Mental Status (BIMS) assessment score was 5, which indicated had severe cognitive impairment.*Her diagnoses included Parkinson's disease, dementia, anxiety, muscle weakness, repeated falls, hypertension, chronic pain, and wandering.-Parkinson's disease affects brain cells, causing movement and balance problems.-Dementia causes memory loss and confusion, affecting daily life activities.-Anxiety makes a person feel worried or scared about things often.-Muscle weakness means a person's muscles are too weak to work well.-Repeated falls means falling often without a clear reason.-Hypertension is high blood pressure.-Chronic pain means the person experiences long-lasting pain that does not go away easily.-Wandering is when a person becomes lost or moves around without purpose.*She fell on 2/1/25 in the dining room when staff had briefly left her alone.*She fell on 2/8/25 in the dining room and sustained a tiny skin tear on her left hand.*She fell on 2/17/25 in the dining room and sustained a bump to the side of her head.*She had fallen on 4/1/25 at around 7:13 p.m. in the hallway and was found lying face down and sustained a laceration (cut or torn skin) on her cheek.-She went to the emergency room for evaluation.-Per the 4/1/25 fall report, staff were to assist her with using the toilet her every two hours. The last time she was assisted to the bathroom was at 4:30 p.m., which was 2 hours and 43 minutes before fall. Staff were to also monitor her closely when she was out of her room.*She fell in her bathroom on 6/22/25 after a CNA left her alone to grab supplies. As the CNA was re-entering the bathroom, resident 1 attempted to stand up and fell.*She fell on 7/6/25 in her bathroom after a CNA left her alone to grab supplies.-Per her care plan, she was not supposed to be left alone.-She sustained a bump to the back of her head and a skin tear to her right elbow that required Steri-Strips [adhesive strips used to close a wound]. 3. Interview on 7/9/25 at 10:13 a.m. with certified nursing assistance (CNA) N revealed:*Resident 1 had fallen before, but she could not remember if she had fallen recently.*A few months prior, resident 1 had fallen and received a bruise to her face.*The care plan (a personalized plan that addresses a resident's care needs, goals, and interventions) binder was not up to date, as it contained care plans for residents who had since passed away or moved to other halls.*Sometimes there were pocket care plans (a document that identifies residents' care needs and interventions) inside the resident's closet or cabinet in their rooms.*She indicated the lead CNAs would help with updating the resident pocket care plans. 4. Observation on 7/9/25 at 10:42 a.m. of resident 1's room revealed:*There was a sign on the outside of the bathroom door and above the toilet that stated, Please do not leave me unattended while I am using the bathroom.*There was no pocket care plan inside her closet or cabinet doors. 5. Interview on 7/9/25 at 3:00 p.m. with CNA I revealed:*Resident 1 had a diagnosis of Parkinson's disease.*A therapy wedge pillow block was placed by resident 1's right side when she was lying in bed to help her identify where the edge of the bed was. The wedge also helped her legs from flailing around due to her Parkinson's disease.*She stated that resident 1 was the biggest fall risk in the building.*Resident 1 was in a wheelchair for a while after she had fallen, as she was scared of falling. CNA I indicated that resident 1 was also scared to sit on the toilet.*Staff were supposed to always keep resident 1 within their eyesight and were to chart about her whereabouts every two hours in the EMR.-Resident 1 required 24/7 [24 hours a day, 7 days a week] supervision.*Resident 1 was not allowed to be in the bathroom by herself, and that staff were to remain in the bathroom with her. 6. Interview on 7/9/25 at 3:15 p.m. with unlicensed assistive personnel (UAP) G revealed:*Resident 1 was impulsive, would stand up from her chair quickly, and often tripped over her shoes.*Resident 1 was not included in the pocket care plan binder, but she was included on the family sheet located in a different binder.-The family sheets included a list of residents on that unit and their special care needs, such as their diet order, code status, what size of incontinence products to use, and how the resident transferred. 7. Review of the undated SUNSHINE [the secured memory care unit] FAMILY 1 sheet regarding resident 1 revealed:*She needed one staff member to assist her with transfers and required the use of a walker.* Special equipment included a VST (a motion-detection device that alerted staff of a resident's movement), and a WanderGuard (a wearable door-alarming device).* Hip pads under her pants was included in the miscellaneous section.*It also included her code status, diet order, the size of her incontinence products, and that she wore glasses.*No other safety interventions were included. 8. Interview on 7/9/25 at 3:39 p.m. with licensed practical nurse (LPN) E revealed:*Family sheets should have included the residents' fall prevention interventions.*Family sheets were updated by director of nursing (DON) B.*The CNAs wrote notes and updates on the family sheets and turned them in to DON B to update the family sheets. 9. Interview on 7/10/25 at 8:14 a.m. with LPN F revealed:*Resident 1 was very impulsive. She had a hard time understanding directions, as she would usually do the opposite of what was asked of her.-She frequently fidgeted and had tremors (involuntary shaking movements) due to her Parkinson's disease.*Staff tried to engage her with meaningful activities like folding laundry and coloring.*Resident 1 ambulated with staff using a four-wheeled walker.-Staff used a gait belt (a waist strap gripped as support for safe mobility and transfers) around her waist for stability and to remind her to slow down. *Resident 1 walked with a shuffled gait and normally wore tennis shoes. 10. Continued interview with LPN F and review of resident 1's care plan revealed fall-prevention interventions that included: * Follow signage, I will not be left alone in bathroom. That was created on 6/24/25 and revised on 7/7/25.* I will not be left alone in public areas. That was created on 6/24/25.* Ensure that [the] resident is wearing appropriate footwear nonskid shoes/socks when out of bed. That was created on 2/18/25 and revised on 3/10/25.* PT [physical therapy] and OT [occupational therapy] [to] evaluate and treat as ordered or PRN [as needed]. That was created on 11/18/22 and revised on 6/19/24.* Sign on walker to remind to use. That was created on 7/24/24.* I will not be put to bed before 1900 [7:00 p.m.]. That was created on 6/24/25.* 10/30/24: Poor gait balance awareness.* Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: That was created on 12/11/22.-The care plan was not personalized to indicate what type of pleasant diversions the resident prefers.* AMBULATION: Resident['s] usual [performance] consists of supervision/touching assist [assistance] with walker; staff assists as needed. Resident may refuse her walker at times; staff assists as needed. That was created on 11/19/22 and revised on 7/9/25.* DRESSING: .Hip pads [extra padding to provide cushion] to hips per family request; staff assists as needed. That was created on 11/18/22 and revised on 7/9/25.*Her care plan included several restorative therapy interventions. LPN F indicated that resident 1 did not participate in the restorative therapy program. 11. Interview on 7/10/25 at 8:40 a.m. with CNA K revealed the family sheets included that resident 1 was supposed to use hip pads. There were no fall interventions for resident 1 on the family sheets. 12. Observation on 7/10/25 at 8:48 a.m. of resident 1 in the dining room revealed:*She was coloring a picture while seated at a dining room table.*Her feet and her head were tremoring.*She was wearing sneakers. *Resident 1's spouse, who also resided in the memory care unit, was sitting on resident 1's four-wheeled walker and propelling himself in the dining room.*There was no sign on her walker to remind resident 1 to use her walker. 13. Interview on 7/10/25 at 8:58 a.m. with CNA J revealed that resident 1 had a restorative program but had not participated in it for a while, and that it stopped a few months ago after resident 1 fell. 14. Interview on 7/10/25 at 9:59 a.m. with physical therapy assistant H revealed that resident 1 had not been assessed by PT/OT since 6/19/24. 15. Interview on 7/10/25 at 10:12 a.m. with CNA J revealed:*She confirmed resident 1 did not have a sign on her walker to remind her to use it.*The pocket care plans in the care plan binder were not up to date.-The pocket care plans in the binder included several residents that were no longer residing on that unit and was missing seven current residents.*She would have expected to find the residents' fall interventions listed on the pocket care plans or family sheets.-She confirmed that the family sheets did not include resident 1's fall interventions.*She stated that she usually would not look in the provider's EMR for fall interventions.*CNA J was only able to pull up and view the first page of resident 1's 28-page care plan in the EMR. 16. Interview on 7/10/25 at 12:54 p.m. with case managers C and D revealed:*Resident 1 was very impulsive, and did not always voice her needs or wants.*Resident 1 spent a lot of time in the common areas and staff tried to always be present in those areas.*Resident 1's walker was supposed to have been kept within reach with the brakes on.*Resident 1's gait was shuffled, and she tripped over her feet, so they tried to always have someone near her.-Her care plan included interventions such as I will not be left alone in bathroom and I will not be left alone in public areas.*Case manager C was not aware that resident 1 used a blue wedge for positioning and expected that to have been included on the resident's care plan.*She indicated that a lot of people are responsible for updating the care plan.*Both case managers C and D were new to their positions, and they were learning what to include on the residents' care plans.*The facility transitioned to using the family sheets in March 2025 rather than the pocket care plans. -Several people were responsible for updating the family sheets, including the DON, the case managers, and the lead CNAs.*They were not sure what the expectation was for CNAs to have access to the residents' care plans. 17. Interview on 7/10/25 at 2:05 p.m. with DON B revealed:*Resident 1 had a decline in her cognition with her dementia.*She confirmed the resident's sign to remind her to use her walker was not on her walker.*Pocket care plans were no longer to be used. Staff were to use the family sheets for resident care information.-Family sheets were to be updated when a new resident was admitted , and as needed with pertinent resident care information.*CNAs could not access the resident care plans in the EMR.-CNAs were to use the family sheets to understand how to care for the residents.*They also utilized shift-to-shift report to update staff on new resident information.*The family sheets included resident care information, such as the resident's diet, how they ambulate, how they transfer, if they wear hearing aids or dentures, their code status, what they prefer in their room, and if they were on enhanced barrier precautions.*She hung a sign on resident 1's bathroom door on 7/7/25, after the resident was left alone in the bathroom again and fell, to remind staff that resident 1 should not be left alone while in the bathroom. 18. Review of the providers 4/11/24 Falls and Fall Risk, Managing policy revealed:* Definition*.Fall Risk Factors-1. Environmental -a. wet floors -b. poor lighting .f. footwear that is unsafe or absent.-2. Resident conditions that may contribute to the risk of falls include: -a. fever -.d. pain -e. lower extremity weakness -.k. incontinence-3. Medical factors that contribute to the risk of falls include: -.e. balance and gait disorders; etc.* Resident-Centered Approaches to Managing Falls and Fall Risk-1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.-2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions.-3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc.-.6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified and unavoidable.-7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling.-8. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.* Monitoring Subsequent Falls and Fall Risk-1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.-2. If interventions have been successful in preventing falls, staff will continue the interventions.-3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.-4. The staff and/or physician will document the basis for conclusion that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Review of the providers 4/11/24 Care Planning-Interdisciplinary Team policy revealed:* Policy Statement: Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident.* Policy Interpretation and Implementation-.2. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team which includes, but is not necessarily limited to the following personnel:--a. The residents' attending physician;--b. The registered nurse who has responsibility for the resident;--.f. Therapists (speech, occupational, recreational, etc.), as applicable;--.h. The director of nursing (as applicable);--i. The charge nurse responsible for the resident's care;--j. Nursing assistants responsible for the resident's care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to protect one of two sampled resident (1) from physical and verbal abuse, and one of two sampled resident (2) from verbal abuse and involuntary seclusion by resident 3's spouse. Findings include: 1. Review of the SD DOH FRI submitted on 6/15/24 at 7:35 p.m. revealed: *Registered nurse (RN) D reported that certified nurse aide (CNA) C witnessed resident 3's spouse wheeling resident 1 down the hall. *Resident 1 was holding his hand up as if he may have been attempting to grab resident 3's spouse. *In response to resident 1's action, resident 3's spouse hit [resident 1] over the head with her right hand. *RN D immediately assessed resident 1 and when asked if resident 3's spouse hit him, his response was that resident 3's spouse tried to hit him, and I blocked her. *RN D's physical assessment of resident 1 did not reveal any redness, bruising, or raised areas on resident 1's head. *Resident 1 then stated that resident 3's spouse did hit him on his temple, but not very hard. *During interview with resident, he did not show any fear of the situation. *RN D notified the facility administrator. Administrator will be in the facility to discuss the situation with [resident 3's spouse]. *The report indicated that local law enforcement and the South Dakota Department of Human Services (DHS) were not notified. -Under the section Why or why not? for law enforcement notification, the report indicated, Administrator will be in facility in am [a.m.] -Under the section Why or why not? for DHS notification, the report indicated, Notified Ombudsman via email. 2. Observation on 6/24/24 at 5:15 p.m. in the South Ridge common area revealed: *The common area consisted of the dining room and television room. *Residents were eating supper at the time. *Resident 1 was sitting at a table near the window. *Residents 2 and 3 were sitting at the same table. *Resident 3's spouse was sitting in a recliner in the television room. *Interview at that time with resident 3's spouse revealed: -She came to the facility twice per day, every day. -She helped resident 3 with lunch and supper and to get ready for bed each night. 3. Interview on 6/24/24 at 5:32 p.m. with administrator A regarding the FRI revealed: *The incident happened on Saturday 6/15/24 around 6:30 p.m. *She was informed of the incident on 6/15/24 and instructed RN D to complete a state report. *Director of human resources (DHR) I and administrator A came to the facility on Sunday 6/16/24 and met with resident 3's spouse to discuss the incident. *Administrator A told resident 3's spouse that you can't move or touch other residents. *Resident 1 was interviewed several times on the evening of 6/15/24. -He was not a good historian. -One time he said that resident 3's spouse hit him, and another time he said that I blocked it. -He was not consistent with answering if he was hurt or not. *CNA C witnessed the incident and immediately informed RN D. *RN D immediately assessed resident 1 and found no injuries. *She confirmed that resident 3's spouse continued to assist resident 3 with his nighttime routine and left the building around 7:30 p.m. *Resident 3's spouse came back to the facility on 6/16/24 around 11:00 a.m. to meet with DHR I and administrator A. -During that conversation, resident 3's spouse admitted to moving resident 2 to his room and told him, You can come out when you can act like a grown man. -Resident 3's spouse did not admit to hitting resident 1. -They verbally made an agreement with administrator A to not touch other residents. *Resident 3's spouse had a pattern of when she visited. She came around 11:00 a.m., stayed through the lunch hour, left for a couple of hours in the afternoon, came back to the facility around 4:00 p.m., and stayed until resident 3 went to bed. -This pattern was an everyday occurrence. *Administrator A contacted the regional ombudsman regarding the incident. -The ombudsman came to the facility on 6/17/24 to act as an advocate for resident 1 since he did not have a power of attorney. 4. Interview on 6/24/24 at 6:25 p.m. with CNA E regarding the above incident revealed: *He confirmed he was working on the evening of 6/15/24. *He did not witness the incident. *There was a meeting about the incident at the nurse's station including CNA E, CNA C, and RN D. -During the meeting, CNA C said, [resident 3's spouse] slapped resident 1 on the back of his head for no reason. *He verbalized the correct procedure for reporting potential abuse or neglect. 5. Interview on 6/24/24 at 6:37 p.m. with resident 3's spouse regarding the above incident revealed: *When asked about the incident, resident 3's spouse said, That was resolved with [administrator A]. That's all I'm [going to] say. *Resident 3's spouse said, I've held up my end of the bargain. -The bargain was to not speak with resident 1, and to not push any other resident in their wheelchairs. *Surveyors then explained that law enforcement had been contacted by the provider to report the incident. *Resident 3's spouse said, I will not speak to him or her on these premises. 6. Interview on 6/24/24 at 6:45 p.m. with licensed practical nurse (LPN) J regarding the above incident revealed: *She was not at the facility at the time of the incident, but had been made aware of it by RN L. *She explained that resident 1 and resident 2 were known to [NAME] with each other, which was normal for those residents. *Regarding the bickering, she said that staff monitored them and separated them as needed. *When asked about resident 3's spouse, she said, I was surprised that it happened, but not surprised that it was [resident 3's spouse]. 7. Interview on 6/25/24 at 10:20 a.m. with resident 1 regarding the above incident revealed: *When asked how he would get help, he said, I would tell them. *He was unable to express how to use his call light. The call light was next to him within his line of sight. *When asked if he remembered the incident, he said, not really. *When asked about the care he received from staff, he said, I'm well taken care of. 8. Interview on 6/25/24 at 12:41 p.m. with dietary aide F regarding the above incident revealed: *She confirmed she was working on the evening of 6/15/24. *No one had interviewed her about the incident to obtain her formal statement. *She was in the South Ridge kitchenette doing dishes when CNA C came to her looking stressed and informed her of what happened. *The incident must have happened down the hallway because it did not happen in the living room or dining area. *She had not seen the events on 6/15/24 unfold but had seen a similar situation between resident 1 and resident 3's spouse before. -It happened within the previous week of 6/15/24. It may have happened on 6/13/24, but she could not remember. -Resident 2 was sitting in his normal spot in the dining room. -Resident 1 wheeled himself into the dining room. -They started bickering with each other. -She could not understand what they were arguing about. -Resident 3's spouse grabbed resident 1's wheelchair to take him out of the dining room. -She overheard resident 3's spouse call resident 1 incompetent and asshole. -Regarding that incident, she said, those two [residents 1 and 2] are defenseless against [resident 3's spouse]. -Dietary aide F reported what she overheard to both the CNA and the nurse on duty at that time. -She could not remember the names of the CNA or the nurse. -She was not sure what was done with her report. *Dietary aide F indicated that resident 3's spouse was known to fly off the handle with staff, and sometimes other residents. 9. Interview on 6/25/24 at 1:10 p.m. with RN D regarding the above incident revealed: *When asked about the relationship between residents 1 and 2, she said, they get into verbal confrontations, and we intervene, and redirect and they are okay. *She was not aware of resident 1 and resident 2 ever having a physical confrontation. *When asked about resident 3's spouse, she said that resident 3's spouse visited frequently. -She explained that resident 3's spouse would get frustrated when residents 1 and 2 were bickering. *She said that if staff were not around, resident 3's spouse would intervene between residents 1 and 2. 10. Interview on 6/25/24 at 1:32 p.m. with administrator A regarding the above incident revealed: *She was aware that the resident 3's spouse had been verbal with other residents before. -The social worker had been involved. -Resident 3's spouse was educated that she must get staff to move patients away from each other. *When asked if there had been any additional interventions to prevent resident 3's spouse from handling other patients, administrator A said that staff were paying closer attention to resident 3's spouse but there was no additional documentation. 11. Interview on 6/25/24 at 3:25 p.m. with CNA C regarding the above incident revealed: *He confirmed he was working on 6/15/24 and witnessed the incident. *Residents 1 and 2 did not like each other. -He said, they really can't hurt each other, they fight like siblings, and they just yell at each other. *He said that resident 3's spouse was there on most days and is usually in good spirits, but resident 2 definitely annoys [resident 3's spouse]. *He recalled that residents 1 and 2 were bickering with each other from across the dining area on the day of the incident. -When the meal was over, he went to the nurse's station for shift-to-shift report. *When he left the nurses station, he saw that resident 2's door was closed and assumed someone had already transferred him to his room for the night. *He then observed resident 1 making animal noises. -This was normal behavior for resident 1. *He saw resident 3's spouse transferring resident 1 down the hall in his wheelchair. -Resident 1 raised his right hand as if to grab at resident 3's spouse. -Resident 3's spouse whacked him on the side of his head with her right hand. *He was able to hear the slap and confirmed that resident 1 made a verbal response. -He was not sure if the response was because of pain or not. *He immediately reported what he had seen to RN D and LPN K. *He was not sure if resident 3's spouse was asked to leave the facility. *He said that a nurse told him that a couple weeks prior, resident 3's spouse had been reported for calling resident 1 useless and other unpleasant comments. -He could not remember which nurse reported this to him. 12. Interview on 6/25/24 at 3:50 p.m. with resident 3 regarding feelings of safety revealed: *He indicated that staff treat us very good. *He denied having issues with other residents. *He indicated the survey team could talk to my [spouse] when [they] get here, when asked about concerns with specific incidents. 13. Interview on 6/25/24 at 4:17 p.m. with LPN K regarding the above incident revealed: *She was working 6/15/24 when the incident happened, but she did not witness the incident. *She was aware of the relationship between residents 1 and 2. -She said that resident 1 thinks it's funny, he pushes resident 2's buttons. *She said that staff were aware of their arguing and kept them separated. *She noted that resident 3's spouse was there every day. She is very dedicated. She does a good job with resident 3's care. *When asked if she knew of any other incidents between other residents and resident 3's spouse, she said that last year, there was a resident with dementia, and she snapped at him, nothing over the top. -See F610, finding 16. 14. Interview on 6/25/24 at 4:53 p.m. with director of social services G regarding the above incident revealed: *Regarding the relationship between residents 1 and 2, she said, they periodically [NAME], staff usually intervene, and they are easy to redirect. *She said that there had never been physical aggression between them. *When asked if there had ever been a discussion about moving them to separate units, she revealed that resident 2 was recently moved to a room in a different hallway from resident 1. -She said that this has been helpful because they do not always see each other when they come out of their rooms. -Regarding moving one of them to a different unit, she said, you hate to uproot. *She said that resident 3's spouse is a consistent person in the building, visiting multiple times a day. *She was not aware of any previous physical aggression from resident 3's spouse. I've never seen that side of her. 15. Interview on 6/25/24 at 5:24 p.m. with administrator A regarding the above incident revealed: *When asked if there were any other known incidents between resident 3's spouse and resident 1, she was not aware of a previous incident. *She reviewed resident progress notes and was not able to find any information about any other incidents between resident 3's spouse and resident 1. 16. Continued interview on 6/26/24 with administrator A regarding the above incident revealed: *The first step in the facility's investigation process when there was a complaint of potential abuse of a resident was to ensure resident safety. -RN D performed her assessment of resident 1 and notified administrator A. -RN D then had CNA C give a handwritten statement of what he had witnessed. -She asked RN D where resident 3's spouse was and was told that she was in the room with resident 3 helping him get ready for bed. -RN D completed the FRI that evening. -She said that she entered the facility at 8:00 a.m. the next morning and talked to resident 3's spouse, RN D, and the ombudsman. -She said that she asked the ombudsman if law enforcement needed to be notified, and the ombudsman did not tell her that it was required. -She said that resident 1 was asked if he wanted to call law enforcement regarding the incident and he did not. -When asked if there were any interviews of involved staff or residents and she said she had not. She felt that resident 3's spouse gave enough information about the incident, that there was no need to interview any other residents or staff. *She said that there had been increased education to staff regarding incident reporting. 17. Phone interview on 6/26/24 at 9:48 a.m. with RN D regarding the above incident revealed: *She was unaware of any other incidents in which resident 3's spouse was verbally aggressive with other residents. *She said that she did hear from RN L that resident 3's spouse had spoken to resident 3 in an unpleasant manner before. 18. Interview on 6/26/24 at 9:56 a.m. with RN M regarding the above incident revealed: *She was the case manager for the nursing home. *She revealed that resident 3's spouse was at the facility often. *She said that she was present for resident 3's senior psychological appointment in which resident 3's spouse voiced concerns that resident 3's roommate always has his TV volume very loud. -During the appointment, resident 3's spouse reported that [they] would turn down the volume and turn off the TV when the volume bothered resident 3. -She said that it was verbally reinforced that resident 3's roommate has rights and that resident 3's spouse must not control the TV belonging to resident 3's roommate. -[They] were not happy about this. *Resident 3's spouse said that if the volume is bothering resident 3, [they] would turn the TV off. 19. Interview on 6/26/24 at 10:21 a.m. with DHR I regarding the above incident revealed: *She stated that she was present for the meeting between administrator A and resident 3's spouse on 6/16,24. -She said that she was there to take notes on the conversation and was not an active participant. *Regarding the demeanor of resident 3's spouse, she said that resident 3's spouse did not want to be there. *She said that resident 3's spouse wanted to record the conversation and was given the opportunity to do so but did not record the conversation. *She said that resident 3's spouse then wanted to take written notes regarding the conversation and was given the opportunity to do so but did not take notes. *During the conversation, resident 3's spouse said that resident 1 had hit her. *When asked if resident 3's spouse had hit resident 1, she did not answer the questions and just shook her head. *Administrator A then told resident 3's spouse that she was not to move or touch other residents and not to talk to resident 1 going forward. *Resident 3's spouse then agreed to these terms as a verbal agreement. The agreement was not put in writing. 20. Review of resident 1's electronic medical record revealed: *He was admitted on [DATE]. *His medical diagnoses included: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, vascular dementia, moderate, with agitation, major depressive disorder, unspecified anxiety disorder. *His most recent Brief Interview for Mental Status (BIMS) score from 3/15/24 was a 13, which indicated he was cognitively intact. *An incident note from 6/15/24 at 7:02 p.m. read: -Staff reported to nursing during shift change that they had witnessed a visitor hit resident in the head when pushing him down the hall to his room. -This resident and another male resident had been verbally arguing with each other and the visitor had separated them and took resident down the hall to his room. -Per the staff member, the visitor did not know he was behind them when she was rolling resident to his room. -This writer did an interview with resident, and it is unclear other than the witnessed event as to what happened. -Writer asked resident what happened between him and the other male resident to start the conversation. -Resident initially would not answer, once writer explained to him it was ok to talk about that writer was trying to figure out the situation for them to both be safe. -Resident stated he and the other 'guy' were cussing at each other. -He denies each other having physical contact. -It is not uncommon for the two residents to argue at each other; however, staff do monitor as they do have a history with each other. -This writer did ask if the visitor had taken him to his room and he stated yes. -Writer asked resident if the visitor had hit him and he originally stated, 'She tried to,' I asked resident what he did and he stated, 'I blocked her.' -Later in the conversation resident did state the [visitor] hit him and when asked how hard [the visitor] hit him he stated, 'not very hard.' -Writer asked resident where the [visitor] hit him at, and he pointed to the left side of his temple. -An assessment was completed head to toe and no redness is noted, no bruising is noted, and no raised area is noted. -Writer assured resident that we are here to ensure he is safe and that we would monitor and keep all safe in the facility. -Resident when asked if he would like to press charges on the [visitor], he made the comment 'I want to make them pay, they took all my money I had saved up.' -Writer attempted to notify [resident's] daughter to notify her of the situation, however, when calling a recording comes across 'the person you are calling cannot take calls at this time, the number you have dialed is not answering, please try later.' -Administrator was notified of the situation and will be here tomorrow while the visitor is in the facility to take care of the situation. *A follow-up health status note entered on 6/16/24 at 1:10 a.m. read: -Resident has been monitored frequently this shift for any s/s [signs or symptoms] of distress related to recent incident early in the shift. Resident has been resting in bed with eyes closed. Has not shown any distress this part of the shift. *A follow-up health status note entered on 6/16/24 at 12:15 p.m. read: -Resident denies having any pain. Transfers per usual. Alert and out for meals. No bruising noted. Denies having any pain. *A social work note entered on 6/18/24 at 3:49 p.m. read: -[This] writer met with resident to follow up on recent incident involving another resident's family member hitting him on the head. -Writer and resident visited about this incident. -Resident initially did not recall the incident, however, was able to briefly state that he remembers 'that [person] that pushed me back to my room.' -Writer asked resident if he is fearful of this person and he said 'no.' -This writer asked resident if he feels safe at [facility] and he stated 'yes.' -Will continue to check in with resident. *There were no other follow-up notes regarding the incident between resident 1 and resident 3's spouse. 21. Review of CNA C's handwritten statement revealed: *[Resident 1] and [resident 2] altercation led to [resident 3's spouse] wheeling [resident 1] back to his room. *While doing so, [resident 1] was holding up his right hand possibly trying to [grab] her. *In response, [resident 3's spouse] hit [resident 1] over the head with her right hand. *It was hard enough to be clearly heard 20 feet back and led to a vocalization of pain from [resident 1]. *[Resident 3's spouse] appeared to be angry about [resident 1] and [resident 2's] altercation. 22. Review of staff schedules from the evening of 6/15/24 on the South Ridge unit revealed the following employees were on-site: *CNA C from 2:15 p.m. to 10:45 p.m. *CNA E from 2:15 p.m. to 9:00 p.m. *LPN K from 6:00 a.m. to 6:30 p.m. *RN D from 6:00 p.m. to 6:30 a.m. *Dietary aide F from 4:30 p.m. to 7:30 p.m. 23. Review of resident 2's electronic medical record revealed: *He was admitted on [DATE]. *His medical diagnoses included: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified anxiety disorder, major depressive disorder, vascular dementia. *His most recent BIMS score from 4/10/24 was 13, which indicated he was cognitively intact. *A social work progress note entered on 6/18/24 at 2:16 p.m. read: -[This] writer met with resident to follow up on incident of him being wheeled into his room by other resident's family member. -Resident was able to recall this incident, but did not feel threatened by the family member and stated he does not feel fearful of her. -This writer asked resident if he feels safe at [facility] and he stated 'yes.' *There was no indication that the resident's wife, his responsible party, was notified of the incident. 24. Review of resident 3's admission documentation revealed that his spouse signed the acknowledgement that they received a copy of the Residents' Rights document on 5/31/23. 25. Review of the provider's March 2017 Acknowledgement of Resident Rights and Responsibilities policy revealed: *Policy Statement: Each resident (or resident representative) will be provided and must acknowledge receipt of a written copy of resident rights and all rules, regulations, and policies governing the resident's conduct and responsibilities during his/her stay in the facility. *Policy Interpretation and Implementation: -1. Prior to or upon admission, a representative of the admitting office will give the resident, or the resident's representative, a written copy of resident rights and responsibilities, including facility rules, regulations, and policies governing the resident's conduct and responsibilities during his/her stay in the facility. -2. A representative from the business office or from social services will review the rights and responsibilities with the resident or the resident's representative. This review will occur as soon as possible within the first week of the individual's admission to the facility. -3. The resident, or the resident's substitute decision maker or representative, will be required to sign a statement acknowledging his/her receipt of a written copy of resident rights and responsibilities and that an oral review of such rights and responsibilities was conducted. -4. For individuals who have been formally declared incompetent or who cannot make decisions in accordance with this state's current laws, regulations, and guidelines, the resident's representative will be informed of the resident's rights and the representative will be entitled to act on the resident's behalf. -5. A representative of the administration or business office will inform residents orally and in writing of changes in federal or state regulations relative to resident rights or when changes in facility policy affects the rights or responsibilities of residents. Notices will be provided within 14 days of such change(s) taking effect. -6. Signed and dated copies of the resident's acknowledgement of rights and responsibilities and any subsequent revisions are maintained in the resident's medical record. 26. Review of an email communication sent by RN M following resident 3's psychological appointment on 3/28/24 revealed: *RN M provided education to resident 3's spouse on resident rights. -Resident 3 and his spouse had been expressing feelings of frustration because they had been continually turning down resident 3's roommate's television because it was too loud. -RN M wrote, Please remind her that this is a violation of [roommate's] rights. 27. Review of a Formal Grievance submitted by resident 3's spouse on 5/15/24 revealed: *Resident 3's spouse submitted a formal grievance to discuss the care that resident 3 was receiving. *Resident 3's spouse named a specific CNA in their grievance, stating that [I find] bruises on [resident 3] when [I come] to see [resident 3] in the morning. -Resident 3's spouse did not provide any specific situations, nor could she recall any. *Education was provided to [resident 3's spouse] regarding how [facility] investigates suspicious bruising and the importance of reporting these concerns when they happen so they can be properly investigated . Information provided regarding [facility's] zero tolerance for retaliation, specifically regarding incident reporting. *Education regarding policy on when/how police are called was given to [resident 3's spouse], specifically that [facility] would not call Police before attempting to contact [resident 3's spouse], with the only exception being imminent danger to staff or [resident 3]. *[Resident 3's spouse] expressed verbal understanding . *Education regarding Resident Rights provided at this time. *Action Plan: -1. Monthly Care Conferences will be held with [resident 3's spouse], [director of social services G] and [DON B] to address any concerns and follow up on the Grievance action plan. These meetings will begin the week of June 17th, 2024, at [resident 3's spouse's] request. - .4. Education regarding Resident Rights will be given to [facility] staff at the next all staff meeting on May 28th, 2024. 28. Review of the provider's undated Nursing Home Resident's Rights document revealed: *Residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination. Many States also include residents' rights in state law or regulation. *Right to a Dignified Existence -Be treated with consideration, respect, and dignity, recognizing each resident's individuality. -Freedom from abuse, neglect, exploitation, and misappropriation of property . - .Quality of life in maintained or improved. -Exercise rights without interference, coercion, discrimination, or reprisal. -A homelike environment . -Equal access to quality care. 29. Review of the provider's February 2024 Abuse policy revealed: *Policy Statement: Each resident has the right to be free from abuse, neglect . This includes but is not limited to freedom from corporal punishment, involuntary seclusion . Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. *Policy Explanation and Compliance Guidelines: -1. The Abuse coordinator in the facility is the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: Administrator, Other Officials in accordance with State Law, State Survey and Certification agency through established procedures. -2. 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -- .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. --It includes verbal abuse .physical abuse, and mental abuse . --'Willful' means the individual deliberately, not that the individual must have intended to inflict injury or harm. -3. 'Verbal Abuse' means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. - .5. 'Physical Abuse' includes, but not limited to hitting, slapping, punching and kicking. It also includes controlling behavior through corporal punishment. -6. 'Mental Abuse' includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . - .8. 'Involuntary Seclusion' refers to the separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will or the will of the resident's legal representative . - .11. 'Mistreatment' means inappropriate treatment or exploitation of a resident. *The facility must: -1. Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. - .5. Prevention of Abuse, Neglect, and Exploitation - The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: -- .d. Provide education on what constitutes abuse, neglect and misappropriation of property. --e. React to all allegations or questions of abuse by residents, family members, employees or visitors. --f. Take appropriate actions when abuse, neglect or exploitation is suspected.