**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) 1/2/25 facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to: *Ensure there was a plan of action implemented following an incident where one of one sampled resident (1) had become physically aggressive with staff and had struck another resident (2) in the face during the interaction. *Ensure one of one sampled resident (1) who had cognitive impairment was free from psychological and physical abuse by three of three certified nursing assistants (CNA) (G, K, and L) during an episode of the resident having had increased agitation and aggression. *Ensure extended education and training on how to take care of residents with dementia and psychosocial behaviors for all staff had occurred to help them assist one of one sampled resident (1) during episodes of increased agitation and aggression. *Ensure all direct care-givers had knowledge of how to access and review updated care plan changes for the residents. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on 1/8/25 at 4:57 p.m. to licensed social worker (LSW) A, executive assistant D, and director of finance M for F600: *The provider failed to have an immediate plan of action in place and implemented following an incident that occurred on 1/2/25. *When resident 1 had become physically aggressive with staff and had struck resident 2 in the face during that occurrence. *His behaviors are impulsive, unpredictable, and have the potential to cause harm to both the residents and staff. *Through interviews, document review, and video review, it was identified that there was no plan or education presented to the staff on how to address their ongoing concerns about how to assist the resident during those episodes to ensure the safety of the residents and staff had occurred. *A plan for the removal of the immediacy was requested at that time. IMMEDIATE JEOPARDY REMOVAL PLAN On 1/9/25 at 4:43 p.m. the provider gave the following acceptable immediate jeopardy removal plan: *On 1/8/2025 1309 [1:09 p.m.] a message was sent to residents' psychiatric provider with updates on behaviors. Verbal orders were received by a nurse 1-9-2025 from Psych Provider stated to discontinue Hydroxyzine [allergy and anxiety medication] and to use the PRN [as needed] Seroquel [antipsychotic]. He is also scheduled with the Psychiatric provider for a revisit on 1/13/25. PRN pain medication Tylenol has been scheduled instead of PRN, and Labs CBC, and CMP are ordered by PCP. *1/8/2025 starting at 0645 pm [6:45 p.m.] In person Dementia training Lewy Body Dementia What Everyone Needs to Know was given to staff from day shift and for the overnight. [Name] Administrative Assistant who is Teepa Snow Dementia certified. Training will resume in the morning at 0630-830 [6:30 a.m. - 8:00 a.m.], 12-2 [12:00 noon - 2:00 p.m.], and 3:30-5:30 [3:30 p.m. - 5:30 p.m.] and will continue until all staff are educated before their next scheduled shift. Monitoring of efficacy will be done by scenario role playing drills of all staff by picking random 5 people per week for 1 month and 5 random people a month for 6 months will be documented. *1/9/2025 education on how to find care plans was sent to all staff via email and put on each kiosk, and by the nurse's station computers. Will do one to one education with each staff and they will sign they have received the education. Care plan updates will be added to the 7-day sheet which is communicated in the report to nurses and CNA. MDS [Minimum Data Set] or designee will monitor care plan documentation to the seven-day sheet for updates only from the care plans that were updated weekly for 3 months. *1-8-2025 Residents whole care plan was reviewed to ensure appropriate for resident and if any updates needed to be established. Care plan was updated with ways to approach resident from the front instead of the side or from behind do [due] to diagnosis of dementia. Resident is care planned one to one. One to one is provided as definition of one to one is 1 person assigned to resident that focuses on 1 person needs, abilities, strengths, and interests during staff to resident one to one situation while awake. *Cameras will be monitored especially on nights and weekends random 1-hour snips will be viewed 5 times per week for 1 month 3 times a week for 6 months and will be reviewed at that time for further discussion. *To ensure the safety of all the residents who are likely to suffer or have suffered serious adverse outcomes we are doing current medication review for the resident. We have been in contact with his Psychiatric provider in person. Education for staff including training on dementia before working next shift and setting up quarterly training through the state's ombudsman program. The immediate jeopardy was removed on 1/9/25 at 4:43 p.m. after the survey team verified the provider had implemented their removal plan through document review and staff interviews. After the removal of the immediate jeopardy, the scope and severity of the citation level was an H. Current census was 44. 2. Review of the provider's 1/2/25 submitted SD DOH FRI regarding resident 1's interaction with resident 2 revealed: *His Brief Interview for Mental Status (BIMS) assessment score was zero which indicated he was severely cognitively impaired. *[Resident 1's name] was laying on the floor next to the window, CNA attempted to assist resident off the floor, [the resident] attempted to go after another CNA chasing her, swung his arms as he was running and hit another resident in the face [and] made contact with her right cheek. *Investigation Conclusion: -Investigation started. Separated the resident and staff tried to get [resident 1's name] out of dining room. LSW [licensed social worker] came in and assisted to get his [him] calmed down and then got him ready for bed. Staff stated [resident 1's name] got upset and threw up his arms and hit [resident 2's name]. -Called and updated [resident 1's name] PCP [primary care provider] and will update his psych [psychiatry] provider tomorrow. Plans going forward will continue to monitor [resident 1's name] and will wait and see if his providers make any changes. -The facility has reached out to HSC [Human Service Center] and [behavioral health provider's name] through November and December and have been told his [he] [resident 1] doesn't need an inpatient stay. *No documentation that indicated how the staff should have monitored and assisted resident 1: -To ensure the safety of the other residents and staff during episodes of increased agitation. -Until they received further direction from his providers. -To help decrease his agitation and aggressive behaviors. -No documentation that indicated if resident 2 had been assessed for injury after being struck in the face by resident 1. 3. Observation on 1/7/25 at 12:50 p.m. of resident 2 in the dining room revealed: *She had been sitting at the dining room table visiting with another resident. *She was pleasantly confused and answered simple questions. *They had just finished lunch and the dirty dishes remained on the table. *She repeatedly made gestures towards the dirty dishes and had commented several times that we needed to pick them up. *No visible injury had been observed to her face. Observation on 1/7/25 at 1:10 p.m. of resident 1 in his room revealed: *He was attempting to get out of his bed. *His legs were hanging over the edge of the mattress and he was waving his left arm while yelling hey, hey. *LSW A went into his room and assisted him with getting out of bed. 4. Interview on 1/7/25 at 1:15 p.m. with CNA N revealed: *All of her dementia and abuse training had been online. *She was not aware of any additional dementia training outside of those online course. Interview on 1/7/25 at 1:20 p.m. with resident 5 in her revealed: *Her room was located across the hall from resident 1's room. *She would have left her room once a day to exercise per her preference. *She had: -Changed the time of day that she exercised to avoid resident 1. -Not felt safe from resident 1 and could hear interactions he had with staff and other residents. *She stated: -He goes into other people's rooms. -He tried to come into my room once but an aide stopped him. -We can't lock our doors to keep him out. -I've never seen it, but I know he hits the aides because I hear everything that's going on out there. -About four days ago they gave him a bath and he was fighting, yelling, and screaming the entire time. -He has a bad mouth and says the F word all the time and I find it very offensive. -I don't want to be around him either. Interview on 1/7/25 at 1:50 p.m. and again on 1/8/25 at 11:00 a.m. with CNA E revealed: *She was a traveling CNA and had been working at the facility for approximately two months. *Her dementia and abuse training had been through the mandatory online courses. -She had completed those upon hire at the facility. -There had not been additional training on dementia care outside of those online courses. *She had worked with resident 1 frequently and he had required a lot of staff to take care of him when he was agitated. *She stated: -Nothing will trigger him and he will just start throwing stuff, like chairs, anything in front of him. -He pushes and hits at the staff. -He'll start fighting with you when you try to take care of him. Sometimes it takes three of us to work with him. -He's hit other residents too. -It's happens almost daily. -He only likes the office staff. -The office staff take him to their office sometimes when he is awake. -When they're not here we just have to deal with it. -Yeah, it's scary because I don't want to get hit. -I just get the nurse or someone who knows him when he acts like that. *He had required one to one (one staff assigned to one resident) monitoring when he was awake. *The CNAs were assigned to him and when he was awake someone had to stop helping on the floor and stay with him. -No additional staff were scheduled to work with him. *She stated: -When there are just two CNAs, one of us stops helping on the floor and work just with him. -If the other CNA needs help with a transfer the med [medication] aide had to help or the nurse if she could. -The med aide was supposed to stop what she was doing and help. *She confirmed that unit where resident 1 resides had nine residents who required two staff to assist with a transfer. *There had been times when resident 1 was calm and she would have left him to assist with other residents. *She stated: Usually I was not far [away] and was in the area where he was. *She confirmed: -His behaviors had been unpredictable, quick, and aggressive. -Those behaviors had placed the other residents at risk for being struck by him when staff were not sitting with him. *She stated When he's awake, he's the priority over the others. *She had been working on 1/2/25 when he had an aggressive outburst with the staff and struck resident 2. -He was awake and had required a one to one to follow him around. -The incident happened in the dining room and he had been sitting on the floor. -After the staff tried to help get him up off the floor he turned around and started running after CNA K. She had been assigned to be his one to one. -His arms were waving around and he had punched resident 2 in the cheek. She had been sitting at the dining room table. -The hit had left a red mark on resident 2's cheek. -The police had been called and came to the facility. *Resident 2: -Was confused and had forgotten the incident shortly after it had occurred. -Her husband had recently passed away and she would wander around the two wings looking for him. *Since that incident: -There had been no additional training and education on how to take care of resident 1 or those residents with dementia and behaviors. -There had been an all-staff meeting in December but she had not attended it. To her knowledge those meetings were not mandatory. -The one to one monitoring had been in place prior to the 1/2/25 incident. *She: -Knew where the care plans were located in the electronic system but would not have checked it. -Was not aware if the care plan information was located in the electronic kiosk system where the CNAs charted on the residents. -Had relied upon the nurses and other staff to inform her of care changes for the residents. -Had not been instructed on what the policy and process for one to one monitoring was. -Had relied upon the other staff to tell her. Interview on 1/7/25 at 2:26 p.m. with CNA H revealed: *She was a traveling CNA and was on her fourth contract with the facility. *She had been involved in two incidents with resident 1 where he had hit her. *Regarding the first incident: -She had her hands full of laundry, he came up from behind her, and without warning started hitting her in the head. -She had required medical treatment, had two knots on her head, and missed two days of work. -The travel staffing agency would not allow her to work with him after that incident. *Regarding the second incident she: -Had been on vacation for two weeks and was not informed he had moved to another wing. -Happened to be outside of the room where he had moved to, he came out of his room, and started to punch her in the face. -Had no interaction with him that shift prior to him coming out of his room and hitting her. -Stated: I had no idea he was even down that wing. I was told to take a breather. *His behaviors had been impulsive, unpredictable, and quick. *He had attacked other residents during his episodes of increased agitation. *She stated: -I heard he hit [resident 2's name] in the face, I think it was last week. -Such a sweet lady, but very confused. -She wanders down here [from the other wing] looking for her husband. -The only dementia training we've had is the required course online. -He's a one to one now. Someone has to be with him when he's awake. *There had not been any recent training on abuse, dementia care, or how to take care of residents with aggressive behaviors. Interview on 1/7/25 at 3:15 p.m. with CNA N revealed: *Regarding resident 1: -When he was calm he was a peach. -He could chit-chat with you but he could not have a full conversation. -He was unpredictable and the staff could not tell what triggered his aggressive behaviors. -When he would become aggressive with residents and staff she would have called LSW A to help work with him. -She had been scared of him at times depending on the situation. -He would not have targeted anyone during one of his episodes unless someone was in his way at that time. -He was to have one to one monitoring while awake. -There was no extra staff scheduled to monitor him and the staff had been pulled from the floor to perform one to one monitoring of resident 1. *She stated: -That leaves us one person short on the floor to help with transfers and answer lights. -He is very unpredictable and quick, there is no plan for his outbursts. -He hurt [resident 2's name] last week. -He hit her on the cheek and it left a mark across it. *A dementia training had been offered a couple of months ago. -The training had been offered from 11:00 a.m. to 3:00 p.m. and was not mandatory. -Anyone working during that time, students, and the night shift staff would not have been able to participate in that training. -She was unsure if it had been recorded. *She was not aware of a plan on how to take care of residents like resident 1. *She was not aware of any mandatory or updated training and education after above incident between residents 1 and 2. Interview on 1/7/25 at 3:45 p.m. with CNA G revealed: *He had been a college student and only worked during holiday leave. *He was required to catch-up on additional trainings and education prior to working. *Regarding resident 1: -He had worked frequently with the resident and was aware of his episodes of increased agitation and aggression. -The resident was to have one to one monitoring by staff when awake. -He was sporadic in allowing assistance with personal cares and toileting. -At times it would take two or three CNAs to assist him. -He had a history of biting, kicking, screaming, spitting, and hitting at staff when they had tried to calm him down or assist him with cares. -He had increased behaviors almost daily. Those behaviors occurred mostly during the evening hours when the office staff had left for the day. -No one was aware of what triggered his behaviors. Those behaviors were sporadic and hard to control. -There had not been extra staff scheduled to take care of him when he was awake. -A CNA would have been pulled off the floor to work with him during those times. -That would have left them short staffed on the floor to assist other residents with transfers, cares, and to answer their call lights. -LSW A would have been called to assist with watching him during the daytime hours. -When he was awake he became a priority over the other residents. *CNA G had been working on 1/2/25 when resident 1 had become upset and aggressive towards others. -The resident had sat down on the floor and he attempted to help him get up. -He had been told by the nurses to pick him up and not leave him on the floor. -After staff had assisted resident 1 in getting up, he had taken off after resident 2 and hit her in the face. -He ran to the refrigerator at the nurse's station and threw some yogurt on the floor. -Staff had attempted to get him to sit down in his Broda chair [specialized positioning wheelchair]. *After the incident CNA G had been told he was not following resident 1's care plan and had been reprimanded. -He was not aware that one of the resident's interventions was to let him lay on the floor when he had put himself there. *He was not aware of where the care plans were or how to locate them. *He stated: -I think they are in a book down the hallway. -I don't know, I just do what the nurses tell us to do. *He had not received any extra training on residents with dementia and how to take care of them. -The training he had completed was on the provider's online training site and had been required to be completed on a yearly basis. *He was not aware of any updated training or plan on how to take care of resident 1. *He was not aware of additional training on one to one monitoring or a policy for that. Interview on 1/8/25 at 8:30 a.m. with the interim Minimum Data Set (MDS) coordinator J revealed: *She had been hired: *She started a 13-week contract on 11/4/24 as the interim MDS coordinator until the full-time MDS coordinator returned. *She had been working on 1/2/25 when resident 1 had become upset, aggressive, and hard to calm down. -The incident happened just after dinner and during the nurse's shift report. -He had sat down on the floor and the staff assisted him up off of the floor. -He had bumped into another resident on his way out of the dining area. -He went into the kitchen area and was assisted into a Broda chair. -The police were called per the direction of the on-call staff. -Being in the Broda chair calmed him down and he was calmer by the time the police arrived. -He had not hit resident 2 but rather brushed up against her. She did not have a red mark on her face, it appeared to be an age spot. -Resident 2 had been uninjured and did not remember the incident shortly after it occurred. -There had been a video recording of the incident and she had watched it. -After resident 1 was assisted off the floor he had taken off with his arms flying and brushed up against resident 2. *She had provided verbal education to the staff at that time on resident 1's care plan interventions. -He should have been left to lay on the floor per his wishes. *She stated: -We talk about him all the time and we tell the staff what they should do. -He is a priority, we talk about him daily. -Those staff should tell the other staff. *There was no documentation that indicated she had provided that verbal education. *There was a clipboard at the nurse's station that contained updated resident care plan information. -Sometimes those updates were given verbally to the direct care staff. -She agreed if it had not been documented there was nothing to support that education had been provided. -She would have expected those staff to inform the other staff of any care plan changes/updates. *She stated: Everyone knows to use it [regarding the clipboard at the nurse's station] they use it every day. *Resident 1 was on a one to one monitoring plan and staff were assigned to take care of him on the daily sheet at the nurse's station. -The staff had been pulled off the floor to work with the resident when he was awake. -The nurse and med aide had been expected to assist with transferring and answering other residents' call lights during that time. -During the daytime hours, resident 1 spent a lot of his time with the office staff to help assist with the one to one monitoring. -Those office staff had not been there on weekends or after daytime hours to have assisted with resident 1. *She was not aware of any additional training, education, or updates regarding resident 1's episode on 1/2/25. *She stated: -There is extra hands-on training for dementia care in the works. -In the meantime we are trying to keep him a one to one. -No, the one to one is not a new change for him. *She agreed the staff should have had hands-on dementia care training sooner. Interview on 1/8/25 at 9:56 a.m. with licensed practical nurse (LPN) F revealed: *She had been working the evening of 1/2/25 when resident 1 had an outburst. -He had been agitated prior to her leaving the area for the nurse's change of shift report. -She had walked with him until he had calmed down prior to that meeting. -A CNA came and got her out of the report room to help with resident 1. -Resident 1 had sat on the floor and the staff had attempted to assist him with standing. -He became upset and ran after CNA K and in the process had hit resident 2 in the face. -He was uncontrollable and was in the kitchen area going through the refrigerator. -The staff helped him to sit down in his Broda chair. -Most of the time the Broda chair was a comfort for him. -She called the on-call administrator and was instructed to call the police. -She checked resident 2's right cheek and it had a large reddened area and measured it. It was not raised or hurtful to the resident. *The CNA assigned as resident 1's one to one that evening was fearful of him and had been involved in other episodes of his agitated and uncontrolled aggressive behaviors. *Resident 1: -Had frequent, almost daily outbursts of uncontrollable and aggressive behaviors. -During those episodes he had been hard to calm down and would start hitting, scratching, biting, and kicking at staff. -There had been times when LPN F had walked with him during those episodes and he hit and scratched at her. -She had received bruises from his hitting. -She had not filled out an incident report on all of those resident-to-staff occurrences because she thought nothing would have changed with his plan. -His behaviors were unpredictable because they were sporadic, quick, and it was hard for staff to tell what would have triggered an onset of increased aggression. -Most of the staff had been scared of him because of his aggressive behaviors. -During the daytime hours through the week days he spent most of the time in LSW A's office. She thought the LSW had a good relationship with the resident. *He had been placed on one to one monitoring after the last complaint survey on 10/31/24. -The direct caregivers working the floor had all been assigned to do that task. -Whoever was available would take over the one to one task with him when he was awake. *No extra staff had been scheduled to provide his one to one monitoring only the already scheduled staff. -At times this would have left them short staffed on the floor to assist the other residents with transfers, cares, and answering resident call lights. -The nurses and med aides had been expected to assist him or the other residents during those times. *She had been told he was a priority when he was awake. *She helped the staff on the floor and with his one to one as much as she could. -She had other tasks that she was responsible for and had to finish herself. *She confirmed: -Nine out of the twenty-two residents that lived on the same wing as resident 1 had required two staff for assistance with transfers. -Those nine residents had to wait at times for assistance when resident 1 was awake and required one on one. *There had been no changes since the last episode with resident 1 on 1/2/25. -There had been no changes to the staffing to accommodate the needs of resident 1. -Resident 1's plan of care had not been updated or shared with staff if it had been updated. -No mandatory education was provided on how to work with him or residents who had dementia and increased behaviors. *She had completed dementia and abuse training that year. -That training was mandatory and part of the yearly required online trainings. *The staff had not been educated on what the provider's one to one monitoring policy requirements were. -She was not sure if they had a policy or process in place on how to take care of resident 1. *She was not part of the care planning process and was not aware of how that process worked. *She did not know how to access the care plans to check for any changes. *She had not been informed of any resident care plan updates or changes. *She stated: -I would think I should be updated on any care plan changes so we know how to take care of the residents. -I'm in charge of the residents and staff and new myself so I would think I should know these things. -I don't think there is a good plan in place to take care of [resident 1's name] and if there is I'm not aware of it. *The all-staff meetings had not been mandatory. -There was one in December and dementia care was scheduled to be discussed. -She had not attended it because it was not mandatory, she had not worked that day, and had other obligations. -It was optional for the staff to attend the dementia training and all staff meetings. Interview on 1/8/25 at 11:54 a.m. with LSW A revealed: *She had assisted the staff with one to one monitoring of resident 1 during the week and during the daytime hours. *A staff had not been assigned one to one monitoring for resident 1 until December. -The office staff had been providing the one to one monitoring since the last complaint survey on 10/31/24 to support that plan of correction. *To her knowledge there had been extra staff to provide the one to one, but she was not responsible for the scheduling. *Since the incident on 1/2/25 they had been in touch with the Ombudsman to try and set-up additional dementia care training for the staff. -To her knowledge there had not been any other changes or updates to resident 1's care plan to help the staff with taking care of him. *She stated: -He is just fine with me and I'm not scared of him. -I talk to the staff all the time on different things they can do to help keep him calmer. -He has problems with his peripheral vision and I'm not sure if that's a part of his care plan. -But the care plan doesn't explain the one to one expectations either. -The expectation is that staff keep him, other residents, and staff safe. *She agreed: -The peripheral vision difficulties should have been a part of his care plan so the staff would have known how to approach him better. -One to one monitoring expectations should have been a part of his care plan so the staff would have known how to take care of him. *They had mis-interpreted the CMS guidance for gradual dose reductions and his antipsychotic medication had been discontinued a few months ago. -Since then his behaviors had increased and the Seroquel had been restarted. He was not quite to the dose he had been on before it was discontinued. *She had no response when asked if the staff had been properly educated on: -How to take care of resident 1 or residents with dementia and aggressive behaviors. -What the one to one monitoring expectations for resident 1 had been. Interview on 1/8/25 at 12:42 p.m. with CNA K revealed: *She had been working there for approximately 6 months. *She had been working the evening of 1/2/25 during the episode with resident 1. *The expectation was for her to be with him at all times while he was awake. -That had included walking with him, giving him things to do, and assisting him with his care needs. *She had been walking with him when he laid down on floor in the dining room. *She and CNA G had not been aware that when he sat or laid down on the floor he was to have been left there. *CNA G assisted resident 1 up off the floor and he ran after her. *In the process of running after her, he had hit resident 2 in the face. *Resident 1 ran into the kitchen area and rummaged through the refrigerator. *They had tried to help him sit down in the Broda chair but he kept trying to get out. *She stated: -I was afraid of getting hit. -Honestly, I'm scared of him and so are some others. -Leadership knows we are, they just ignore it. *She confirmed: -Resident 1 had required one to one monitoring when he was awake. -She had not received extra training on what the one to one person should have done when working with him. -There had not been extra staff scheduled to assist or monitor him when he was awake. -Whoever was available would have provided the one to one monitoring. -That staff person still had other residents to take care of and tasks. -The needs of the other residents had to wait until a staff person was available to assist them. -She had been instructed that the one to one resident had taken priority over the other residents. -She thought resident 1 had been neglected because of his increased behaviors. There had been times he had sat in his bowel movement because they had been to scared to change him. *She stated. Sometimes it takes up to three of us to change him or work with him so that no one gets hurt or kicked. *She had: -Not felt that she had the proper training to help take care of resident 1 and other residents with similar behaviors. -Not been aware of any updates or changes to his plan of care since the incident on 1/2/25 to ensure the safety of others and himself. -Had not been kept informed of when the resident's care plans had updated or changed. *She stated. One time a resident's diet changed to puree [food blended to a smooth consistency] and the o

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) 9/25/24 facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to: *Ensure the physical and psychosocial wellbeing for one of one sampled resident (1) with a history of trauma expressed feelings of fear, feeling unsafe, and suicidal thoughts that potentially increased after an unwanted entry into her room and an act of physical aggression made towards her by resident (2) who has cognitive impairment. *Ensure two of two sampled residents (2 and 3) were free from acts of verbal and physical aggression towards each other. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on 10/30/24 at 3:06 p.m. to administrator A and executive assistant K for F600 related to resident 1's fears and expressed suicidal thoughts following unwanted encounters with resident 2, lack of necessary interventions to keep resident 2 from entering other rooms and aggressing and maintaining separation of residents 2 and 3 to minimize verbal and physical aggression towards each other. A plan for removal of the immediacy was requested. 2. Review of the provider's 9/25/24 SD DOH FRI revealed: *Resident 2 entered resident 1's room and a verbal altercation occurred. *Resident 1 became scared due to pass [past] personnel events earlier in her life. *Resident 1 has a trauma history and does not care for this resident [resident 2] who walked into her room. *Regarding resident 2 Medication has been restarted is aware of behaviors with behaviors getting better with medication adjustments. -No other interventions to keep resident 1 safe were included in the FRI. Observation on 10/29/24 at 2:17 p.m. of resident 2 revealed: *He was in the commons area, walking with socks on his feet and no shoes. -He was smiling and laughing, was able to say words, but his statements were nonsensical. Observation on 10/29/24 at 2:43 p.m. of resident 2 revealed: *He was in the kitchenette area and staff were able to redirect him to the commons area. -He agreed to sit on the couch, was assisted to the couch, and then refused to sit down. -He continued to attempt to enter the kitchenette. Interview and observation 10/29/24 at 3:07 p.m. with resident 1 revealed: *There was a mental health therapist who came to the facility, weekly, to counsel her. -She had received counseling from that therapist for many years and felt it was very helpful. -She stated, She has dug me out of a hole more than once. *When asked specifically about other residents she stated that's a hard piece to chew because some of them have hearing and vision deficits. *When asked if she felt safe, she replied no. *She stated resident 2 had tried to strangle me about a month ago, he came from behind and grabbed her neck with both hands and then let go and left. -She demonstrated by placing both of her hands around her neck. -She stated that she had not provoked him. She didn't know what got into his head. *He entered her room again on 9/25/24, she yelled at him, and he left after a short time. -She stated, I was so shaky it caused me to go to the hospital. -She stated that she has been at the hospital before for severe depression, PTSD (Post Traumatic Stress Disorder),anxiety and all that stuff. *She stated, He [resident 2] is still here so I don't think they have done anything and the staff tell her it takes time. *She had been instructed by the staff to push her call button, yell, or scream, when resident 2 came into her room. -He has continued to come into her room, she tells him to leave, and he does. *She stated, I choose to stay in my room because I don't want any contact, I think he needs to go somewhere where he can get the proper attention. Review of the provider's 8/1/24 SD DOH FRI revealed: *On 7/31/24 resident 2 was very agitated. -He had a verbal altercation with resident 3. -Both men were separated into different ways. Recommendation: continue to monitor. -No other interventions were included in the FRI. Review of the provider's 10/15/24 SD DOH FRI revealed: *On 10/15/24 resident 2 entered resident 3's room. -Resident 2 was yelling and swearing at resident 3. -Resident 3 reported resident 2 grabbed his forearms. -There was no visible injury. 3. IMMEDIATE JEOPARDY REMOVAL PLAN On 10/30/24 at 7:11 p.m. administrator A provided the survey team with a final written immediate jeopardy removal plan. The removal plan had been approved by the survey team on 10/31/24 at 8:32 a.m. with guidance from the assistant administrator and long-term care advisor for the South Dakota Department of Health. The provider gave the following acceptable immediate jeopardy removal plan on 10/31/24 at 10:30 a.m. 1. On 10/30/24 at 3:25 p.m. implemented one-to-one staff assistance for resident 2 to ensure his safety and residents 1 and 2's safety. 2. On 10/30/24 updated resident 2's care plan with the new interventions to keep residents 1 and 3 safe. 3. On 10/30/24 at 4:06 p.m. resident 2 was moved to the opposite household to limit interactions between residents 2 and 3. 4. On 10/30/24 at 4:23 p.m. resident 2's primary care physician was notified and an order for Rexulti and a second referral to psychiatric counseling was received. 5. On 10/30/24 at 5:19 p.m. a paper stop sign was placed next to resident 1 and 3's doorways to deter resident 2 from entering their rooms. 6. On 10/30/24 approximately 5:25 p.m. completed immediate education with all staff on duty. 7. On 10/30/24 at 5:34 p.m. emailed all staff resident 2's updated care plan. 8. On 10/30/24 at 6:16 p.m. texted all staff that they needed to read that email and care plan. The immediate jeopardy was removed on 10/31/24 at 10:30 a.m. after the survey team verified the provider had implemented their removal plan. After the removal of the immediate jeopardy, the scope and severity of the citation level was lowered to a G. Current census was 43. 4. Interview on 10/29/24 at 2:20 p.m. with housekeeper I revealed: *She felt resident 1 did not like resident 2 because, He has choked her before a couple of months ago. -Resident 1 went to a psychiatric hospital as she was afraid of resident 2. *Housekeeper I had no training regarding dementia and behaviors of residents. Interview on 10/29/24 at 2:44 p.m. with licensed practical nurse (LPN) F revealed: *He [resident 2] is very busy and he wandered quite a bit. -He wandered into other resident rooms when he was not provided one-to-one assistance from staff. -Other residents would get upset with resident 2. -He would spend most of the day in the social service staff's office. -He often became worked up and anxious. -She indicated that loud noises triggered his behaviors and would set him off. -He had a history of becoming physically abusive to staff. -She was not aware if he had become physically abusive to other residents. -She stated that resident 3 often sets him off. *She identified the following interventions for resident 2's behavior: -Direct him to the social service staff office. -A staff member was to spend one-to-one time with him. -When he was exit seeking, a staff member was to walk with him around the facility. *She knew that on 8/22/24 at 6:30 p.m. there was an incident between resident 2 and resident 1 but had no further knowledge of that incident. Interview on 10/29/24 at 2:50 p.m. with CNA/CMA E revealed: *Resident 2 and resident 3 had gotten into it but were now friends. *Resident 2 would go into other residents rooms. -A staff member would re-direct him out of the room. Interview on 10/29/24 at 3:10 p.m. with activities supervisor H regarding resident 2 revealed: *He had a short attention span. *When she saw he was becoming agitated she would try to redirect him to a different area. *A staff member was to have eyes on him. *Resident 3 likes to antagonize resident 2 to see his reaction. -Resident 3 would call resident 2 names and would say do you want to fight. Interview on 10/30/24 at 8:35 a.m. with RN G regarding resident interactions revealed: *Interventions for keeping resident 1 safe included that she stayed in her room or the activity room and she can remove herself from the situation. -Other interventions had included notes on the doors, and to keep doors closed. --There was no note observed resident 1's door. *Interventions for keeping resident 2 safe were to keep him distracted and keep resident 2 and 3 separated. *Any changes to interventions would be provided to her during nurse-to-nurse report with updated care plans. Interview on 10/30/24 at 8:45 a.m. with CNA D regarding resident interactions revealed: *She was aware of an incident between resident 1 and resident 2. -She made sure resident 2 did not go into resident 1's room. -When resident 2 went towards resident 1's room, she would make sure they were both safe. *Interventions for keeping resident 2 safe were to monitor as able, intervene if needed, re-direct to keep them apart, and resident 3 was easier to redirect. Interview on 10/31/24 at 11:19 a.m. with licensed social worker (LSW) C, administrator A, and director of nursing (DON) B via teleconference revealed: *They had not reviewed the psychiatric hospital notes upon resident 1's return to the facility. -They were not sure if anyone else had reviewed the notes. -They would have expected the nurse on duty at the time of resident 1's return to review the notes and update the resident's EMR. 5. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 8/23/24 Brief Interview of Mental Status (BIMS) assessment score was a 15, which indicated her cognition was intact. *Her diagnoses included cerebral palsy, anxiety, depression, sleep disturbance, and heart disease. Review of resident 1's nurses progress notes revealed: *On 8/22/24 at 6:30 p.m., Resident [1] informed CNA [certified nursing assistant/certified medication aide (CNA/CMA E)] of incident in her room with resident (2) entering her room while she was watching TV [television] and putting his hands on her shoulders by her neck and squeezing tightly. Resident [1] states she has pain but declines pain med [medication]. Resident [1] has no marks on her neck/shoulders at this time. Resident is calm but doesn't want this to happen again and wants to do what she can to make sure. Resident does seem fearful for her safety and the safety of others. *On 8/22/24 at 8:47 p.m., She [resident 1] informed me that she wanted to file a complaint with the city police. RN [registered nurse] did call [out of town] dispatch and police arrived at 2040 [8:40 p.m.] to get statement from resident. *On 8/23/24 resident 1, Stated she was shook but doing ok. She stated she feels safe most of the time just not safe now around the male resident [2]. She stated she avoids coming out of her room at night because of another resident. *On 8/26/24, She [resident 1] then made her own appointment to see her counselor [name] today at 11am [11:00 a.m.] She reported to the CNA that 'her mind is all over the place after what happened last week'. *On 8/30/24, a care conference note indicated she [resident 1] feels staff aren't doing anything about him and getting him out of the facility. [Resident 1] did state will continue to stay in her room until he leaves facility or she is gone. *On 9/4/24, resident 1 wants to find another nursing home to live in because of resident [2]. She voices to staff that she feels like her rights have been taken away from her and that she does not want to be out of her room much. She states that she will go 'anywhere but here'. *On 9/25/24, Resident [1] upset that another resident [2] took a step into her room while walking down the hallway with a CNA. [Resident 2] did not fully go into room. Resident was using bathroom at the time and door was half closed. CNA quickly direct [resident 2] back into the hallway. *On 9/26/24 at 9:11 a.m., Resident 1 reported to Dakota at Home (South Dakota's aging and disability resource center) an incident. This RN spoke with resident [1] who states she was in her bathroom getting ready for bed at and was halfway undressed when resident [2] came into her room. RN asked if resident [1] was physically harmed and she denied but stated she was mentally harmed. Resident [1] states she 'wants the hell out of this place'. Resident [1] stated that she is tired of the run-a-round, that he's [resident 2] is supposed to be on a 24 hour watch and how does he get into her room twice. she stated she feels like she has no rights and that he shouldn't even be here. Resident [1] held up her thumb and fore-finger tightly together and said 'I'm this close to committing suicide.' She said she shouldn't have to stay in her room for 3 weeks. Resident [1] is frustrated and states feels like she isn't important and that she doesn't matter. *On 9/26/24 at 4:09 p.m., resident 1 was transferred to a psychiatric inpatient hospital. This RN talked to resident [1] prior to leaving and resident states she still feels the same urge for suicide and denies having any methods to carry out thoughts. *On 10/10/24 at 4:15 p.m., resident 1 returned to the facility from the psychiatric inpatient hospital. *On 10/21/24, resident 1 reported that [resident 2] had been in her room x2 [two times] this morning. 6. Review of resident 2's electronic medical record (EMR) revealed: *His diagnoses included: dementia without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety; Alzheimer's Disease, Parkinson's disease, pain in right shoulder, and conduct disorder. *His 9/4/24 primary care provider progress notes included: -There have been a lot of changes over the past couple months. Per state requirements we took him off all antipsychotic medications as his diagnosis did not meet their recommendations. As a result, the patient's behaviors became significantly worse to the point of threatening physical harm to other residents in long-term care. -A lot of his issues depend on who is working and how they are able to handle him, however, there is some room for improvement as he is not as good as he used to be. Review of resident 2's nurses progress notes included: *On 10/17/24 resident 3 stopped beside resident 2 who was sitting quietly at the nurses station. -Resident 3 stated, I should just smack him now. -Resident 2 yelled at resident 3. -Resident 3 then started punching [resident 2] in the upper left arm. -Resident 2 grabbed at resident 3 and started to swing and punched him in the arm. -Staff intervened and separated the residents. -Resident 2 had no noted injuries. -It was documented that resident 3 stated he did not get hit and denied pain to his fist from hitting resident 2. -He then stated that, I want to hit him again and again as he laughed. -There were no other documented interventions to ensure the safety of resident 2 or resident 3. 7. Review of resident 3's EMR revealed: *His diagnoses included: Tourette's disorder (a chronic nervous system condition that causes people to have involuntary tics, or repetitive movements and sounds, that they cannot control), depression, and nicotine dependence. *His 8/16/24 BIMs score was a 10, which indicated he was cognitively impaired. Review of resident 3's nurses progress notes revealed: *There was no progress note regarding the 7/31/24 altercation with resident 2. *On 8/13/24 he was calling two other residents, Coo-Coo and stated, I don't have to be nice, I pay enough, to live here, and then [they] don't even know/understand I'm [I am] even calling then names. *He had physical altercations with resident 2 on 10/15/24 and on 10/17/24. *His 10/25/24 primary care provider progress note revealed: -He had a history of cognitive impairment. -He is due to see Behavioral Health as he does have some outbursts that are slightly inappropriate at times. Behavior Health is due to see him on 12/4 [12/4/24]. 8. Review of the provider's 6/30/23 Abuse Prevention policy revealed: *Purpose: -To identify, correct, and intervene in situations in which abuse, neglect, or misappropriation of residents' property is more likely to occur. -Physical Abuse: includes, hitting, slapping, pinching, kicking, etc. -Psychosocial Abuse: includes, but is not limited to, humiliation, harassment, threats of punishment, deprivation, restraints, silence, or exposing. -Neglect: a failure, through inattentiveness, carelessness, seclusion, or omission, without a reasonable justification to provide timely, consistent and safe services, treatment and care to a resident. *Procedure: -Administration and Head of Dept. [Department] will provide a plan to correct and intervene in situations identified that abuse is more likely to occur: -The assessment, care planning, and monitoring of the resident needs and behaviors which might lead to conflict or neglect, such as aggressive behaviors, wandering, self-injurious behaviors, communication disorders, and residents requiring high levels of care or are totally dependent.