**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** HARM 2. Resident 11 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included quadriplegia, C1-C4 incomplete, type 2 diabetes mellitus without complications, edema, benign prostatic hyperplasia, autonomic neuropathy, pain, major depressive disorder, muscle weakness, and muscle spasm. On 6/7/22 at 9:24 AM, an interview was conducted with resident 11. Resident 11 stated that recently a CNA from an agency was assisting him to get out of bed using a Hoyer lift. Resident 11 stated his foot got caught between the Hoyer lift and the bed. Resident 11 stated the staff thought his foot was broken, but he did not break any bones with this incident. Resident 11 stated an x-ray was done and showed he had broken some of the bones in his foot sometime before this incident. On 6/13/22 at 2:29 PM, a review of resident 11's medical record was conducted. The nursing progress notes revealed the following: a. On 4/17/22 at 4:36 PM: The afternoon CNA came to the nurse and said that [resident 11's] R [right] feet was hit by Hoyer lift this morning, per [resident 11] report. The nurse went to assess him immediately. Swelling noted to bilateral feet as his norm [normal]. C/o [complaint of] pain while the nurse move his foot and abrasion noted on the top of the feet. PRN [as needed] hydrocodone was administered. Wrapped foot and applied ice pack. [Resident 11] and his daughter .wanted to wait until tomorrow for X-ray if he still is in pain. Nursing will continue to monitor and follow up. b. On 4/18/22 at 8:30 PM: When the nurse assess his R foot this morning, he was still in pain. PRN hydrocodone was administered. NP [nurse practitioner] was informed about the incident. Received new order for 3 view X-ray of R [right] foot . X-ray was done. Received result, possible acute fracture of the necks of the second, third and fourth metatarsals. NP and his daughter were informed. New order to apply ace-[NAME], lab, and Orthopedic consult. Applied wrapped and ice-pack. Nursing will continue to monitor. c. On 4/18/22 at 11:03 PM: Patient is noted to have a boot to RLE [right lower extremity] related to recent fractures to RLE [right lower extremity]. Patient continues on prn acetaminophen and prn Norco which appears to be effective at this time. Patient did not c/o [complain of] pain during this shift and appears to be comfortable in bed. He is laying down with even and unlabored breathing. Call light is within reach and functioning. d. On 4/19/22 at 8:04 PM: Continue to have pain in R foot. PRN Hydrocodone was administered X2 [twice] today and applied ice-pack. Tolerated well. e. On 4/20/22 at 9:48 PM: Medicated for pain in right foot, x1 [one time]. Stated it helped. Will continue to monitor. f. On 4/25/22 at 1:58 PM: Resident went to his [NAME] [orthopedic] appointment today, MD [medical doctor] note of acute vs. Chronic fx [fracture] of right distal metarsals 2,3,4,5 with soft tissue injury of foot/ankle. It's non-surgical treatment as the recommendation. Non WB [weight bearing] right LE [lower extremity], continue with multi podus boot, compression and elevation. F/u [follow up] in 5 weeks with repeat imaging. Transportation .aware of appointment needed. g. 5/9/22 1:06 PM: Per [resident 11] Foot (sic) cna have been educated properly on how to use the hoyer properly [Note: this nursing progress note dated 5/9/22 is the only record that education was provided to the CNAs on the proper use of the Hoyer lift after the incident with resident 11.] The Event Report dated 4/17/22 was reviewed and each section of the report revealed the following: a. Event Information: completed b. Description: R foot got it by Hoyer lift, painful and abrasion on the top of the R foot c. Event Details: Physical Observation, Mental Status, Possible Contributing Factors, and Interventions were not completed. Notifications were made in a timely manner. d. Vital Signs: not completed e. Orders: no orders recorded f. Notes: progress notes from 4/17/22 until 5/9/22 included g. Evaluation: no further pain foot remains in protected boot and incident resolved with no further intervention needed Resident 11's medication administration record (MAR) showed the following documented pain scores for resident 11 from 4/17/22 through 4/29/22 [It should be noted that resident 11 experienced increased pain scores after the incident that occurred on 4/17/22]: a. On 4/17/22 at 9:02 AM, resident 11 reported a pain score of 4/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective b. On 4/17/22 at 4:13 PM, resident 11 reported a pain score of 5/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective c. On 4/18/22 at 6:42 AM resident 11 reported a pain score of 5/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective d. On 4/18/22 at 5:07 PM resident 11 reported a pain score of 6/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective e. On 4/19/22 at 6:56 AM resident 11 reported a pain score of 6/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective f. On 4/19/22 at 7:57 PM resident 11 reported a pain score if 6/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective g. On 4/20/22 at 7:30 PM resident 11 reported a pain score of 5/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective h. On 4/21/22 at 7:44 PM resident 11 reported a pain score of 5/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective i. On 4/22/22 at 7:46 AM resident 11 reported a pain score of 6/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective j. On 4/24/22 at 5:18 PM resident 11 reported a pain score of 8/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective k. On 4/25/22 at 7:58 PM resident 11 reported a pain score of 7/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective l. On 4/27/22 at 7:40 AM resident 11 reported a pain score of 5/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective m. On 4/27/22 at 10:20 PM resident 11 reported a pain score of 6/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective n. On 4/29/22 at 4:10 PM resident 11 reported a pain score of 8/10 and received hydrocodone-acetaminophen 7.5/325mg 1 tablet by mouth, reported to be effective Resident 11's x-ray results completed on 4/18/22 were reviewed. The x-ray findings stated profound osteopenia. Deformed the forefoot. Possible acute fractures of the necks of the second, third, and fourth metatarsals without laceration no radiodense foreign bodies. The x-ray impression stated possible acute fractures of the necks of the second, third, and fourth metatarsals. On 6/13/22 at 1:34 PM, an interview was conducted with the DON. The DON stated nobody claimed the incident with resident 11, so the investigation was started with the x-ray to see what injuries had occurred. The DON stated it was concluded that resident 11 had medical conditions that put him at risk for injury. The DON stated the facility provided education on proper use of the Hoyer lift with CNA's on a continual basis. The DON stated he was not able to educate the specific person involved in the incident because he was unable to determine which CNA caused the injury. The DON stated the facility had educated all CNAs in huddles and in-service meetings. On 6/13/22 at 4:22 PM, an interview was conducted with CNA 4 and CNA 5. CNA 4 stated they used the Hoyer lift to transfer resident 11. CNA 4 and CNA 5 both stated to use the Hoyer lift required two people. CNA 4 stated when she used 2 people when repositioning resident 11 using the Hoyer lift. CNA 4 stated she checked resident 11 to see if he needed his brief changed and would assist resident 11 to get dressed. CNA 4 stated resident 11 had to be rolled from side to side to get the sling for the Hoyer positioned correctly. CNA 4 stated they would bring in the Hoyer lift, hook resident 11 to the Hoyer, and lift him into his wheelchair. CNA 4 stated she ensured resident 11's catheter was safely in place and covered. CNA 4 stated resident 11 liked to have a gait belt around his knees and a strap around his left arm. CNA 5 stated two people were needed to get resident back in bed with the Hoyer. CNA 4 stated they made sure resident 11's arms were inside the sling for safety. CNA 4 stated she asked resident 11 if everything felt OK. CNA 4 stated resident 11 will say stop if he noticed something was wrong. CNA 5 stated they made sure the sling was in the right position before they lifted resident 11. CNA 4 and CNA 5 both stated they have had no accidents with resident 11. Based on observation, interview and record review it was determined, for 1 of 39 sample residents, that the facility did not provide each resident adequate supervision to prevent accidents. Specifically, a resident with a diagnoses of dementia and pica was found with hazardous liquids and foreign objects. This was found to have occurred at an Immediate Jeopardy (IJ) level. In addition, a resident sustained an injury during a transfer with a Hoyer lift. This was found to have occurred at a harm level. Resident identifiers: 11 and 29. NOTICE: On 6/9/22 at 6:25 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify hazard(s) and risk(s); evaluate and analyze the hazard(s) and risk(s); implement interventions to reduce hazard(s) and risk(s); and monitor for effectiveness and modify the interventions when necessary. Specifically, the facility failed to ensure a resident with dementia and pica had supervision and interventions to prevent the resident from eating or drinking hazardous chemicals and foreign objects. Notice of the IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON) and the Assistant [NAME] President of clinical quality for Skill Nursing Facilities were informed of the findings of IJ pertaining to F689. On 6/13/22, the facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 6/10/22 at 11:00 PM: Resident 29 placed on 1:1 supervision with staff on 6/9/22 @ 1900 until new interventions can be evaluated for effectiveness. Resident 29's IDT with hospice team completed on 6/10/2022 @ 0900 Resident 29's Labs scheduled to be obtained for medical evaluation 6/10/2022 Resident 29's IDT with son scheduled for 6/10/2022 [name removed] crisis team evaluation utilizing [name removed]Translation services completed on 6/9/2022 @ 2050 Resident 29's Care plans updated to reflect current interventions on 6/9/2022 Resident 29's behavior tracking updated to reflect current potential behaviors on 6/9/2022 All resident elopement risk assessments updated by 6/10/2022 All dietary care plans assessed for residents with potential for PICA behaviors on 6/10/2022. Housekeeping cart locks updated on 6/10/2022 Education provided to all staff regarding securing cleaning supplies, pica symptoms, redirection techniques for wandering, non-pharmacological interventions in a staff meeting on 6/10/2022. Staff will complete post-test after training to ensure understanding. Staff unable to attend staff meeting will be required to complete training prior to their next scheduled shift. Agency staff will be required to complete education at the start of their shift. Staff will complete post-test after training to ensure understanding. Nurse management team will utilize admission checklist to review elopement risk for all new admissions. Dietician or designee to assess for PICA concerns with each new admission. A regional team member will visit the facility weekly to provide oversight, audits, and additional training as needed. On 6/13/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 6/10/22 at 11:00 PM. Findings include: 1. Resident 29 was admitted on [DATE] with diagnoses that included cerebral infarction, Alzheimer's disease, dysphagia, failure to thrive, anxiety disorder and PICA. On 6/7/22 at 1:00 PM, resident 29 was observed in her room with no staff supervision. On 6/8/22 at 2:10 PM, resident 29 was observed in the lobby with music playing without staff supervision. Resident 29 was observed to be walking through the 100 hallway at 3:09 PM. The Medical Records staff member was observed redirecting resident 29 and speaking English to her. Resident 29's medical record was reviewed on 6/8/22. A history and physical dated 3/20/22 revealed that the resident's son was concerned resident 29 had gotten into antifreeze or debugging chemicals. Resident 29 was admitted to the intensive care unit and intubated in critical condition. It was noted in her hospitalization resident 29 pulled out her feeding tube because she had mental confusion. A Minimum Data Set (MDS) admission Assessment note dated 4/15/22 revealed resident 29 had episodes of PICA. Resident 29 used a manual wheelchair for locomotion on the unit. Resident 29 was alert to self only and speech was mumbled with a primary language of Malayalam. A care plan dated 4/15/22 for resident 29 eats/sucks on non-edible items. The goal was resident 29 will refrain from eating non-edible items. The approach was staff will not give resident 29 items that she may eat. Another care plan dated 6/7/22 revealed resident 29 experienced wandering and rummaging through others' belongings at time. The goal was that resident 29 would not injure/harm self secondary to wandering. Approaches included to remove resident from other resident rooms and unsafe situations, when resident begins to wander. Additional approaches were to administer medications, follow familiar routines when possible, involve significant support persons, when resident begins to wander provide comfort measures for basic needs. A nurses note dated 4/1/22 revealed that resident 29's son stated she did not understand when spoken to in English. A nurses note dated 4/6/22 revealed that resident 29 pulled out her catheter. A skilled nursing note dated 4/12/22 revealed that staff were educated on need to keep items such as Styrofoam, paper, etc out of patient reach and staff understood the teaching. A social service admission note dated 4/14/22 revealed that resident 29 had been known to eat non-food items. A recreational therapy note dated 4/15/22 revealed that resident 29 had anxiety and little interest/pleasure in doing things. In addition, [Resident 29] is able to participate in activities of importance. Impaired mobility, mood, and cognitive impairment are potential barriers to leisure participation. An abdominal X-ray dated 4/20/22 at 8:31 PM, revealed that resident 29 may have eaten thumb tacks about 2 hours ago. There were no evidence of items in abdomen. A hospice progress note 4/25/22 revealed resident 29 liked to eat paper and Styrofoam. A dietary note dated 4/29/22 revealed that resident 29 was gaining weight which was desirable due to oral intake meeting/exceeding nutritional needs. A dietary department note dated 5/3/22 revealed a concern resident 29 was observed in dining area consuming unsafe items when asked to spit out resident 29 refused and began pushing staff away. Several attempts were made before items were removed and disposed of. A skilled nursing visit note from the hospice Licensed Practical Nurse (LPN) dated 5/5/22 revealed that resident 29 tried to stick non-edible items in her mouth and eat them. A late entry nurses note dated 5/11/22 which was documented on 5/12/22 revealed that resident 29 was found with a plastic container with bleach. Certified Nursing Assistant (CNA) reported that she appeared to have drank some. Hospice notified. Watched resident until she went to sleep. Just checked on her again and sound asleep. Will notify the next nurse to observe. A nursing note dated 5/20/22 revealed resident 29 placed a rubber glove in her mouth, a staff member witnessed this and was able to remove the glove before resident choked. Glove had slipped down her throat, a staff member got it out before it went all the way down. Gloves have been removed from her room and staff were aware and were going to monitor her closely. A long term weekly assessment dated [DATE] but documented on 5/23/22 revealed that resident 29 wanders into other resident rooms eating things and upsetting other residents. There were no notifications made and resident 29 was at her baseline. A nursing note dated 6/3/22 revealed that resident 29 continued to wander and she was going into other resident rooms and taking their belongings. A nursing note dated 6/5/22 revealed resident 29 wandered into other resident rooms and was seen rummaging through a resident's room. On 6/9/22 at 10:20 AM, the Housekeeping (HK) Supervisor was interviewed. The HK supervisor stated that all chemicals were locked in the utility room. The HK Supervisor stated that the housekeepers used carts. A HK cart was observed in the utility room. The HK cart was observed to have a compartment with chemicals and a spring latch on the outside. The HK Supervisor stated there was no lock on the compartment with the chemicals. The HK cart was observed to have a cleaner and disinfectant with beach in a bottle. The bottle revealed to Keep out of reach of children. There was a cleaner degreaser that contained sodium hydroxide that revealed If swallowed: Call a poison control center or doctor for treatment advice. Sip a glass of water if able to swallow. There was multisheen concentrated glass cleaner which revealed on the label to Keep out of reach of children. At 10:31 AM, the HK cart was observed unsupervised in the dining room. The cart was not locked and had a spring latch on the compartment the chemicals were stored in. At 11:11 AM, an observation was made of the housekeeping cart in the 200 hallway. The cart was observed to have a spring latch without a lock on the outside of the chemicals compartment. HK 1 was observed in a resident room and the cart was not within HK 1 line of sight. At 11:45 AM, the housekeeping cart was observed outside room [ROOM NUMBER]. The cart was observed to have a clear chemical on top of the cart labeled with a black marker #2 on the container. There was a toilet brush in a container with a clear chemical not secured in the cart. HK 1 was interviewed. HK 1 stated that she usually put chemicals inside her cart in a compartment that was not locked. HK 1 stated that she put a chemical inside the container with the toilet brush that was not secured inside her cart. HK 1 stated that she did not leave a resident alone with her cart. HK 1 stated that if resident 29 was by her chart and touching everything she did not leave her cart. HK 1 stated resident 29 did not listen and was confused. HK 1 stated that resident 29 ate toilet paper so she did not leave toilet paper in her room. HK 1 stated that another staff member left toilet paper in her room after she took it out. On 6/9/22 at 3:23 PM, resident 29 was observed to touch things on the medication cart and then walked behind the nurses station. Staff were observed to redirect her. Resident 29 was observed to walk to the front door and 2 staff were observed to redirect her. On 6/9/22 at 9:41 AM, an interview was conducted with CNA 9. CNA 9 stated she had heard that resident 29 tried eating a glove. CNA 9 stated that they suspected resident 29 drank body wash. CNA 9 stated there was a full bottle of body wash and then it was gone. CNA 9 stated that was about a week ago. CNA 9 stated that she notified the nurse on duty. CNA 9 stated that staff tried to put things outside of her reach. On 6/9/22 at 9:50 AM, an interview was conducted with CNA 10. CNA 10 stated she had witnessed resident 29 eat the small plastic cups with butter in them. CNA 10 stated resident 29 messed with the cup with her fingers, broke it down and then plopped it in her mouth. CNA 10 stated resident 29 had not choked, Luckily she pulled it out. CNA 10 stated she tried to substitute the plastic container with something she could actually eat. CNA 10 stated she saw resident 29 eat large amounts of orange peels. CNA 10 stated that she then tried to spit because she was pocketing the orange peels in her mouth. CNA 10 stated the language barrier made it hard to communicate with resident 29 to spit out the non-edible items. CNA 10 stated that she tried use her finger to sweep resident's mouth to get out the orange peels. CNA 10 stated one of the orange peels in her mouth was dime sized and some smaller ones. CNA 10 stated that resident 29 wandered and it was hard to find her because she like to crouch down. CNA 10 stated she had not heard anything about resident 29 drinking hazardous liquids and had not been provided education to prevent resident 29 from eating or drinking non-food items. CNA 10 stated there was not enough staff to keep the residents safe. CNA 10 stated there was an aide on the 200 hallway and a shared aide from the 100 hallway. CNA 10 stated 2 CNA's needed to transfer residents with Hoyer lifts, so when 2 CNAs were in a room that left resident 29 to wander in the hallways without supervision. CNA 10 stated that today there was a nursing student that sat with her and that really helped. CNA 10 stated there was usually not enough staff to sit with resident 29. On 6/9/22 at 10:25 AM, a follow up interview was conducted with the HK Supervisor. The HK Supervisor stated there was bleach in the laundry room. The HK Supervisor stated that no residents have been able to get a hold of chemicals. The HK stated that resident 29 might have gotten bleach off the HK cart because she was into everything. The HK stated that resident 29 drank a chemical named Contender but thankfully it wasn't harmful. The HK stated she was told resident 29 was found drinking bleach but determined it was contender. The HK supervisor stated she looked it up in the Material Safety Data Sheet and it revealed there was no known significant side effects or critical hazards. The HK Supervisor stated that resident 29 drank the chemical sometime last month. The HK stated the chemical was probably on top of a cart and not inside the cart. The HK stated there was no investigation and there were no changes to the process to prevent residents from getting the chemicals. The HK stated if there was an investigation the Director of Nursing (DON) or Administrator (ADM) would have conducted the investigation. On 6/9/22 at 4:18 PM, an interview was conducted with Licensed Practical Nurse (LPN) 3. LPN 3 stated resident 29 drank bleach on 5/20/22. LPN 3 stated that apparently somebody had the bleach in her restroom and did not take it out. LPN 3 stated she saw the bottle in resident 29's hand and made the assumption that she drank it. LPN 3 stated that was the first time she was aware of resident 29 eating something that she was not supposed to. LPN 3 stated she notified the physician and hospice about what happened and was instructed to monitor her. LPN 3 stated she talked to the DON the next day about it. LPN 3 stated that the DON told her to make sure everybody knew to put things away from resident 29. On 6/15/22 at 3:05 PM, an interview was conducted with Employee 7. Employee 7 stated that resident 29 had thumbtacks in her mouth, and staff pulled them out of her mouth. Employee 7 stated that the thing that bothered her was that Administration knew and did not move the thumb tacks. Employee 7 stated that a CNA removed a glove from resident 29's mouth and the CNA had to reach her fingers down her throat. Employee 7 stated the CNA could barely reach the glove out of her mouth. Employee 7 stated she was not aware of resident 29 drinking chemicals but stated that resident 29 had had plastic plants in her mouth. Employee 7 stated resident 29 had drank shampoo and lotion. Employee 7 stated she reported the glove incident to LPN 4. On 6/9/22 at 11:36 AM, an interview was conducted with LPN 4. LPN 4 stated that she worked at the facility as the Staffing Coordinator. LPN 4 stated that she witnessed a staff member retrieve a rubber glove out of resident 29's mouth. LPN 4 stated that she reported that incident to the Director of Nursing and the Social Worker. LPN 4 stated that it was reported to me the other night that she (resident 29) was in another resident's room trying to drink lotion. LPN 4 stated that she reported that incident to the Director of Nursing. LPN 4 stated that she had not received any additional education with regard to resident 29's behaviors and what interventions staff were supposed to implement. On 6/8/22 at 2:59 PM, an interview was conducted with the DON. The DON stated that resident 29 admitted to the facility on her death bed. The DON stated that resident 29 woke up and started wandering. The DON stated that resident 29 then started behaviors of spitting and eating non-food items. On 6/9/22 at 12:32 PM, a follow-up interview was conducted with the DON. The DON stated he was not sure resident 29 ingested bleach or a chemical. The DON stated that resident 29 found a bottle in her room and she was holding it. The DON stated we believe a CNA borrowed the chemical and put it in resident 29's room or resident 29 found it on the housekeeping cart. The DON stated he was not aware if the housekeeping carts were locked because that would be the HK Supervisors job. The DON stated hospice was notified and the DON believed housekeepers were given education about safety. The DON stated he did not provide education and would assume that the Administrator or HK Supervisor would do that. The DON stated there was no documentation that CNA's were provided education to prevent resident 29 from getting hazardous liquids. The DON stated that resident 29 got a glove and it was pulled out of her mouth by a CNA. The DON stated there was no investigation because they knew the glove came from resident 29's room. The DON stated the glove was allegedly in her mouth. The DON stated that the gloves were removed from her room. The DON stated he was really strict with the CNA's having gloves in the hallways. The DON stated there was no education for staff to protect resident 29 from eating gloves and choking on them. The DON stated he was aware that resident 29 put things in her mouth. The DON stated staff have reported that resident 29 had put paper towels in her mouth. The DON stated that as of yesterday the staff were being educated that when resident 29 was rummaging she was hungry and to offer her a snack. The DON stated he had been working to discharge resident to a memory care unit because she needed the correct level of care. The DON stated that the facility was unable to provide the correct level of care. On 6/9/22 at 1:30 PM, an interview was conducted with the ADM. The ADM stated he was made aware that resident 29 had a bottle of chemicals the day after the incident occurred. The ADM stated that it was reported during their morning stand-up meeting that resident 29 had a bottle of chemicals that she drank. The ADM stated staff looked at the MSDS form to see what interventions would be needed and what harm the chemical would cause. The ADM stated the MSDS revealed to just monitor resident 29. The ADM stated he was not sure how resident 29 got a hold of the chemical. The ADM stated there were no changes made after the incident to ensure resident 29 did not obtain chemicals again. The ADM stated that it was reported a nurse took a glove out of resident 29's mouth. The ADM stated nursing staff removed gloves from resident 29's room.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 7 of 39 sample residents, that the facility did not ensure that residents were free from abuse and neglect. Specifically, one resident with severe cognitive impairment was found to be hitting and spitting on other residents. Additionally, interventions were inconsistent or non-existent with regard to how facility staff addressed resident behaviors (prevention, re-direction, allowing privacy, and the administration of psychoactive medications). These identified deficient practices were found to have occurred at the Immediate Jeopardy (IJ) Level for 5 residents, including residents 11, 18, 29, 41, and 250. Resident identifiers: 7, 11, 18, 29, 35, 41 and 250. NOTICE: On 6/9/22 at 6:25 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to identify and prevent abuse. Specifically, the facility failed to identify certain behaviors as abuse and or potential abuse, failed to properly investigate and document the incidences, failed to develop interventions to prevent the recurrence of abuse and failed to provide the necessary supervision to protect residents from abuse by other residents. Notice of the IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON) and the Assistant [NAME] President of clinical quality for Skill Nursing Facilities were informed of the findings of IJ pertaining to F600. On 6/13/22, the facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 6/10/22 at 11:00 PM: Resident 29 placed on 1:1 supervision with staff on 6/9/22 @ 1900 (7:00 PM) until new interventions can be evaluated for effectiveness. Resident 29's IDT (interdisciplinary team) with hospice team completed on 6/10/2022 @ 0900 (9:00 AM) Resident 29's Labs scheduled to be obtained for medical evaluation 6/10/2022 Resident 29's IDT with son scheduled for 6/10/2022 [Name of local crisis facility] team evaluation utilizing [name of Translation services]completed on 6/9/2022 @ 2050 (8:50 PM) Resident 29's Care plans updated to reflect current interventions on 6/9/2022 Resident 29's behavior tracking updated to reflect current potential behaviors on 6/9/2022 All resident elopement risk assessments updated by 6/10/2022 All dietary care plans assessed for residents with potential for PICA behaviors on 6/10/2022. Housekeeping cart locks updated on 6/10/2022 Education provided to all staff regarding securing cleaning supplies, pica symptoms, redirection techniques for wandering, non-pharmacological interventions in a staff meeting on 6/10/2022. Staff will complete post-test after training to ensure understanding. Staff unable to attend staff meeting will be required to complete training prior to their next scheduled shift. Agency staff will be required to complete education at the start of their shift. Staff will complete post-test after training to ensure understanding. Nurse management team will utilize admission checklist to review elopement risk for all new admissions. Dietician or designee to assess for PICA concerns with each new admission. A regional team member will visit the facility weekly to provide oversight, audits, and additional training as needed. On 6/13/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 6/10/22 at 11:00 PM. Findings include: 1. Resident 29 was admitted on [DATE] with diagnoses that included cerebral infarction, Alzheimer's disease, dysphagia, failure to thrive, anxiety disorder and PICA. On 6/7/22 at 11:25 AM, an observation was made of resident 29 in her room. There was no staff member present in the room or outside the room. Resident 29 was observed sitting up in bed. An interview was attempted with resident 29, however resident 29 simply repeated back what the surveyor had asked. On 6/8/22 at 3:06 PM, an observation was made of resident 29 sitting in the lobby. Resident 29 was observed to be listening to music in her native language while kissing a doll in the face. Resident 29 then proceeded to put her left index finger up her own nose. Resident 29 then proceeded to get up from her chair and started to wander down the hall. Facility staff was observed to approach resident 29, who was standing outside of another resident's door. Resident 29 was subsequently offered snacks and redirected back to her room. Resident 29's medical record was reviewed on 6/9/22. Hospital records dated 3/30/22 revealed that resident 29 had severe dementia and tended to eat inappropriate items frequently. Resident 29 was brought to the hospital by her son due to concerns of ingesting antifreeze or bedbug chemicals. Resident 29 was intubated and taken to the Intensive Care Unit (ICU) in critical condition due to ingestion of Diacetome, an organic pest control agent. It was noted during her hospitalization that resident 29 would pull out her nasojejunal (NJ) tube if not restrained due to her mental state of confusion. An Minimum Data Set (MDS) dated [DATE] revealed resident 29 did not have a brief interview for mental status (BIMS) completed. The BIMS score was unknown but resident 29 was identified as severely impaired in making decisions, regarding tasks of daily living. Resident 29 was not identified as a wandering risk or having any kinds of behavioral symptoms. Resident 29's care plans revealed the following behavioral problems and approaches taken by facility: a. On 6/9/22 a problem identified was resident 29 ingests non edible items RT (related to) pica. The goal was resident 29 will be kept safe from all hazards items she could ingest. Approaches included: We will place resident 29 on 1 to 1 to provide the constant amount of care resident 29 requires to prevent harm. [Note: This intervention was developed after the facility was notified of an IJ on 6/9/22] b. On 6/9/22 a problem identified was resident 29 is resistant to brief changes and cares at times. The goal was Resident 29 will accept assistance with cares. Approaches included: 1. Assess her resistance. Actively involve the resident in care. Express willingness to adjust regimen. 2. Respect and try to incorporate her culture in her daily cares. 3. Follow familiar routines/ staff when possible. 4. Convey an attitude of acceptance toward the resident. 5. Allow resident to choose options. [Note: This intervention was developed before the facility was notified of an IJ, but after the survey had been initiated]. c. On 6/8/22 a problem identified was resident 29 experiences restlessness and fidgetiness at times. The goal was resident 29 will have no negative outcomes r/t (related to) restless and fidgetiness. Approach(s) included: 1. Offer her activities, music, her doll, walk PRN (as needed). 2. Assure basic needs are assessed. [Note: This intervention was developed after the survey had been initiated.] d. On 6/7/22 a problem identified was resident 29 experiences wandering and will rummage through others' belongings at times. The goal was resident 29 will not injure/harm self secondary to wandering. Approach(s) included: 1. Involve significant support persons. 2. Remove resident from other resident's rooms and unsafe situations. 3. When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). 4. Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. 5. Follow familiar routines when possible. [Note: This intervention was developed after the survey had been initiated.] e. On 5/1/22 a problem identified was resident 29 spits on desks, floors, and people. The goal was resident 29 will not spit on desk, floors, and people. Approach(s) developed on 6/3/22 included: 1. Resident 29 will be redirected PRN (as needed). Resident 29 will be offered a snack PRN. Resident 29 will be given a busy box PRN. No documentation could be located to indicate which residents were affected by the behavior. f. On 4/15/22 problems identified were resident 29 exhibits alteration in thought process manifested by cognitive impairment r/t (related to) dementia; needs reminders/prompts/cues to choose activities; has communication difficulties: fragmented thought process; mood problem: anxiety; has little interest/pleasure in doing things; on hospice. The goals developed included: 1. Resident 29 will participate in activities of importance/interest daily, as desired, through next review date. 2. Resident will engage, as desired, in activities of interest at least: 1 cognitive activity per week for retention of cognitive abilities as evidence by recalling memories during activities; 1 social activity per week for communication as evidence by verbalizing thoughts and ideas during activities; 1 emotional activity per week for increase in interest/pleasure in doing things as evidenced by participating in activities through next review date. Approach(s) included: 1.1 PRN (as needed). Support independent leisure choices. 2.1 Invite, involve and encourage participation in activities of importance/interest including: family/ friend phone calls/visits, TV/movies, Native American (sic) music, pets, socials, outdoors, spiritual support, reminisce, &/or special events. 2.2 Encourage participation in accordance to comfort level and encourage a sense of inclusion and acceptance during activities. 2.3 Provide with opportunities to recall long/short term memories to retain cognitive abilities during activities. 2.4 Provide adaptations to activities PRN (as needed): cognition: task segmentation; physical: adapt size/height/weight of items to match physical abilities; communication: allow time to speak and encourage communication/verbalization during activities. No elopement assessment was done at on admission. No significant change MDS was documented about resident 29's behavior. A psychosocial assessment dated [DATE] indicated that resident 29 would hide and eat non food items. The assessment also indicated that resident 29 would steal other residents' food items to eat them, and did not like to give up the items once she had them. The assessment listed resident 29's behaviors as theft, wandering and combativeness. Resident 29's progress notes revealed the following entities: a. A skilled nursing visit note from the hospice Licensed Practical Nurse (LPN) dated 5/5/22 revealed that resident 29 tried to stick non-edible items in her mouth and eat them. b. A late entry nurses note dated 5/11/22 which was documented on 5/12/22 revealed that resident 29 was found with a plastic container with bleach. Certified Nursing Assistant (CNA) reported that she appeared to have drank some. Hospice was notified. Watched resident until she went to sleep. Just checked on her again and sound asleep. Will notify the next nurse to observe. c. A nursing note dated 5/20/22 revealed resident 29 placed a rubber glove in her mouth, a staff member witnessed this and was able to remove the glove before resident choked. Glove had slipped down her throat, a staff member got it out before it went all the way down. Gloves have been removed from her room and staff were aware and were going to monitor her closely. d. A long term weekly assessment dated [DATE] but documented on 5/23/22 revealed that resident 29 wanders into other resident rooms eating things and upsetting other residents. There were no notifications made. No documentation could be located to indicate which residents were affected by the behavior. e. A nursing note dated 6/3/22 revealed that resident 29 continued to wander and she was going into other resident rooms and taking their belongings as well as sometimes spitting on them. No documentation could be located to indicate which residents were affected by the behavior. f. A nursing note dated 6/5/22 documented that resident 29 wandered into another residents room. The resident was awakened by [resident 29] rummaging through her room and told [resident 29] to leave. [Resident 29] began hitting and also spit on that resident. g. A nursing note dated 6/7/22 documented that I explained to hospice nurse again how resident (29)'s wandering (sic), spitting, playing with her feces, hitting and biting others is very disruptive to the other residents and that the other residents are/have been very upset. [Note: This note was later marked as invalid.] No documentation could be located to indicate which residents were affected by the behavior. [Note: Monitoring for spitting on residents was implemented by facility staff on 6/3/22.] On 6/1/22 a grievance form was completed by resident 41 indicating that she was spit on by resident 29. Resident 29's May 2022 Medication Administration Record (MAR) was reviewed. The MAR indicated that resident 29 received an antianxiety medication, Lorazepam, on 5/6, 5/7, 5/8, 5/13, 5/14, 5/19, 5/22 (twice), 5/25, 5/28, and 5/30/22 for behavior issue or other. The MAR also indicated she received the medication twice for pain. No behavior tracking was in place to indicate why the resident received the medication, what other interventions had been attempted, etc. In addition, the diagnoses for the use of lorazepam were listed as anxiety or shortness of breath. Resident 29's June 2022 MAR was reviewed. The MAR indicated that resident 29 received Lorazepam on 6/1, 6/3, and 6/5 for behaviors, and 6/2/22 for pain. No behavior tracking was in place to indicate why the resident received the medication, what other interventions had been attempted, etc. In addition, the diagnoses for the use of lorazepam were listed as anxiety or shortness of breath. 2. Resident 250 was admitted on [DATE] with diagnoses which included neurological condition, hypertension, septicemia and malnutrition. Resident 250's MDS dated [DATE] revealed a BIMS score of 10. On 6/6/22 at 2:33 PM, an interview was conducted with resident 250. Resident 250 stated that there was a resident who wandered into her room at night and helped themselves to anything when her door is open. Resident 250 stated that resident 29 had come into her room while she was sleeping and had unhooked her oxygen. Resident 250 stated that she had reported the issues to staff, but that staff is doing nothing about it. Resident 250 stated that she is afraid resident 29 will steal her things, and that she doesn't feel safe around resident 29. 3. Resident 18 was admitted to the facility on [DATE] with diagnoses which included progressive neurological condition, heart failure, and diabetes mellitus. A MDS dated [DATE] revealed a BIMS score of 4 On 6/7/22 around 9:00 AM, an interview was conducted with resident 18. Resident 18 stated that someone had come into her room recently and was bashing her. Resident 18 could not indicate which resident had hit her. Resident 18 was tearful when describing the incident, and stopped the interview. 4. Resident 35 was admitted to the facility on [DATE] with diagnoses which included orthopedic condition, hypertension and malnutrition. A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 15 was cognitively intact. On 6/7/22 around 9:30 AM, an interview was conducted with resident 35. Resident 35 stated that she was resident 18's roommate and had witnessed multiple incidents between resident 18 and resident 29. Resident 35 stated approximately a week ago, resident 29 came into her room and scratched and hit resident 18. Resident 35 stated that they reported it to a CNA, but I don't think the CNA told anyone. Resident 35 stated that approximately 3 to 4 days ago at 1:30 AM, resident 29 came into her room again and was hitting resident 18 again. Resident 35 stated that a night nurse came in and stayed with resident 18 until she felt better. On 6/9/22 at 4:01 PM, a phone interview was conducted with employee 7. Employee 7 stated they did not visualize what happened between resident 29 and resident 18 but was told by the CNA that resident 29 had been in resident 18's room spitting and hitting resident 18. Employee 7 stated that the CNA was able to separate the two residents and take resident 29 back to her room. Employee 7 stated they checked on resident 18 as soon as resident 29 was taken out of the room. Employee 7 stated there were no visible injuries identified on resident 18. Employee 7 was told by resident 35, who was the roommate to resident 18, that resident 18 was woken up by resident 29 rummaging through her belongings. Employee 7 stated that resident 35 said that resident 18 was upset. Employee 7 stated that it did not take long for the CNA to respond because resident 35 pushed the call light as soon as she noticed resident 29 was in the room. Employee 7 stated that LPN (Licensed Practical Nurse) 4 was notified and was told they have to do something with resident 29 but was unsure of the exact wording used by LPN 4. Employee 7 stated that they had never seen resident 29 be aggressive and that resident 29 was pretty redirectable as long as she had her baby doll. Employee 7 stated that resident 29 had been receiving extra medication that had helped her sleep better. Employee 7 stated resident 29 was just started on a new medication named Seroquel. 5. Resident 11 was admitted to the facility on [DATE] with diagnoses which included neurological condition, diabetes mellitus, quadriplegia and depression. A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 11 was cognitively intact. On 6/9/22 at 10:05 AM, an interview was conducted with resident 11. Resident 11 stated that resident 29 spit all over his arm and mug while he was right outside his room and that it made him feel sick and mad. Resident 11 stated that he had to take his mug to the kitchen and have it washed out and sanitized. Resident 11 stated that resident 29 did not know what she was doing and he had told resident 29 she was not suppose to spit on other people but resident 29 cannot understand him since she did not speak English. Resident 11 stated they went to the DON and told them they needed to get resident 29 out of the facility and resident 11 was told by the Administrator that he was trying but having a hard time finding the appropriate placement that could handle resident 29. Resident 11 stated that he did not believe them. Resident 11 stated that since that encounter, he made sure he did not come in contact with resident 29 by avoiding her and keeping his door shut when he was not in his room because he was afraid resident 29 would enter his room and steal items. Resident 11 stated that he had to be rough and gruff with resident 29 when she tried to enter resident 11's room. Resident 11 stated that he had seen resident 29 eat paper, spit on the floor and go into other resident's rooms and take things out. Resident 11 stated that staff had chased resident 29 to get the stuff back from resident 29 and return it to the proper owner. 6. Resident 41 was admitted to the facility on [DATE] with diagnoses which included cardiorespiratory, anemia, coronary artery disease, and diabetes mellitus. A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 41 was cognitively intact. On 6/6/22 an interview was conducted with resident 41. Resident 41 stated that 29 wandered into multiple resident rooms, spits on residents, breaks things, and steals items. Resident 41 stated that she had repeatedly told resident 29 to stop. On 6/9/22 at 10:37 AM, another interview was conducted with resident 41. Resident 41 stated while she ate dinner in her room one night, resident 29 came in a spat on her shoulder and down her back. Resident 41 stated they told resident 29 not to spit on her again and to leave her room. Resident 41 stated she felt so violated after what resident 29 did and she should not be living in a place where she was worried that someone was going to spit on her. Resident 41 stated that resident 29 did not belong at the facility, resident 29 needed to be in a facility where they had 1 on 1 care. Resident 41 stated that resident 29 was like a child and did not know what she was doing. Resident 41 stated that resident 29 had been in her room and broken things. Resident 41 stated at one point resident 29 was able to take resident 41's instruction book for her wheel chair. Resident 41 stated that the instruction book was not something resident 29 could just pick up, resident 29 had to get inside a bag and go looking for it. Resident 41 stated that she felt pissed and frustrated. Resident 41 also stated that there was another resident that would call resident 29 stupid and crazy and would yell get that crazy lady out of here while resident 29 was close by. Resident 41 stated that if resident 29 was treated with disrespect or talked to in a tough voice, resident 29 would be mean. Resident 41 stated resident 29 did not appreciate people being mean to her. Resident 41 stated this was the first time that she had seen staff babysitting resident 29. On 6/9/22 at 11:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that she worked at the facility as the Staffing Coordinator. LPN 4 stated that she was aware that resident 29 likes to spit, and had witnessed resident 29 spitting on a facility staff member's desk. LPN 4 also stated that she had heard that resident 29 had spit on resident 9. LPN 4 stated that she had not received any additional education with regard to resident 29's behaviors and what interventions staff were supposed to implement. On 6/8/22 at 2:10 PM, an interview was conducted with Employee 3. Employee 3 stated they received yearly abuse training and continuing education. Employee 3 stated that an action may or may not be considered abuse if the confused resident knew what they were doing. Employee 3 stated that they would consider it a form of bullying if a confused resident were to spit on another resident. Employee 3 stated staff made a note if someone was being bullied in the facility and they would monitor that resident more often and possibly move the resident who did the bullying to a different facility. On 6/8/22 at 2:48 PM, an interview was conducted with Employee 1. Employee 1 stated they used to have a 1 on 1 supervision for resident 29 but it depended on staffing. Employee 1 stated that resident 29 had a behavior issue where she liked to touch people's stuff. Employee 1 stated if resident 29 started to exhibit any kind of behavior issues, then they initiate a 1 on 1 care until the behavior was better. Employee 1 stated that other residents have complained about resident 29 going into their rooms. Employee 1 stated they tried to keep resident 29 away from other residents and prevent her from going into other rooms, residents had to make sure they closed their doors. Employee 1 stated that other residents should not have to be worried about resident 29 going into their rooms. Employee 1 stated that they received training on abuse and if abuse was identified, they had to report it to the administrator or manager. Employee 1 stated that abuse depended on the resident's mental status. Employee 1 defined a confused mental status as the resident not being in their right mind and unaware of what they were doing. Employee 1 stated if they were confused then they did not mean to, that was not considered abuse. Employee 1 stated if a confused resident hit another resident then staff opened a resident to resident event, notified the doctor and looked for any injuries. Employee 1 stated that they followed up with the resident for about 3 to 5 days if no injury was identified. Employee 1 stated if there was an injury then staff continued to follow until the injury was healed. On 6/8/22 at 3:24 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 29 was a little confused. CNA 1 stated that normally with confused residents, staff kept a closer eye on them and made sure they were not causing issues with other residents. CNA 1 stated she had not seen resident 29 be aggressive towards other staff or residents. CNA 1 stated normally when resident 29 was in the hallway, staff tried and talked to her and then redirected her by giving her a snack or taking her to an activity. CNA 1 stated she had abuse training and stated that she first report the abuse to the nurse and then to the DON. CNA 1 stated if a resident was being abused by another resident, she would first separate the two residents and then inform the nurse, so they can document what was happening. CNA 1 stated that if a confused resident were to spit on another, she would not consider it abuse because the resident was confused. CNA 1 stated that when the resident was all there mentally and they act purposefully then it would be considered abuse. On 6/9/22 at 9:50 AM, an interview was conducted with CNA 10. CNA 10 stated there was not enough staff to keep resident 29 safe and other residents safe from resident 29. CNA 10 stated there was usually not enough staff to sit with resident 29. On 6/9/22 at 9:32 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated she had never seen resident 29 hurt anyone. RN 4 stated they were doing their best to redirect resident 29 by providing her with activities and giving her snacks. RN 4 stated there was no one to one care for resident 29 but stated the staff were on high alert when resident 29 was out of their room. RN 4 stated that resident 29's level of confusion exacerbates her communication barrier but they try to communicate with her using hand gestures and some staff have tried using google translate. On 6/9/22 at 9:42 AM, an interview was conducted with Employee 5. Employee 5 stated that they were aware of resident 29 behaviors such as confusion and being combative with staff. Employee 5 stated they will redirect resident 29 by using a calm voice and offering her snacks and a blanket. Employee 5 stated that they were aware of resident 29 spitting on resident 11 and believed it happened sometime last week. Employee 5 told resident 11 that resident 29 did not mean it and it probably was not personal that resident 29 had spit on him. Employee 5 stated they heard that resident 29 may have drank some body wash. Employee 5 stated they went into resident 29 room and put items out of resident 29's reach. Employee 5 stated that resident 29 liked to sit on the couch and spit on the floors and the other residents complained about resident 29 spitting. Employee 5 stated they would consider resident 29 spitting on other residents as abuse, especially on the other residents that can not protect themselves or get away from her. Employee 5 stated that administration was aware of resident 29's behavior. On 6/9/22 at 4:18 PM, an interview was conducted with LPN 3. LPN 3 stated they felt bad for resident 29 since she wasn't able to communicate and she spent a great deal of time in her room. LPN 3 stated that resident 29 would do better in a memory care unit than where she was at now. LPN 3 stated that resident 29 had a really nasty habit of spitting but believed it might be a part of resident 29 culture. LPN 3 stated that resident 29 did not spit at anyone directly, resident 29 spits to clean things with. LPN 3 stated they had heard other residents threaten to hit resident 29. LPN 3 stated that communication was the biggest problem with resident 29. LPN 3 stated they had given Ativan to help resident 29 sleep and keep her out of other residents' rooms. On 6/9/22 at 3:05 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 29 is very quiet and you can see why she scares the residents when she goes into their rooms at night. CNA 3 also stated that resident 29 is very strong and can hurt somebody. During this interview, resident 29 was observed to wander into another resident's room and observed to get upset while being redirected by CNA 3. Resident 29 was observed to hit CNA 3. CNA 3 stated that resident 29 needed one to one care. CNA 3 also stated that resident 7 had a back scratcher/stick and had threatened to hit resident 29 once she entered into resident 7's room. CNA 3 also stated that resident 18 became aggressive and was prepared to fight resident 29 once she entered resident 18's room. On 6/8/22 at 2:59 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 29 was on her death bed when she was admitted to the facility and then she woke up which led to her wandering and having behaviors. The DON stated that he had never seen resident 29 be aggressive but that did not mean it had not happened. On 6/9/22 at 12:14 PM, a follow up interview was conducted with the DON. The DON stated that he was not aware that resident 29 had hit any other resident until 6/7/22 when he reviewed the nurses notes entered over the weekend. The DON stated that they were conducting an investigation on what happened the night of 6/5/22. The DON stated he had never seen resident 29 be violent. The DON stated he was uncertain of what happened but stated it could had been a reaction from resident 18 being approached by resident 29, that could of caused resident 18 to hit resident 29. The DON stated neither, residents 18 and resident 29, had any signs or symptoms of any injuries. The DON stated that both residents were severely demented and no one was able to tell staff if it was a reaction so they did not know who hit who. The DON stated that resident 29 could not act willfully to abuse other residents because she did not have ill intent, but then later stated if resident 29 hit resident 18, then it would have been willful. The DON defined willful in two ways; first it was an aggressive movement towards another and secondly, it was an action the resident chose to do with an understanding of what has happened. The DON stated that resident 29 was a wanderer and will go where the wind takes her. The DON stated that resident 29 went into other resident rooms, squatted in the rooms and looked at the resident in the room. The DON stated that he was aware that resident 29 spat on other residents and that they were in the process of trying a new medication with resident 29 that would help reduce secretions so resident 29's spitting episodes would occur less frequently. The DON stated that spitting was not ever ill intent. The DON stated that resident 41 approached him a week or two ago and stated that resident 29 had walked up behind her and spit down her back. In addition, the DON stated that resident 11 had made an accusation against resident 29 for spitting on her. The DON stated that he apologized to resident 11 for resident 29's behavior. The DON stated that he was sorry residents were victims of resident 29 spitting. The DON stated that these were the only complaints he had received about resident 29's abuse toward other residents. The DON stated he had tried to discharge resident 29 to a memory care unit and knew that resident 29 had not been receiv[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview it was determined for 7 of 39 sample residents, that the facility did not ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the State Survey Agency. Specifically, reports of multiple abuse allegations were not submitted to the State Survey in a timely manner. These findings were determined to have occurred at an Immediate Jeopardy Level for 5 residents, including residents 11, 18, 29, 41, and 250. Resident identifiers: 7, 11, 18, 29, 35, 41 and 250. On 6/9/22 at 6:25 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to report all allegations of resident abuse. Notice of the IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON) and the Assistant [NAME] President of clinical quality for Skill Nursing Facilities were informed of the findings of IJ pertaining to F609. On 6/13/22, the facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 6/10/22 at 11:00 PM: Resident 29 placed on 1:1 supervision with staff on 6/9/22 @ 1900 until new interventions can be evaluated for effectiveness. Resident 250 discharged on 6/7/2022 Residents 11, 18, 41, interviewed about potential abuse and notified of new safety interventions. Social worker or designee will continue to follow up with residents ' 11, 41, 18, 29, and any other potential affected resident to ensure safety and privacy needs continue to be met. Skin evaluations completed and reviewed on residents 11, 18, and 41, 29 by 6/10/22. Abuse reports submitted for residents ' 11, 41, 18, 29, 250, 7 on 6/9/2022 All residents interviewed to assess potential abuse on 6/10/2022 Any additional allegations of abuse will be reported as applicable. Starting 6/10/2022 all nurses ' notes, events, and 24 hour report will be reviewed daily for documentation of potential abuse. Starting 6/10/2022 nursing management will obtain daily report from the nurses. Education provided to all residents regarding how to report concerns and grievances on 6/10/2022. Staff will complete post-test after training to ensure understanding. Education provided to administrator and facility leadership team by regional nurse and facility nurse educator on 6/10/2022 Education provided to all staff regarding abuse prevention and reporting in a staff meeting on 6/10/2022. Staff will complete post-test after training to ensure understanding. Staff unable to attend staff meeting will be required to complete training prior to their next scheduled shift. Staff will complete post-test after training to ensure understanding. Agency staff will be required to complete education at the start of their shift. Staff will complete post-test after training to ensure understanding. Social services or designee will review concern and grievance process during initial IDT (interdisciplinary team). A regional team member will visit the facility weekly to provide oversight, audits of resident interviews and reports, and additional training as needed. The administrator or designee will continue to interview residents on a monthly basis to ensure they have not experienced abuse. The findings of these interviews will be presented to the QAPI Committee. On 6/13/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 6/10/22 at 11:00 PM. Findings include: 1. Resident 29 was admitted on [DATE] with diagnoses that included cerebral infarction, Alzheimer's disease, dysphagia, failure to thrive, anxiety disorder and PICA. On 6/7/22 at 11:25 AM, an observation was made of resident 29 in her room. There was no staff member present in the room or outside the room. Resident 29 was observed sitting up in bed. An interview was attempted with resident 29, however resident 29 simply repeated back what the surveyor had asked. On 6/8/22 at 3:06 PM, an observation was made of resident 29 sitting in the lobby. Resident 29 was observed to be listening to music in her native language while kissing a doll in the face. Resident 29 then proceeded to put her left index finger up her own nose. Resident 29 then proceeded to get up from her chair and started to wander down the hall. Facility staff was observed to approach resident 29, who was standing outside of another resident's door. Resident 29 was subsequently offered snacks and redirected back to her room. Resident 29's medical record was reviewed on 6/9/22. Hospital records dated 3/30/22 revealed that resident 29 had severe dementia and tended to eat inappropriate items frequently. Resident 29 was brought to the hospital by her son due to concerns of ingesting antifreeze or bedbug chemicals. Resident 29 was intubated and taken to the Intensive Care Unit (ICU) in critical condition due to ingestion of Diacetome, an organic pest control agent. It was noted during her hospitalization that resident 29 would pull out her nasojejunal (NJ) tube if not restrained due to her mental state of confusion. An Minimum Data Set (MDS) dated [DATE] revealed resident 29 did not have a brief interview for mental status (BIMS) completed. The BIMS score was unknown but resident 29 was identified as severely impaired in making decisions, regarding tasks of daily living. Resident 29 was not identified as a wandering risk or having any kinds of behavioral symptoms. Resident 29's care plans revealed the following behavioral problems and approaches taken by facility: a. On 6/9/22 a problem identified was resident 29 ingests non edible items RT (related to) pica. The goal was resident 29 will be kept safe from all hazards items she could ingest. Approaches included: We will place resident 29 on 1 to 1 to provide the constant amount of care resident 29 requires to prevent harm. [Note: This intervention was developed after the facility was notified of an IJ on 6/9/22] b. On 6/9/22 a problem identified was resident 29 is resistant to brief changes and cares at times. The goal was Resident 29 will accept assistance with cares. Approaches included: 1. Assess her resistance. Actively involve the resident in care. Express willingness to adjust regimen. 2. Respect and try to incorporate her culture in her daily cares. 3. Follow familiar routines/ staff when possible. 4. Convey an attitude of acceptance toward the resident. 5. Allow resident to choose options. [Note: This intervention was developed before the facility was notified of an IJ, but after the survey had been initiated]. c. On 6/8/22 a problem identified was resident 29 experiences restlessness and fidgetiness at times. The goal was resident 29 will have no negative outcomes r/t (related to) restless and fidgetiness. Approach(s) included: 1. Offer her activities, music, her doll, walk PRN (as needed). 2. Assure basic needs are assessed. [Note: This intervention was developed after the survey had been initiated.] d. On 6/7/22 a problem identified was resident 29 experiences wandering and will rummage through others' belongings at times. The goal was resident 29 will not injure/harm self secondary to wandering. Approach(s) included: 1. Involve significant support persons. 2. Remove resident from other resident's rooms and unsafe situations. 3. When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). 4. Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. 5. Follow familiar routines when possible. [Note: This intervention was developed after the survey had been initiated.] e. On 5/1/22 a problem identified was resident 29 spits on desks, floors, and people. The goal was resident 29 will not spit on desk, floors, and people. Approach(s) developed on 6/3/22 included: 1. Resident 29 will be redirected PRN (as needed). Resident 29 will be offered a snack PRN. Resident 29 will be given a busy box PRN. No documentation could be located to indicate which residents were affected by the behavior. f. On 4/15/22 problems identified were resident 29 exhibits alteration in thought process manifested by cognitive impairment r/t (related to) dementia; needs reminders/prompts/cues to choose activities; has communication difficulties: fragmented thought process; mood problem: anxiety; has little interest/pleasure in doing things; on hospice. The goals developed included: 1. Resident 29 will participate in activities of importance/interest daily, as desired, through next review date. 2. Resident will engage, as desired, in activities of interest at least: 1 cognitive activity per week for retention of cognitive abilities as evidence by recalling memories during activities; 1 social activity per week for communication as evidence by verbalizing thoughts and ideas during activities; 1 emotional activity per week for increase in interest/pleasure in doing things as evidenced by participating in activities through next review date. Approach(s) included: 1.1 PRN (as needed). Support independent leisure choices. 2.1 Invite, involve and encourage participation in activities of importance/interest including: family/ friend phone calls/visits, TV/movies, Native American (sic) music, pets, socials, outdoors, spiritual support, reminisce, &/or special events. 2.2 Encourage participation in accordance to comfort level and encourage a sense of inclusion and acceptance during activities. 2.3 Provide with opportunities to recall long/short term memories to retain cognitive abilities during activities. 2.4 Provide adaptations to activities PRN (as needed): cognition: task segmentation; physical: adapt size/height/weight of items to match physical abilities; communication: allow time to speak and encourage communication/verbalization during activities. No elopement assessment was done at on admission. No significant change MDS was documented about resident 29's behavior. A psychosocial assessment dated [DATE] indicated that resident 29 would hide and eat non food items. The assessment also indicated that resident 29 would steal other residents' food items to eat them, and did not like to give up the items once she had them. The assessment listed resident 29's behaviors as theft, wandering and combativeness. Resident 29's progress notes revealed the following entities: a. A skilled nursing visit note from the hospice Licensed Practical Nurse (LPN) dated 5/5/22 revealed that resident 29 tried to stick non-edible items in her mouth and eat them. b. A late entry nurses note dated 5/11/22 which was documented on 5/12/22 revealed that resident 29 was found with a plastic container with bleach. Certified Nursing Assistant (CNA) reported that she appeared to have drank some. Hospice was notified. Watched resident until she went to sleep. Just checked on her again and sound asleep. Will notify the next nurse to observe. c. A nursing note dated 5/20/22 revealed resident 29 placed a rubber glove in her mouth, a staff member witnessed this and was able to remove the glove before resident choked. Glove had slipped down her throat, a staff member got it out before it went all the way down. Gloves have been removed from her room and staff were aware and were going to monitor her closely. d. A long term weekly assessment dated [DATE] but documented on 5/23/22 revealed that resident 29 wanders into other resident rooms eating things and upsetting other residents. There were no notifications made. No documentation could be located to indicate which residents were affected by the behavior. e. A nursing note dated 6/3/22 revealed that resident 29 continued to wander and she was going into other resident rooms and taking their belongings as well as sometimes spitting on them. No documentation could be located to indicate which residents were affected by the behavior. f. A nursing note dated 6/5/22 documented that resident 29 wandered into another residents room. The resident was awakened by [resident 29] rummaging through her room and told [resident 29] to leave. [Resident 29] began hitting and also spit on that resident. g. A nursing note dated 6/7/22 documented that I explained to hospice nurse again how resident (29)'s wandering (sic), spitting, playing with her feces, hitting and biting others is very disruptive to the other residents and that the other residents are/have been very upset. [Note: This note was later marked as invalid.] No documentation could be located to indicate which residents were affected by the behavior. [Note: Monitoring for spitting on residents was implemented by facility staff on 6/3/22.] On 6/1/22 a grievance form was completed by resident 41 indicating that she was spit on by resident 29. 2. Resident 250 was admitted on [DATE] with diagnoses which included neurological condition, hypertension, septicemia and malnutrition. Resident 250's MDS dated [DATE] revealed a BIMS score of 10. On 6/6/22 at 2:33 PM, an interview was conducted with resident 250. Resident 250 stated that there was a resident who wandered into her room at night and helped themselves to anything when her door is open. Resident 250 stated that resident 29 had come into her room while she was sleeping and had unhooked her oxygen. Resident 250 stated that she had reported the issues to staff, but that staff is doing nothing about it. Resident 250 stated that she is afraid resident 29 will steal her things, and that she doesn't feel safe around resident 29. 3. Resident 18 was admitted to the facility on [DATE] with diagnoses which included progressive neurological condition, heart failure, and diabetes mellitus. A MDS dated [DATE] revealed a BIMS score of 4 On 6/7/22 around 9:00 AM, an interview was conducted with resident 18. Resident 18 stated that someone had come into her room recently and was bashing her. Resident 18 could not indicate which resident had hit her. Resident 18 was tearful when describing the incident, and stopped the interview. 4. Resident 35 was admitted to the facility on [DATE] with diagnoses which included orthopedic condition, hypertension and malnutrition. A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 15 was cognitively intact. On 6/7/22 around 9:30 AM, an interview was conducted with resident 35. Resident 35 stated that she was resident 18's roommate and had witnessed multiple incidents between resident 18 and resident 29. Resident 35 stated approximately a week ago, resident 29 came into her room and scratched and hit resident 18. Resident 35 stated that they reported it to a CNA, but I don't think the CNA told anyone. Resident 35 stated that approximately 3 to 4 days ago at 1:30 AM, resident 29 came into her room again and was hitting resident 18 again. Resident 35 stated that a night nurse came in and stayed with resident 18 until she felt better. On 6/9/22 at 4:01 PM, a phone interview was conducted with employee 7. Employee 7 stated they did not visualize what happened between resident 29 and resident 18 but was told by the CNA that resident 29 had been in resident 18's room spitting and hitting resident 18. Employee 7 stated that the CNA was able to separate the two residents and take resident 29 back to her room. Employee 7 stated they checked on resident 18 as soon as resident 29 was taken out of the room. Employee 7 stated there were no visible injuries identified on resident 18. Employee 7 was told by resident 35, who was the roommate to resident 18, that resident 18 was woken up by resident 29 rummaging through her belongings. Employee 7 stated that resident 35 said that resident 18 was upset. Employee 7 stated that it did not take long for the CNA to respond because resident 35 pushed the call light as soon as she noticed resident 29 was in the room. Employee 7 stated that LPN (Licensed Practical Nurse) 4 was notified and was told they have to do something with resident 29 but was unsure of the exact wording used by LPN 4. Employee 7 stated that they had never seen resident 29 be aggressive and that resident 29 was pretty redirectable as long as she had her baby doll. Employee 7 stated that resident 29 had been receiving extra medication that had helped her sleep better. Employee 7 stated resident 29 was just started on a new medication named Seroquel. 5. Resident 11 was admitted to the facility on [DATE] with diagnoses which included neurological condition, diabetes mellitus, quadriplegia and depression. A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 11 was cognitively intact. On 6/9/22 at 10:05 AM, an interview was conducted with resident 11. Resident 11 stated that resident 29 spit all over his arm and mug while he was right outside his room and that it made him feel sick and mad. Resident 11 stated that he had to take his mug to the kitchen and have it washed out and sanitized. Resident 11 stated that resident 29 did not know what she was doing and he had told resident 29 she was not suppose to spit on other people but resident 29 cannot understand him since she did not speak English. Resident 11 stated they went to the DON and told them they needed to get resident 29 out of the facility and resident 11 was told by the Administrator that he was trying but having a hard time finding the appropriate placement that could handle resident 29. Resident 11 stated that he did not believe them. Resident 11 stated that since that encounter, he made sure he did not come in contact with resident 29 by avoiding her and keeping his door shut when he was not in his room because he was afraid resident 29 would enter his room and steal items. Resident 11 stated that he had to be rough and gruff with resident 29 when she tried to enter resident 11's room. Resident 11 stated that he had seen resident 29 eat paper, spit on the floor and go into other resident's rooms and take things out. Resident 11 stated that staff had chased resident 29 to get the stuff back from resident 29 and return it to the proper owner. 6. Resident 41 was admitted to the facility on [DATE] with diagnoses which included cardiorespiratory, anemia, coronary artery disease, and diabetes mellitus. A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 41 was cognitively intact. On 6/6/22 an interview was conducted with resident 41. Resident 41 stated that 29 wandered into multiple resident rooms, spits on residents, breaks things, and steals items. Resident 41 stated that she had repeatedly told resident 29 to stop. On 6/9/22 at 10:37 AM, another interview was conducted with resident 41. Resident 41 stated while she ate dinner in her room one night, resident 29 came in a spat on her shoulder and down her back. Resident 41 stated they told resident 29 not to spit on her again and to leave her room. Resident 41 stated she felt so violated after what resident 29 did and she should not be living in a place where she was worried that someone was going to spit on her. Resident 41 stated that resident 29 did not belong at the facility, resident 29 needed to be in a facility where they had 1 on 1 care. Resident 41 stated that resident 29 was like a child and did not know what she was doing. Resident 41 stated that resident 29 had been in her room and broken things. Resident 41 stated at one point resident 29 was able to take resident 41's instruction book for her wheel chair. Resident 41 stated that the instruction book was not something resident 29 could just pick up, resident 29 had to get inside a bag and go looking for it. Resident 41 stated that she felt pissed and frustrated. Resident 41 also stated that there was another resident that would call resident 29 stupid and crazy and would yell get that crazy lady out of here while resident 29 was close by. Resident 41 stated that if resident 29 was treated with disrespect or talked to in a tough voice, resident 29 would be mean. Resident 41 stated resident 29 did not appreciate people being mean to her. Resident 41 stated this was the first time that she had seen staff babysitting resident 29. On 6/9/22 at 11:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that she worked at the facility as the Staffing Coordinator. LPN 4 stated that she was aware that resident 29 likes to spit, and had witnessed resident 29 spitting on a facility staff member's desk. LPN 4 also stated that she had heard that resident 29 had spit on resident 9. LPN 4 stated that she had not received any additional education with regard to resident 29's behaviors and what interventions staff were supposed to implement. On 6/8/22 at 2:10 PM, an interview was conducted with Employee 3. Employee 3 stated they received yearly abuse training and continuing education. Employee 3 stated that an action may or may not be considered abuse if the confused resident knew what they were doing. Employee 3 stated that they would consider it a form of bullying if a confused resident were to spit on another resident. Employee 3 stated staff made a note if someone was being bullied in the facility and they would monitor that resident more often and possibly move the resident who did the bullying to a different facility. On 6/8/22 at 2:48 PM, an interview was conducted with Employee 1. Employee 1 stated they used to have a 1 on 1 supervision for resident 29 but it depended on staffing. Employee 1 stated that resident 29 had a behavior issue where she liked to touch people's stuff. Employee 1 stated if resident 29 started to exhibit any kind of behavior issues, then they initiate a 1 on 1 care until the behavior was better. Employee 1 stated that other residents have complained about resident 29 going into their rooms. Employee 1 stated they tried to keep resident 29 away from other residents and prevent her from going into other rooms, residents had to make sure they closed their doors. Employee 1 stated that other residents should not have to be worried about resident 29 going into their rooms. Employee 1 stated that they received training on abuse and if abuse was identified, they had to report it to the administrator or manager. Employee 1 stated that abuse depended on the resident's mental status. Employee 1 defined a confused mental status as the resident not being in their right mind and unaware of what they were doing. Employee 1 stated if they were confused then they did not mean to, that was not considered abuse. Employee 1 stated if a confused resident hit another resident then staff opened a resident to resident event, notified the doctor and looked for any injuries. Employee 1 stated that they followed up with the resident for about 3 to 5 days if no injury was identified. Employee 1 stated if there was an injury then staff continued to follow until the injury was healed. On 6/8/22 at 3:24 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 29 was a little confused. CNA 1 stated that normally with confused residents, staff kept a closer eye on them and made sure they were not causing issues with other residents. CNA 1 stated she had not seen resident 29 be aggressive towards other staff or residents. CNA 1 stated normally when resident 29 was in the hallway, staff tried and talked to her and then redirected her by giving her a snack or taking her to an activity. CNA 1 stated she had abuse training and stated that she first report the abuse to the nurse and then to the DON. CNA 1 stated if a resident was being abused by another resident, she would first separate the two residents and then inform the nurse, so they can document what was happening. CNA 1 stated that if a confused resident were to spit on another, she would not consider it abuse because the resident was confused. CNA 1 stated that when the resident was all there mentally and they act purposefully then it would be considered abuse. On 6/9/22 at 9:50 AM, an interview was conducted with CNA 10. CNA 10 stated there was not enough staff to keep resident 29 safe and other residents safe from resident 29. CNA 10 stated there was usually not enough staff to sit with resident 29. On 6/9/22 at 9:32 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated she had never seen resident 29 hurt anyone. RN 4 stated they were doing their best to redirect resident 29 by providing her with activities and giving her snacks. RN 4 stated there was no one to one care for resident 29 but stated the staff were on high alert when resident 29 was out of their room. RN 4 stated that resident 29's level of confusion exacerbates her communication barrier but they try to communicate with her using hand gestures and some staff have tried using google translate. On 6/9/22 at 9:42 AM, an interview was conducted with Employee 5. Employee 5 stated that they were aware of resident 29 behaviors such as confusion and being combative with staff. Employee 5 stated they will redirect resident 29 by using a calm voice and offering her snacks and a blanket. Employee 5 stated that they were aware of resident 29 spitting on resident 11 and believed it happened sometime last week. Employee 5 told resident 11 that resident 29 did not mean it and it probably was not personal that resident 29 had spit on him. Employee 5 stated they heard that resident 29 may have drank some body wash. Employee 5 stated they went into resident 29 room and put items out of resident 29's reach. Employee 5 stated that resident 29 liked to sit on the couch and spit on the floors and the other residents complained about resident 29 spitting. Employee 5 stated they would consider resident 29 spitting on other residents as abuse, especially on the other residents that can not protect themselves or get away from her. Employee 5 stated that administration was aware of resident 29's behavior. On 6/9/22 at 4:18 PM, an interview was conducted with LPN 3. LPN 3 stated they felt bad for resident 29 since she wasn't able to communicate and she spent a great deal of time in her room. LPN 3 stated that resident 29 would do better in a memory care unit than where she was at now. LPN 3 stated that resident 29 had a really nasty habit of spitting but believed it might be a part of resident 29 culture. LPN 3 stated that resident 29 did not spit at anyone directly, resident 29 spits to clean things with. LPN 3 stated they had heard other residents threaten to hit resident 29. LPN 3 stated that communication was the biggest problem with resident 29. LPN 3 stated they had given Ativan to help resident 29 sleep and keep her out of other residents' rooms. On 6/9/22 at 3:05 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 29 is very quiet and you can see why she scares the residents when she goes into their rooms at night. CNA 3 also stated that resident 29 is very strong and can hurt somebody. During this interview, resident 29 was observed to wander into another resident's room and observed to get upset while being redirected by CNA 3. Resident 29 was observed to hit CNA 3. CNA 3 stated that resident 29 needed one to one care. CNA 3 also stated that resident 7 had a back scratcher/stick and had threatened to hit resident 29 once she entered into resident 7's room. CNA 3 also stated that resident 18 became aggressive and was prepared to fight resident 29 once she entered resident 18's room. On 6/8/22 at 2:59 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 29 was on her death bed when she was admitted to the facility and then she woke up which led to her wandering and having behaviors. The DON stated that he had never seen resident 29 be aggressive but that did not mean it had not happened. On 6/9/22 at 12:14 PM, a follow up interview was conducted with the DON. The DON stated that he was not aware that resident 29 had hit any other resident until 6/7/22 when he reviewed the nurses notes entered over the weekend. The DON stated that they were conducting an investigation on what happened the night of 6/5/22. The DON stated he had never seen resident 29 be violent. The DON stated he was uncertain of what happened but stated it could had been a reaction from resident 18 being approached by resident 29, that could of caused resident 18 to hit resident 29. The DON stated neither, residents 18 and resident 29, had any signs or symptoms of any injuries. The DON stated that both residents were severely demented and no one was able to tell staff if it was a reaction so they did not know who hit who. The DON stated that resident 29 could not act willfully to abuse other residents because she did not have ill intent, but then later stated if resident 29 hit resident 18, then it would have been willful. The DON defined willful in two ways; first it was an aggressive movement towards another and secondly, it was an action the resident chose to do with an understanding of what has happened. The DON stated that resident 29 was a wanderer and will go where the wind takes her. The DON stated that resident 29 went into other resident rooms, squatted in the rooms and looked at the resident in the room. The DON stated that he was aware that resident 29 spat on other residents and that they were in the process of trying a new medication with resident 29 that would help reduce secretions so resident 29's spitting episodes would occur less frequently. The DON stated that spitting was not ever ill intent. The DON stated that resident 41 approached him a week or two ago and stated that resident 29 had walked up behind her and spit down her back. In addition, the DON stated that resident 11 had made an accusation against resident 29 for spitting on her. The DON stated that he apologized to resident 11 for resident 29's behavior. The DON stated that he was sorry residents were victims of resident 29 spitting. The DON stated that these were the only complaints he had received about resident 29's abuse toward other residents. The DON stated he had tried to discharge resident 29 to a memory care unit and knew that resident 29 had not been receiving the appropriate level of care at the facility. When asked how the DON was protecting other residents from resident 29, the DON stated he had been attempting to discharge the resident. On 6/9/22 at 1:30 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he was aware that resident 41 reported that resident 29 had spit on her back. The ADM stated that he did not identify this as abuse because resident 29 didn't know what she was doing. The ADM stated that resident 41 told the ADM that resident 29 should not be residing in the building, but I feel like that was her opinion but I feel like other residents feel the same way. The ADM stated that when resi[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review it was determined that in response to allegations of abuse, neglect, exploitation, or mistreatment the facility failed to have evidence that all alleged violations were thoroughly investigated for 7 of 39 sample residents. Multiple instances of resident to resident physical, verbal and sexual abuse occurred with an insufficient investigation. This was determined to have occurred at an Immediate Jeopardy level for 5 residents, including residents 11, 18, 29, 41, and 250. Resident identifiers: 7, 11, 18, 29, 35, 41 and 250. NOTICE: On 6/9/22 at 6:25 PM, an Immediate Jeopardy was identified when the facility failed to implement Centers for Medicare and Medicaid Services (CMS) recommended practices to investigate abuse. Notice of the IJ was given verbally to the facility Administrator (ADM), Director of Nursing (DON) and the Assistant [NAME] President of clinical quality for Skill Nursing Facilities were informed of the findings of IJ pertaining to F610. On 6/13/22, the facility ADM provided the following written abatement plan for the removal of the Immediate Jeopardy effective on 6/10/22 at 11:00 PM: Resident 29 placed on 1:1 supervision with staff on 6/9/22 @ 1900 until new interventions can be evaluated for effectiveness. Residents 11, 18, 41, interviewed about potential abuse and notified of new safety interventions. Social worker or designee will continue to follow up with residents ' 11, 41, 18, 29, and any other potential affected resident to ensure safety and privacy needs continue to be met. Skin evaluations completed and reviewed on residents 11, 18, 41, and 29 by 6/10/22. Abuse reports submitted for residents ' 11, 41, 18, 29, 250, 7 on 6/10/2022, investigations will be completed. All residents interviewed to assess potential abuse on 6/10/2022 Any additional allegations of abuse will be reported as applicable Starting 6/10/2022 all nurses ' notes, events, and 24 hour report will be reviewed daily for documentation of potential abuse. Starting 6/10/2022 nursing management will obtain daily report from the nurses. Education provided to all residents regarding how to report concerns and grievances on 6/10/2022 Education provided to administrator and facility leadership team by regional nurse and facility nurse educator on 6/10/2022 Social services or designee will review concern and grievance process during initial IDT. A regional team member will visit the facility weekly to provide oversight, audits, and additional training as needed. The administrator or designee will complete an audit of abuse investigations monthly. The findings of these interviews will be presented monthly to the QAPI Committee. On 6/13/22, while completing the recertification survey, surveyors conducted an onsite revisit to verify that the Immediate Jeopardy had been removed. The surveyors determined that the Immediate Jeopardy was removed as alleged on 6/10/22 at 11:00 PM. Findings include: 1. Resident 29 was admitted on [DATE] with diagnoses that included cerebral infarction, Alzheimer's disease, dysphagia, failure to thrive, anxiety disorder and PICA. On 6/7/22 at 11:25 AM, an observation was made of resident 29 in her room. There was no staff member present in the room or outside the room. Resident 29 was observed sitting up in bed. An interview was attempted with resident 29, however resident 29 simply repeated back what the surveyor had asked. On 6/8/22 at 3:06 PM, an observation was made of resident 29 sitting in the lobby. Resident 29 was observed to be listening to music in her native language while kissing a doll in the face. Resident 29 then proceeded to put her left index finger up her own nose. Resident 29 then proceeded to get up from her chair and started to wander down the hall. Facility staff was observed to approach resident 29, who was standing outside of another resident's door. Resident 29 was subsequently offered snacks and redirected back to her room. Resident 29's medical record was reviewed on 6/9/22. Hospital records dated 3/30/22 revealed that resident 29 had severe dementia and tended to eat inappropriate items frequently. Resident 29 was brought to the hospital by her son due to concerns of ingesting antifreeze or bedbug chemicals. Resident 29 was intubated and taken to the Intensive Care Unit (ICU) in critical condition due to ingestion of Diacetome, an organic pest control agent. It was noted during her hospitalization that resident 29 would pull out her nasojejunal (NJ) tube if not restrained due to her mental state of confusion. An Minimum Data Set (MDS) dated [DATE] revealed resident 29 did not have a brief interview for mental status (BIMS) completed. The BIMS score was unknown but resident 29 was identified as severely impaired in making decisions, regarding tasks of daily living. Resident 29 was not identified as a wandering risk or having any kinds of behavioral symptoms. Resident 29's care plans revealed the following behavioral problems and approaches taken by facility: a. On 6/9/22 a problem identified was resident 29 ingests non edible items RT (related to) pica. The goal was resident 29 will be kept safe from all hazards items she could ingest. Approaches included: We will place resident 29 on 1 to 1 to provide the constant amount of care resident 29 requires to prevent harm. [Note: This intervention was developed after the facility was notified of an IJ on 6/9/22] b. On 6/9/22 a problem identified was resident 29 is resistant to brief changes and cares at times. The goal was Resident 29 will accept assistance with cares. Approaches included: 1. Assess her resistance. Actively involve the resident in care. Express willingness to adjust regimen. 2. Respect and try to incorporate her culture in her daily cares. 3. Follow familiar routines/ staff when possible. 4. Convey an attitude of acceptance toward the resident. 5. Allow resident to choose options. [Note: This intervention was developed before the facility was notified of an IJ, but after the survey had been initiated]. c. On 6/8/22 a problem identified was resident 29 experiences restlessness and fidgetiness at times. The goal was resident 29 will have no negative outcomes r/t (related to) restless and fidgetiness. Approach(s) included: 1. Offer her activities, music, her doll, walk PRN (as needed). 2. Assure basic needs are assessed. [Note: This intervention was developed after the survey had been initiated.] d. On 6/7/22 a problem identified was resident 29 experiences wandering and will rummage through others' belongings at times. The goal was resident 29 will not injure/harm self secondary to wandering. Approach(s) included: 1. Involve significant support persons. 2. Remove resident from other resident's rooms and unsafe situations. 3. When resident begins to wander, provide comfort measures for basic needs (e.g., pain, hunger, toileting, too hot/cold, etc.). 4. Administer medications as ordered. Monitor and record effectiveness. Report adverse side effects. 5. Follow familiar routines when possible. [Note: This intervention was developed after the survey had been initiated.] e. On 5/1/22 a problem identified was resident 29 spits on desks, floors, and people. The goal was resident 29 will not spit on desk, floors, and people. Approach(s) developed on 6/3/22 included: 1. Resident 29 will be redirected PRN (as needed). Resident 29 will be offered a snack PRN. Resident 29 will be given a busy box PRN. No documentation could be located to indicate which residents were affected by the behavior. f. On 4/15/22 problems identified were resident 29 exhibits alteration in thought process manifested by cognitive impairment r/t (related to) dementia; needs reminders/prompts/cues to choose activities; has communication difficulties: fragmented thought process; mood problem: anxiety; has little interest/pleasure in doing things; on hospice. The goals developed included: 1. Resident 29 will participate in activities of importance/interest daily, as desired, through next review date. 2. Resident will engage, as desired, in activities of interest at least: 1 cognitive activity per week for retention of cognitive abilities as evidence by recalling memories during activities; 1 social activity per week for communication as evidence by verbalizing thoughts and ideas during activities; 1 emotional activity per week for increase in interest/pleasure in doing things as evidenced by participating in activities through next review date. Approach(s) included: 1.1 PRN (as needed). Support independent leisure choices. 2.1 Invite, involve and encourage participation in activities of importance/interest including: family/ friend phone calls/visits, TV/movies, Native American (sic) music, pets, socials, outdoors, spiritual support, reminisce, &/or special events. 2.2 Encourage participation in accordance to comfort level and encourage a sense of inclusion and acceptance during activities. 2.3 Provide with opportunities to recall long/short term memories to retain cognitive abilities during activities. 2.4 Provide adaptations to activities PRN (as needed): cognition: task segmentation; physical: adapt size/height/weight of items to match physical abilities; communication: allow time to speak and encourage communication/verbalization during activities. No elopement assessment was done at on admission. No significant change MDS was documented about resident 29's behavior. A psychosocial assessment dated [DATE] indicated that resident 29 would hide and eat non food items. The assessment also indicated that resident 29 would steal other residents' food items to eat them, and did not like to give up the items once she had them. The assessment listed resident 29's behaviors as theft, wandering and combativeness. Resident 29's progress notes revealed the following entities: a. A skilled nursing visit note from the hospice Licensed Practical Nurse (LPN) dated 5/5/22 revealed that resident 29 tried to stick non-edible items in her mouth and eat them. b. A late entry nurses note dated 5/11/22 which was documented on 5/12/22 revealed that resident 29 was found with a plastic container with bleach. Certified Nursing Assistant (CNA) reported that she appeared to have drank some. Hospice was notified. Watched resident until she went to sleep. Just checked on her again and sound asleep. Will notify the next nurse to observe. c. A nursing note dated 5/20/22 revealed resident 29 placed a rubber glove in her mouth, a staff member witnessed this and was able to remove the glove before resident choked. Glove had slipped down her throat, a staff member got it out before it went all the way down. Gloves have been removed from her room and staff were aware and were going to monitor her closely. d. A long term weekly assessment dated [DATE] but documented on 5/23/22 revealed that resident 29 wanders into other resident rooms eating things and upsetting other residents. There were no notifications made. No documentation could be located to indicate which residents were affected by the behavior. e. A nursing note dated 6/3/22 revealed that resident 29 continued to wander and she was going into other resident rooms and taking their belongings as well as sometimes spitting on them. No documentation could be located to indicate which residents were affected by the behavior. f. A nursing note dated 6/5/22 documented that resident 29 wandered into another residents room. The resident was awakened by [resident 29] rummaging through her room and told [resident 29] to leave. [Resident 29] began hitting and also spit on that resident. g. A nursing note dated 6/7/22 documented that I explained to hospice nurse again how resident (29)'s wandering (sic), spitting, playing with her feces, hitting and biting others is very disruptive to the other residents and that the other residents are/have been very upset. [Note: This note was later marked as invalid.] No documentation could be located to indicate which residents were affected by the behavior. [Note: Monitoring for spitting on residents was implemented by facility staff on 6/3/22.] On 6/1/22 a grievance form was completed by resident 41 indicating that she was spit on by resident 29. Resident 29's May 2022 Medication Administration Record (MAR) was reviewed. The MAR indicated that resident 29 received an antianxiety medication, Lorazepam, on 5/6, 5/7, 5/8, 5/13, 5/14, 5/19, 5/22 (twice), 5/25, 5/28, and 5/30/22 for behavior issue or other. The MAR also indicated she received the medication twice for pain. No behavior tracking was in place to indicate why the resident received the medication, what other interventions had been attempted, etc. In addition, the diagnoses for the use of lorazepam were listed as anxiety or shortness of breath. Resident 29's June 2022 MAR was reviewed. The MAR indicated that resident 29 received Lorazepam on 6/1, 6/3, and 6/5 for behaviors, and 6/2/22 for pain. No behavior tracking was in place to indicate why the resident received the medication, what other interventions had been attempted, etc. In addition, the diagnoses for the use of lorazepam were listed as anxiety or shortness of breath. 2. Resident 250 was admitted on [DATE] with diagnoses which included neurological condition, hypertension, septicemia and malnutrition. Resident 250's MDS dated [DATE] revealed a BIMS score of 10. On 6/6/22 at 2:33 PM, an interview was conducted with resident 250. Resident 250 stated that there was a resident who wandered into her room at night and helped themselves to anything when her door is open. Resident 250 stated that resident 29 had come into her room while she was sleeping and had unhooked her oxygen. Resident 250 stated that she had reported the issues to staff, but that staff is doing nothing about it. Resident 250 stated that she is afraid resident 29 will steal her things, and that she doesn't feel safe around resident 29. 3. Resident 18 was admitted to the facility on [DATE] with diagnoses which included progressive neurological condition, heart failure, and diabetes mellitus. A MDS dated [DATE] revealed a BIMS score of 4 On 6/7/22 around 9:00 AM, an interview was conducted with resident 18. Resident 18 stated that someone had come into her room recently and was bashing her. Resident 18 could not indicate which resident had hit her. Resident 18 was tearful when describing the incident, and stopped the interview. 4. Resident 35 was admitted to the facility on [DATE] with diagnoses which included orthopedic condition, hypertension and malnutrition. A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 15 was cognitively intact. On 6/7/22 around 9:30 AM, an interview was conducted with resident 35. Resident 35 stated that she was resident 18's roommate and had witnessed multiple incidents between resident 18 and resident 29. Resident 35 stated approximately a week ago, resident 29 came into her room and scratched and hit resident 18. Resident 35 stated that they reported it to a CNA, but I don't think the CNA told anyone. Resident 35 stated that approximately 3 to 4 days ago at 1:30 AM, resident 29 came into her room again and was hitting resident 18 again. Resident 35 stated that a night nurse came in and stayed with resident 18 until she felt better. On 6/9/22 at 4:01 PM, a phone interview was conducted with employee 7. Employee 7 stated they did not visualize what happened between resident 29 and resident 18 but was told by the CNA that resident 29 had been in resident 18's room spitting and hitting resident 18. Employee 7 stated that the CNA was able to separate the two residents and take resident 29 back to her room. Employee 7 stated they checked on resident 18 as soon as resident 29 was taken out of the room. Employee 7 stated there were no visible injuries identified on resident 18. Employee 7 was told by resident 35, who was the roommate to resident 18, that resident 18 was woken up by resident 29 rummaging through her belongings. Employee 7 stated that resident 35 said that resident 18 was upset. Employee 7 stated that it did not take long for the CNA to respond because resident 35 pushed the call light as soon as she noticed resident 29 was in the room. Employee 7 stated that LPN (Licensed Practical Nurse) 4 was notified and was told they have to do something with resident 29 but was unsure of the exact wording used by LPN 4. Employee 7 stated that they had never seen resident 29 be aggressive and that resident 29 was pretty redirectable as long as she had her baby doll. Employee 7 stated that resident 29 had been receiving extra medication that had helped her sleep better. Employee 7 stated resident 29 was just started on a new medication named Seroquel. 5. Resident 11 was admitted to the facility on [DATE] with diagnoses which included neurological condition, diabetes mellitus, quadriplegia and depression. A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 11 was cognitively intact. On 6/9/22 at 10:05 AM, an interview was conducted with resident 11. Resident 11 stated that resident 29 spit all over his arm and mug while he was right outside his room and that it made him feel sick and mad. Resident 11 stated that he had to take his mug to the kitchen and have it washed out and sanitized. Resident 11 stated that resident 29 did not know what she was doing and he had told resident 29 she was not suppose to spit on other people but resident 29 cannot understand him since she did not speak English. Resident 11 stated they went to the DON and told them they needed to get resident 29 out of the facility and resident 11 was told by the Administrator that he was trying but having a hard time finding the appropriate placement that could handle resident 29. Resident 11 stated that he did not believe them. Resident 11 stated that since that encounter, he made sure he did not come in contact with resident 29 by avoiding her and keeping his door shut when he was not in his room because he was afraid resident 29 would enter his room and steal items. Resident 11 stated that he had to be rough and gruff with resident 29 when she tried to enter resident 11's room. Resident 11 stated that he had seen resident 29 eat paper, spit on the floor and go into other resident's rooms and take things out. Resident 11 stated that staff had chased resident 29 to get the stuff back from resident 29 and return it to the proper owner. 6. Resident 41 was admitted to the facility on [DATE] with diagnoses which included cardiorespiratory, anemia, coronary artery disease, and diabetes mellitus. A MDS dated [DATE] revealed a BIMS score of 15 which indicated resident 41 was cognitively intact. On 6/6/22 an interview was conducted with resident 41. Resident 41 stated that 29 wandered into multiple resident rooms, spits on residents, breaks things, and steals items. Resident 41 stated that she had repeatedly told resident 29 to stop. On 6/9/22 at 10:37 AM, another interview was conducted with resident 41. Resident 41 stated while she ate dinner in her room one night, resident 29 came in a spat on her shoulder and down her back. Resident 41 stated they told resident 29 not to spit on her again and to leave her room. Resident 41 stated she felt so violated after what resident 29 did and she should not be living in a place where she was worried that someone was going to spit on her. Resident 41 stated that resident 29 did not belong at the facility, resident 29 needed to be in a facility where they had 1 on 1 care. Resident 41 stated that resident 29 was like a child and did not know what she was doing. Resident 41 stated that resident 29 had been in her room and broken things. Resident 41 stated at one point resident 29 was able to take resident 41's instruction book for her wheel chair. Resident 41 stated that the instruction book was not something resident 29 could just pick up, resident 29 had to get inside a bag and go looking for it. Resident 41 stated that she felt pissed and frustrated. Resident 41 also stated that there was another resident that would call resident 29 stupid and crazy and would yell get that crazy lady out of here while resident 29 was close by. Resident 41 stated that if resident 29 was treated with disrespect or talked to in a tough voice, resident 29 would be mean. Resident 41 stated resident 29 did not appreciate people being mean to her. Resident 41 stated this was the first time that she had seen staff babysitting resident 29. On 6/9/22 at 11:36 AM, an interview was conducted with Licensed Practical Nurse (LPN) 4. LPN 4 stated that she worked at the facility as the Staffing Coordinator. LPN 4 stated that she was aware that resident 29 likes to spit, and had witnessed resident 29 spitting on a facility staff member's desk. LPN 4 also stated that she had heard that resident 29 had spit on resident 9. LPN 4 stated that she had not received any additional education with regard to resident 29's behaviors and what interventions staff were supposed to implement. On 6/8/22 at 2:10 PM, an interview was conducted with Employee 3. Employee 3 stated they received yearly abuse training and continuing education. Employee 3 stated that an action may or may not be considered abuse if the confused resident knew what they were doing. Employee 3 stated that they would consider it a form of bullying if a confused resident were to spit on another resident. Employee 3 stated staff made a note if someone was being bullied in the facility and they would monitor that resident more often and possibly move the resident who did the bullying to a different facility. On 6/8/22 at 2:48 PM, an interview was conducted with Employee 1. Employee 1 stated they used to have a 1 on 1 supervision for resident 29 but it depended on staffing. Employee 1 stated that resident 29 had a behavior issue where she liked to touch people's stuff. Employee 1 stated if resident 29 started to exhibit any kind of behavior issues, then they initiate a 1 on 1 care until the behavior was better. Employee 1 stated that other residents have complained about resident 29 going into their rooms. Employee 1 stated they tried to keep resident 29 away from other residents and prevent her from going into other rooms, residents had to make sure they closed their doors. Employee 1 stated that other residents should not have to be worried about resident 29 going into their rooms. Employee 1 stated that they received training on abuse and if abuse was identified, they had to report it to the administrator or manager. Employee 1 stated that abuse depended on the resident's mental status. Employee 1 defined a confused mental status as the resident not being in their right mind and unaware of what they were doing. Employee 1 stated if they were confused then they did not mean to, that was not considered abuse. Employee 1 stated if a confused resident hit another resident then staff opened a resident to resident event, notified the doctor and looked for any injuries. Employee 1 stated that they followed up with the resident for about 3 to 5 days if no injury was identified. Employee 1 stated if there was an injury then staff continued to follow until the injury was healed. On 6/8/22 at 3:24 PM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated that resident 29 was a little confused. CNA 1 stated that normally with confused residents, staff kept a closer eye on them and made sure they were not causing issues with other residents. CNA 1 stated she had not seen resident 29 be aggressive towards other staff or residents. CNA 1 stated normally when resident 29 was in the hallway, staff tried and talked to her and then redirected her by giving her a snack or taking her to an activity. CNA 1 stated she had abuse training and stated that she first report the abuse to the nurse and then to the DON. CNA 1 stated if a resident was being abused by another resident, she would first separate the two residents and then inform the nurse, so they can document what was happening. CNA 1 stated that if a confused resident were to spit on another, she would not consider it abuse because the resident was confused. CNA 1 stated that when the resident was all there mentally and they act purposefully then it would be considered abuse. On 6/9/22 at 9:50 AM, an interview was conducted with CNA 10. CNA 10 stated there was not enough staff to keep resident 29 safe and other residents safe from resident 29. CNA 10 stated there was usually not enough staff to sit with resident 29. On 6/9/22 at 9:32 AM, an interview was conducted with Registered Nurse (RN) 4. RN 4 stated she had never seen resident 29 hurt anyone. RN 4 stated they were doing their best to redirect resident 29 by providing her with activities and giving her snacks. RN 4 stated there was no one to one care for resident 29 but stated the staff were on high alert when resident 29 was out of their room. RN 4 stated that resident 29's level of confusion exacerbates her communication barrier but they try to communicate with her using hand gestures and some staff have tried using google translate. On 6/9/22 at 9:42 AM, an interview was conducted with Employee 5. Employee 5 stated that they were aware of resident 29 behaviors such as confusion and being combative with staff. Employee 5 stated they will redirect resident 29 by using a calm voice and offering her snacks and a blanket. Employee 5 stated that they were aware of resident 29 spitting on resident 11 and believed it happened sometime last week. Employee 5 told resident 11 that resident 29 did not mean it and it probably was not personal that resident 29 had spit on him. Employee 5 stated they heard that resident 29 may have drank some body wash. Employee 5 stated they went into resident 29 room and put items out of resident 29's reach. Employee 5 stated that resident 29 liked to sit on the couch and spit on the floors and the other residents complained about resident 29 spitting. Employee 5 stated they would consider resident 29 spitting on other residents as abuse, especially on the other residents that can not protect themselves or get away from her. Employee 5 stated that administration was aware of resident 29's behavior. On 6/9/22 at 4:18 PM, an interview was conducted with LPN 3. LPN 3 stated they felt bad for resident 29 since she wasn't able to communicate and she spent a great deal of time in her room. LPN 3 stated that resident 29 would do better in a memory care unit than where she was at now. LPN 3 stated that resident 29 had a really nasty habit of spitting but believed it might be a part of resident 29 culture. LPN 3 stated that resident 29 did not spit at anyone directly, resident 29 spits to clean things with. LPN 3 stated they had heard other residents threaten to hit resident 29. LPN 3 stated that communication was the biggest problem with resident 29. LPN 3 stated they had given Ativan to help resident 29 sleep and keep her out of other residents' rooms. On 6/9/22 at 3:05 PM, an interview was conducted with CNA 3. CNA 3 stated that resident 29 is very quiet and you can see why she scares the residents when she goes into their rooms at night. CNA 3 also stated that resident 29 is very strong and can hurt somebody. During this interview, resident 29 was observed to wander into another resident's room and observed to get upset while being redirected by CNA 3. Resident 29 was observed to hit CNA 3. CNA 3 stated that resident 29 needed one to one care. CNA 3 also stated that resident 7 had a back scratcher/stick and had threatened to hit resident 29 once she entered into resident 7's room. CNA 3 also stated that resident 18 became aggressive and was prepared to fight resident 29 once she entered resident 18's room. On 6/8/22 at 2:59 PM, an interview was conducted with the Director of Nursing (DON). The DON stated that resident 29 was on her death bed when she was admitted to the facility and then she woke up which led to her wandering and having behaviors. The DON stated that he had never seen resident 29 be aggressive but that did not mean it had not happened. On 6/9/22 at 12:14 PM, a follow up interview was conducted with the DON. The DON stated that he was not aware that resident 29 had hit any other resident until 6/7/22 when he reviewed the nurses notes entered over the weekend. The DON stated that they were conducting an investigation on what happened the night of 6/5/22. The DON stated he had never seen resident 29 be violent. The DON stated he was uncertain of what happened but stated it could had been a reaction from resident 18 being approached by resident 29, that could of caused resident 18 to hit resident 29. The DON stated neither, residents 18 and resident 29, had any signs or symptoms of any injuries. The DON stated that both residents were severely demented and no one was able to tell staff if it was a reaction so they did not know who hit who. The DON stated that resident 29 could not act willfully to abuse other residents because she did not have ill intent, but then later stated if resident 29 hit resident 18, then it would have been willful. The DON defined willful in two ways; first it was an aggressive movement towards another and secondly, it was an action the resident chose to do with an understanding of what has happened. The DON stated that resident 29 was a wanderer and will go where the wind takes her. The DON stated that resident 29 went into other resident rooms, squatted in the rooms and looked at the resident in the room. The DON stated that he was aware that resident 29 spat on other residents and that they were in the process of trying a new medication with resident 29 that would help reduce secretions so resident 29's spitting episodes would occur less frequently. The DON stated that spitting was not ever ill intent. The DON stated that resident 41 approached him a week or two ago and stated that resident 29 had walked up behind her and spit down her back. In addition, the DON stated that resident 11 had made an accusation against resident 29 for spitting on her. The DON stated that he apologized to resident 11 for resident 29's behavior. The DON stated that he was sorry residents were victims of resident 29 spitting. The DON stated that these were the only complaints he had received about resident 29's abuse toward other residents. The DON stated he had tried to discharge resident 29 to a memory care unit and knew that resident 29 had not been receiving the appropriate level of care at the facility. When asked how the DON was protecting other residents from resident 29, the DON stated he had been attempting to discharge the resident. On 6/9/22 at 1:30 PM, an interview was conducted with the Administrator (ADM). The ADM stated that he was aware that resident 41 reported that resident 29 had spit on her back. The ADM stated that he did not identify this as abuse because resident 29 didn't know what she was doing. The ADM stated that resident 41 told the ADM that resident 29 should not be residing in the building, but I feel like that was her opinion but I feel like other residents feel [TRUNCATED]