2a. For Resident #167 the facility staff failed to ensure the Resident was free from abuse from Resident #61. Resident #167 was discharged from the facility on 1/15/2020, so a closed record review was performed. Diagnoses for Resident #167 included but were not limited to: Chronic obstructive pulmonary disease, schizoaffective disorder, diabetes, hypertension, and collapsed vertebra. Resident #167's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 1/9/2020 was coded as an annual assessment. Resident #167 was coded as having had a BIMS (brief interview for mental status) score of 15, which indicated cognitively intact. The Resident was also coded on this assessment as having had no behavioral symptoms. Resident #167 required extensive assistance of staff for dressing, personal hygiene and bed mobility. The Resident was totally dependent upon staff for transfers, bathing and toileting. Resident #61 was an active Resident at the time of survey. Resident #61 is Spanish speaking. Diagnoses for Resident #61 included but were not limited to: personality disorder, major depressive disorder, sicca syndrome, and blindness left eye. Resident #61's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 11/12/2019 was coded as an annual assessment. Resident #61 was coded as having had a BIMS (brief interview for mental status) score of 15, which indicated cognitively intact. The Resident was coded as having required extensive assistance of staff for transfers, dressing, personal hygiene and toileting. On 1/29/2020 the facility staff was asked to provide all FRI's (facility reported incidents) involving Resident #61. Review of these documents revealed that on 9/25/2018 the facility staff were made aware that Resident #61 had assaulted Resident #167 on 9/24/2018. Enclosed in the investigation file was a hand-written letter, signed by Resident #167 that read, yesterday, Mon. 24, Sept. I had an altercation with [Resident #61's]. I know you know who that is. As I was entering the dining room to get a seat for Bingo, [Resident #61's] came up behind me, and started pushing my chair and assaulting me with hard blows. I was shocked. I wasn't going to sit at her table, I was just going past it. She even pulled my hair, hard, and continued hitting me! Someone pulled her away and I went on. I think you need to have a talk with her, as I was hurt with the blows and pulled hair. Thanks [Resident #167's signature]. The nursing notes in the closed record of Resident #167 revealed an entry on 9/25/2018 that read, Resident states, I was wheeling in the main dining room getting ready for bingo and [Resident #61] started pounding my back and pulled my hair and she hurt me. On 1/31/2020 at 8:50 AM an interview was conducted with the facility Administrator (Employee A) and Assistant Administrator (Employee C) in the Administrator office. When asked who wrote the hand-written letter, Employee C stated Resident #167. On 1/31/2020 at 11:53 AM, the Social Work Supervisor (Employee D) came into the conference room to discuss the incident of abuse towards Resident #167 by Resident #61. Employee D reported that Resident #167 had left the hand-written letter describing the assault under her office door. Employee D stated Resident #167 would frequently write letters when she had concerns. Employee D went on to state, [Resident #167] was pretty upset by having her hair pulled, she said it hurt her. She felt she had done nothing to provoke it. She wanted us to talk to Resident #61 and tell her it wasn't appropriate. She had no lingering pain, just at the time. She denied being fearful of her, and said she just avoided her. The facility investigation revealed that Resident #61 stated, she did hit [Resident #167's] because she took a bingo card. Further review of FRI's regarding Resident #61 revealed Resident #61 had displayed prior aggression toward other Residents prior to the assault of Resident #167. 2b. For Resident #20 the facility staff failed to ensure the Resident was free from abuse from Resident #61. Resident #20 was an active Resident of the facility at the time of survey. Diagnoses for Resident #20 included but were not limited to: Hypertension, hyperlipidemia, vascular dementia without behavioral disturbance and bilateral osteoarthritis of the knee. Resident #20's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/24/2019 was coded as a quarterly assessment. Resident #20 was coded as having had a BIMS (brief interview for mental status) score of 14, which indicated cognitively intact. The Resident was also coded on this assessment as having had no behavioral symptoms. Resident #20 required limited assistance of staff for bed mobility, dressing, toilet use, and personal hygiene. On 1/29/2020 the facility staff was asked to provide all FRI's (facility reported incidents) involving Resident #61. Review of these documents revealed that on 6/18/2019 Resident #20 came to the dining room, sat at the table, Resident #61 got upset and intentionally knocked the cup of coffee over onto Resident #20. Included in the documents the facility provided was a witness statement that read, she [Resident #20] went into the dining room and proceeded to sit at the table with [Resident #61's]. [Resident #61's] became very mad and agitated, shook the table, yelling at Resident. [Resident #20's] sat her coffee on the table and [Resident #61's] intentionally hit it and knocked it over onto [Resident #20's] lap. [Resident #20's] yelled out, you knocked over my coffee, it's hot. Facility record review also revealed a two-page hand written note dated 6/25/2019 titled Psychiatry, which read, Staff has updated me on recent events- last week throwing cup of hot coffee on another resident for no reason then laughing about it. Patient is known to me since admission and above behaviors resulting in harm to others is not new. She has never shown any remorse. When her wants/needs are not immediately met, she acts out. Resident #20 was assessed by nursing staff and not noted to have any injury as a result of Resident #61 knocking coffee into her lap. The facility had taken the temperature of the coffee prior to it leaving the kitchen and being delivered to the nursing unit. Resident #61 was presented a behavioral contract as a result of this incident, which included not eating meals at the table with other Residents. 2c. For Resident #368 the facility staff failed to ensure the Resident was free from abuse by Resident #61. Resident #368 was discharged from the facility on 12/7/19, therefore a closed record review was performed. Diagnoses for Resident #368 included but were not limited to: vascular dementia with behavioral disturbance, chronic obstructive pulmonary disease, chronic kidney disease stage 3, and major depressive disorder. Resident #368's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 10/10/2019 was coded as a quarterly assessment. Resident #368 was coded as having had a BIMS (brief interview for mental status) score of 4, which indicated severe cognitive impairment. The Resident was also coded on this assessment as having had no behavioral symptoms. Resident #368 required limited assistance of staff for dressing, toilet use, and bed mobility. The Resident was totally dependent upon facility staff for bathing and required extensive assistance with personal hygiene. On 1/29/2020 the facility staff was asked to provide all FRI's (facility reported incidents) involving Resident #61. Review of these documents revealed that on 5/6/18 Resident #61 started yelling at Resident #368, when Resident #368 walked over to Resident #61, Resident #61 kicked her on the leg. A witness statement was included in the documents from a staff member (not identified) who witnessed the altercation. After Resident #61 kicked Resident #368, Resident #368 hit Resident #61 with a plastic spoon and then Resident #61 grabbed the shirt of Resident #368 before staff could intervene. Resident #61 was educated as a result of this incident of abuse towards Resident #368. Following the end of day meeting held on 1/31/2020 the facility staff provided the survey team with a color coded copy of the HEAR (health, environment, approach, resident) document where they discussed interventions for Resident #61's behaviors and aggression/abuse towards other residents. Following the abuse inflicted on Resident #368 on 5/6/18, the following entry was made on this document: different seating arrangement for her to protect others- we need to protect others from her because she becomes physically violent. 2d. For Resident #95 the facility staff failed to ensure the Resident was free from abuse from Resident #61. Resident #95 was an active Resident of the facility at the time of survey. Diagnoses for Resident #95 included but were not limited to: hemiplegia, personal history of traumatic brain injury, pseudobulbar affect, anxiety disorder, and pedestrian injured in traffic accident involving unspecified motor vehicles sequela. Resident #95's most recent MDS (minimum data set) (an assessment tool) with an ARD (assessment reference date) of 12/2/2019 was coded as a quarterly assessment. Resident #95 was coded as having had a BIMS (brief interview for mental status) score of 14, which indicated cognitively intact. The Resident was also coded on this assessment as having had no behavioral symptoms. Resident #95 required extensive assistance of staff for all ADL's (activities of daily living), with the exception of bathing, in which the Resident was totally dependent upon staff. Review of nursing notes revealed an entry on 7/31/19 that indicated Resident #95 and Resident #61 were observed hitting each other. The FRI prepared by the facility staff described the incident in more detail and stated, On 7/31/19 at approximately 1:25 PM Resident #61 became physically and verbally aggressive with [Resident #95's]. [Resident #61] pushed another Resident's wheelchair out of her way but made no physical contact with the Resident. [Resident #61's] then struck [Resident #95] with her fists on his arms. This report further states that the two Residents began hitting each other and staff intervened. The community services board was contacted and recommended the facility contact the police for Resident #61's behavior. However, the facility chose not to carry out this recommendation and stated, Resident's behavior was calm immediately following the incident. Facility records revealed a letter dated 8/7/19 to Resident #61's son, with a copy being given to the Resident and other son as well. The letter stated, [facility name redacted] has determined we can no longer meet her needs. In addition, we have determined that [Resident #61's] behavioral status continues to endanger the health of other in the facility. Nursing notes revealed an entry dated 8/12/19 that read, Staff witnessed Resident getting too close to Resident #61, who yelled at him [referring to Resident #95], and both Resident's observed hitting each other on the arms. The facility investigation revealed the following details: Resident #61 was sitting at the nursing station when Resident #95 wheeled by, Resident #61 started yelling at him. Resident #95 yelled back and swung to hit Resident #61 and both started hitting each other. On 1/31/19 an interview was conducted with Resident #95 regarding the relationship with Resident #61. Resident #95 indicated they don't get along. The facility investigation file revealed that on 10/16/19 Resident #95 reported to the facility social worker there was a personality conflict between the two. Review of the facility policy titled Freedom from Abuse, Neglect, and Exploitation read on page 1 under the definition heading, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Page 4 of this policy under the heading prevention read, [facility name redacted] will prevent verbal, mental, sexual or physical abuse. Page 5 read, [facility name redacted] will maintain protocols and procedures to identify, correct and intervene in situations in which abuse, neglect, mistreatment and/or misappropriation of resident property is more likely to occur. During an end of day meeting held on 1/30/2020 the facility Administrator, Director of Nursing and Assistant Administrator were made aware of the concerns surrounding Resident #61's behaviors towards other Residents. No further information was provided. Based on observation, staff interview, resident interview, clinical record review, and facility documentation review, the facility staff failed to ensure 8 residents were free from abuse (Residents #118, #161, #69, #120, #167, #20, #368, #95) by two residents (#50, #61) in a survey sample of 46 residents. This resulted in harm to Resident #118. The findings included; 1) For Residents #118, #69, #20, #161, and #120, the facility staff failed to ensure that they were free from abuse by Resident #50. Resident #118's diagnoses upon admission included; peripheral vascular disease, sleep apnea, hypertension, morbid obesity, and depression single episode. The Minimum Data Set assessment tool review revealed that Resident #118 was coded as having a Brief Interview of Mental Status Score of 15 out of a possible 15 points indicating no impaired cognition. The Resident was coded as requiring 1 staff member for physical assistance with all activities of daily living, with the exceptions of, eating with set up help only, and the Resident was able to self propel a wheel chair, although, slowly. Resident #50's diagnoses upon admission included; Anoxic brain damage, dementia with behavioral disturbance, diabetes, major depressive disorder single episode, and heart disease. The Minimum Data Set assessment tool review revealed that Resident #50 was coded as having a Brief Interview of Mental Status Score of unable to complete indicating severe impaired cognition. The Resident was coded as requiring staff members for physical assistance with activities of daily living, with the exceptions of locomotion off of the unit in a wheel chair, and the Resident was able to self propel a wheel chair, and was coded as needing supervision. On 1-28-2020 at 11:30 a.m., on initial tour of the facility, an observation and interview were conducted with 2 surveyors and Resident #118 in the hallway of the Resident's room. The Resident was sitting in a wheel chair. An activity was being conducted in the dining room area of the unit and Resident #118 was asked by surveyors if she would like to attend. The Resident stated no, I can't do that because (Resident #50's name) is in there and she is mean. Resident #118 was asked if Resident #50 had hurt her in the past, and she stated yes, twice, the first time she pinched me and left a big bruise on my arm, and the second time she grabbed my arms and hit me and left bruises on me. Immediately following the 1-28-2020 11:30 a.m. interview with Resident #118, an interview was conducted with Resident #50's room mate (Resident #53). The room mate stated that Resident #50 did curse and yell at her and the staff, and threatened to Kill staff, but stated that Resident #50 had not hit her, and further stated when she's like that I just stay quiet, and don't say anything, she is sick in the head, you know, you can't get mad at someone acting that way if they are sick in the head. On 1-30-2020 at 3:20 p.m., an interview was conducted with Resident #118. Two surveyors, and the Administrator were present in an open empty dining room. The Resident was asked to tell the Administrator if Resident #50 had hurt her. She stated yes . When asked how many times she had been hurt by Resident #50, she stated Twice, I told [LPN C] the first time when she pinched me, and then the nurses came and saw when she grabbed me the second time. Resident #50's clinical records and facility records were reviewed. On 7-8-19 facility investigation documents revealed Resident #50 wandered into the room of Resident #161, grabbing and hitting Resident #161 inflicting bruises. Note: Residents #161 was not able to be interviewed due to dementia. 8-6-19 Psychiatric physicians notes read Per staff acute worsening of behavior, having difficulties sleeping. Patient aggressive toward peer this morning, entered peer's room. Often sleeps during the day and awakes at night. Agitated attempted to elope during exit. Start Ativan 0.5 mg (milligrams) for PRN (as needed) aggression with risk of harm to self or others. On 8-6-19 at 3:28 p.m., facility investigation documents revealed Resident #50 wandered down the hall of Resident #118, grabbed and pinched the Resident on the elbow while Resident #118 was gazing outside from the exit door where she liked to sit, inflicting bruises. On 8-6-19 at 3:38 (nursing notes) Resident #50 wandered down the hall of Resident #118 again, and grabbed her arms inflicting bruises. The 2 Resident's rooms are on different halls. The record review showed no other instances of Resident #50 assaulting Resident #118. 8-20-19 Psychiatric physicians notes read Patient has been sleeping poorly, got almost no sleep last night. She's had more episodes of aggressive behavior toward staff and residents in the last week, and these are notably more frequent when she does not sleep well. 9-3-19 Psychiatric physicians notes read Agitated /frustrated because she's tired. She just pierced another resident with a fork for no reason .Close monitoring .as there is no medication even off label that is appropriate. On 9-3-19 facility investigation documents revealed Resident #50 was sitting at the dining table with Resident #69, and attempted to take meat off of Resident #69's plate with a fork. When Resident #69 tried to brush Resident #50's hand away from her plate, Resident #50 pierced her (per doctor's note) with the fork leaving a red mark on Resident #69. Residents #69 was not able to be interviewed due to due to extreme hearing loss and language barrier. 10-22-19 Psychiatric physicians notes read Patient seen wheeling self about loud and hostile difficult to redirect is responding well to PRN (as needed) Ativan On 10-30-19 facility investigation documents revealed while in an activity, Resident #50 grabbed and hit Resident #20 on the left arm. On 1-29-2020 at 10:00 a.m., an interview was conducted with Resident #20. The Resident was alert, oriented to person, place, and situation. She stated she did remember Resident #50 leaving bruises when she grabbed me, and I was minding my own business in my own room. She came in here. The Resident denied being afraid of Resident #50, however, did state that she stayed out away from (name) Resident #50, so she can't get ahold of me. On 12-10-19 facility investigation documents revealed Resident #50 wandered into the room of Resident #120, and when Resident #120 told her to leave Resident #50 kicked her in the shin causing pain. On 1-29-2020 at 9:30 a.m. an interview was conducted with Resident #120. The Resident was oriented to person, place, time, and situation, and was also found to be a good historian. The Resident stated that Resident #50 wandered daily, and had wandered in her room several times, taking things that belonged to Resident #120. Resident #120 stated that the time she was kicked by Resident #50, she had told her to leave her room, and that Resident #50 kicked her in her sore leg causing pain, but no other injury. Resident #120 stated that Resident #50 (name) yells, curses you out, and beats on staff and Residents both, and if Resident #50 (name) comes back in my room, there's gonna be trouble. Resident #120 was asked what kind of trouble, she stated I will kick her back. Staff interviews on 2 units (staff wished to remain anonymous due to fear of retaliation) indicated that Resident #50 had aggressive behaviors of lashing out at Residents and staff. Nursing staff stated they were told to go to urgent care by Administration if Resident #50 hurt them, and asked if they wanted to press charges, however, the staff chose not to. Staff also stated that the Resident will routinely sleep for 3 days then be up for 3 days. On 1-30-2020 after the 3:20 pm interview (see above), the Administrator joined the surveyors back in the conference room after the interview, and stated that the staff had already placed Resident #50 on 1:1 (one to one) supervision that morning, and it would continue at all times while she was out of bed. The Administrator stated that the Resident needed assistance to get out of bed, and so the only time supervision was required would be when Resident #50 was in her wheel chair. The facility policy entitled Freedom from abuse, neglect, and exploitation was reviewed and revealed at area 6 protection The facility will provide increased supervision of the alleged victim and residents. Room changes or staffing changes will occur if necessary to protect the resident(s) from the alleged perpetrator. On 1-30-2020 at the end of day debrief, the Administrator and DON were notified of the findings for Resident #118. The facility stated they had no further information to provide.