Based on record review and resident and staff interview, the facility failed to ensure the psychosocial wellbeing of a resident was met following a traumatic event, due to failing to follow up with Resident #1 to assess her psychosocial wellbeing and make necessary referrals for Resident #1 to maintain her psychosocial wellbeing. Multiple incidents took place in which Resident #2 was physically abusive to other residents in the facility. The facility failed to take necessary action to prevent further abuse. This created an immediate jeopardy situation. Resident identifiers: #1,and #2. Facility census: 65 Findings included: a) Resident #1 On 05/20/24 at approximately 11:30 am, a record review was conducted of a facility reported incident dated 03/28/24. During review it was determined Resident #2 entered Resident #1's room between 9:30 PM and 10:00 PM. Resident #2 told Resident #1 she was going to, leave my house one way or another. Resident #2 then proceeded to place a blanket over Resident #1's face and attempted to smother her. Resident #2 then grabbed a towel, stating, If that's not good enough, I'll use this and placed a towel over Resident #1's face as well. Resident #1 was heard screaming by a Nurse Aide who came into the room to intervene. The Nurse Aide escorted Resident #2 out of the room. The Licensed Social Worker stated referrals were made for a psychiatric facility for Resident #2 and they were accepted. One on one supervision was put into place, and Resident #2 was care planned for behaviors. The facility made an offer to Resident #1 to move to another room or to put a stop sign at her door. Resident #1 chose to stay in the room and put a stop sign up. On 05/20/24 at approximately 11:53 AM, an interview was conducted with Resident #1 regarding the incident from 03/28/24. Resident #1 stated She tried to kill me. She took a blanket and a towel and put it over my face and tried to smother me with it. If I didn't have this oxygen on, I would be dead. I fought and fought her for 10-15 minutes while she held the blanket and towel over my face. The only thing that kept me alive was this oxygen. She told me I was gonna leave her house, one way or another, and I didn't ' t know what she meant at first, but once she started, I knew she meant I was going to die. They were supposed to have her on one on one after that, but there was a new nurse here that no one told, and I looked up and she was taking the stop sign down off my door to try and come back in my room again. She went into another woman's room after she went in mine, while she was supposed to be on one on one and no one was with her, and that woman can't speak up for herself. It still makes me very upset. Resident #1 was asked if they were afraid, to which she stated Very much so. I am very much afraid of her, I can't get up and move, I have to be lifted out of bed, so yes, I am very fearful that she will come back in here and do it again. Resident #1 was asked if she had voiced these concerns to facility staff, to which she stated Yes, and they tell me they won't let her come in here. Resident #2 resided next door to Resident #1, which Resident #1 stated, That makes me even more afraid that it will happen again. Every time she walks by my room, she looks in here and says she needs to talk to me. At approximately 12:00 PM on 05/20/24, a record review was conducted of progress notes pertaining to the facility's response to the incident on 03/28/24. Progress notes are typed as written, with resident names replaced with identifiers: 03/29/24 at 12:57 PM- SW (Social Worker) spoke with resident regarding the incident that happened the previous night. Resident #1 admits the incident scared her. SW offered her the opportunity to switch rooms so her room would not be as close to Resident #2. Resident #1 declined the invitation. She said she likes her room and wants to stay there. SW offered to have a stop gate put up on her door to deter other residents from coming in her room. Resident #1 said she would like that. SW inquired how Resident #1 is feeling regarding the incident. Resident #1 said as of right now she isn't having any anxiety or fears related to the incident. SW encouraged her to call on her is (sp) she does or if she needs anything. There were no further progress notes or follow-up visits regarding the incident. On 05/20/24 at approximately 1:07 PM, an interview was conducted with the Licensed Social Worker (LSW) regarding the incident. The LSW stated the facility offered Resident #1 to move rooms or put a stop sign on the door. The LSW stated there was not an attempt to move Resident #2 farther away from Resident #1, nor were there conversations had with the Medical Power of Attorney for Resident #2 concerning a move. The LSW was asked if there had been follow up interviews conducted with Resident #1 since the incident and if the resident felt safe. The LSW stated, I have talked to her a few times. When asked about documentation concerning the follow up interviews with Resident #1, the LSW stated it could be found in Point Click Care (PCC). Upon review, the only note in PCC regarding a follow up for Resident #1 was on 03/29/24, the day after the incident occurred. The state agency (SA) determined these failures caused Resident #1 to suffer psychosocial harm. Due to the facility's failure to follow up with Resident #1, proper services were unable to be provided to the resident after an instance of abuse, causing further psychosocial harm. This placed the resident in an Immediate Jeopardy (IJ) situation. The facility was first notified of the IJ at 3:40 PM on 05/20/24. The SA received the Plan of Correction (POC) at 5:49 PM on 05/20/24. The SA accepted the POC at 5:49 PM on 05/20/24. The plan of correction stated: Resident #2 will be put on 1:1 supervision 24hr/d (day) effective immediately on 05/20/24. Resident #2 will be moved to another private room on the opposite hallway from Resident #1 on 05/20/24. Social Worker will visit Resident #1 on 05/20/24 to assess the resident's psychosocial well-being and continue to do so every morning 5d/week until the resident, Social Worker and psychologist deem a change in level of care is required. Psychologist (name) will visit Resident #1 this week and continue recommended scheduled follow up visits until the resident and psychologist deem a change in the level of care is required. Resident #2 will be issued a 30-day discharge notice on 05/20/24. 1:1 education will be provided to staff that provide 1:1 service to residents. After notification of the IJ the facility intervened, and the following progress notes were made by the social worker. 05/20/24 at 04:58 PM- SW spoke with resident after being informed that she has been feeling anxious and fearful regarding the incident that had happened between her and Resident #2. SW was not award(sp) that Resident #1 had been feeling anxious and fearful. Resident #1 said that she has been holding it inside because she doesn't like to complain. SW assured her that reporting her fear and anxiety is not complaining. Resident #1 said that she is very anxious and fearful and isn't able to sleep at night. She said that she has been sleeping during the day. SW asked Resident #1 if she would be interested in talking to the psychologist and taking medication for the anxiety. She said that she would. SW informed Resident #1 That Resident #2 was being moved and would no longer be her neighbor. Resident #1 expressed relief and said she hope(sp) that she will now be able to sleep at night. 05/21/24 at 08:02 AM- SW spoke with resident this morning to see how she is feeling. Resident #1 said that she slept better last night knowing Resident #2 was no longer next door to her. Resident #1 said she is feeling less fearful and stressed today. At approximately 10:13 AM on 05/21/24, a follow up interview was conducted with Resident #1 after the IJ was issued, and plan of correction accepted. Resident #1 was asked if anyone from the facility met with her regarding the incident. Resident #1 stated the Social Worker had been to her room and met with her and got everything situated. Resident #1 mentioned Resident #2 had been moved and stated, Thank you for looking into that, last night was the first time I have been able to sleep during the night in months. The IJ was abated on 05/21/24 at 10:46 AM.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** b) Resident # 64 On 05/20/24 at 12:00 PM a record review of the facility reported incident dated 04/01/24 was performed. During the review, it was noted that on 04/01/24 at approximately 12:00 PM, Resident #64 was in the facility dining room. She requested to be taken back to her room stating she needed to have a bowel movement. Employee #56 reported she took Resident #64 down the hall to Employee #70. Employee #56 informed Employee #70 that Resident #64 wanted to be put in bed and placed on the bed pan to have a bowel movement. Employee #56 stated that Employee #70 stated she would, get her. Employee #56 reported that she also informed Employee #71 and that Employee #71 also stated she would get her. At approximately 1:30 PM, Employees #57 and #42 went into give Resident #64 a bath, at which time it was noted Resident #64 had the lift pad under her and was noted to have stool on her. Employees #57 and #71 reported to facility staff their findings. It was also noted during the review of the facility reported incident in the 5 (five) day, that the facility had substantiated the allegation of neglect for Resident #64. On 05/20/24 at 03:13 PM an interview with facility Social Worker (SW) was conducted. The SW acknowledged that the facility substantiated neglect in the investigation. Based on record review, observation, resident and staff interview, the facility failed to ensure that residents were free from physical abuse. Multiple incidents took place in which Resident #2 was physically abusive to other residents in the facility. The facility failed to take necessary action to prevent further abuse. This created an immediate jeopardy sitaution for more than an isolated number of residents. Resident identifiers: #1,# 2, #3,# 4, #57. Facility census: 65. Findings included: a) On 05/20/24 at approximately 11:30 AM, a record review was conducted of a facility reported incident dated 03/15/24. During review, it was determined Resident #2 was witnessed by facility staff hitting another resident in the face during an argument in the hallway. The Licensed Social Worker confirmed in the report that Resident #2 was trying to move Resident #3's wheelchair and an argument started. Two nurse aides witnessed Resident #2 strike Resident #3 in the face. The residents were then separated and redirected. Further record review revealed a facility reported incident dated 03/26/24. During review, it was determined Resident #2 got into an argument in the dining room with Resident #4. During the argument, Resident #2 swung her cane and hit Resident #4 in the stomach. The Licensed Social Worker confirmed the residents were separated, redirected, and a one-on-one talk was provided to the residents. A review of facility reported incident (FRI) dated 03/28/24 determined Resident #2 entered Resident #1's room between 9:30 PM and 10:00 PM. Resident #2 told Resident #1 she was going to, leave my house one way or another. Resident #2 then proceeded to place a blanket over Resident #1's face and attempted to smother her. Resident #2 then grabbed a towel, stating If that's not good enough, I 'll use this and placed a towel over Resident #1's face. Resident #1 was heard screaming by a Nurse Aide who came into the room to intervene. The Nurse Aide escorted Resident #2 out of the room. The Licensed Social Worker stated referrals were made for a psychiatric facility for Resident #2 and they were accepted. One on one supervision was put into place, and Resident #2 was care planned for behaviors. A facility reported incident dated 05/17/24 revealed Resident #2 slapped Resident #57. This incident was currently under investigation. On 05/20/24 at approximately 11:30 AM, a record review of orders for Resident #2 was conducted. During the review, it was noted Resident #2 had orders for one-on-one supervision beginning on 05/20/24 with a start time of 6:00 PM. One on one supervisions were ordered to take place between 12:00 PM and 8:00 PM. On 05/20/24 at approximately 11:45 AM, during a tour of the facility, two surveyors witnessed Resident #1 in her room with no one on one supervision. On 05/20/24 at approximately 11:53 AM, an interview was conducted with Resident #1 regarding the incident from 03/28/24. Resident #1 stated, She tried to kill me. She took a blanket and a towel and put it over my face and tried to smother me with it. If I didn't have this oxygen on, I would be dead. I fought and fought her for 10-15 minutes while she held the blanket and towel over my face. The only thing that kept me alive was this oxygen. She told me, I was gonna leave her house, one way or another, and I didn't know what she meant at first, but once she started, I knew she meant I was going to die. They were supposed to have her on one on one after that, but there was a new nurse here that no one told, and I looked up and she was taking the stop sign down off my door to try and come back in my room again. She went into another woman's room after she went in mine, while she was supposed to be on one on one and no one was with her. And that woman can't speak up for herself. It still makes me very upset. Resident #1 was asked if they were afraid, to which she stated, Very much so. I am very much afraid of her, I can't get up and move, I have to be lifted out of bed, so yes, I am very fearful that she will come back in here and do it again. Resident #1 was asked if she had voiced these concerns to facility staff, to which she stated, Yes, and they tell me they won't let her come in here. Resident #2 resides next door to Resident #1. Resident #1 stated, That makes me even more afraid that it will happen again. Every time she walks by my room she looks in here and says she needs to talk to me. Resident #1 stated she had trouble sleeping at night, knowing Resident #2 is in the room beside her. On 05/20/24 at approximately 12:30 PM a review of progress notes for Resident #2 from 01/27/24 through 05/20/24 revealed: 01/28/24 at 5:05 PM - Resident having more confusion noted this evening with sun downing. Easily agitated. Worried over her two small dogs and getting home to them. Redirected by staff with distractions. 01/29/24 at 6:06 PM- Resident (sp) became agitated around time of shift changed (sp). Resident was walking around facility going in and out of other residents rooms taking items that did not belong to her. Resident was shouting I am working with the FBI government and I am here to watch of of you. Resident was not able to be redirected at first. Several attempts were made to try and redirect resident with food, drink, comfort, distraction, walking. Resident was adamant that she did not want any of that, she was insistant(sp) that we all get out of her house. Resident then struck staff member in the face and stated get out of my way why can't you just leave me in here (in another residents room). That staff person walked out of the room to try and deescalate (sp) the situation. Nurse then was able to redirect resident out of the room and in to the hallway. Resident then grabbed the nurse by the arms and scratched stating get away from me. Resident then started walking down the hallway with a staff member following behind to ensure safetyof (sp) resident. At this point to keep staff and resdient(sp) safe a close eye was kept on resident at all times for duration of shift. Resident continued to have behaviors throughout the shift but was able to be redirected. 01/30/24 at 3:56 PM- This nurse spoke with resident MPOA (medical power of attorney) regarding recent behaviors to staff and sundowning. Discussed medication changes and POA in agreement. This nurse notified MPOA that resident roommate has voiced being scared of resident, MPOA agreed he is fine with room change if needed. 01/31/24 at 10:09 PM- Res was wandering into other reside4nts (sp) rooms yelling in the hallway at staff to get out of her house. Res is refusing to use her walker. Res smacked me across the face twice and tried biting me when I tried to redirect her away from pulling the fire alarm. I walked along side res in the halls and she was grabbing anything she could pick up and throwing it. Res would yell out anytime I asked her to not go into another res room. Multiple staff tried to redirect res. Res refused a snack & to sit in living room area by nurses station. Res was walked backed to her room per staff & laid back down. 02/01/24 at 10:32 AM- Resident upset wanting everyone out of her home walking down hallways yelling and throwing items. Resident hitting staff and attempted to pull fire alarm. Resident unable to be redirected. 02/01/24 at 5:24 PM- After supper meal resident wanders back from dining room location. She has sun downing behaviors. She is unable to locate her room and doesn't recognize her surroundings. She is very intrusive in and out of other resident's rooms and beds. She was drinking other patients water from pitcher that was then replaced. She becomes very verbally agitated. She took a swing towards staff trying to assist her to her own room. She curses at them very loudly. She upset roommate due to her cursing. She was relocated to lounge and given distractions with short success only. She yells I just want to get the hell out of her and go home! Offered to watch movie, NO, Magazines given as a distraction at this time. 02/05/24 at 6:27 AM- late entry for 2/4/24 at 1800 resident yelling and cussing at roommate, residents seperated(sp) and roommate stated she was afraid to stay in that room. Roommate stated that this resident has been throwing things at roommate and yelling at screaming at her, states the roommate stated she was going to hit her with her cane. On call nurse manager(sp) notified. Roommate moved to room [ROOM NUMBER] for the night. Roommates POA aware. 03/15/24 at 2:27 PM- LATE ENTRY- Resident observed attempting to propel another res. In her wheelchair, when co res asked her to stop, this res begun to yell and tell co res she owned the place, then they both begun to yell at each other then the both struck out at each other landing strikes to faces. Res were immediately separated and re-directed. No injuries noted to either resident. All parties made aware. 03/26/24 12:49 PM- IDT follow up Type of incident: resident on resident What was happening at the time: Resident was in dining room and started swinging her cane. Another resident asked her to stop. This resident started insisting her husband owned her place. The second resident argued with her. This resident supposedly hit second resident in stomach with cane. 03/28/24 10:48 PM- notification:resident attempted to smother another resident. Confused, escalating behaviors. 03/28/24 11:00 PM- Resident had incident this evening where she would ask staff who they were, how they got in her house, who hired them and what company they work for. Resident didn't 't understand she was in the nursing home she thought she was in her own home. Resident tookher(sp) quad cane and hit the med cart with it and then tried hitting this nurse. Staff member was able to talk to resident and get her to calm down. CNA was able to get resident back to her own room and lay down in bed. Spoke with telehealth provider [provider name] to obtain order to send resident out for evaluation. 03/29/24 at 12:00 AM- What was happening at the time: Resident had incident this evening where she would ask staff whoable(sp) to talk to resident and get her to calm down. CNA came to me later and reported that resident was in another residents room and tried to smother resident with a blanket and then with a towel. CNA was able to get resident back to her own room and lay down in bed. Spoke with telehealth provider [provider name] to obtain order to send resident out for evaluation. Root cause of incident: Dementia, impaired cognitive functioning, resident wanders aimlessly throughout the facility, resident believes she owns the facility and becomes irritated when residents and staff will not leave. 04/15/24 at 6:40 PM- the resident was observed by two aides smacking another resident in the mouth on blue hall. The resident seemed frustrated because of the other resident yelling out. Both of the resident (sp) were separated. The resident then went to her room. No injuries observed. No signs of pain. Md has been notified and a vm was left for poa. Orders are to place resident back on 1:1 supervision. No further changes at this time. 04/20/24 at 3:32 AM- Resident up/out of room, yelling at CNA, cursing. Aggressive behavior. Started to enter another residents room with this nurse intervening and redirecting back to room. Very irritable and anxious. Asking Where's Steve What the hell are you all doing in my house? Redirected, reassured resident. Assisted resident back to bed, offered food and fluids. Calmed. Currently lying quietly in bed with 1-1 supervision continued. 05/17/24 at 4:48 PM- Resident had altercation with another resident. Resident 's (sp) separated. MD, DON, Administrator notified. Order placed for 1:1 from 12p-8pm At approximately 12:50 PM on 05/21/24, a record review was conducted of Resident #2's care plan. The care plan focus for behaviors reads as follows: The resident has a behavior problem. Patient with sundowners. Patient believes at times that other residents are looking at her or in her home. Patient noted to hit staff and yelling out to get out of her house. Patient noted to go in other patient's rooms and drink out of other resident's water pitcher. Behaviors of throwing items and screaming at others. Resident to close her door and place furniture in front of the door to block anyone from coming in. Resident noted to have delusions, believing she owns the facility. Resident known to comment on the race of caregivers. It was discovered during review of the care plan that Resident #2 was not care planned for aggressive or abusive behaviors towards other residents in the facility, only staff, despite multiple incidents involving Resident #2 and other residents. On 05/20/24 at approximately 1:07 PM, an interview was conducted with the Licensed Social Worker (LSW) regarding the incident. The LSW stated the facility offered Resident #1 to move rooms or put a stop sign on the door. The LSW states there was not an attempt to move Resident #2 further away from Resident #1, nor were there conversations had with the Medical Power of Attorney for Resident #2 concerning a move. The LSW was asked if there had been follow up interviews conducted with Resident #1 since the incident and if the resident felt safe. The LSW stated., I have talked to her a few times. When asked about documentation concerning the follow up interviews with Resident #1, the LSW stated they could be found in Point Click Care (PCC). Upon review, the only note in PCC regarding a follow up for Resident #1 was on 03/29/24, the day after the incident occurred. The state agency (SA) determined these failures caused the victims of Resident #2's abuse to suffer physical and psychosocial harm. Due to the facility's failure to follow up with the victims of Resident #2's abuse, proper services were unable to be provided to the victims after an instance of abuse. This caused further psychosocial harm. Not only did these failures harm the victims of Resident #2's abuse, but it also placed them and at risk of serious harm/death. This was due to the facility's failure to put proper interventions in place to ensure Resident #2 would not abuse other residents in the future. This placed more than a limited number of residents in an Immediate Jeopardy (IJ) situation. The facility was first notified of the IJ at 3:40 PM on 05/20/24. The State Agency (SA) received the Plan of Correction (POC) at 5:49 PM on 05/20/24. The SA accepted the POC at 5:49 PM on 05/20/24. The abatement time was 10:46 AM on 5/21/24. The plan of correction included the following: Resident #2 is immediately placed back on 24 hours a day one-on-one supervision. Resident #2 is being moved away from Resident #1 effective 05/20/24. The center will issue a 30-day discharge immediately for Resident #2. Dr. (name) (psychologist) has been contacted to see Resident #2 this week for further evaluation. 1:1 education will be provided to staff that provide 1:1 services to residents. After the IJ was removed, a deficient practice remained at a scope and severity of D, due to incontinence care for Resident #64.