Health inspection·December 16, 2021

CFR §483.12 (c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or 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 administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. T22 Section 72523. Patient Care Policies and Procedures (a) Written patient care policies and procedures shall be established and implemented to ensure that patient related goals and facility objectives are achieved. On 9/24/2021, the State Survey Agency (the Department) made an unannounced visit to the facility to investigate a complaint regarding resident abuse. The facility failed to report an allegation of resident-to-resident abuse to the SSA within two hours after the allegation was made and failed to establish and implement policies that aligned with the abuse regulations. On 9/22/2021 at around 10:30 p.m., Resident 1 notified Licensed Vocational Nurse 1 (LVN 1) that Resident 2 went to his room and physically attacked him. LVN 1 did not report the alleged abuse to supervision, Administrator and the SSA. The facility’s abuse reporting policy was outdated and did not include to notify the SSA, law enforcement and the Ombudsman Program no later than two hours after the allegation is made. As a result, Resident 1 was placed at risk for further abuse and caused the resident to be fearful of Resident 2. A review of Resident 1's Admission Record indicated the facility admitted the resident, a 58-year-old male, on 5/15/2021, with diagnoses including diabetes mellitus (a group of diseases that result in too much sugar [glucose] in the blood, schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly), generalized muscle weakness, and myalgia (pain in a muscle or group of muscles). A review of Resident 1's Minimum Data Set (MDS, - a standardized assessment and care-planning tool) dated 8/22/2021, indicated the resident had no memory problem and required extensive assistance with bathing, personal hygiene, dressing, and mobility. A review of Resident 2's Admission Record indicated the facility admitted the resident, a 60-year-old female on 9/11/2021 with diagnoses including bipolar disorder (mental disorder with periods of depression [severe feeling of loneliness and hopelessness] and periods of elevated mood) and cognitive communication impairment (difficulty with any aspect of communication). A review of Resident 2's MDS dated 9/17/2021 indicated the resident had severely impaired cognition (ability to understand). The MDS indicated Resident 2 required limited assistance with transfers, walking in room and in corridor, dressing, eating, toilet use and personal hygiene. A review of Resident 2’s plan of care dated 9/23/2021 indicated the resident has episodes of wandering in co-resident room. The care plan interventions included re directing the resident to room or group activities when resident is observed attempting to enter co- resident rooms. A review of the facility's undated policy and procedures titled, "Abuse Allegation Reporting" indicated allegation of resident abuse should be reported to the Licensing and Certification program, local Ombudsman, and local law enforcement either by phone or in writing within 24 hours for non-serious bodily injury and within two hours for serious bodily injury. On 9/24/2021, at 1:30 p.m., during an interview, the Administrator and Director of Nursing (DON) stated LVN 1 did not notify them of Resident 1's alleged physical attack by Resident 2 on 9/22/2021, at around 10:30 p.m. DON stated if they knew about Resident 1’s allegation, they would have reported it within two hours to the SSA, the Ombudsman and the Police Department. Resident 1's family member (FM 1) reported the incident to the Police Department and on 9/23/2021, a police officer came to the facility to investigate the allegation. The Administrator stated he did not know that the facility's policy for abuse reporting had not been updated to no later than two hours after the allegation was made. On 9/24/2021, at 2:51 p.m., during an interview, Resident 1 stated Resident 2 physically attacked him while he was lying in bed on 9/22/2021 at around 10:30 p.m. Resident 1 stated Resident 2 grabbed his left arm and scratched his left little finger when Resident 1 tried to prevent Resident 2 from getting his two bowls of covered food on the table. Resident 1 stated LVN 1 entered his room after he had been grabbed and scratched by Resident 2. Resident 1 stated he complained to LVN 1 that Resident 2 physically attacked him and told LVN 1 to call the police. Resident 1 stated Resident 2 weighed 300 pounds and he did not feel safe because Resident 2 could cause serious harm to him. On 9/30/2021, at 3:31 p.m., during a telephone interview, LVN 1 stated he on 9/22/2021 after 10 p.m., he was walking toward Nursing Station 2, when he saw Resident 2 entering Resident 1's room. LVN 1 did not remove Resident 2 from Resident 1's room because he was busy taking care of another resident. At around 10:30 p.m., LVN 1 heard a loud noise from Resident 1’s room, went inside the room, and saw Resident 1 and Resident 2 pulling a tray of food from each other. Resident 1 complained Resident 2 physically attacked him. LVN 1 stated he texted DON about the incident on 9/22/2021, at 9:45 p.m., but he did not mention on his text message about Resident 1's alleged physical attack by Resident 2. LVN 1 stated he was not aware of the reporting requirements of notifying the Department of Public Health, Ombudsman, and Police Department no later than two hours after the allegation of abuse was made. The facility failed to report an allegation of resident-to-resident abuse to the SSA within two hours after the allegation was made and failed to establish and implement policies that aligned with the abuse regulations. On 9/22/2021 at around 10:30 p.m., Resident 1 notified Licensed Vocational Nurse 1 (LVN 1) that Resident 2 went to his room and physically attacked him. LVN 1 did not report the alleged abuse to supervision, Administrator and the SSA. The facility’s abuse reporting policy was outdated and did not include to notify the SSA, law enforcement and the Ombudsman Program no later than two hours after the allegation is made. As a result, Resident 1 was placed at risk for further abuse and caused the resident to be fearful of Resident 2. The above violations jointly, separately, or in any combination, had a direct or immediate relationship to the health, safety, or security of Resident 1.