Failure to Investigate Resident-to-Resident Altercation
Penalty
Summary
The deficiency involves the facility’s failure to investigate a resident-to-resident altercation that occurred on 1/31/2026 involving Resident 2 and Resident 4. Resident 2, who had diagnoses including anxiety disorder and dementia, had an MDS dated 1/8/2026 indicating no cognitive impairments and independence with oral hygiene and dressing. Resident 4, with diagnoses including COPD and CHF, also had an MDS indicating no cognitive impairments and independence with ADLs. A Change of Condition Assessment for Resident 2 dated 1/31/2026 documented that on the morning of that date, Resident 2 displayed verbal and physical aggression with an anger outburst and initiated a physical altercation with Resident 4 without provocation, attempting to strike him for no apparent reason. Staff separated the residents to minimize escalation. Despite this documented altercation, the Administrator stated in an interview on 3/18/2026 that she was not aware of the incident and that it was not investigated. Facility policies titled “Abuse, Neglect, Exploitation, and Misappropriation Prevention Program” and “Abuse, Neglect, Exploitation, and Misappropriation – Reporting and Investigating” required that any allegations of abuse be thoroughly investigated within required federal timeframes and that the investigation be initiated by the Administrator. The lack of any investigation into the documented resident-to-resident physical altercation constituted the cited deficiency.
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