Haven of Sandpointe

Based on clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #1 was free from abuse from resident #2. The deficient practice could result in residents experiencing emotional and mental trauma from abuse. Findings include: Related to resident #1- Resident #1 was admitted to the facility on July 14, 2022 with diagnoses of type 2 diabetes, major depressive disorder, and partial paralysis on the left side following a stroke. Review of a quarterly Minimum Data Set (MDS), dated October 21, 2024 revealed resident #1 completed a Brief Interview for Mental Status (BIMS) and scored a 15 which indicated the resident was cognitively intact. A review resident #1's progress note in her Electronic Health Record (EHR), a progress note dated November 26, 2024 at 4:32 PM indicated that resident #1 had made an inappropriate comment about her roommate's, at the time, mother. The roommate (resident #2) then grabbed resident #1's hair. Related to resident #2- Resident #2 was admitted to the facility on July 31, 2024 with diagnoses of partial paralysis on the left side following a stroke, type 2 diabetes, schizoaffective disorder and major depressive disorder. Review of the admission MDS, dated November 12, 2024 revealed resident #2's BIMS score was 12 which indicated the resident was moderately cognitively intact. The MDS also noted the resident had not exhibited any behaviors during the look-back period. The care plan for Resident #2 did not indicate the resident had a behavior problem towards others. Review of resident #2's progress notes in her EHR (Electronic Health Record) revealed a progress note dated November 26, 2024 at 4:47 PM. The note shared that resident #2 was witnessed pulling her roommate's pony tail because the roommate made an inappropriate comment about resident #2's mother. An interview was conducted on December 9, 2024 at 4:44 p.m. with resident #1 in her room. Resident #1 indicated that she currently felt safe in the facility. She also shared that the "girl next door attacked me". Resident #1 continued to explain that the girl used to be her roommate but she had pulled resident #1's hair which was witnessed by a Certified Nursing Assistant (CNA/Staff #46). An interview was conducted on December 10, 2024 at 8:26 a.m. with resident #2 in her room. She explained that she has changed rooms many times at the facility during her stay because she can't get along with people. She also shared that she pulled the hair of her former roommate because she had "called her mom a bitch". An interview was conducted on December 10, 2024 at 4:52 p.m. with a Certified Nursing assistant (CNA/staff #46). She confirmed that she was working on November 26, 2024 and had witnessed the altercation between residents #1 and #2. Staff #46 explained that both residents had returned to their room from an afternoon outing and she had walked into the room to assist resident #2. Both residents were relaxed,

Based on clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #1 was free from abuse from resident #2. The deficient practice could result in residents experiencing emotional and mental trauma from abuse. Findings include: Related to resident #1- Resident #1 was admitted to the facility on July 14, 2022 with diagnoses of type 2 diabetes, major depressive disorder, and partial paralysis on the left side following a stroke. Review of a quarterly Minimum Data Set (MDS), dated October 21, 2024 revealed resident #1 completed a Brief Interview for Mental Status (BIMS) and scored a 15 which indicated the resident was cognitively intact. A review resident #1's progress note in her Electronic Health Record (EHR), a progress note dated November 26, 2024 at 4:32 PM indicated that resident #1 had made an inappropriate comment about her roommate's, at the time, mother. The roommate (resident #2) then grabbed resident #1's hair. Related to resident #2- Resident #2 was admitted to the facility on July 31, 2024 with diagnoses of partial paralysis on the left side following a stroke, type 2 diabetes, schizoaffective disorder and major depressive disorder. Review of the admission MDS, dated November 12, 2024 revealed resident #2's BIMS score was 12 which indicated the resident was moderately cognitively intact. The MDS also noted the resident had not exhibited any behaviors during the look-back period. The care plan for Resident #2 did not indicate the resident had a behavior problem towards others. Review of resident #2's progress notes in her EHR (Electronic Health Record) revealed a progress note dated November 26, 2024 at 4:47 PM. The note shared that resident #2 was witnessed pulling her roommate's pony tail because the roommate made an inappropriate comment about resident #2's mother. An interview was conducted on December 9, 2024 at 4:44 p.m. with resident #1 in her room. Resident #1 indicated that she currently felt safe in the facility. She also shared that the "girl next door attacked me". Resident #1 continued to explain that the girl used to be her roommate but she had pulled resident #1's hair which was witnessed by a Certified Nursing Assistant (CNA/Staff #46). An interview was conducted on December 10, 2024 at 8:26 a.m. with resident #2 in her room. She explained that she has changed rooms many times at the facility during her stay because she can't get along with people. She also shared that she pulled the hair of her former roommate because she had "called her mom a bitch". An interview was conducted on December 10, 2024 at 4:52 p.m. with a Certified Nursing assistant (CNA/staff #46). She confirmed that she was working on November 26, 2024 and had witnessed the altercation between residents #1 and #2. Staff #46 explained that both residents had returned to their room from an afternoon outing and she had walked into the room to assist resident #2. Both residents were relaxed,

Based on staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure a resident was free from abuse. Findings include: Resident #21 was admitted on April 12, 2024 with diagnoses of anxiety disorder, and depression. A quarterly Minimum Data Set (MDS) dated October 19, 2024 revealed the resident had a BIMS (Brief interview for mental status) of 2, indicating that this resident was severely cognitively impaired and included inattention and disorganized thinking continuously present. A care plan dated April 15, 2024 included this resident had a behavior problem including impaired cognitive function, impaired safety awareness, wandering/exit-seeking, threatening, throwing water cups to staff despite staff reorientation/education and resident to resident altercation despite staff redirection with interventions. Interventions including intervene as necessary to protect the rights and safety of others. These interventions note a revision on November 25, 2024, however the revisions noted to the care plan do not include any changes or new interventions. No new interventions were added to this focus since April 15, 2024 A progress note dated July 13, 2024 at 6:01 p.m. included that the nurse writer witnessed an altercation between resident and another patient. This note included that a male resident sat down at a dining table and this resident started cursing at the other resident and lunged towards him. This note included that a CNA stopped resident this from making contact and that the male resident was escorted to another table ..." However, no new interventions were added to the care plan for this interaction and review of the tracking system did not find that this incident was reported. A progress note dated July 27, 2024 included "Resident is aggressive towards other residents and staff; throw objects across table; difficulty redirecting. Will continue to monitor" However, no new interventions were added to the care plan for this interaction and review of the tracking system did not find that this incident was reported. A progress note dated September 4, 2024 included " at 3:30 p.m. (resident #21) was choking (resident #6) and that a CNA noticed and stopped her. This note included that (resident #21) said she was just playing and that no injuries noted on (resident #6). (Resident #6) stayed in the dining area and (resident #21) went to her room right after." A progress note dated November 18, 2024 at 7:50 p.m. included that "Resident was upset due to another resident letting staff know that resident spit her pills out when staff turned away and that this resident got upset and threw plastic cup at the other resident. This note included that this resident attempted to kick resident and that she was redirected. However, no new interventions were added to the care plan for this interaction and review of the tracking system did not find that this incident was reported. -Resident #6 was admitted on April

Based on clinical record review, staff and resident interviews, and a review of the facility's policy and procedures, the facility failed to ensure 9 residents (#5, #8, #6, #2, #1, #14, #11, #15, #10) were not subjected to abuse. Findings include: Regarding residents #5 and #8 -Resident #5 was admitted to the facility on August 2, 2021, with diagnoses that included dementia, metabolic encephalopathy, major depressive disorder, and anxiety disorder. The resident was discharged on February 10, 2022. A review of resident #5's care plan dated August 19, 2021, revealed that the resident exhibited behaviors that included physical aggression toward others, wandering into other residents' rooms and handling their belongings. Interventions included that staff were to intervene as necessary to protect the rights and safety of others, divert attention, and remove the resident from the situation. A review of resident #5's Minimum Data Set (MDS) dated August 8, 2021, revealed a Brief Interview for Mental Status (BIMS) score of 6 that indicated the resident had severe cognitive impairment. -Resident #8 was admitted to the facility on July 19, 2021, with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unsteadiness on feet, repeated falls, anxiety disorder, schizoaffective disorder - bipolar type, and major depressive disorder. The resident was discharged on May 15, 2023. Review of resident #8's care plan dated July 25,2021, revealed that the resident exhibited behaviors that included physical aggression toward others. Interventions included that staff were to intervene as necessary to protect the rights and safety of others, divert attention, and remove the resident from the situation. A review of resident #8's MDS dated October 25, 2021, revealed a BIMS score of 7 which indicated the resident had severe cognitive impairment. On October 23, 2021, the facility submitted a self-report to the SA (State Agency) regarding a resident-to-resident altercation between residents #5 and #8 where resident #5 hit resident #8 once on the knee with a hairbrush. A review of resident #5's progress note dated October 23, 2021 at 5:02 p.m., revealed documentation that stated resident #8 self-propelled their wheelchair from their room into the hallway and yelled "she hit me, she hit me". Resident #8 reported that resident #5 entered resident #8's room and took resident #8's hairbrush. When resident #8 tried to get the brush back by tapping resident #5 on the hand and saying "No", resident #5 hit resident #8 in the knee once using the hairbrush and then threw the hairbrush on the bed and left the room. A review of resident #8's progress note dated October 23, 2021 at 4:52 p.m., revealed documentation that stated resident #8 self-propelled their wheelchair from their room into the hallway and yelled "she hit me, she hit me". Resident #8 reported that resident #5 entered resident #8's room and took resident #8's hairb