West Valley Post Acute

During an interview on 11/14/2025 at 11:48 a.m. with Licensed Vocational Nurse 1 (LVN ) 1, LVN 1 stated that a resident-to-resident altercation between Resident 1 and Resident 2 occurred on 10/30/2025 after dinner (does not recall exact time) during the 3 p.m.-11 p.m. shift (a work schedule from 3 p.m. to 11 p.m.) LVN 1 stated that prior to the incident Resident 2 approached LVN 1 and stated that his roommate's (Resident 1) TV was on and he wanted it off. LVN 1 stated that she explained to Resident 2 that Resident 1 has the right to have his TV on. LVN 1 stated that next thing she knew, she (LVN 1) heard Certified Nursing Assistant 2 (CNA) 2 running towards her (LVN 1) reporting that Resident 1 and Resident 2 were yelling at one another. LVN 1 stated when she arrived in Resident 1 and Resident 2's room, she witnessed Resident 2 holding his wheelchair footrest and hitting Resident 1 with the wheelchair footrest.

LVN 1 stated that Resident 2 was swinging the wheelchair footrest and Resident 1 was holding on to the footrest trying to protect himself. LVN 1 stated both Resident 1 and Resident 2 were going back and forth pushing and pulling the wheelchair footrest towards one another. LVN 1 stated that she and CNA 2 separated Resident 1 and Resident 2 when it was safe to do so. LVN 1 stated that she observed blood all over Resident 1's face. LVN 1 stated that when she asked Resident 2 why he hit Resident 1 with the footrest, Resident 2 stated it was because of the TV.

During an interview on 11/17/2025 at 10:40 a.m. with the Director of Nursing (DON), the DON stated that the facility was aware that Resident 2 has behavioral triggers.

The DON stated that Resident 2's anger is triggered when his roommates' TVs are on or when Resident 2 hears other residents screaming.

The DON stated that the roommates' TVs being on and the loud noises triggers behaviors that cause the resident to become angry.

During a concurrent interview and record review on 11/17/2025 at 11:00 a.m., with the Director of Nursing (DON), reviewed Resident 2's Care Plans.

The DON stated that Resident 2 does not have a care plan specific to Resident 2's behavioral triggers.

The DON stated that a care plan should have been developed to address Resident 2's triggers so that specific interventions could have been in place to avoid behavioral outbursts.

During an interview on 11/14/2025 at 3:35 with the Administrator (ADM), the ADM stated the resident altercation between Resident 1 and Resident 2 was avoidable based on Resident 2's history of not liking noises and roommate incompatibility and that interventions should have been put in place to prevent the incident from occurring.

During a review of the facility's policy and procedure (P&P) titled Care plans, Comprehensive Person-Centered, reviewed 1/10/2024, the P&P indicated a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

The interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident.

The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

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