**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record reviews, interviews, and review of facility policy and procedures, the facility failed to protect the rights of one resident (#1) to be free from verbal and physical abuse by another resident (#2). The deficient practice resulted in psychosocial harm to resident #1 and the potential for abuse of other residents. As a result, the condition of Immediate Jeopardy (IJ) and Substandard Quality of Care was identified.Findings include:On September 10, 2025, at 4:10 PM, a condition of IJ was identified. The administrator (staff #110) and the assistant administrator (staff #103) were informed of the facility's failure to ensure resident #1 was protected from abuse by resident #2. Review of the clinical record resident #2 revealed a pattern of verbal abuse that started in June and escalated to physical abuse on September 3, 2025. Staff interviews revealed that these incidents were reported to administration, however, there was no evidence that the facility took steps to protect resident #1 from further abuse by resident #2. Further, staff interviews revealed that these incidents were considered as behaviors and not abuse. On September 10, 2025 at 5:46 p.m., the administrator and assistant administrator submitted a removal plan which was not accepted because the the plan did not address how they were going to implement their plan, who is responsible in ensuring that plan was implemented, and when they will start and end their plan.On September 11, 2025, at 8:51 AM, the removal plan was not accepted because it failed to to include specific procedures and timelines involved in the removal plan.On September 11, 2025, at 11:27 AM, the administrator and the assistant administrator submitted the revised IJ removal plan which was not acceptable because it failed to include completion of resident interviews, in-service training to staff and new hires, specific procedures, and timelines involved.On September 12, 2025, at 8:46 AM, the revised Immediate Jeopardy (IJ) Removal Plan was accepted. The plan included the following actions:Resident #2 was assigned a 1:1 sitter and relocated to a different unit, with behavior monitoring for three days;Resident #1 was assessed for injuries, including possible psychosocial harm. Clinical documentation was reviewed, and behavior was tracked for three days;Individualized care plans were updated;Ongoing staff training was implemented on how to identify abuse;Ongoing staff training was provided on how to intervene and stop abuse;Ongoing staff training was conducted on the proper protocol for reporting abuse;All residents were interviewed to identify any potential abuse. For residents unable to be interviewed, the MDS nurse completed an assessment for signs or symptoms of abuse; and,Monthly Quality Assurance and Performance Improvement (QAPI) meetings were scheduled to review any incidents or concerns related to abuse.Multiple observations were conducted on the facility implementing their removal plan, including resident #2 placed on 1:1 sitter and moved to another unit, resident #1 was assessed for injury including psychosocial harm and in-service training completed. Staff interviews conducted revealed that staff acknowledged training had been completed according to the facility's removal plan.On September 12, 2025, at 1:55 PM, the administrator and the assistant administrator were informed that the condition of the IJ had been removed.-Resident #3 (witness) was admitted on [DATE] with diagnoses of dementia, abnormalities of gait and mobility and muscle weakness.The care plan dated December 22, 2020 included that the resident had behaviors of wandering, impaired safety awareness related to dementia and was receiving behavioral health services. Interventions included all ADLs (activities of daily living) will be met by staff daily and resident in the secured memory care unit.The late entry provider visit note dated August 19, 2025 revealed the resident was alert, oriented 2-3, ambulated with 1-person assist and had no focal neurological deficits. Assessment included dementia.-Resident #1 (alleged victim) was admitted on [DATE], with diagnoses of dementia, muscle weakness, and history of falling.Review of the care plan dated December 24, 2024, included the resident needed assistance with activities of daily living (ADL) and was an elopement risk. Interventions included encourage resident to participate in activities that promote exercise, daily staff assistance with ADL's, distracting resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books that resident prefers and, to monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in functionThe MDS (Minimal Data Set) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00, indicating the resident had severe cognitive impairment. The NP (nurse practitioner) psychiatric progress note dated June 29, 2025 included that resident #1 had history of dementia without behaviors and had no issues or concerns regarding psychiatric needs. Diagnosis included dementia without behavioral disturbance. Recommendations included medication management, strategic skills to cope with stress, modulation of interpersonal/occupational/family/social dynamics to reduce stress and behavioral modification encouragement.A behavior note dated July 10, 2025 revealed that the resident was agitated, confused, wanted to go home and insisted that her car was parked right outside.The orders-administration note dated July 10, 2025 included that the resident had one episode of frustration regarding seeing someone outside her window; and, the resident asked if she could go home. The orders-administration note dated July 23, 2025 revealed that the resident was awake, confused, oriented to self and was tearful. Per the documentation, the resident told staff that she got to go; and when the staff told her that she would be staying, the resident asked the staff if she could come with the staff; and that, when the staff encouraged the resident to try to sleep, the resident appeared shocked and told staff that she thought it was morning. The documentation also included that the staff sat with the resident until the resident was calm; and reminded the resident that staff were there with her and she was not alone. According to the documentation, hourly and PRN (as needed) rounds were conducted throughout the night.The care plan dated August 15, 2025 revealed that with reminders, the resident was independent for meeting emotional, intellectual, physical and social needs. Intervention included to introduce the resident to residents with similar background, interests and encourage/facilitate interaction.A restorative nursing assistant note dated August 21, 2025 included that resident told staff that she was following another resident in her wheelchair and they were looking to see if they could find her husband.An infection note dated September 3, 2025 revealed that residents #1, #2, and #3 were sitting at the same table before dinner. Per the documentation, staff witnessed resident #2 standing over and yelling at resident #1; and that, staff intervened and moved resident #1 to the nurse's station and resident #2 returned to her room. The documentation also included that resident #3 told staff that resident #2 yelled and hit resident #1.A communication note dated September 6, 2025 included that the resident's family requested to speak with staff related to the resident's recent altercation with another resident (#2).The NP psychiatric progress note dated September 7, 2025 included that the resident was extremely hard of hearing, very confused, was not mobile, and required total care. The documentation also included that the resident had advanced dementia showing stable psychiatric symptoms and had no current behavioral issues reported by staff. -Resident #2 (alleged perpetrator) was admitted on [DATE], with diagnose of dementia, major depressive disorder, anxiety disorder, and schizoaffective disorder.Review of the care plan dated October 17, 2024, revealed resident was dependent on staff and family for all emotional, intellectual, physical, and social needs. Interventions included to encourage ongoing family involvement and inviting to attend special events, activities, and meals, introducing resident to residents with similar backgrounds, interests, and encourage/facilitate interaction, invite the resident to scheduled activities and assist to and from programs to help encourage participation. The care plan did not include that the resident had behaviors such as verbal or physical aggression towards staff and/or residents.The NP psychiatric note dated December 3, 2024 included that the resident was calm, attentive, communicative, casually groomed, with scanty speech and difficulty naming objects. Per the documentation resident had intact associations, fair judgment and logical thinking. Diagnoses included schizoaffective disorder, bipolar type, anxiety disorder, moderate dementia without behavioral/psychotic disturbance.A late entry provider visit note dated June 4, 2025 revealed the resident was alert and oriented to self and environment. Assessments included dementia, schizoaffective disorder, anxiety and depression.A behavior note, dated June 12, 2025, revealed resident #2 displayed anger every time resident #1 who was sitting near resident #3. Per documentation, resident #2 had paranoia and reported that resident #1 was taking resident #3 from her; and that, resident #2 threatened resident #1 with physical violence and yelled at resident #1 who remained seated and looked confused while being yelled at by resident #2. The documentation also included that this behavior of resident #2 happens every time resident #1 tried to sit by resident #3. The clinical record revealed no evidence of any intervention implemented to prevent altercation from happening again between resident #1 and #2.The behavior note dated July 2, 2025 included resident #2 yelled at and threatened resident #1 because resident #1 was looking at her at the dinner table.Review of a behavior note dated July 8, 2025 revealed that resident #2 told resident #3 that resident #1 was wearing her shirt; and that, resident #2 then approached resident #1, grabbed the shirt of resident #1 and told resident #1 to give the shirt back. Per the documentation, resident #2 told resident #3 that they should beat up resident #1; and that, resident #3 told resident #2 they should not do that because they would go to jail. The documentation also included that the CNA (certified nurse assistant) was able to separate the residents. Another behavior note dated July 8, 2025 included that resident #2 was sitting with resident #3 and other residents watching tv. Per the documentation, resident #1 was just passing down the hallway to her room and resident #2 yelled at resident #1 to go away and to get out of here; and, staff noticed this behavior from resident #2 before when resident #1 was sitting with resident #3. The documentation included that staff called a family member who explained that the brother of resident #2 had married a woman with the same first name as resident #1 and that person was very abusive to the family and her children; and that, the family of resident #2 believed the resident was reliving her past when she sees resident #1. Further, the documentation included that the NP and the DON (Director of Nursing) were notified.A late entry provider visit note dated July 9, 2025 revealed documentation of resident #2 yelling at other residents. Per the documentation the resident was alert & oriented x self/environment with normal affect. Assessments included dementia, schizoaffective disorder, anxiety and depression. Plan included for medications. The note did not include any interventions to address resident #2's verbal and physical aggression towards resident #1.A behavior note dated July 9, 2025 included resident #2 approached the dining room table where resident #1 was sitting at and yelled at resident #1. The documentation included that staff stepped in front of resident #1 to block the view of resident #2 who was then requested to return to her table. It also included that after a couple of minutes, resident #2 returned to her table but she was keeping an eye on resident #1.Another behavior note dated July 9, 2025 revealed that Psych was in to evaluate resident #2; and that, the ADON (Assistant Director of Nursing) notified the provider of the resident's behaviors. The documentation included that there were no new orders.The behavior note dated July 10, 2025 included that resident #2 continued to make comments about resident #1 at meal times; and that, all 3 residents (#1, #2, and #3) were placed at different tables during meals.Despite documentation of verbal and physical aggression of resident #2 towards resident #1, there was no evidence found that interventions such as increased supervision or monitoring of resident #2 were put in place and were implemented.The psychiatric NP note dated July 14, 2025 included that staff reported that the resident had become irritable with certain resident, specifically with a resident (#1) with a certain name who she associated with someone that her husband had an affair with; and that, the resident was unable to recall being upset with any resident. Recommendations included to to continue to monitor the resident's mood and to redirect resident as needed.A general nursing progress note dated July 15, 2025 revealed that during dinner time, resident #2 was verbally aggressive toward resident #1; and that, resident #2 accused resident #1 of stealing her clothes and demanded that they were returned. Further, the documentation included that this behavior appear to frighten and intimidate resident #1; and that, situation was de-escalated and redirected and both residents were separated during meals.The behavior note dated July 16, 2025 included resident #2 had a verbal altercation with resident #1 regarding a cat blanket which resident #2 claimed to belong to resident #3 who acknowledged that the blanket looked similar to what resident #3 has. Per the documentation, staff reassured resident #3 that her blanket was in her room but resident #2 continued to raise her voice towards resident #1. The documentation included that all 3 residents were separated redirected to different areas. The quarterly MDS assessment dated [DATE], revealed a BIMS score of 05, indicating severe cognitive impairment. The assessment also included that the resident was coded for verbal behaviors directed toward others exhibited within the last four to six days.Review of a behavior note dated July 20, 2025 included resident #2 yelled at and accused resident #1 of wearing a shirt that does belong to resident #3; and that resident #1 and #3 were moved away from resident #2 who continued to yell at accused staff of being prejudiced of her. The documentation revealed that staff were unable to convince resident #2 that resident #1 was not wearing the shirt of resident #3. It also included that resident #1 told staff that she did nothing wrong.A behavior note dated July 20, 2025 revealed that the ADON and the NP were updated on the behaviors of resident #2.The psychiatric NP note dated July 20, 2025 revealed that the resident was seen for a follow-up psychiatric evaluation; and that, the resident was not aware of her current situation, had periods of confusion with disorientation and memory problems, had diffuse memory loss for recent and remote events; and, was psychiatrically stable at this time. The documentation did not include any verbal and physical aggressive behaviors exhibited by resident #2. Plan included medication management, strategic skills to cope with stress, modulation of interpersonal/occupational/family/social dynamics to reduce stress, behavioral modification encouragement and to continue to monitor resident and to coordinate with staff regarding moods/behavior. A late entry behavior note dated July 31, 2025 revealed that staff spoke with BHT (behavioral health tech) related to increased behaviors and noted agitation towards other peers.Another behavior note dated July 31, 2025 included resident #2 was overheard telling another resident that she was going to get a stick and put her, (referring to resident #1), in the ground. Per the documentation, resident #1 was not even speaking to resident #2 at the time.The behavior note dated August 21, 2025 included that resident #2 was sitting at the table with resident #3 when resident #1 came over to the table. Per the documentation, resident #2 then yelled at and called resident #1 a liar and a thief. The documentation included that all residents were separated and calmed down.Despite documentation that resident #2 continued to to be verbally abusive to resident #1, there was no evidence found that interventions were put in place to protect and prevent resident #1 from continued abuse by resident #2. On September 4, 2025, a complaint was filed with the State Agency (SA) regarding 2 staff witnessing resident #2 pushed and hit resident #1 in the dementia unit; and that, this incident was reported to administration by staff.However, review of the clinical record revealed no documentation of this incident until September 10, 2025 (approximately 6 days after the alleged incident).A communication note dated September 10, 2025 included that staff spoke with the family of resident #2 regarding resident's behavior of perseverating on one particular resident; and that the resident would be moved to another unit and the resident having a sitter in place to ensure safety of all parties.The social service note dated September 11, 2025 revealed that the resident was informed by her family that she had slapped someone; and that, resident #2 was upset that she slapped someone.The care plan for resident #2 was revised on September 11, 2025 to include that the resident had been physically and verbally aggressive towards other residents related to dementia. The goal was that the resident will not harm self or others. Interventions included 1:1 sitter in place, moved to another unit, remove other residents from resident #2 when her aggression escalates, intervene before agitation escalates, guide away from source of distress, administer medications as ordered and BHT services to evaluate and treat.The TAR (treatment administration record) for July through September 2025 revealed that the resident was being monitored for behaviors of inability to sleep and verbalization of sadness were monitored. However, the resident was monitored for verbal and physical aggressive behaviors. An interview with the family of Resident #1 was conducted on the patio on September 10, 2025, at 10:33 AM. During the interview, Resident #1 became visibly upset, repeatedly asking her family, You're not leaving, are you? and You're coming back, right? The family said that Resident #1 and Resident #3 had been very close friends until Resident #2 moved into the facility; and that, resident #2 became possessive of resident #3 and did not want resident #1 or any other residents interacting with resident #3. The family reported receiving a phone call from a staff member on September 3, 2025, stating that Resident #1 had been slapped by Resident #2, and that the incident was witnessed by Resident #3; and, when she visited resident #1 the next day, she noticed a bruise on the side of the face of resident #1. She also said she was aware of ongoing comments that resident #2 had been bullying resident #1, and, the facility failed to take action to stop it. The family stated that it was not until the day after the slapping incident that staff told her that resident #2 would be separated from Resident #1. The family further stated that while she understands that resident #1 was in a dementia unit where residents in the unit have behaviors, she did not want resident #1 to be harmed. Further, the family stated that since the slapping incident, resident #1 had been more agitated and had now resisted going to bed at night.An interview was conducted on September 10, 2025 at 10:51 AM with Certified Nursing Assistant (CNA/staff #101) who stated that the incident between resident #1 and resident #2 happened around dinner time. The CNA said she was at the nurse's station when she heard shouting. She said she then went to the dining room where resident #2 was standing over resident #1, who was in her wheelchair, and resident #1's eye looked red. The CNA stated that she and a Licensed Practical Nurse (LPN/staff #102) deescalated the situation; and that, resident #3 approached her and reported that resident #2 pushed resident #1 who pushed resident #2 back which resulted in resident #2 punching resident #1 in the eye. The CNA said there was a history of resident #2 being verbally aggressive/abusive towards resident #1 and it escalated to the point of physical abuse. The CNA said she had seen resident #2 was very possessive of resident #3 and resident #2 did not not want resident #1 to associate with resident #3. The CNA stated the unit attempted to keep both resident #1 and resident #2 separated as much as possible but it could be difficult staff were also attending to other residents in the unit. The CNA further stated that resident #1 was fearful to go to bed at night, always the last to go into her room and when the CNA get resident #1 in her room, resident #1 would constantly ask her if she was staying and was not leaving. The CNA stated there were no issues between resident #1 and any other residents in the unit. In another interview with the CNA (staff#101) conducted on September 10, 2025 at 4:50 PM, the CNA stated that a room change was initiated by the family of resident #1 on July 7, 2025, because the family wanted resident #1 off the back hallway and closer to the dining area. The CNA said that the move was not encouraged by the staff due to the fact that resident #1 would be closer to the room of resident #2; and, all the verbal altercations between resident #1 and resident #2 occurred in the dining area. However, the CNA stated that the family was insistent on the move. Further, the CNA stated it was that after the move that issues began with resident #1 not wanting to go to bed and became fearful of being alone in her room.An interview was conducted with another CNA (staff #106) on September 10, 2025 at 5:04 PM, The CNA (staff #106) said that resident #1 has suffered from harm from the verbal and physical abuse by resident #2. She stated staff in the unit were doing the best they could to keep both residents #1 and resident #2 separated from each other but it can be difficult at times. Further, the CNA said that when staff reported these incidents to management, the management team did not listen, and nothing was done to address the behavior or resident #2.An interview was conducted on September 10, 2025 at 5:08 PM with an LPN (staff #102) who stated that on the evening of September 3, 2025, she was at the nurse's station when she heard a commotion and looked over to the dining room. She said that resident #2 was standing over and was yelling at resident #1 who in her wheelchair; and that, resident #3 told the LPN that resident #2 slapped resident #1. The LPN said she believed resident #3 because resident #3 can tell staff what happened at a particular time or instance. The LPN further stated that she interviewed resident #1 who reported that resident #2 had called her a b*&#ch and had placed her hand on the shoulder of resident #1. However, the LPN stated that resident #1 could not remember if she was hit by resident #2. An observation of the dementia unit was conducted on September 10, 2025 at 8:26 PM. There were several residents sitting in the common area watching television. Residents #2 and #3 were going down the hall with the CNA (staff #101), when resident #1 called for the CNA. Resident #2 then stopped, turned around, and told the CNA that resident #1 was not her boss.Another observation of the dementia unit was conducted on September 10, 2025 at 8:40 PM. The CNA (staff #101) was trying to get resident #1 to go to her room and get ready for bed. Resident #1 was very resistant to go to her room and told the CNA that she will just go with another resident to her room for the night. When the staff got resident #1 to her room, resident #1 asked the CNA not to go anywhere to stay with her and for the CNA to be with her as she might climb out the window. The CNA calmed resident #1 and settled her in bed. When the CNA was going to exit the room, resident #1 told the CNA to turn the light on if the CNA was going to leave her in the room. An attempt to interview resident #2 was conducted on September 11, 2025 at 9:28 AM but was unsuccessful because the resident became very agitated. Resident #2 was in the dementia unit; had a 1:1 sitter and was watching television.In an interview with the ADON (staff #104) conducted on September 11, 2025 at 11:09 AM, the ADON stated that yelling, swearing at, and taunting were considered as verbal abuse even if these behaviors happened in the dementia unit. She stated she was made aware of incidents of verbal aggression between resident #1 and resident #2 after it happened; and, she reported it the DON, who had been gone roughly 10 days. The ADON further stated, at that time, she was told to have the psychiatrist see resident's #1 and #2.An interview was conducted on September 11, 2025, at 11:37 AM, with the Administrator (staff #110), and the Assistant Administrator (staff #103). Both staffs (#110 and #103) stated that abuse was defined as sexual, verbal, financial, physical, exploitation, derogatory speech, belittling, yelling, intimidation, and having an aggressive tone. The assistant administrator stated that if a resident had cognitive issues or if something was witnessed on the dementia unit, it was still considered to be abuse. She stated she was aware of the incident on September 3, 2025 between resident #1 and resident #2; however, she stated that the only witness to the incident was another resident (#3) and resident #1 was interviewed by staff, resident #1 could not remember being hit. The assistant administrator denied receiving verbal abuse allegations related to resident #1 prior to the slapping incident ; and the only incident between resident #1 and #2 that the facility was aware of was the slapping incident on September 3, 2025.An interview with a CNA (staff #109) was conducted on September 12, 2025 at 9:29 AM. The CNA stated she was the 1:1 sitter assigned to resident #2, who was now very calm, relaxed, was not tense or agitated, and was smiling after she had moved to a different unit. In another interview with CNA (staff #101) conducted on September 12, 2025, at 1:45 PM, the CNA stated that resident #2 was transferred to another unit, resident #1 went to bed early and did not ask her to stay; and that, resident slept well. Review of the facility's policy on Abuse, Neglect, and Exploitation, dated July 2025 revealed that it was their policy to provide protections for health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse was defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations. Verbal abuse was defined as the use of oral, written or gestured communication or sounds that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. Mental abuse includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation. Physical abuse includes, but is not limited to hitting, slapping, punching, biting, and kicking. The policy also included that the facility will develop and implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation of residents; and, the facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to increased supervision of the alleged victim and residents, room or staffing changes, if necessary, to protect the resident(s) from the alleged perpetrator.