**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based interview, record review, and review of the facility's policy, the facility failed to ensure four of 29 sampled residents (R) (R245, R74, R6, and R70) were free from abuse. The facility's administration was aware of incidents where either abuse occurred or incidents of possible abuse; however, the facility did not act to protect the residents from abuse. The facility's failure had affected and/or had the likelihood to affect residents of the facility including any future admissions to the facility. On [DATE], a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator, Director of Nursing, and the Senior [NAME] President were informed of the Immediate Jeopardy (IJ) on [DATE] at 5:47 pm. The noncompliance related to the IJ was identified to have existed on [DATE]. The facility presented an acceptable plan of removal of the Immediate Jeopardies on [DATE]. The removal plan included interviewing and assessing all residents related to abuse (Verbal Abuse, Sexual Abuse, Physical Abuse, Mental Abuse, and Involuntary Seclusion); reviewing, revising, and updating the resident care plans; educating the Administrator, Director of Nursing, Director of Social Services/Abuse Coordinator, and facility staff regarding the facility's Patient Protection and Response Policy for Allegations/incidents of Abuse, Neglect, Misappropriation of Property and Exploitation; conducting an Emergency Quality Assurance Meeting to review the survey citations and the facility's policy related to Patient Protection and Response Policy for Allegations/incidents of Abuse, Neglect, Misappropriation of Property and Exploitation. Based on observation, record reviews, review of facility policies as outlined in the Removal Plan, and staff interviews, it was validated that the corrective plans and the immediacy of the deficient practice was removed on [DATE]. The facility remained out of compliance while the facility continues management level staff oversight as well as continues to develop and implement a Plan of Correction (POC). This oversight process includes the analysis of facility staff's conformance with the facility's policies and procedures governing abuse in the facility. Findings included: A review of the facility's policy titled, Patient Protection and Response Policy for Allegations/Incidents of Abuse, Neglect, Misappropriation of Property and Exploitation, revised [DATE] revealed, .1. Definition Policy. Abuse, Neglect, Misappropriation of Patient Property, and exploitation, as hereafter defined, will not be tolerated by anyone, including staff, patients, consultants, volunteers .The patient has the right to be free from abuse, neglect, misappropriation of patient property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the patients' medical symptoms. The center administrator is responsible for assuring that patient safety, including freedom from risk of abuse or neglect, holds the highest priority .Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish .Willful, as used in this definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal Abuse: the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability .Physical Abuse: includes hitting, slapping, pinching, and kicking. It also includes controlling behavior through corporal punishment. Mental Abuse: includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation, and staff taking, keeping, or using photographs or recordings in any manner that would demean or humiliate regardless of consent or cognitive status .Injuries of Unknown Source: An injury should be classified as an 'injury of unknown source' when all of the following conditions are met: The source of the injury was not observed by any person; and the source of the injury could not be explained by the patient; and the injury is suspicious because of the extent of the injury or the location of the injury (e.g., the is located in an area not generally vulnerable to trauma) or the number of injuries observed at one particular point in time or the incidence of the injuries over time .Patients with needs and behaviors that might lead to conflict with partners or other patients will be identified by the Care Planning team, with interventions and follow through designed to minimize the risk of conflict . 1. A review of R56's undated Resident Face Sheet, located in the resident's electronic medical record (EMR) under the Face Sheet, tab revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included psychotic disorder. A review of R56's quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] revealed the facility assessed the resident to have a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated the resident was fully cognitively intact. The MDS also revealed the facility assessed the resident to have engaged in verbal behavioral symptoms directed toward others. a. A review of R245's undated Resident Face Sheet, located in the resident's closed EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia. The resident expired on [DATE]. A review of R56's nursing Progress Note, dated [DATE], located in the resident's EMR under the Progress Notes, tab revealed Nurse called to pt. [patient] room r/t [related to] her taking off her roommate's [R245] sweater that belongs to another pt. She is being very aggressive with staff and roommate. Nurse attempted to intervene, and this pt [R56] started hitting nurse and cussing. Nurse had CNA [Certified Nurse Aide] and another nurse as witness [sic] to this behavior. Both nurses decided to move roommate [R245] r/t this pt. trying to hit her in the bed. She also kicked CNA and she was hitting her roommate's bed. Roommate [R245] is scared for her safety d/t this pt.'s behavior . A review of R245's Census Records, located in the resident's EMR under the Census tab revealed the resident had on room change completed on [DATE] and was no longer R56's roommate. b. A review of R74's undated Face Sheet, located in the resident's EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included Alzheimer's disease, dementia, and major depressive disorder. A review of R56's nursing Progress Note, dated [DATE], located in the resident's EMR under the Progress Notes tab revealed Pt continues to exhibit behaviors this night. Staff overheard pt yelling at roommate [R74], commanding roommate to get into the room right now. Staff proceeded to patient's room where pt had blocked roommate in room and refused to let her out. The other party [R74] stated, I feel unsafe to stay in room with pt. NP/ DON [Nurse Practitioner/Director of Nursing] notified of and agree that pt [R56] should be sent to ER [emergency room] for evaluation in regard to continued behaviors. Pt son called and notified of intent to transfer to hospital for eval and agrees to have pt sent in for eval. A review of R74's Census Records, located in the resident's EMR under the Census tab revealed the resident had on room change completed on [DATE] and was no longer R56's roommate. During an interview on [DATE] at 6:30 AM, CNA1 stated R56 could not keep a roommate due to how she treats them. CNA1 also stated R56 will call cognitively impaired residents stupid, or yell at the residents saying, get out of here, we don't want you here. The CNA stated the [verbally abused] residents will normally apologize, say ok, and then leave the area. During an interview on [DATE] at 9:53 AM, LPN2 stated R56 was very hateful and demeaning to residents. LPN2 stated they are supposed to document residents' behaviors; however, they (staff) have been told that was who R56 was, and it was not identified as a behavior. During an interview on [DATE] at 10:09 AM, CNA5 stated R56 was abusive to residents and staff. CNA5 stated the abuse had been reported to the Director of Social Services (DSS) but has never been addressed. During an interview on [DATE] at 12:00 PM, the DON stated R56 had a history of yelling out; however, it was not directed towards her roommates or other residents. When reviewing R56's nursing progress notes where the resident was abusive to other residents with the DON, the DON was asked if he would find any of the notes indicated abuse. The DON stated without investigating, he would not know. 2. A review of R72's undated Resident Face Sheet, located in the resident's EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included alcohol abuse, major depressive disorder, and anxiety disorder. A review of R72's quarterly MDS with an ARD of [DATE], located in the resident's EMR under the MDS tab revealed the facility assessed the resident to have a BIMS score of 11 out of 15 which indicated the resident was moderately cognitively impaired. The MDS did not reflect any behaviors during the assessment period. a. A review of R72's nursing Progress Note, dated [DATE], located in the resident's EMR under the Progress Notes tab revealed Resident has had several incidents today yelling at other residents in nasty manner. Residents separated immediately. Attempted to explain to resident that kind of behavior is not tolerated or appropriate. Resident upset and is now in room . b. A review of 72's nursing Progress Note, dated [DATE], located in the resident's EMR under the Progress Notes tab revealed Resident in dining room yelling at another resident. When redirected and educated about how other residents have dementia, she started yelling that they can get out of her face. The resident that she was yelling about was calmly sitting in front of the big window in the dining room. [R72's Name] continuously sits in the dining room area and yells at the other residents and tries to tell them to do things. She is always verbally loud with them and then gets verbal with the staff when redirection is attempted. Resident was educated that she is able to move out away from them and around them if she feels they are in her way at any time. She throws her hands up and shouts to just forget it. This is a daily situation with her. Staff will continue to educate and redirect the resident as much as she will allow. During an interview on [DATE] at 8:38 AM, R48 who was also the Resident Council President, stated during the [DATE] resident council meeting, residents voiced complaints about some residents bullying and yelling at residents with dementia. R72 who was in attendance spoke up and stated, I F .ing[explicit] yell at them because they are so deaf . F .ing[explicit] tired of hearing dementia excuse. Continued interview revealed R48 spoke directly to the DON and the DSS prior to the resident council meeting and told both of them about the concern regarding R72 and their responses were that they would look into it. R48 also stated R72 frequently verbally abuses residents with dementia. A review of the resident council minutes dated [DATE], provided by the DSS revealed New Business: .Ongoing issue with some residents being verbally aggressive to dementia residents . During an interview on [DATE] at 11:27 AM, the DSS stated he did not attend the [DATE] resident council meeting and he had not reviewed the minutes. The DSS sated the Activity Director attended the meeting and recorded the minutes. Continued interview revealed the Activity Director verbally told him the minutes were in his mailbox; however, she did not indicate that he needed to look at them nor did she report to him the concern raised about residents abusing other residents. The surveyor reviewed the nursing progress note dated [DATE] with the DSS. When asked if he was aware that R72 engaging in the behavior noted, the DSS stated yes I am. During an interview on [DATE] at 9:42 AM, Licensed Practical Nurse (LPN3) stated R72 was very bossy and mean to other residents. LPN3 stated that when R72 is in the dining room, she yells at residents, calls residents stupid, tells them to shut up. LPN3 stated R56 bullies her roommates and was mean to residents, calling them names and yelling at them. During an interview on [DATE] at 10:05 AM, CNA4 stated R56 and R72 were mean and abusive to residents with dementia. CNA4 stated R72 was meaner to the residents, and it happened more frequently than R56. The CNA stated she has reported this to the nurses and the DSS. During an interview on [DATE] at 10:09 AM, CNA5 stated R72 treats other residents horrible. The CNA stated R72 belittles them, calls them names, and yells at them. The CNA stated the residents are shocked by this and usually leave the area. CNA5 also stated she has reported this to the DSS, but he was dismissive and never did anything about it. c. A review of R6's undated Face Sheet, located in the resident's EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE]. The Face Sheet revealed the resident had diagnoses which included dementia. During an interview on [DATE] at 6:30 AM, CNA1 stated a few weeks ago R72 yelled at her roommate (R6). The CNA stated when she redirected R72, the resident replied with shut up. You all are mean to her too. CNA1 also stated R72 yells and bosses cognitively impaired residents around and she was only abusive to cognitively impaired residents. d. A review of R70's undated Face Sheet, located in the resident's EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses which included dementia. During an interview on [DATE] at 5:12 PM, LPN1 stated R72 was mean to R70 who was cognitively impaired. The LPN stated she has reported this directly to the DSS and he always stated he would take care of it. During an interview on [DATE] at 12:00 PM, when asked to define abuse per the facility's practice, the DON stated abuse was the willful intent to harm, meaning the resident meant to hurt someone [even though the facility's policy defines willful as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm]. The DON also stated R72 sometimes needed to be redirected from yelling out. The DON stated R72 yells out telling residents not to do something. When asked about R72's nursing progress note dated [DATE], the DON stated he was aware of this behavior of the resident becoming quickly irritated; however, he was not aware it was directed towards other residents. 3. A review of R19's undated Face Sheet, located in the resident's EMR under the Face Sheet tab revealed the resident was admitted to the facility on [DATE] with diagnoses which included dementia. A review of an untitled and undated document provided by the facility revealed CNA .reported incident between patients [R19's Name] and [R70's Name] on [DATE] .[CNA's Name] stated that she witnessed [R70's Name] and [R19's Name] in the dining room [sic] and they were close to each other. [R70's Name] touch [R19's Name] on the arm and [R19's Name] smacked at [R70's Name] .RN .reported that her CNA reported to her that [R19's Name] and [R70's Name] got in a disagreement and [R19's Name] had smacked [R70's Name] in the dining room [sic]. [RN's Name] did a skin assessment on both patients and no injuries, pain, redness was noted .Both patients were interviewed, but unable to recall any disagreement. Both have diagnosis of dementia. No patient-to-patient abuse occurred. A review of R19's annual MDS with an ARD of [DATE] revealed the facility assessed the resident to have a BIMS score of three out of 15 which indicated the resident was severely cognitively impaired. The MDS did not identify any behaviors for the assessment period. A review of R70's nursing Progress Note, dated [DATE], located in the resident's EMR under the Progress Notes tab revealed This nurse was informed that the resident [R70] was being smacked by one of the residents [R19] to her right arm twice. Skin assessment done with no apparent injuries, no swelling, no bruising observed to the affected area. She denies any pain/discomfort .Will continue to monitor. A review of the facility's undated and untitled document revealed CNA reported incident between patients [R19's name] and [R70's name] on [DATE]. [CNA's Name] stated that she witnessed [R70's name and R19's name] in the dining room [sic] and they were close to each other. [R70's name] touched [R19's name] on the arm and [R19's name] smacked at [R70's name] .reported to her nurse supervisor .RN reported that her CNA reported to her that [R19] and [R70] got into a disagreement and [R19] had smacked [R70] in the dining room [sic] .no patient-to-patient abuse occurred. The document was not signed and had no indication of who completed the document. During an interview on [DATE] at 4:28 PM, the DSS was asked about R70 getting smacked by another resident. The DSS stated he knows they would have completed an abuse in-service after this event. The DSS also stated the altercation was witnessed so he would have reported this to the state survey agency. During a subsequent interview on [DATE] at 11:10 AM, the DSS stated he mistakenly told the surveyor he had reported the altercation between R19 and R70 to the SSA as resident-to-resident abuse; however, he did not report this as abuse because both residents have dementia and dementia residents could not have the willful intent to cause harm [even though the facility's policy defines willful as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm]. During an interview on [DATE] at 12:00 PM, the DON stated the incident between R19 and R70 was not identified and reported as abuse because there was no willful intent as R19 was just trying to get R70's attention. 4. A review of R70's nursing Progress Note, dated [DATE], located in the resident's EMR under the Progress Notes tab revealed It was brought to the attention that the patient had a new bruise to her LT [left] thigh. I evaluated the bruise, and the patient is unsure of where the bruise came from. Patient stated that it was little painful to touch. Patient's emergency contact was present at the time of the finding, so she was aware of bruise on the patient's thigh . A review of R70's nursing Progress Note, dated [DATE], located in the resident's EMR under the Progress Notes, tab revealed Alert charting r/t [related to] bruise to left thigh. Resident is resting quietly on her bed. Bruising cont. [continued] with purplish-black appearance. She denies any pain/discomfort . During an interview on [DATE] at 4:28 PM, the DSS stated he was the facility's abuse coordinator. When asked what constitutes injury of unknow origin, the DSS read the facility's policy. When asked if R70's bruise to her left inner thigh would meet the definition for injury of unknown origin the DSS stated, I would classify this as an injury of unknown origin. During an interview on [DATE] at 11:15 PM, the Administrator stated it was her expectation residents were free from abuse. During an interview on [DATE] at 11:26 PM, the Senior [NAME] President (SVP) stated he would have expected the DON and DSS would have taken the abuse allegations seriously and immediately took action to protect the residents.