**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews and reviews of the facility's policies, it was determined the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychological well-being, in accordance with the comprehensive assessment and plan of care. This deficient practice affected one (1) (Resident #6) of six (6) sampled residents reviewed for behaviors. Specifically, Resident #6 displayed behaviors directed toward other residents, and no new interventions were implemented to address behaviors. Resident #6 had multiple episodes of verbal and physical aggression towards other residents. Resident #6 exposed self sexually during an activity. Staff reported that when Resident #6 came into the common area, other residents left due to the resident's behaviors. Staff indicated they were fearful Resident #6 would hurt another resident. The Director of Nursing (DON) indicated Resident's #6's behaviors created a stressful environment for the other residents. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.40 (Behavioral Health) at a scope and severity of J. The Immediate Jeopardy (IJ) began on 04/01/2021 when Resident #6 was yelling and cursing at another resident and the facility failed to investigate the allegation of verbal abuse. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of the IJ and provided with the IJ Template on 08/26/2021 at 12:00 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 08/27/2021 at 6:00 PM. The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that was not immediate jeopardy. The finding included: On 08/26/2021 at 1:45 PM, the Director of Nursing (DON) provided the policy on, Unmanageable Residents, dated 09/2010, and indicated this was the policy currently being used by the facility. Review of the facility's policy revealed that should a resident's behavior become abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately: a) provide for the safety of all concerned, b) notify the resident's attending physician for instructions, notify the Director of Nursing. Complete documentation of the incident must be recorded in the resident's medical record and an incident report must be filed with the Administrator. On 08/26/2021 at 1:45 PM, the DON provided the policy on, Behavioral Assessment, Intervention and Monitoring, dated 12/2016, and indicated this was the policy currently being used by the facility. The policy indicated the interdisciplinary team would evaluate behavior symptoms in a resident to determine the degree of severity, distress, and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm. The care plan will incorporate findings from the comprehensive assessment and be consistent with current standards of practice. Interventions will be individualized and part of an overall care environment that supports physical, functional, and psychosocial needs, and strives to understand, prevent, or relieve the resident's distress or loss of abilities. Interventions and approaches will be based on a detailed assessment of physical, psychological, and behavioral symptoms and their underlying causes. Record review revealed Resident #6 was admitted to the facility on [DATE] with diagnoses of dementia with behavioral disturbances, anxiety/agitation, schizophrenia, adult failure to thrive, anorexia, intellectual disability, and depression. The Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #6's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) of three (3) out of fifteen (15). The resident required supervision with ambulation using a walker. Further review revealed the MDS indicated the resident had no behaviors. The most recent Quarterly MDS, dated [DATE] indicated a diagnosis of impulse disorder and physical and verbal aggression directed toward others occurred one (1) - three (3) days during the seven (7) day assessment period. Review of a care plan, dated 02/02/2017, indicated Resident #6 exhibited or had the potential to exhibit or demonstrate verbal behaviors such as the use of abusive language and sexually inappropriate language. Interventions included to place resident on one on one, place in lobby to provide decreased stimulation, provide consistent, trusted caregivers and structured daily activities, and postpone activities if resident becomes combative or resistive. Review of the care plan, dated 10/26/2020, indicated Resident #6 exhibited or had the potential to exhibit physical behaviors related to poor anger management, poor impulse control, and public masturbation. Interventions included: resident will have quite time in room to include rest time, listening to music, and to divert by giving alternative choices. Review of a Progress Note, dated 03/26/2021, indicated Resident #6 had a resident-to-resident altercation. Resident #6 continued to curse other residents and threatened to harm self and other residents. Record review revealed a Progress Note, dated 04/01/2021, that indicated Resident #6 was cursing and yelling at another resident. Further review revealed a Progress note, dated 04/03/2021, that indicated Resident #6 was cursing other residents and making multiple verbal threats. Review of a Progress Note, dated 04/04/2021 at 3:57 PM, revealed Resident #6 was inappropriately touching another resident. Further review revealed a Progress Note, dated 04/04/2021 at 5:20 PM, indicated Resident #6 was extremely agitated and yelling at other residents. Review of a Progress Note, dated 04/09/2021 at 10:04 AM, indicated Resident #6 was verbally aggressive with other residents, threatening harm, and cursing. Review of a Progress Note, dated 04/13/2021 at 7:50 AM, indicated Resident #6 was cursing and threatening to harm other residents. Review of a Progress Note, dated 04/16/2021, indicated Resident #6 was yelling and cursing at other residents, and the facility had Director of Nursing (DON) come back to the unit. Record review revealed a Progress Note, dated 04/18/2021, indicated Resident #6 was yelling, throwing stuff, and cussing at other residents. On 04/30/2021, Resident #6 was publicly masturbating during an activity. Continued review revealed on 05/08/2021, Resident #6 was yelling and cussing at other residents. On 05/29/2021, Resident #6 had been cursing, yelling, and threatening other residents. Record review revealed a psychiatrist initial visit, dated 06/04/2021, indicated Resident #6 was being seen for depression. However, there was no mention of verbal and physical aggression documented. Continued review revealed a Progress Note, dated 06/05/2021, that indicated Resident #6 was verbally aggressive with another resident. Review of a Psychotherapy Comprehensive Clinical Assessment, dated 06/09/2021, revealed Resident #6 was referred due to concern of increased anxiety, impulsive behavior, and feeling angry. However, there was no mention of verbal and physical aggression documented. Record review revealed a Progress Note, dated 06/14/2021, that indicated Resident #6 had been cursing and yelling at other residents and throwing items in the resident's room. Review of a Physician's Progress Note, dated 06/16/2021, revealed Resident #6 was noted to have the potential to harm staff, other residents, or self. Record of a Physician's Progress Note, dated 06/17/2021, revealed Resident #6 had a long history with physical aggression related to schizoaffective bipolar disorder. Review of Psychotherapy Progress Notes, dated 06/18/2021, 06/23/2021, 07/04/2021, 07/05/2021, 07/17/2021, 07/21/2021, 07/31/2021, 08/06/2021, 08/14/2021 indicated Resident #6 was being seen for individual psychotherapy. However, there was no mention of verbal and physical aggression documented. Record review revealed a Progress Note, dated 06/29/2021, that indicated Resident #6 was threatening to hit other residents, was cursing, and being verbally aggressive with other residents. Record review revealed a psychiatry follow-up note, dated 07/16/2021, indicated Resident #6 was being seen for depression. There was no mention of verbal and physical aggression documented. Record review revealed a Progress Note, dated 07/27/2021, that indicated Resident #6 was cursing and threatening to hit other residents. Continued review revealed a Progress Note, dated 08/11/2021, that indicated Resident #6 was being verbally aggressive with other residents and was threatening to harm other residents. Review of a psychiatry follow-up note, dated 08/15/2021, indicated Resident #6 was being seen for depression. There was no mention of verbal and physical aggression documented. Review of a Progress Note, dated 08/14/2021, indicated Resident #6 had exposed self and touched self inappropriately in front of other residents during an activity. The DON had come to the unit to talk to the resident regarding behaviors. Record review revealed a Progress Note, dated 08/18/2021 at 12:00 AM, indicated Resident #6 was verbally and physically aggressive, was throwing things, trying to break things, slamming the resident's walker, and yelling and cursing. Haldol 2.5 mg (milligrams) was given. Record review revealed a Social Service Note, dated 08/19/2021, that indicated Resident #6 had diagnoses of anxiety and major depressive disorder, schizoaffective disorder, and intellectual disabilities. There were no social service notes available to indicate the facility was providing a plan of care for Resident #6's behaviors. Review of a Psychotherapy Progress Note, dated 08/23/2021, indicated Resident #6 had generalized anxiety and other specified depressive disorders and was seen for individual psychotherapy to explore and utilize coping techniques to manage isolation and depressed mood. During an interview on 08/24/2021, Licensed Practical Nurse (LPN) #3 indicated Resident #6 threatened to kill other residents, and it was just a matter of time before the resident hurt another resident. She indicated administration was aware of Resident #6's aggressive physical and verbal behaviors. During an interview on 08/24/2021 at 2:16 PM, Resident #54 indicated Resident #6 had kicked (Resident #54) in the leg with 3 staff members present who witnessed the incident. During an interview on 08/24/2021 at 3:30 PM, the Activity Assistant (AA) indicated she had witnessed Resident #6 kick Resident #54. During an interview on 08/25/2021 at 12:59 PM, the SSD (Social Service Director) indicated she was aware of the Resident #6 kicking someone and exposing himself/herself. She indicated the resident was sent back to their room for quite time. She stated she was new to her position, and she was unsure of the previous incidents in the progress notes. During an interview on 08/25/2021 at 2:23 PM, the Director of Nursing (DON) indicated she was familiar with Resident #6. She stated they have had behavioral issues with the resident before. The resident had a room to themself so they could go cool off if the resident got upset. The DON stated Resident #6 yelled and sometimes used explicit words. She stated, the resident may say I'm going to hit you., but he/she had not. She was not aware if the resident had ever hit any staff. The DON stated Resident #6 had emptied the catheter bag on the floor. She was not aware that the resident punched the TV or had thrown the walker. She stated he/she had moved the walker towards people. The DON stated she did not doubt that the resident had cursed or yelled at other residents. She stated she did not know any specifics, I don't doubt that there are incidents documented, but I don't know any specifics. Since her time at the facility, they had intervened between the resident and who ever was involved. Continued interview revealed they had called for EMS (emergeny medical services) or an officer for back up if needed. She stated to protect residents, the resident's room was near the nurse's station. When the resident was near people, it made the resident's behaviors worse. They had tried to reward Resident #6's good behavior. Review of a statement for the psychotherapy provider, dated 08/25/2021, indicated Resident #6 started receiving therapy in June of 2021 to decrease mood and reduce anger outbursts. The interventions included using a stress ball for 5-10 minutes when the resident felt his/her stress level was at a five (5) or higher and to practice deep breathing exercises 2-3 times a week. Record review revealed there were no other updates noted to Resident #6's plan of care for behaviors. During an interview on 08/26/2021 at 12:15 PM, the AA indicated Resident #6 exposed self to two female residents during an airshow while outside in the courtyard. During an interview on 08/26/2021 at 12:20 PM, Resident #58 indicated Resident #6 had exposed self to (Resident #58) during the airshow, and that it made the resident feel uncomfortable, Wondering what [Resident #58] did to provoke this. During an interview on 08/26/2021 at 12:30 PM, Resident #87 indicated Resident #6 was exposing self to Resident #58. The resident indicated he/she felt bad for Resident #58. During an interview on 08/26/2021 at 12:20 PM, the Assistant Director of Nursing (ADON) indicated there were no other notes available for psychotherapy services or social services in relation to multiple behaviors displayed over the last several months. The facility provided a Removal Plan that included: 1. Resident #6 was placed on 15 min checks when [the resident] was out of [his/her] room as of 08-26-2021. Resident was seen on 08-25-2021 by psychiatric services and seen again on 08-27-2021. Care plan updated to observe for signs of over stimulation such as grumbling while walking, complaints of other residents, etc. Staff to take resident to room, close the door and practice the interventions recommended by the psychologist such as using a stress ball and deep breathing. IDT met on 08-26-2021 and developed new interventions and updated care plan. 2. All residents with 8 or above were interviewed by social services on 08-25-2021 and 08-26-2021 to ensure there were no concerns of safety, or feelings of abuse while in this facility. None were noted. Unit Manager Nurse, MDS, and SS [social services] assistant evaluated all residents with BIMS 7 and below for any signs of change in baseline mood or behavior and normal daily routine. Documentation placed in medical record 08-26-2021 and 08-27-2021. No concerns or changes noted. 4. LNHA [licensed nursing home administrator], DON [DON], Unit Managers [UM], ADON, MOS [sic, MDS, Minimum Data Set], Business office, Payroll, Activities, Maintenance, Therapy, Scheduling were educated per Regional Director of Clinical Services on 08-26-2021 at 2:15 PM on What is abuse and neglect, when to report abuse and neglect, and to report all abuse to the LNHA. 5. IDT [interdisciplinary team] meeting held 8-27-2021; behaviors reviewed to ensure all residents that have behaviors per the comprehensive assessment have intervention and care plan in place. All interventions and care plans communicated to floor staff per DON 8-27-2021. 6. DON, and LNHA, and or designee will educate all staff on the following: - Abuse and Neglect - When to report suspected abuse and neglect - Reporting of abuse and neglect directly to the administrator immediately - This education completed 8/27/2021 - If any behaviors occur on your shift please protect the resident, stay with them until the Administrator has been notified and intervention is in place. - In addition, a list of all staff has been developed and no persons will be allowed to work without having completed this education prior to assuming the floor. 7. Facility system changes: i. Facility added behavior monitoring to TAR [treatment administration record] to be completed Q [every] shift. ii. All residents with noted behaviors were referred to psych services by assistant social services. iii. Residents with identified behavioral health needs have person centered care plans that were updated on 08-27-2021 by MDS. Care plans include behavioral health needs which are identified in the comprehensive assessment. iv. Individualized interventions related to diagnoses and conditions were added to each resident with behavioral health needs by DON, UM and MOS nurses on 08-27-2021. DON, LNHA, and/or designee audited: i. Behavior documentation audited weekly x 3 months and then quarterly x 12 months. Any concerns will be documented, corrected immediately, and staff will be educated accordingly. ii. A trigger report was run by RN, BSN, RDO on 08-27-2021 and all issues were immediately addressed. The results of the assessments/audits reported reviewed and trended for compliance through the campus quality assurance performance improvement committee for a minimum of 6 months. QAPI [quality assurance performance improvement] meetings weekly times 4 weeks and then monthly thereafter. The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Onsite verification of the implementation of the Removal Plan was conducted during the survey. On 08/27/2021 between the hours of 11:00 AM and 6:00 PM. Review of the educational materials indicated 100% of staff to include all departments had been completed on 08/26/2021. Twelve interviews were conducted to verify in-service training had been completed on the facility's Abuse Policy and Procedure training to include the types of abuse, what to report, to whom to report the allegations of abuse and when to report. Of those interviewed included certified nursing assistants (CNAs), licensed practical nurses (LPNs), registered nurses (RNs), housekeeping and scheduling staff. The staff interviewed revealed knowledge of what constituted abuse, what to do if abuse was observed, both staff to resident abuse and in the event of resident-to-resident abuse, when to report abuse and to whom the abuse should be reported. The interviews revealed a consistent message that staff understood not only the different types of abuse, but that resident-to-resident altercations also constituted abuse. Staff indicated that through training they understood the need to intercede immediately and to always protect the resident before reporting any incident of abuse to the Administrator. Staff also acknowledged that have assuring resident safety, the abuse should be reported immediately. Resident #6 had been placed on every 15-minute checks, and the care plan had been updated on measures to address behaviors, and an IDT meeting was held on 08/27/2021. Resident #6 was seen by psych services on 08/25/2021. Surveyors verified 54 Residents with BIMS 8 or above were interviewed and indicated they felt safe. The LNHA, DON, unit managers, ADON, MDS, business office, payroll department, activities, maintenance, therapy, scheduling received education on what constitutes abuse and when to report.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed the facility admitted Resident #85 on 01/27/2020 and last re-admitted him/her on 04/22/2021. The resident's diagnoses included schizoaffective disorder, vascular dementia with behaviors, early onset Alzheimer's disease, anxiety, and depression. Record review revealed Resident #85 was also readmitted on [DATE], and on readmission experienced agitation, restlessness, hyperactivity, and sought companionship. Review of the most recent Quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had moderately impaired cognition with a Brief Interview for Mental Status (BIMS) of nine (9) out of fifteen (15). The resident's behaviors included physical aggression toward others occurring one (1) to three (3) days during the seven (7) day assessment period; other behaviors not directed toward others were documented as occurring one (1) - three (3) days; and, rejection of care one (1) to three (3) days during the assessment period. No verbal behaviors were identified as occurring during the assessment period. Review of Resident 85's medical record revealed the resident had previously been discharged from another skilled nursing facility due to two (2) resident-to-resident altercations in two (2) days with behaviors that had become more aggressive leading up to the transfer. Review of the Nurse's Progress Notes and/or incident reports indicated Resident #85 had physical or verbal altercations with other residents on the following days: 05/05/2021, 06/13/2021, 07/07/2021, 07/09/2021, 07/24/2021, 08/21/2021, and 08/22/2021. A review of the Nursing Progress Notes dated 03/10/2021 at 2:51 PM indicated Resident #85 was transferred to the hospital for geriatric psychiatric services due to anxiousness, agitation, and endangering self and others. The documentation did not reveal how the resident endangered self or others. A review of the care plan, did not indicate behavior interventions were put into place after readmission. On 08/21/2021 at 2:40 PM, a review of the Nursing Progress Notes, revealed Licensed Practical Nurse (LPN) #6, observed Resident #85 grab Resident #35 by the shirt. Resident #35 attempted to pull away, and Resident #85 pulled Resident #35 closer. When Resident #85 let go of the resident's shirt, Resident #35 fell to the floor. Resident #35 sustained no apparent injury. Review of a Facility Reported Incident, 08/22/2021, revealed on 08/22/2021, Resident #85 pushed Resident #8 down, resulting in a fracture requiring surgery. Resident #8 remained in the hospital. Record review revealed a verbal aggression behavior care plan, created 08/23/2021, had a goal of decreased impulsive behaviors. Continued review revealed no care plan for physical behaviors of grabbing residents, pushing residents down, or stealing food. Observation at 9:15 AM on 08/23/2021, this Surveyor overheard the Nurse Practitioner ask Resident #85, in the hallway, why the resident had pinched and pushed another resident during the past weekend. The resident's response was not heard. A telephone interview was conducted on 08/23/2021 at 1:43 PM, with Resident #85's Responsible Party (RP). The RP stated staff had called that weekend because Resident #85 had gotten into it with another resident. The RP added Resident #85 had been sent to inpatient behavioral health services multiple times. Interview with the Director of Nursing (DON), on 08/25/2021 at 9:53 AM, revealed she was aware that Resident #85 appeared to have had an altercation with Resident #8. The DON acknowledged Resident #85 grabbed at other residents, but she did not think Resident #85 meant this as an aggressive act. Interview with Certified Nursing Assistant (CNA) #1, on 08/25/2021 at 9:16 AM, revealed at the present time Resident #85 was on a special observation schedule of every 15 minutes due to an incident over the weekend. CNA #1 stated she had worked the weekend and added on Saturday, 08/21/2021, Resident #85 had pushed Resident #35 down in the living area. The CNA added Resident #85 had grabbed Resident #35 by the shirt and then as Resident #35 tried to get away, Resident #85 let go of the shirt causing Resident #35 to fall. On Sunday, 08/22/2021, Resident #85 hit Resident #8 with the left hand. Resident #8 fell and was transferred to the hospital for a fracture. The CNA stated the only thing done on Saturday to protect other residents was taking Resident #85 to the resident's room and turning on the television. After the incident on Sunday, the CNA stated Resident #85 was taken to the bedroom, where the resident stayed until dinner. The CNA added the 15-minute checks were started on Sunday afternoon after Resident #8 had been transferred to the hospital. CNA #1 stated she worked three (3) twelve (12)-hour shifts per week, and usually at least one day during her three (3) days working, Resident #85 would slap another resident's hand, spit on other residents, and pinch or push other residents. Interview with CNA #2 on 08/25/2021 at 10:19 AM, revealed she had worked on the secure unit on Saturday 08/21/2021. At around 1:00 PM - 1:30 PM, she stated Resident #85 had a hold on Resident #35. When Resident #85 let go, Resident #35 fell, but there was no apparent injury. The CNA stated staff took Resident #85 to his/her bedroom for rest. CNA #2 stated she also worked on Sunday 08/22/2021. The CNA stated that after breakfast (10:30 AM) she had been at the nurse's station and heard Resident #85 making sounds. When she looked up, she saw Resident #85 push Resident #8 with his/her hand and saw Resident #8 fall. At that time, 15-minute checks were started for Resident #85. The CNA added she worked three (3) twelve (12) hour shifts per week, and Resident #85 usually got into an altercation with another resident at least one (1) of the three (3) days. The altercations included grabbing or poking other residents, running over other residents with the wheelchair, pinching other residents, and taking the food of other residents. The CNA indicated she reported the incidents but could not remember exact dates or who the nurse was at the time. Interview with LPN #6, on 08/25/2021 at 11:43 AM revealed that on 08/21/2021 she was sitting at the nurse's station when she heard a CNA yell Resident #85's name. LPN #6 added Resident #85 was pulling Resident #35 close by grabbing Resident #35's clothing. When Resident #85 let go of Resident #35, Resident #35 fell to the floor. LPN #6 stated Resident #85 was put to bed and stayed in the resident's room until dinner. LPN #6 stated staff was not assigned to monitor Resident #85, adding that if another resident had wandered into the room, staff would have to have waited to see if anything happened. LPN #6 stated on Sunday, 08/22/2021, Resident #85 was sitting in the common area of the unit and Resident #8 was also in the area. The LPN stated she heard Resident #8 yell and hit the floor. She stated CNA #1 and CNA #2, who were working, reported to LPN #6 that Resident #85 had pushed Resident #8 down. LPN #6 stated that while she did not see the incident first-hand, she knew Resident #8 had no history of falls and she believed what the two CNAs reported. The LPN stated she averaged working three (3) twelve (12)-hour shifts per week. Of those three (3) days, Resident #85 had a negative interaction with another resident on at least one (1) day. She cited negative interactions to include yelling at other residents and stealing food off other residents' trays. LPN #6 stated the 15-minute check sheets started on Sunday after Resident #8 was transferred to the hospital. On 08/21/2021, when Resident #85 had the aggressive interaction with Resident #35, staff had kept an eye on Resident #85, but had no documentation to support this. LPN #6 stated both incidents were reported to the weekend supervisor. During an interview with LPN #7 on 08/25/2021 at 1:20 PM, he stated that while he was a contract nurse, he had worked in the facility many times and was familiar with Resident #85. LPN #7 described Resident #85 as combative with other residents and believed Resident #85 was aware of the incidents. He supported his position by saying that when asked why another resident had been hit, Resident #85 would respond, Because I wanted to. LPN #7 stated he had not seen Resident #85 hit anyone, but he had seen the resident trying to push other residents down, grabbing other residents, and grabbing other residents' food and drink. The nurse stated he had complained to the DON about the resident's aggressive behavior, but nothing had been done. Interview with the Director of Nursing (DON), on 08/25/2021 at 2:26 PM, revealed if one resident placed their hands on another, to include pushing, kicking, and hitting, it would be considered resident-to-resident abuse and would be reported to the State. The DON stated she had not read the 08/21/2021 Nurse's Note nor talked with any of the staff that were there. She added that based on what had been reported to her by the weekend supervisor, she had not thought aggression was a part of the incident and therefore had not been abuse. Further interview on 08/26/2021 at 8:21 AM, with the DON, revealed she was unaware of Resident #85's history of aggression toward other residents. She acknowledged there should have been a care plan revision and interventions placed on 08/21/2021, when Resident #85 grabbed Resident #35 causing him/her to fall. The DON stated she was unsure if placing interventions on Saturday would have prevented the fracture to Resident #8 on 08/22/2021. The facility provided an acceptable credible Action Plan that alleged removal of the Immediate Jeopardy (IJ). The facility's Action Plan included: 1. Resident #85 was reported to push Resident #8 resulting in a fractured femur. The incident was reported on 08/26/2021 and the follow up investigation was finalized and reported 08/27/2021. Resident #6 was reported to have exposed himself/herself in a group activity on 08/14/2021. This event was reported to the State Survey agency/OIG (Office of the Inspector General) 08/27/2021. Investigations going forward will include: 2. Conducting observations of the alleged victim, identification of any injuries as appropriate, location where the situation occurred, interaction and relationships between staff and other residents. 3. Interviews conducted with the alleged victim representative, perpetrator, witness, practitioner, outside agencies as needed. The facility conducted a record review for pertinent information such as progress notes, social services notes, physician, therapist and consultant notes, financial records, incident reports, reports from hospital, lab or x ray, medication records and any other agencies as deemed necessary. 4. Depending on the nature of the allegation, the facility put effective measures in place to ensure that further abuse, neglect or exploitation or mistreatment does not occur while the investigation is in progress. The facility will monitor the alleged victim and monitor the other residents at risk, by conducting management visits at different times and shifts. The facility will evaluate if the alleged victim feels safe. If they do not, immediate action will be taken to alleviate fear, i.e. room relocation, increased supervision, etc., immediate notification of the victim's practitioner and the family or the victims responsible party. The facility will oversee the implementation of corrective action and evaluate effectiveness through the QAPI process. All alleged abuse, neglect or exploitation will be monitored and recorded on a reportable event log. The investigation is in progress. 5. All residents with BIMs of 8 or above were interviewed by Social Services on 08-25-2021 and 08-26-2021 to ensure there were no concerns of safety, or feelings of abuse while in this facility. None were noted. The MOS Nurse and SS (Social Services) assistant reviewed residents with BIMS of 7 and below for any signs of change in baseline mood or behavior and normal daily routine. No changes or concerns were identified. 6. The LNHA, DON, Unit Managers, ADON, MOS, Business office, Payroll, Activities, Maintenance, Therapy, Scheduling were educated per the Regional Director of Clinical services on 08-26-2021 at 2:15 PM, on What is abuse, how to prevent abuse and neglect, when to report abuse and neglect, and to report all abuse to the LNHA immediately. The licensed Nursing Home Administrator will make the initial report to the Office of the Inspector General, Department of Community Based Services, the State Ombudsman and local Ombudsman, the responsible parties and the MD or Nurse practitioner within two hours. 7. IDT meting was held on 08-27-2021, the team met and all residents with behaviors affecting others; have interventions and care plans in place. All interventions and care plans were communicated to the floor staff on 08-27-2021. Referrals were made to psychiatric services as appropriate by assistant the Social Services Director. DON, and LNHA, and or designee educated all staff on the following: - Identify types of Abuse and Neglect. - When to report suspected abuse and neglect - Reporting of abuse and neglect directly to the administrator immediately - This education completed by 8/27/2021 - In addition, a list of all staff has been developed and no persons will be allowed to work without having completed this education prior to assuming the floor. 1. Facility system changes: i. behavior monitoring added to TAR to be completed Q shift by [name redacted] RN/Clinical Support services. ii. Facility is reviewing TAR daily in morning clinical meeting. TAR reviewed by DON on 08/27/2021. iii. A trigger report was run by RDO on 08/27/2021 and all concerns were addressed immediately. iv. The facility identified characteristics that could increase the risk for abuse such as attitudes, increase in resident behaviors, reports of shame, fear or retaliation, change in psychological, behavioral or psychosocial outcomes. v. allegations including staff to resident, resident to resident, visitor to resident, neglect, or exploitation facility is to report immediately and immediately start investigation and protect residents. vi. The LNHA had reported all investigations 08-27-2021 2. DON, LNHA, and or designee will audit: i. The Abuse QAPI tool and the reportable events logs completed monthly by the LNHA. Events audited weekly x 3 months and then quarterly x 12 months. Any concerns documented, corrected immediately, and staff educated accordingly. ii. Findings/trends reported at the monthly quality assurance and performance improvement committee by the Director of Nursing or designee for a minimum of six months. iii. QAPI meetings will occur weekly for four weeks to monitor progress and then monthly thereafter. The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Action Plans had been implemented. Onsite verification of the implementation of the Removal Plan was conducted during the survey. On 08/27/2021 between the hours of 11:00 AM and 6:00 PM. Review of the educational materials indicated 100% of staff to include all departments had been completed on 08/26/2021. Twelve interviews were conducted to verify in-service training had been completed on the facility's Abuse Policy and Procedure training to include the types of abuse, what to report, to whom to report the allegations of abuse and when to report. Of those interviewed included certified nursing assistants (CNAs), licensed practical nurses (LPNs), registered nurses (RNs), housekeeping and scheduling staff. The staff interviewed revealed knowledge of what constituted abuse, what to do if abuse was observed, both staff to resident abuse and in the event of resident-to-resident abuse, when to report abuse and to whom the abuse should be reported. The interviews revealed a consistent message that staff understood not only the different types of abuse, but that resident-to-resident altercations also constituted abuse. Staff indicated that through training they understood the need to intercede immediately and to always protect the resident before reporting any incident of abuse to the Administrator. Staff also acknowledged that after assuring resident safety, the abuse should be reported immediately. Observations during the survey revealed Resident #85 was receiving 1:1 supervision. Record review for Resident #85 indicated the care plan had been revised to include exhibited physical behaviors and stealing food from other residents' trays. Interventions for Resident #85 included 1:1 supervision, psychiatric referral, laboratory testing and a care conference with family members to determine the resident's past interest. Resident #6 had been placed on every 15 minute checks, and the care plan had been updated on measures to address behaviors, and an IDT meeting was held on 08/27/2021. Resident #6 was seen by psych services on 08/25/2021. Surveyors verified 54 Residents with BIMS 8 or above were interviewed and indicated they felt safe. The LNHA, DON, Unit Managers, ADON, MDS, business office, payroll department, activities, maintenance, therapy, scheduling received education on what constitutes abuse and when to report. Based on interviews, record reviews and facility policy review, it was determined that the facility failed to protect residents from physical, sexual, and verbal abuse for five (5) (Residents #35, #8, #58, #54, and #87) of five (5) sampled residents reviewed for abuse by Resident #85 and Resident #6. Specifically, Resident #85 knocked down Resident #35 down on 08/21/2021, and knocked Resident #8 down on 08/22/2021, resulting in a femur fracture. Resident #6 had multiple episodes of verbal and physical aggression towards other residents. Resident #6 exposed himself/herself, sexually during an activity, to Resident #58 and Resident #87. Staff reported that when Resident #6 came into the common area, other residents left due to the resident's behaviors. Staff indicated they were fearful Resident #6 would hurt another resident. The Director of Nursing (DON) indicated Resident's #6's behaviors created a stressful environment for the other residents. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was identified at 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of K. The Immediate Jeopardy (IJ) was determined to exist on 04/01/2021 when Resident #6 was yelling and cursing at another resident and the facility failed to investigate the allegation of verbal abuse. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of the IJ and were provided the IJ Template on 08/26/2021 at 12:00 PM. AN acceptable Removal Plan was received on 08/27/2021. The IJ was determined to be removed on 08/27/2021, before exit. after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of pattern E, no actual harm with potential for more than minimal harm that was not immediate jeopardy. The findings included: Review of the Abuse Prevention Program, revised 09/2020, indicated in Paragraph #1 that as part of the resident abuse prevention, administration would protect residents from abuse by anyone including, but not necessarily limited to staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, or any other individuals. Review of the facility's policy, titled, Abuse and Neglect - Clinical Protocol, revised July 2017, revealed Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. Review of the Unmanageable Resident policy, revised 04/2010, indicated that if a resident's behavior became abusive, hostile, assaultive, or unmanageable in any way that would jeopardize his or her safety or the safety of others, the Nurse Supervisor/Charge Nurse must immediately provide for the safety of all concerned, notify the attending physician for instruction, and notify the Director of Nursing and the resident's representative. The policy further indicated complete documentation of the incident must be recorded in the resident's medical record, and an incident report must be filed with the Administrator. Additionally, unmanageable residents may not be retained by the facility. 1. Record review revealed the facility admitted Resident #6 on 01/19/2017 with diagnoses of dementia with behavioral disturbances, anxiety/agitation, schizophrenia, adult failure to thrive, intellectual disability, and depression. Review of the annual Minimum Data Set (MDS) dated [DATE], revealed Resident #6's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) score of three (3) out of fifteen (15). The resident required supervision with ambulation using a walker. The MDS indicated the resident had no behaviors. The most recent Quarterly MDS, dated [DATE] indicated diagnoses of impulse disorder and physical and verbal aggression directed toward others occurred one (1) to three (3) days during the seven (7) day assessment period. Review of a care plan, dated 02/02/2017, indicated Resident #6 exhibited or had the potential to exhibit or demonstrate verbal behaviors such as the use of abusive and sexually inappropriate language. Review of a care plan, dated 10/26/2020, indicated Resident #6 exhibited or had the potential to exhibit physical behaviors related to poor anger management, poor impulse control, and public masturbation. Review of a Progress Note, dated 03/26/2021, indicated Resident #6 had a resident-to-resident altercation. Resident #6 continued to curse other residents and threatened to harm self and other residents. Review of a Progress Note, dated 04/01/2021, indicated Resident #6 was cursing and yelling at another resident. There was no evidence provided that showed this incident was investigated. Review of a Progress Note, dated 04/03/2021, indicated Resident #6 was cursing other residents and making multiple verbal threats. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 04/04/2021 at 5:20 PM, indicated Resident #6 was extremely agitated and yelling at other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 04/09/2021 at 10:04 AM, indicated Resident #6 was verbally aggressive with other residents, threatening harm, and cursing. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 04/13/2021 at 7:50 AM, indicated Resident #6 was cursing and threatening to harm other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 04/16/2021, indicated Resident #6 was yelling and cursing at other residents, and the facility had the Director of Nursing come back to the unit. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 04/18/2021, indicated Resident #6 was yelling, throwing stuff, and cussing at other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 04/30/2021, indicated Resident #6 was publicly masturbating during an activity. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 05/08/2021, indicated Resident #6 was yelling and cussing at other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 05/29/2021, indicated Resident #6 had been cursing, yelling, and threatening other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 06/05/2021, indicated Resident #6 was verbally aggressive with another resident. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 06/14/2021, indicated Resident #6 had been cursing and yelling at other residents and throwing items in the resident's room. There was no evidence provided that this incident was investigated. Review of a Physician's Progress Note, dated 06/16/2021, indicated Resident #6 was noted to have the potential to harm staff, other residents, or self. Review of a Physician's Progress Note, dated 06/17/2021, indicated Resident #6 had a long history with physical aggression related to schizoaffective bipolar disorder. Review of a Progress Note, dated 06/29/2021, indicated Resident #6 was threatening to hit, was cursing, and was being verbally aggressive with other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 07/27/2021, indicated Resident #6 was cursing and threatening to hit other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 08/11/2021, indicated Resident #6 was being verbally aggressive with other residents and was threatening to harm other residents. There was no evidence provided that this incident was investigated. Review of a Progress Note, dated 08/14/2021, indicated Resident #6 had exposed himself/herself and touched himself/herself inappropriately in front of other residents during an activity. The DON went to the unit to talk to the resident regarding his/her behaviors. There was no evidence provided that this incident was investigated. Review of a Physician's Progress Note, dated 08/18/2021 at 12:00 PM, indicated Resident #6 was verbally and physically aggressive, was throwing things, trying to break things, slamming the walker, and yelling and cursing. Record review revealed Haldol 2.5 mg (milligrams) was given. During an interview on 08/24/2021 at 3:15 PM, Licensed Practical Nurse (LPN) #3 indicated Resident #6 threatened to kill other residents, and it was just a matter of time before the resident hurt another resident. She indicated the facility's administration was aware of Resident #6's aggressive physical and verbal behaviors. During an interview on 08/24/2021 at 2:16 PM, Resident #54 indicated Resident #6 had kicked him/her in the leg with three (3) staff members present who witnessed the incident. During an interview on 08/24/2021 at 3:30 PM, the Activity Assistant (AA) indicated she had witnessed Resident #6 kick Resident #54. During an interview on 08/26/2021 at 12:15 PM, the AA indicated Resident #6 exposed himself/herself to two residents during an airshow while outside in the courtyard. During an interview on 08/26/2021 at 12:20 PM, Resident #58 indicated Resident #6 had exposed himself/herself to Resident #58 during the airshow, and that it made the resident feel uncomfortable, wondering what [Resident #58] did to provoke this. During an interview on 08/26/2021 at 12:30 PM, Resident #87 indicated Resident #6 had their genitals in his/her hand and was exposing himself/herself to Resident #58. Resident #87 indicated (he/she) felt bad for Resident #58. During an interview on 08/25/2021, the DON indicated allegations of abuse were to be reported to their immediate supervisor, and it would then be reported to the DON or NHA. She indicated she was not aware of the allegations of physical, verbal, and sexual abuse. The DON indicated she would report verbal allegations of abuse depending on how the other residents felt about it. She indicated the incident of Resident #6 exposing self during an activity should have been reported. During an interview with the Administrator, on 8/26/2021 at 2:30 PM, she stated she was aware of behaviors that Resident #58 had been displaying and that the resident was like a child. She indicated she had not been notified that the resident kicked another resident or that the resident had exposed themself in front of female residents during the outside activity for the air show.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Record review revealed the facility admitted Resident #85 on 01/27/2020 with diagnoses that included schizoaffective disorder, vascular dementia with behaviors, anxiety disorder, early onset Alzheimer's, and depression. Review of Resident 85's medical record revealed the resident had previously been discharged from another skilled nursing facility due to two (2) resident-to-resident altercations in two (2) days with behaviors that had become more aggressive leading up to the transfer. Review of the Nursing Progress Notes dated 03/10/2021 at 2:51 PM revealed Resident #85 was transferred to the hospital for geriatric psychiatric services due to anxiousness, agitation, and endangering self and others. The documentation did not reveal how the resident endangered self or others. The facility readmitted Resident #85 on 03/22/2021. Upon readmission Resident #85 experienced agitation, restlessness, hyperactivity, and sought companionship. Review of a SBAR dated 05/22/2021 indicated Resident #85 pushed another resident down. Review of the facility's list of State-Reported Incidents for the past three (3) months revealed there was no report for this incident. There was no documentation presented that supported an investigation of this incident had been completed. Review of a facility reported incident (FRI) dated 07/06/2021 indicated a certified nursing assistant (CNA) came out of the shower room and saw Resident #85 in the hallway with two (2) other unidentified residents, with all residents hitting one another. Review of the facility's list of state-reported incidents revealed a report had not been submitted to the State. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed the facility assessed Resident #85 as moderately cognitively impaired with a Brief Interview for Mental Status score of nine (9). Physical behaviors occurred (1) - three (3) days during the assessment period, other behaviors not directed toward others were documented as occurring (1) - three (3) days, and rejection of care (1) - three (3) days. No verbal behaviors were identified as occurring during the assessment period. A review of the facility's list of state-reported incidents revealed no reports had been submitted to the State during the assessment period, although the MDS indicated there had been one (1) - three (3) incidents during the assessment period. Record review revealed on 08/21/2021 at 2:40 PM, Licensed Practical Nurse (LPN) #6 documented she observed Resident #85 grab Resident #35 by the shirt. Resident #35 attempted to pull away, and Resident #85 pulled the resident closer. When Resident #85 let go of the resident's shirt, Resident #35 fell to the floor. Resident #35 sustained no injury. Review of the facility's list of state-reported incidents revealed there had been no submission of a report for Resident #85's incident on 08/21/2021. Licensed Practical Nurse (LPN) #6 was interviewed on 08/25/2021 at 11:43 AM. She stated on 08/21/2021, she was sitting at the nurse's station when she heard a CNA yell Resident #85's name. LPN #6 stated the 08/21/2021 incident with Resident #85 was reported to the weekend supervisor. The Director of Nursing (DON) was interviewed on 08/25/2021 at 2:26 PM. She stated if one (1) resident placed their hands on another, to include pushing, kicking, and hitting, it would be considered resident-to-resident abuse and would be reported to the State agencies. The DON stated she had not read the 08/21/2021 Nurse's Note or talked with any of the staff that were there. She added that based on what had been reported to her by the Weekend Supervisor, she had not thought aggression was a part of the incident and therefore, it was not considered abuse. The DON stated that was the reason the 08/21/2021 incident involving Resident #85 had not been reported or investigated. The DON reviewed the state-reported folder for the 05/07/2021 incident, including the CNA's statement dated 05/05/2021, and stated the CNA might have dated the statement wrong. Observation revealed that on 08/25/2021 at 12:16 PM, the Nursing Home Administrator (NHA) brought in the facility's state-reported incidents for the past three (3) months. When asked, the NHA confirmed the folders she brought in represented all she had reported to the State Agency or investigated for the past three (3) months. A review of the information provided by the facility indicated Resident #85 had two (2) incidents reported to the State agencies, one (1) incident for 05/05/2021 and another for 08/22/2021. The DON was interviewed on 08/26/2021 at 8:21 AM. She stated she had not reported the incident or investigated the incident involving Resident #85 that occurred on 08/21/2021 due to the way the incident had been presented to her. She reviewed the remaining physically aggressive incident reports and Nurse's Notes and had no reason why those incidents had not been reported or investigated. 3. Record review revealed the facility admitted Resident #83 on 10/16/2019 with diagnoses that included cerebral palsy, chronic obstructive pulmonary disease, contractures, dysphagia, paranoid schizophrenia, need for assistance with personal care, mild cognitive impairment, major depressive disorder, anxiety disorder, and intermittent explosive disorder. Review of the Significant Change Minimum Data Set (MDS) for Resident #83, dated 07/27/2021, revealed the facility assessed that Resident #83 had a Brief Interview for Mental Status (BIMS) score of 00 out of 15, which indicated significant cognitive impairment. Resident #83 required extensive assistance of two (2) people with bed mobility, dressing, and toileting. Resident #83 required limited assistance of one person with eating. The resident was totally dependent on staff for bathing. Review of a Progress Note dated 07/20/2021 at 1:05 PM revealed, CNAs asked this nurse to come to room to look at resident. When this nurse went in the room the CNA's (sic) showed me that the resident had some yellow bruising to [the resident's] right inner thigh that wrapped around to the front and back of [the] thigh, 3 small open areas to [the] scrotum, and some discoloration spots to [the] right outer foot. An interview on 08/26/2021 at 12:48 PM with the DON revealed that if an injury was found that has no immediate known cause, it would be unknown and should be reported. The DON stated that when staff reported on 07/20/2021, significant bruising was observed on the resident's thigh it was not reported to the State Survey Agency at that time. The DON stated she concluded it was most likely a result of improper incontinent care. 3b. Review of a Progress Note dated 07/23/2021 at 5:46 PM, for Resident #83 revealed, ER nurse called to inform of acute right hip fracture, unknown cause at this time, DON [Director of Nursing] aware. [The resident had been sent out for a possible bowel obstruction. During the CT scan for this, the fracture was found.] An interview on 08/26/2021 at 12:48 PM with the Director of Nursing (DON) revealed she did not report the right hip fracture to the State Survey Agency that was discovered in the hospital and reported to the facility on [DATE]. The DON stated it was not reported since she felt it was also a result of improper incontinent care and that she did not feel either incident met the criteria for reporting. The facility's Removal Plan included: 1. Resident #85 was reported to push Resident #8 resulting in a fractured femur. The incident was reported on 08/26/21 and the follow up investigation was finalized and reported 08/27/21. Resident #6 was reported to have exposed (himself/herself) in a group activity on 08/14/21. This event reported to OIG (Office of the Inspector General/Sttae Survey Agency) 08/27/21. 2. All incidents identified during the survey reported on 08/27/2021 3. All alleged violations involving abuse, neglect, exploitation, mistreatment, including injuries of unknown source and misappropriation were reported immediately but not later than two hours after the allegation if they result in serious bodily injury, but not later than 24 hours if they do not involve abuse and do not result in serious bodily injury. 4. All the findings of the investigation reported to the Administrator and to the Survey Agency within 5 working days. 5. Alleged violations identified are reported to the Administrator. LNHA will immediately report and protect the identified residents prior to conducting the investigation. 6. LNHA, DON, Unit Managers [UM], ADON, MOS [sic] [Minimum Data Set, MDS], Business office, Payroll, Activities, Maintenance, Therapy, Scheduling were educated per Regional Director of Clinical services on 08-26-2021 at 2:15 pm on What is abuse, how to prevent abuse and neglect, when to report abuse and neglect, and to report all abuse to the LNHA immediately. The licensed Nursing Home Administrator makes the initial report to the Office of the Inspector General, Department of Community Based Services, the State Ombudsman and Local Ombudsman, the responsible parties and the MD or Nurse practitioner within two hours. 7. IDT [interdisciplinary team] meeting held 8-27-2021 reviewed behaviors for all residents that have behaviors affecting others. Interventions and care plans were put in place by DON, UM and MOS [sic, MDS]. All interventions and care plans communicated to floor staff per [NAME], and referrals made to psychiatric services as appropriate. DON, and LNHA, and or designee educated all staff on the following: - Identify types of Abuse and Neglect. - When to report suspected abuse and neglect - Reporting of abuse and neglect directly to the administrator immediately - This education completed 08/27/2021 - In addition, a list of all staff has been developed and no persons will be allowed to work without having completed this education prior to assuming the floor. 1. DON, LNHA, and or designee reported all findings to QAPI i. The Abuse QAPI [quality assurance performance improvement] tool and the reportable events logs completed monthly by the LNHA. Events audited weekly x 3 months and then quarterly x 12 months. Any concerns will be documented, corrected immediately, and staff educated accordingly. ii. Findings/trends reported at the monthly quality assurance and performance improvement committee by the Director of Nursing or designee for a minimum of six months. iii. QAPI meetings weekly for four weeks to monitor progress and then monthly thereafter. The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Onsite verification of the implementation of the Removal Plan was conducted during the survey. On 08/27/2021 between the hours of 11:00 AM and 6:00 PM. Review of the educational materials indicated 100% of staff to include all departments had been completed on 08/26/2021. Twelve interviews were conducted to verify in-service training had been completed on the facility's Abuse Policy and Procedure training to include the types of abuse, what to report, to whom to report the allegations of abuse and when to report. Of those interviewed included certified nursing assistants (CNAs), licensed practical nurses (LPNs), registered nurses (RNs), housekeeping and scheduling staff. The staff interviewed revealed knowledge of what constituted abuse, what to do if abuse was observed, both staff to resident abuse and in the event of resident-to-resident abuse, when to report abuse and to whom the abuse should be reported. The interviews revealed a consistent message that staff understood not only the different types of abuse, but that resident-to-resident altercations also constituted abuse. Staff indicated that through training they understood the need to intercede immediately and to always protect the resident before reporting any incident of abuse to the Administrator. Staff also acknowledged that have assuring resident safety, the abuse should be reported immediately. Observations during the survey revealed Resident #85 was receiving 1:1 supervision. Record review for Resident #85 indicated the care plan had been revised to include exhibited physical behaviors and stealing food from other resident's trays. Interventions for Resident #85 included 1:1 supervision, psychiatric referral, laboratory testing and a care conference with family members to determine the resident's past interest. Resident #6 had been placed on every 15 minute checks, and the care plan had been updated on measures to address behaviors, and an IDT meeting was held on 08/27/2021. Resident #6 was seen by psych services on 08/25/2021. Surveyors verified 54 Residents with BIMS 8 or above were interviewed and indicated they felt safe. The LNHA, DON, unit managers, ADON, MDS, business office, payroll department, activities, maintenance, therapy, scheduling received education on what constitutes abuse and when to report. Based on interviews, record reviews, and facility policy review, it was determined the facility failed to report abuse allegations and injuries of unknown origin to the State Survey Agency for six (6) (Residents #35, #8, #58, #54, #83, and #87) out of six (6) residents reviewed for abuse. Resident #6 had multiple occurrences of cursing, yelling, throwing things, threatening other residents, and publicly masturbating in front of other residents. These incidents were not reported. Resident #85 had physical or verbal altercations with other residents and the incidents were not reported. One of the physical altercations with Resident #85 caused Resident #8 to fall, and Resident #8 sustained a hip fracture. Resident #83 had injuries of unknown origin, including bruising and a hip fracture, that were not reported to the State Survey Agency. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was identified at 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of K. The Immediate Jeopardy (IJ) determined to exist on 04/01/2021 when Resident #6 was yelling and cursing at another resident and the facility failed to investigate the allegation of verbal abuse. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of the IJ and provided with the IJ Template on 08/26/2021 at 12:00 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 08/27/2021 at 6:00 PM. The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that was not immediate jeopardy. The findings included: Review of the facility's policy, The Abuse Prevention Program, reviewed September 2020 indicated under Paragraph #7 that allegations of abuse would be investigated and reported within the timeframes required by federal requirements. A review of the facility;s policy, titled, Abuse and Neglect - Clinical Protocol, revised July 2017, revealed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. 1. Record review revealed the facility admitted Resident #6 on 01/19/2017 with diagnoses of dementia with behavioral disturbances, anxiety/agitation, schizophrenia, adult failure to thrive, anorexia, intellectual disability, and depression. The Annual Minimum Data Set (MDS) dated [DATE] indicated Resident #6's cognition was severely impaired with a Brief Interview for Mental Status (BIMS) of three (3) out of fifteen (15). The resident required supervision with ambulation using a walker. This MDS indicated the resident had no behaviors. The most recent Quarterly MDS, dated [DATE] indicated diagnoses of impulse disorder and physical and verbal aggression directed toward others occurred one (1) - three (3) days during the seven (7) day assessment period. Review of a Progress Note, dated 04/01/2021, indicated Resident #6 was cursing and yelling at another resident. There was no evidence provided that this was reported to the State Survey Agency. Review of a Progress Note, dated 04/03/2021, indicated Resident #6 was cursing other residents and making multiple verbal threats. There was no evidence provided that this was reported to the State Survey Agency. Review of Progress Note, dated 04/04/2021 at 5:20 PM, indicated Resident #6 was extremely agitated and yelling at other residents. There was no evidence provided that this was reported to the State Survey Agency. Review of a Progress Note, dated 04/09/2021 at 10:04 AM, indicated Resident #6 was verbally aggressive with other residents, threatening harm, and cursing. There was no evidence provided that this was reported to the State Survey Agency . Review a Progress Note, dated 04/13/2021 at 7:50 AM, indicated Resident #6 was cursing and threatening to harm other residents. There was no evidence provided that this was reported to the State Survey Agency. Review of a Progress Note, dated 04/16/2021, indicated Resident #6 was yelling and cursing at other residents, and the facility had the Director of Nursing come back to the unit. There was no evidence provided that this was reported to the State Survey Agency. Review of a Progress Note, dated 04/18/2021, indicated Resident #6 was yelling, throwing stuff, and cussing at other residents. There was no evidence provided that this was reported to the State Survey Agency . Review of a Progress Note, dated 05/08/2021, indicated Resident #6 was yelling and cussing at other residents. There was no evidence provided that this was reported to the State Survey Agency. Review of a Progress Note, dated 05/29/2021, indicated Resident #6 had been cursing, yelling, and threatening other residents. There was no evidence provided that showed this was reported to the State Survey Agency. Review of a Progress Note, dated 06/29/2021, indicated Resident #6 was threatening to hit, was cursing, and was being verbally aggressive with other residents. Review of a Progress note, dated 07/27/2021, indicated Resident #6 was cursing and threatening to hit other residents. There was no evidence provided that showed this was reported to the State Survey Agency. Review of a Progress Note, dated 08/11/2021, indicated Resident #6 was being verbally aggressive with other residents and was threatening to harm other residents. There was no evidence provided that showed this was reported to the State Survey Agency. During an interview on 08/24/2021 at 3:15 PM, Licensed Practical Nurse (LPN) #3 indicated Resident #6 threatened to kill other residents, and it was just a matter of time before the resident hurt another resident. During an interview on 08/24/2021 at 2:16 PM, Resident #54 indicated Resident #6 had kicked Resident #54 in the leg with three (3) staff members present who witnessed the incident. During an interview on 08/24/2021 at 3:30 PM, the Activity Assistant (AA) indicated she had witnessed Resident #6 kick Resident #54. Record review and interview revealed there were no reports filed with the State Survey Agency for the verbal, physical, or sexual abuse allegations. During an interview on 08/25/2021, with the DON revealed allegations of abuse were to be reported to their immediate supervisor, and it would then be reported to the DON or NHA. She indicated she was not aware of the allegations of physical, verbal, and sexual abuse. The DON indicated she would report verbal allegations of abuse depending on how the other residents felt about it. She indicated the incident of Resident #6 exposing self during an activity should have been reported.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Review of the facility's Abuse Prevention Program, under Paragraph #7, revealed that allegations of abuse would be investigated and reported within the timeframes required by federal requirements. Record review revealed the facility admitted Resident #85 on 01/27/2020 with diagnoses that included schizoaffective disorder, vascular dementia with behaviors, anxiety disorder, early onset Alzheimer's, and depression. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], indicated the facility assessed Resident #85 as moderately cognitively impaired with a Brief Interview for Mental Status (BIMS) score of nine (9) out of fifteen (15). Physical behaviors occurred one (1) to three (3) days during the assessment period, other behaviors not directed toward others were documented as occurring one (1) to three (3) days, and rejection of care one (1) to three (3) days. No verbal behaviors were identified as occurring during the assessment period. Review of the Nurse's Progress Notes and/or incident reports indicated Resident #85 had physical or verbal altercations with other residents on the following days: 06/13/2021, 07/09/2021, 07/24/2021, 08/21/2021 and 08/22/202; however, there was no documented evidence the incidents were investigated by the facility. Record review revealed that on 08/21/2021 at 2:40 PM, Licensed Practical Nurse (LPN) #6 documented she observed Resident #85 grab Resident #35 by the shirt. Resident #35 attempted to pull away, and Resident #85 pulled Resident #35 closer. When Resident #85 let go of Resident #35's shirt, Resident #35 fell to the floor. Resident #35 sustained no apparent injury. Certified Nursing Assistant (CNA) #1 was interviewed on 08/25/2021 at 9:16 AM. CNA #1 stated at the present time, Resident #85 was on a special observation schedule of every 15 minutes due to an incident over the weekend. CNA #1 stated she had worked the weekend and stated on Saturday, 08/21/2021, Resident #85 had pushed Resident #35 down in the living area. The CNA stated Resident #85 had grabbed Resident #35 by the shirt, and. then as Resident #35 tried to get away, Resident #85 let go of the shirt causing Resident #35 to fall. The CNA stated Resident #85 had been taken to the room and remained in the room until dinner. No special monitoring had been placed for Resident #85. The CNA stated 15-minute checks had not started until 08/22/2021 when Resident #85 pushed Resident #8 down, resulting in a fracture for Resident #8. CNA #2 was interviewed on 08/25/2021 at 10:19 AM. She stated she had worked in the secure unit on Saturday 08/21/2021. Further interview revealed around 1:00-1:30 PM, Resident #85 had a hold on Resident #35's shirt. When Resident #85 let go, Resident #35 fell, but there was no apparent injury. The CNA stated staff took Resident #85 to the bedroom for rest. CNA #2 stated she also worked on Sunday 08/22/2021. The CNA stated after breakfast (10:30 AM) she was at the nurse's station and heard Resident #85 making sounds. When she looked up, she saw Resident #85 push Resident #8 and saw Resident #8 fall. At that time, 15-minute checks were started for Resident #85. Licensed Practical Nurse (LPN) #6 was interviewed on 08/25/2021 at 11:43 AM. She stated on 08/21/2021 she had been sitting at the nurse's station when she heard a CNA yell Resident #85's name. LPN #6 added Resident #85 was pulling Resident #35 close by grabbing Resident #35's clothing. When Resident #85 let go of Resident #35, Resident #35 fell to the floor. LPN #6 stated Resident #85 was put to bed and stayed in the room until dinner. Staff was not assigned to monitor Resident #85, adding that if another resident had wandered into the room, staff would have to have waited to see if anything happened. The nurse stated the incidents had been reported to the weekend supervisor. During the survey, the weekend supervisor was supposed to come in for an interview, but she did not. Follow up phone calls made to the weekend supervisor were not answered. The DON was interviewed on 08/25/2021 at 2:26 PM. The DON stated she had not investigated the incident that occurred on 08/21/2021. She had not read the Nurse's Notes regarding the incident nor talked to any staff involved based on the report received from the weekend supervisor. The DON stated the incident was investigated by the weekend supervisor. Requests were made several times for investigative information related to the 08/21/2021 incident. No information was provided. The DON reviewed the Nurse's Progress Notes and incident reports from other physically aggressive incidents involving Resident #85 and other residents. She stated she would look for any investigations and if found would return them to the Surveyors for review. No investigations were provided. When the DON reviewed the SBARs or the incident reports for the other incidents, she was unable to provide documentation of investigation. 3a. Record review revealed Resident #83 was admitted on [DATE] with diagnoses including cerebral palsy, chronic obstructive pulmonary disease, contractures, dysphagia, paranoid schizophrenia, abnormal posture, neuromuscular dysfunction of the bladder, muscle weakness, type 2 diabetes, need for assistance with personal care, mild cognitive impairment, major depressive disorder, anxiety disorder, and intermittent explosive disorder. A review of the Significant Change Minimum Data Set for Resident #83 dated 07/27/2021 indicated that Resident #83 had a Brief Interview for Mental Status (BIMS) score of zero (00) out of fifteen (15), indicating significant cognitive impairment. Resident #83 required extensive assistance of two (2) persons with bed mobility, dressing, and toileting. Resident #83 required limited assistance of one person with eating. The resident was totally dependent on staff for bathing. A review of a Progress Note dated 07/20/2021 at 1:05 PM revealed, CNAs [Certified Nurse Aide] asked this nurse to come to room to look at resident. When this nurse went in the room the CNA's [sic] showed me that the resident had some yellow bruising to [the resident's] right inner thigh that wrapped around to the front and back of [the] thigh, 3 small open areas to [the] scrotum, and some discoloration spots to [the] right outer foot. An interview on 08/26/2021 at 12:48 PM, with the Director of Nursing (DON) revealed that when staff reported observing significant bruising on Resident #83's thigh on 07/20/2021, the Assistant Director of Nursing (ADON) talked to the staff about their observations. The DON stated that after the ADON spoke to staff, it was determined that CNA staff probably accidentally caused the bruising while providing care. The DON stated that due to the resident's contractures, staff must hold the resident's thighs apart while providing incontinent care. The DON acknowledged there was no documentation of those conversations or determination of the cause. The DON stated she did not ask the ADON for any documentation related to her findings, but there was education provided to the staff. The DON further stated that the nurse practitioner (NP) was made aware, and that she followed up on it. During the interview, the DON reviewed the progress notes and verified the NP did not document anywhere that there was ever any follow up on the bruising when she saw the resident on 07/20/2021. When asked if she would expect staff to document that injuries of an unknown origin are followed up on, the DON stated she would expect nurses to act according to their license and document accordingly. An interview on 08/26/2021 at 12:48 PM with the Nursing Home Administrator (NHA) revealed that when the bruise on Resident #83 was reported by the CNA staff, the ADON talked to staff about the bruise. The NHA stated she did not follow up with the ADON to see if she documented anything in relation to her investigation. The NHA stated there was no documentation that an investigation into how the bruising occurred was completed. An interview on 08/26/2021 at 1:38 PM with the ADON revealed she was on E Hall on 07/20/2021 when staff observed bruising to Resident #83's thigh and staff informed the DON and NP. The ADON stated she looked at the resident's thigh and confirmed bruising and assumed it occurred when CNAs were providing perineal care. The ADON stated staff would use the bend of their arms to open the resident's legs in order to clean the resident's groin and thigh area, and that may have caused the bruising. The ADON stated there was no documentation that staff were interviewed about the bruising. The ADON stated at that time, the ADON provided information to staff on proper perineal care and did education, but there was no documentation in relation to the education and that no staff signed that they attended. The ADON stated it was very informal, and she did not document anything in the electronic medical record because the NP was aware. The ADON stated she assumed the NP was documenting about it. The ADON was unaware that the NP never mentioned or documented anything in relation to the bruising on the resident's thigh but confirmed she never checked to make sure there was documentation. 3b. Review of Resident #83's Progress Note dated 07/23/2021 at 5:46 PM, revealed, ER nurse called to inform of acute right hip fracture, unknown cause at this time, DON aware. [The resident had been sent out for a possible bowel obstruction. During the computer tomography (CT) scan for this, the fracture was found.] An interview on 08/25/2021 at 12:00 PM, with the Director of Nursing (DON) revealed she was aware that the hospital reported on 07/23/2021 that Resident #83 had an acute right hip fracture. The hospital did additional testing, and it was ruled as a chronic condition and not a new acute injury. The DON stated she would get the hospital records and provide those to the Surveyor. The DON also stated she was not sure why there was not any documentation in the Progress notes related to the follow-up or outcome of the final diagnosis. Review of the Imaging dated 07/24/2021 of the CT Cystogram per contrast protocol revealed Resident #83 had a comminuted and impacted fracture in the proximal right femur in the sub-capital region. Further review revealed the assessment was right femoral neck fracture of undetermined age. An interview on 08/26/2021 at 12:48 PM with the DON revealed she did not feel Resident #83's fracture was an injury of unknown origin and therefore it did not need to be investigated. The DON stated they received a report on 07/24/2021 from urology and from the CT scan, and that there were two different findings, but she did not follow up with either urology or with the hospital about the CT scan to verify both results. The DON stated she never contacted urology to ask how they made their determination that it appears to be a chronic since the CT scan contradicted the urology report stating there was a comminuted and impacted fracture in the right femur of undetermined age. The DON stated the facility never initiated an investigation into how the fracture occurred or interviewed any staff in relation to the fracture. The DON stated she felt the fracture was also a result of how the bruising was determined to have been caused due to staff separating the resident's legs during care. The facility's Removal Plan included: 1. Resident #85 was reported to push Resident #8 resulting in a fractured femur. The incident was reported on 08/26/21 and the follow up investigation finalized and reported 08/27/21. Resident #6 was reported to have exposed [himself/herself] in a group activity on 08/14/21. This event reported to OIG [Office of Inspector General] 08/27/21. Investigations going forward will include: - Conducted observations of the alleged victim, identification of any injuries as appropriate, location where the situation occurred, interaction and relationships between staff and other residents. - Interviews conducted with the alleged victim representative, perpetrator, witness, practitioner, outside agencies as needed. The facility conducted a record review for pertinent information such as progress notes, social services notes, physician, therapist and consultant notes, financial records, incident reports, reports from hospital, lab or x ray, medication records and any other agencies as deemed necessary. - Depending on the nature of the allegation, the facility has put effective measures in place to ensure that further abuse, neglect or exploitation or mistreatment does not occur while the investigation is in progress. The facility will monitor the alleged victim and monitor the other residents at risk, by conducting management visits at different times and shifts. The facility evaluated if the alleged victim felt safe. If they do not, immediate action will be taken to alleviate fear, i.e. room relocation, increased supervision, etc., immediate notification of the victim's practitioner and the family or the victims responsible party. The facility oversees the implementation of corrective action and evaluates effectiveness through the QAPI process. All alleged abuse, neglect or exploitation monitored and recorded on a reportable event log. 2. All residents with BIMs of 8 or above were interviewed by Social Services on 08-25-2021 and 08-26-2021 to ensure there were no concerns of safety, or feelings of abuse while in this facility. None were noted. MOS nurse and SS assistant reviewed residents with BIMS of 7 and below for any signs of change in baseline mood or behavior and normal daily routine. No changes or concerns were identified. 3. LNHA, DON, Unit Managers, ADON, MOS, Business office, Payroll, Activities, Maintenance, Therapy, Scheduling were educated per regional director of Clinical services on 8-26-2021 at 2:15 PM on What is abuse, how to prevent abuse and neglect, when to report abuse and neglect, and to report all abuse to the LNHA immediately. The licensed Nursing Home Administrator will make the initial report to the Office of the Inspector General, Department of Community Based Services, the State Ombudsman and Local Ombudsman, the responsible parties and the MD or Nurse practitioner within two hours. 4. IDT meeting held 8-27-2021; behaviors reviewed to ensure all residents that have behaviors affecting others have interventions and care plans in place. All interventions and care plans were communicated to floor staff by way of the [NAME]. Education on this provided by DON on 8-27-2021. Referrals were made to psychiatric services as appropriate by Social services assistant. DON, and LNHA, and or designee educated all staff on the following: - Identify types of Abuse and Neglect. - When to report suspected abuse and neglect - Reporting of abuse and neglect directly to the administrator immediately - This education completed by 8/27/2021 - In addition, a list of all staff has been developed and no persons will be allowed to work without having completed this education prior to assuming the floor. 1. Facility system changes: i. Behavior monitoring to TAR to be completed every shift. By the RN ii. Facility has reviewed TAR daily in morning clinical meeting. Reviewed 8-27-2021 by DONs iii. Weekend Manager reviews TAR every weekend. iv. IDT team reviews weekly TAR meeting to ensure new interventions were effective and care plans were updated. Review nursing notes for trigger words daily to identify events that occurred throughout the day. Any triggers reported to the Administrator immediately and the licensed Nursing Home Administrator will make the initial report to the Office of the Inspector General (State Survey Agency), Department of Community Based Services, the State Ombudsman and Local Ombudsman, the responsible parties and the MD or Nurse practitioner within two hours. v. Behaviors affecting others addressed immediately as appropriate, residents with noted behaviors will be referred to psych services. DON, LNHA, and or designee audited: i. The Abuse QAPI tool and the reportable events logs completed monthly by the LNHA. Events audited weekly x 3 months and then quarterly x 12 months. Any concerns documented, corrected immediately, and staff will be educated accordingly. ii. Findings/trends reported at the monthly quality assurance and performance improvement committee by the Director of Nursing or designee for a minimum of six months. iii. QAPI meetings weekly for four weeks to monitor progress and then monthly thereafter. The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Onsite verification of the implementation of the Removal Plan was conducted during the survey. On 08/27/2021 between the hours of 11:00 AM and 6:00 PM. Review of the educational materials indicated 100% of staff to include all departments had been completed on 08/26/2021. 1. Resident #85 was reported to push Resident #8 resulting in a fractured femur. The incident was reported on 08/26/2021 and the follow up investigation finalized and reported 08/27/2021. Resident #6 was reported to have exposed [himself/herself] in a group activity on 08/14/2021. This event was reported to OIG on 08/27/2021. 2. Surveyors verified 54 Residents with BIMS 8 or above were interviewed and indicated they felt safe. 3. Review of the educational materials indicated 100% of staff to include all departments had been completed on 08/26/2021. Twelve interviews were conducted on 08/27/2021 between the hours of 11:00 AM - 6:00 PM to verify in-service training had been completed on the facility's Abuse Policy and Procedure training to include the types of abuse, what to report, to whom to report the allegations of abuse and when to report. Of those interviewed included certified nursing assistants (CNAs), licensed practical nurses (LPNs), registered nurses (RNs), housekeeping and scheduling staff. The staff interviewed revealed knowledge of what constituted abuse, what to do if abuse was observed, both staff to resident abuse and in the event of resident-to-resident abuse, when to report abuse and to whom the abuse should be reported. The interviews revealed a consistent message that staff understood not only the different types of abuse, but that resident-to-resident altercations also constituted abuse. Staff indicated that through training they understood the need to intercede immediately and to always protect the resident before reporting any incident of abuse to the Administrator. Staff also acknowledged that have assuring resident safety, abuse should be reported immediately. The LNHA, DON, unit managers, ADON, MDS, business office, payroll department, activities, maintenance, therapy, scheduling received education on what constitutes abuse and when to report. 4. Observations during the survey revealed Resident #85 was receiving 1:1 supervision. Record review for Resident #85 indicated the care plan had been revised to include exhibited physical behaviors and stealing food from other resident's trays. Interventions for Resident #85 included 1:1 supervision, psychiatric referral, laboratory testing and a care conference with family members to determine the resident's past interest. Resident #6 had been placed on every 15-minute checks, and the care plan had been updated on measures to address behaviors, and an IDT meeting was held on 08/27/2021. Resident #6 was seen by psych services on 08/25/2021. Based on interviews, record reviews, and facility policy review, it was determined that the facility failed to investigate abuse allegations for six (6) (Residents #35, #8, #58, #54, #87 and #83) out of six (6) residents reviewed for abuse by Resident #85 and Resident #6. Resident #6 had multiple occurrences of cursing, yelling, throwing things, threatening other residents, and publicly masturbating in front of other residents. These incidents were not investigated. Resident #85 had physical or verbal altercations with other residents and the incidents were not investigated. One of the physical altercations with Resident #85 caused Resident #8 to fall, and Resident #8 sustained a hip fracture. Resident #83 had injuries of unknown origin, including bruising and a hip fracture, that were not thoroughly investigated. It was determined the facility's non-compliance with one or more requirements of participation caused, or was likely to cause, serious injury, harm, impairment, or death to residents. The Immediate Jeopardy (IJ) was related to State Operations Manual, Appendix PP, 483.12 (Freedom from Abuse, Neglect, and Exploitation) at a scope and severity of K. The Immediate Jeopardy (IJ) began on 04/01/2021 when Resident #6 was yelling and cursing at another resident and the facility failed to investigate the allegation of verbal abuse. The Director of Nursing (DON) and Nursing Home Administrator (NHA) were notified of the IJ and provided with the IJ Template on 08/26/2021 at 12:00 PM. A Removal Plan was requested. The Removal Plan was accepted by the State Survey Agency on 08/27/2021 at 6:00 PM. The IJ was removed on 08/27/2021 at 6:00 PM after the survey team performed onsite verification that the Removal Plans had been implemented. Noncompliance remained at the lower scope and severity of pattern, no actual harm with potential for more than minimal harm that was not immediate jeopardy. The findings included: Review of the facility's The Abuse Prevention Program reviewed September 2020 indicated under Paragraph #7 that allegations of abuse would be investigated and reported within the timeframes required by federal requirements. A review of the facility's policy, titled, Abuse and Neglect - Clinical Protocol, revised July 2017, revealed abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also included the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, or psychosocial well-being. The management and staff, with the support of the physicians, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations. 1. Record review revealed the facility admitted Resident #6 with diagnoses of dementia with behavioral disturbances and schizophrenia. The Quarterly Minimum Data Set, dated [DATE] indicated Resident #6's cognition was severely impaired with Brief Interview for Mental Score (BIMS) of three (3) out of fifteen (15). Review of a Progress Note, dated 04/01/2021, indicated Resident #6 was cursing and yelling at another resident. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/03/2021, revealed Resident #6 was cursing other residents and making multiple verbal threats. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/04/2021 at 5:20 PM, indicated Resident #6 was extremely agitated and yelling at other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/09/2021 at 10:04 AM, indicated Resident #6 was verbally aggressive with other residents, threatening harm, and cursing. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/13/2021 at 7:50 AM, indicated Resident #6 was cursing and threatening to harm other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/16/2021, indicated Resident #6 was yelling and cursing at other residents, and the facility had the Director of Nursing come back to the unit. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/18/2021, indicated Resident #6 was yelling, throwing stuff, and cussing at other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 04/30/2021, indicated Resident #6 was publicly masturbating during an activity. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 05/08/2021, indicated Resident #6 was yelling and cussing at other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 05/29/2021, indicated Resident #6 had been cursing, yelling, and threatening other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 06/05/2021, indicated Resident #6 was verbally aggressive with another resident. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 06/14/2021, indicated Resident #6 had been cursing and yelling at other residents and throwing items in the resident's room. There was no evidence provided that showed this was investigated. Review of a Physician's Progress Note, dated 06/16/2021, indicated Resident #6 was noted to have the potential to harm staff, other residents, or self. Review of a Physician's Progress Note, dated 06/17/2021, indicated Resident #6 had a long history with physical aggression related to schizoaffective bipolar disorder. Review of a Progress Note, dated 06/29/2021, indicated Resident #6 was threatening to hit, was cursing, and was being verbally aggressive with other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 07/27/2021, indicated Resident #6 was cursing and threatening to hit other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 08/11/2021, indicated Resident #6 was being verbally aggressive with other residents and was threatening to harm other residents. There was no evidence provided that showed this was investigated. Review of a Progress Note, dated 08/14/2021, indicated Resident #6 had exposed himself/herself and touched self inappropriately in front of other residents during an activity. The DON had come to the unit to talk to the resident regarding behaviors. There was no evidence provided that showed this was investigated. Review of a Physician's Progress Note, dated 08/18/2021 at 12:00 PM, indicated Resident #6 was verbally and physically aggressive, was throwing things, trying to break things, slamming the walker, and yelling and cursing. Haldol 2.5 mg (milligrams) was given. During an interview on 08/24/2021 at 3:15 PM, Licensed Practical Nurse (LPN) #3 indicated Resident #6 threatened to kill other residents, and it was just a matter of time before the resident hurt another resident. She indicated the facility's administration was aware of Resident #6's aggressive physical and verbal behaviors. During an interview on 08/24/2021 at 2:16 PM, Resident #54 indicated Resident #6 had kicked Resident #54 in the leg with three (3) staff members present who witnessed the incident. During an interview on 08/24/2021 at 3:30 PM, the Activity Assistant (AA) indicated she had witnessed Resident #6 kick Resident #54. During an interview on 08/26/2021 at 12:15 PM, the AA indicated Resident #6 exposed self to two (2) female residents during an airshow while outside in the courtyard. During an interview on 08/26/2021 at 12:20 PM, Resident #58 indicated Resident #6 had exposed self to Resident #58 during the airshow, and that it made the resident feel uncomfortable, wondering what [Resident #58] did to provoke this. During an interview on 08/26/2021 at 12:30 PM, Resident #87 indicated Resident #6 had their genitals in his/her hand and was exposing self to Resident #58. Resident #87 indicated (gender) felt bad for Resident #58. There were no investigations completed for these verbal, physical, or sexual abuse allegations. During an interview on 08/25/2021 at 2:23 PM, the DON indicated allegations of abuse were to be reported to their immediate supervisor, and it would then be reported to the DON or Nursing Home Administrator (NHA). The DON stated she was not aware of the allegations of physical, verbal, and sexual abuse. The DON indicated she would report verbal allegations of abuse depending on how the other residents felt. She indicated the incident of Resident #6 exposing self during an activity should have been reported.