**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure each resident remained free from physical and psychosocial abuse for 7 (#R1, #1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2) of 9 (#R1, #1, #3, #4, #5, #6, #7, Unknown Resident #1, and Unknown Resident #2) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 02/22/2025, when Resident #4, a cognitively impaired resident, hit Resident #R1 on the back. The facility failed to ensure effective interventions were put into place to protect the resident's from abuse after the 02/22/2025 incident. Resident #4 exhibited continued aggressive and abusive behaviors, and was transferred to the facility's locked dementia care unit on 03/25/2025. On 03/25/2025, Resident #4 was observed grabbing Unknown Resident #1 by the feet and attempting to pull the resident out of their wheelchair. The resident was observed by a former employee to be fearful, displaying physical and verbal signs of stress. Unknown Resident #1 was scared, crying, and kept doing a swatting motion with her hands. The IJ continued on 04/17/2025, when Resident #4 interlocked her arms around Resident #3's throat then began pulling back, choking her. The IJ continued on 05/20/2025, when Resident #4 pushed Resident #5, causing Resident #5 to fall to the floor. Resident #4 then hit Resident #5 in her face. Resident #5 complained of hip pain after the incident. Resident #5's family requested Resident #5 be moved out of the locked dementia care unit for safety, which resulted in Resident #5 crying for days. The IJ continued on 05/26/2025, when Resident #4 grabbed Unknown Resident #2's hair, pulled it, and would not let go. On 05/26/2025, Resident #4 was placed on 1:1 supervision then removed from 1:1 supervision on 06/09/2025. On 06/09/2025, Resident #4 pushed Resident #6 into the wall, causing Resident #6 to hit her head against the wall. Resident #6 complained of a headache after the incident and required administration of Tylenol for pain management. Resident #4 was placed back on continuous 1:1 supervision on 06/09/2025. On 06/16/2025, Resident #1 was found in a resident's room lying on her left side in a fetal position. Resident #4 was observed standing on the right side of Resident #1's wheelchair with Resident #1's wheelchair pad in her hand, and no staff present with Resident #4. Resident #1 was noted to have swelling to the left side of her face and right knee. Resident #1 was transferred to the hospital where it was determined she had a right femur fracture and a left facial hematoma. Due to Resident #1's age, she was unable to undergo surgery and was ultimately transferred to an inpatient hospice facility where she passed away on 06/25/2025. On 07/09/2025 at 5:30 a.m., an observation was made of Resident #4. She was lying in her bed with no staff present at bedside. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Residents #R1, #3, #6, Unknown Resident #1, and Unknown Resident #2, it could be determined a reasonable person would have experienced psychosocial harm as a result of Resident #4's abusive behaviors since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. S1ADM was notified of the Immediate Jeopardy situation on 07/09/2025 at 4:58 p.m. Findings:Review of the facility's policy dated 03/25/2023 and titled, Abuse-Prevention and Prohibition Policy and Procedure, revealed the following, in part:Purpose:Each resident has the right to be free from abuse.3. Physical Abuse may include hitting, slapping, pinching, biting, shoving, and kicking.4. Mental Abuse includes, but is not limited to, harassment.There may be some situations in which the resident is unable to express him/herself due to a medical condition and/or impairment, cannot relate what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. A lack of response by the resident does not mean that mental abuse did not occur. Resident #R1Review of Resident #R1's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #R1's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 07/02/2025 revealed a Brief Interview for Mental Status (BIMS) of 5, which indicated Resident #R1 was severely cognitively impaired. Resident #4Review of Resident #4's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, Dementia with Agitation, Major Depressive Disorder, and Anxiety. Review of Resident #4's Quarterly MDS with an ARD of 05/14/2025 revealed a BIMS of 2, which indicated she had severe cognitive impairment. Further review revealed Resident #4 was ambulatory and required supervision with ADL's. Review of Resident #4's Nurse's Notes revealed the following, in part:02/22/2025 at 4:42 p.m.-While doing medication pass, Resident #4 was in another residents room and Resident #R1 (Resident #4's husband) was standing at doorway. I asked Resident #4 to follow me to her room and she exited with the other residents blanket rolled up in her arms. Resident #R1 attempted to take it from her and give it back to the other resident, and when she followed him out she hit him in his back. Signed, S4EMP. On 07/10/2025 at 9:55 a.m., an interview was conducted with S4EMP. She stated she observed the incident between Resident #4 and #R1 on 02/22/2025. She stated prior to the incident, Resident #4 wandered into another resident's room and stole the blanket off the bed. She stated Resident #R1 attempted to take the blanket from Resident #4 and return it to the bed. She stated Resident #4 then became enraged and hit #R1 on the back. She stated the two were separated immediately by staff and Resident #4 was placed under the direct supervision of staff for the rest of the shift. She further stated Resident #R1 and Resident #4 were not allowed to be alone together and doors were not to be closed to Resident #4's room. She stated #R1 was assessed and no injuries were sustained and he reported no pain. She stated she would consider this incident resident to resident physical abuse. Further review of Resident #4's Nurse's Notes revealed the following, in part: On 03/09/2025 at 3:11 p.m. - Resident went to end of hall and grabbed a wet floor sign. Resident got combative when CNA tried to get her to put the sign down and hit CNA. Signed by S12EMP. On 03/11/2025 at 4:21 p.m.-Resident took an employee's purse/bag, staff attempted to redirect resident and retrieve bag, resident became combative kicking and hitting the nurse in the chest. Resident's husband attempted to talk to the resident and get the bag. The resident was resistant to him as well but finally let go of the bag. Resident was provided time to calm down. Staff applied non-slip socks for safety as resident is wondering around the facility without shoes and only one sock on that she is bending over trying to remove. Signed by S6EMP. Review of Resident #4's admission and discharge report revealed she was transferred to an inpatient psychiatric facility on 03/12/2025 for aggressive behavior and returned to the facility on [DATE], when she was placed on the locked dementia unit. Review of Resident #4's current Physician Orders revealed the following, in part: 03/19/2025-Admit to memory care; secure unit monitoring Review of Resident #4's current Care Plan revealed the following, in part: Problem: Resident went into another resident's room and urinated on the floor, turning on/off others lights. 03/26/25- The resident has been taking other residents food, throwing food at staff, hitting staff members, yelling at other residents, and pushing furniture while other residents are on it. The resident can be difficult to redirect. 03/27/25- The resident has been taking family members belongings and refusing to give them back. The resident attacked a CNA when the resident could not open window.Interventions: Redirect as needed; Administer medications as ordered Unknown Resident #1 Further review of Resident #4's Nurse's Notes revealed the following, in part:On 03/25/2025 at 7:10 p.m.-Resident #4 noted attempting to take residents from the community area against their will. Unable to redirect, she is becoming verbally aggressive. Resident #4 noted tearing padding off a residents wheelchair, when redirection attempted she grabbed Unknown Resident #1 by both feet and began trying to pull her out of her chair by her feet. Unknown Resident #1 is fearful and showing physical as well as expressing verbal signs of stress. Resident #4 then walked away and took a facility chair making attempts to leave with the chair but while sitting in it. Signed by S30FEMP. On 3/25/2025 at 7:19 p.m. - Resident #4 noted making attempts to snatch the same resident, Unknown Resident #1, out of the top of her chair by the shirt. When redirected, Resident #4 became physically aggressive and pushed the couch in the community living room while another resident was sitting on it. Resident #4 continues to act out verbally and physically against staff and fellow residents. Signed by S30FEMP. On 07/10/2025 at 9:38 a.m., a telephone interview was conducted with S30FEMP. She stated she was working on 03/25/2025. She stated Resident #4 attempted to pull another resident out of her wheelchair by her feet. She stated she remembered the resident had a seatbelt in place but was unable to recall which resident it was. She stated the incident was unprovoked. She stated she was close by when it occurred and was able to intervene immediately and separated Resident #4 from the resident in the wheelchair before any injuries occurred. She stated after the incident, Unknown Resident #1 was scared, crying, and kept doing a swatting motion with her hands. She stated she informed S1ADM and S2DON frequently of her concerns for the safety of the other resident's due to Resident #4's aggressive behavior. She stated she told them Resident #4 would become violent with no warning, attacked staff and other residents, and could not be redirected. She stated when Resident #4 was transferred to the locked dementia unit, she felt like she was not able to keep the other resident's safe due to Resident #4's aggressive behaviors. Further review of Resident #4's Nurse's Notes revealed the following, in part:On 3/26/2025 at 12:05 p.m. - During lunch Resident #4 walked over to nurse's desk and removed the top from another resident's food and attempted to pick up the food with her hands. The nurse attempted to redirect resident and she became angry and grabbed a handful of greens and threw them at the nurse and grabbed the bowl of pie and hit the nurse with the pie. Resident swung at nurse multiple times. Resident #4 then lost balance and fell on the floor. Resident #4 did not hit her head. While on the floor, resident attempted to kick nurse multiple time. Nurse was able to remain holding Resident #4's hand while the CNA went to get assistance. S1ADM and S13NP notified of the resident's aggressive behavior. Signed by S7EMP. On 3/27/2025 at 5:30 p.m.-Late Entry-The resident was attempting to open a window with intent to elope. The CNA sitting directly next to the window turned her head to see what was going on and asked Resident #4 what she was doing and to not do that to the window. Resident #4 immediately turned and began grabbing and hitting the CNA in her head and face. The CNA yelled for assistance I went over to get the resident to stop. Resident #4 then became aggressive towards me. Resident #4 was very difficult to redirect but after some time Resident #4 walked away but remained agitated until she went to bed. The situation was reported to S1ADM and her responsible party. Signed by a S30FEMP. Resident #3Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #3's Quarterly MDS with an ARD of 06/11/2025 revealed a BIMS of 9, which indicated Resident #3 was moderately cognitively impaired. Review of Resident #3's Incident report dated 04/17/2025 at 3:00 p.m.Incident Description: Nursing description-Resident #3 witnessed by hall staff sitting in the community living room area watching television when Resident #4 walked over to Resident #3 and said something indecipherable and then began hitting Resident #3. Resident #3 in no way instigated the interaction. Resident #3 reported she did not do or say anything to the Resident #4. No injuries noted. Review of Resident #3's Nurse's Notes revealed the following, in part:04/18/2025 at 1:06 p.m. -Shift Summary: Following report received at shift change, went to visually assess Resident #3 related to incident earlier on previous shift. Assessed Resident #3 for pain and any potential injuries. Resident #3 denied any pain (but specifically to head, neck and back) and no visual markings or bruises noted. Resident #3's speech clear and appropriate. Upon Resident #3 getting up for the day, Resident #3 came and sat by this nurse and described earlier incident, Resident #3 continues to deny any pain or discomfort with associated incident. Resident #3 does not appear in any mental anguish, states she is alright but she will not forget what happened to her. Will continue to monitor. Signed by S6EMP. Further review of Resident #4's Nurses Notes revealed, in part:On 04/16/2025 at 12:15 p.m. -Resident #4 took papers from nurse's desk. Nurse attempted to retrieve papers from resident. Resident #4 became aggressive and pulled nurse's hair and kicked nurse in the stomach. Resident #4 then lost balance trying to kick nurse a second time and fell. Resident #4 did not hit head, no apparent injuries noted. Resident #4 assisted off of the floor by staff. Resident #4 refused vital signs. S13NP and RP notified. Signed by S7EMP. On 04/17/2025 at 9:49 p.m. -Resident #4 exhibited verbal and physical aggression this shift. Resident #4 was pushing Resident #1 down the hall and that resident was asking her to stop. Staff asked Resident #4 not to push her as she didn't want to be pushed and Resident #4 became verbally aggressive and threatening toward staff. As I attempted to administer medication to Resident #1, Resident #4 reached out and grabbed the medication which was crushed in pudding. She then laughed and went to the sink to wash her hands. I went off the unit to report the incident to the administrator. Upon returning to the unit, Resident #4 was noted yelling and sitting on top of Resident #1 while aggressively squeezing her hands and pushing them down where they were also crushed between the sides of the resident's legs and the arm rest of her wheelchair. Resident #4 was verbally and physically aggressive with staff as they tried to convince her to get off of Resident #1. I called for the administrator to come assist us. When he arrived Resident #4 stood up and continued being verbally aggressive while she walked over to Resident #3. Resident #4 leaned down and spoke aggressively to Resident #3 and when that resident started to speak, Resident #4 began attacking her. Resident #4 was noted standing behind Resident #3 using both hands balled into fists and striking her repeatedly in the head. When staff turned to intervene, Resident #4 leaned over the resident and wrapped both arms around Resident #3's neck squeezing it. As staff attempted to remove the resident from Resident #4's clutch, Resident #4 attempted to stop us from moving the resident and had her hands around the resident's neck. Resident #4 began slapping and grabbing at the residents face. We were finally able to block Resident #4 from Resident #3 and she walked away to Resident #1. Resident #4 attempted to push Resident #1 in her wheelchair but staff was able to stand in front of the wheelchair and hold it still. Resident #4 then began pulling on the trunk support contraption and tearing the protective foam padding off of it. Resident #4 continued to try to get the resident's wheelchair away from staff but became more frustrated and began pushing tables around the dining area. Resident #4 walked around to the other side of the dining room in order to pull a table out of the way so she would have access to the back of Resident #1's wheelchair. Once behind the wheelchair, she made more attempts to pull the chair from the grasp of staff. When she was unable to, she grabbed the high back wheelchair handles while putting her foot on the rear tippers and pulled aggressively to tip the wheelchair backwards. Two staff members remained in place holding Resident #1's wheelchair so it could not be tipped. Resident #4 finally walked away, remaining quite agitated. She continued to speak aggressively to other residents and staff but stopped being physically aggressive at that point. After taking evening medication Resident #4 had no more issues and cooperated with her usual bedtime routine. Signed by a S30FEMP. On 07/08/2025 at 8:48 a.m., an interview was conducted with Resident #3. She stated she did not recall being involved in any incidents with another resident On 07/08/2025 at 3:44 p.m. an interview was conducted with S5EMP. She stated she witnessed Resident #4 choke Resident #3 a few months ago. She stated Resident #4's elbows were around the front of Resident #3's neck. She stated she attempted to pull Resident #4's arms away from Resident #3's neck but was told to let her be by S1ADM, who was present at the time of the incident. She stated another nurse S30FEMP witnessed the incident as well. S5EMP stated this incident was resident to resident abuse. She stated Resident #4 was sent to the behavioral hospital after the incident. On 07/08/2025 at 10:28 a.m., a telephone interview was conducted with a S30FEMP. She stated she witnessed the incident between Resident #3 and Resident #4 which occurred on 04/17/2025. She stated Resident #3 was sitting in her wheelchair facing the window. She stated Resident #4 wrapped her arms around Resident #3's neck then began pulling her backward. She stated when S5EMP attempted to break up the resident's, S1ADM instructed S5EMP to take her hands off of Resident #4. She stated then Resident #4 walked calmly toward Resident #1, stood behind her wheelchair and began trying to tip over her wheelchair from the back and the side. She stated the assistant administrator then intervened, sitting on one armrest to prevent the wheelchair from tipping. She stated she continued trying to redirect Resident #4, but it was ineffective as it usually was. She stated Resident #4 eventually walked away, sat on the couch, and cried. She stated Resident #4 was sent to the behavioral hospital after the incident. Review of Resident #4's Nurse Practitioner Notes revealed the following, in part:On 04/18/2025- Resident #4 had an aggressive episode in which she attacked 3 other residents on the secured Dementia Unit. See Nursing Home Notes. Resident #4 appears to be a danger to others as she is impulsive and frequently become aggressive despite recent change in psychotropic medications. Recent inpatient psychiatric evaluation and treatment noted. Physician Emergency Certificate (PEC) written today as Resident #4 appears to be a danger to others. Signed by S13NP. Resident #5Review of Resident #5's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #5's Quarterly MDS with an ARD of 06/11/2025 revealed a BIMS score of 11, which indicated Resident #5 was moderately cognitively impaired. Review of the facility's Incident Log revealed Resident #5 had an unwitnessed fall on 05/20/2025 at 6:00p.m. Review of Resident #5's Incident Report dated 05/20/2025 at 6:00p.m. revealed the following, in part:Incident Location: Resident's RoomNursing description: The CNA reported that she heard a commotion coming from one of the resident's room. She went into Resident #5's room and noted Resident #5 and Resident #4 were on the floor. Spilled cup of water also noted on the floor near the residents along with their clothes noted wet.Resident Description: Resident #5 stated she fell.Was the incident witnessed: NoImmediate Action Taken: Residents were immediately separated. The CNA removed Resident #4 from Resident #5's room and walked her back to her own room. Resident #5 was assessed for injuries, no apparent injuries noted. Vitals obtained. Neuro checks initiated. ROM performed, resident complained of pain in her right hip. On call NP notified. New order obtained for stat x-ray ordered to bilateral hips/pelvis. Resident #5's RP notified. Review of Incident Witness Statement revealed the following, in part:Witness Name: S5EMPResidents Involved: Resident #4 and Resident #5Date of Incident: 05/20/20251. Provide a brief description of what happened: I was helping another resident and turned around and saw Resident #5 and Resident #4's hands up in the air, middle of doorway, going back and forth. Resident #5 was yelling stop. I called for help and as I entered room, Resident #4 and #5 were on the floor. I grabbed Resident #4 and she swung at Resident #5 on the side of face.2. Are you aware of an injury? No3. Where did the incident take place? Resident #5's room4. What actions did you take immediately? Running to get Resident #4 out of room5. Did anyone else other than you witness the incident? No Review of Resident #5's Social Services Note dated 05/23/2025 revealed the following, in part:05/23/2025 at 3:12 p.m.: S17SS went to speak with Resident #5 on the afternoon of 05/23/2025. Upon entering Resident #5's room she was visibly distraught and talking with the nurse. Resident #5 said that she was feeling like she was being taken away from her home. When asked about a prior incident that occurred, Resident #5 stated that she didn't know. She said she was very confused because she couldn't remember how the lady hit her or what happened. She repeated she was very confused and couldn't remember anything about a woman hitting her and started getting upset more. She then changed the subject back to wanting to go back to her room on the memory care unit. She said she was happy there and safe there and needs to go back. S17SS said that she would check in with her more frequently and see how our staff could help her adjust to her new room. SS informed nurse to follow up with NP regarding her mood. S17SS also reached out to NP and to the Psych NP. Psych NP will round on 05/29/2025. Signed by S17SS. On 07/08/2025 at 8:48 a.m., an interview was conducted with Resident #3. She stated she recalled when her friend, Resident #5, was attacked by Resident #4. She stated Resident #5 was walking down the hall when Resident #4 pushed her to the floor and began hitting her. She stated Resident #5 told her she was scared to death and did not treat anyone poorly to deserve being treated like that. On 07/08/2025 at 3:27 p.m., an interview was conducted with Resident #5. Resident #5 stated she previously resided on another hall at the facility. She stated she was involved in an altercation with another resident during which she was hit, unprovoked. She stated her family was worried about her safety after the incident and requested a room change. She stated she did not know the name of the resident that hit her. She was unable to recall when the incident took place. She stated she did not remember if she was injured. On 07/08/2025 at 3:44 p.m., an interview was conducted with S5EMP. She stated she was working on 05/20/2025 and witnessed the incident between Resident #4 and Resident #5. She stated she heard Resident #4 yelling at Resident #5 to get out of her room. She stated she saw Resident #4 push Resident #5 from behind. She stated Resident #5 fell down, then Resident #4 fell down as well. She stated while on the floor, Resident #4 was swinging at Resident #5, and Resident #5 had her hands in the air trying to protect herself. She stated she immediately tried removing Resident #4 from Resident #5, and Resident #4 swung, hitting Resident #5 on the side of her face. She stated she separated the residents and reported the incident to S18EMP. She stated Resident #5 complained of pain after the incident and an x-ray was ordered. She stated she staff told Administration about Resident #4's aggression and abuse of the other residents but they did not do anything to stop or prevent it. She stated Resident #4 was sent out to a behavioral hospital after the incident, but it did not help. On 07/09/2025 at 12:00 p.m., an interview was conducted with S18EMP. She stated she was not in the locked dementia unit at the time of the incident between Resident #4 and Resident #5. She stated when she arrived on the unit, she was notified of what happened and both residents were already separated, and in their rooms. She stated she completed an assessment on Resident #5, and Resident #5 complained of hip pain. She stated she notified the Nurse Practitioner and Resident #5's family. She stated an x-ray was ordered. She stated Resident #5 stated, that lady came in my room, why was she in my room? She stated she reported the incident to Administration. She stated for any allegations of abuse or witnessed abuse, she would notify S1ADM or S2DON. On 07/09/2025 at 9:55 a.m., an interview was conducted with Resident #5's family member. He stated he was told Resident #5 had a fall on 05/20/2025 at 7:42 p.m. resulting in hip pain. He stated the nurse said an x-ray was completed and it later revealed no injury, just arthritis. He stated through his own discussions with staff, he learned the incident was not just a fall, instead it was an altercation with Resident #4. He stated he visited Resident #5 at the facility the following day to check on her. He stated during their visit Resident #5 was paranoid, frequently stating I didn't push her, she pushed me. I don't want to be pushed around again. He stated this prompted him to discuss the incident with S1ADM. He stated when he discussed the incident with S1ADM, S1ADM refused to show him the camera footage, with the reason of him not being Resident #5's Power of Attorney (POA). He stated S1ADM also denied another resident was involved in the incident. He stated he arranged to become Resident #5's POA the same day. He stated when he presented the paperwork to S1ADM, he would not accept it and still would not let him see the camera footage. He stated S1ADM contacted corporate, who agreed to acknowledge the POA and let him see the footage. He stated when he was allowed to watch the camera footage, 2 of the 3 videos had already been deleted. He stated S1ADM did not provide a reason for the deletion. He stated he was initially told the footage was available for 7 days, and it had not yet been that long. He stated when he reviewed the camera footage, it revealed the incident occurred on 05/20/2025 at 7:15 p.m. He stated Resident #5 was followed to her room by Resident #4 at the start of the footage. He stated it appeared Resident #5 was pushed out of the doorway, then the video stopped. He stated Resident #5 never had any altercations with any other residents. He stated after he was made aware the incident involved Resident #4, he requested Resident #5 be moved to another room off the locked dementia unit. He stated if Resident #5 was fully cognitive, she would also classify it as abuse since she had vision impairment causing her to only see 3-4 feet in front of her, and would not be able to defend herself. On 07/10/2025 at 3:35 p.m., an interview was conducted with S17SS. She stated she saw Resident #5 within 72 hours of the incident and room change. She stated Resident #5 cried for days following the incident. Further review of Resident #4's current Care Plan revealed the following, in part:Goal: The resident will have fewer episodes of behavior by review date of 08/12/2025.Intervention: Every 30 minute checks for behavior x 24 hours, initiated 05/20/2025. Redirect as needed. Resident separated on 05/20/2025. Unknown Resident #2Review of Resident #4's Nurse's Notes revealed the following, in part:On 5/26/2025 at 7:47 p.m. -Late entry for 4:30 p.m.-Resident #4 agitated at another resident continuously calling staff lil N***** girls. Resident #4 jumped up out of chair and rushed over to another resident yelling, Ok you are being obnoxious and I've had enough! Resident #4 abruptly grabbed Unknown Resident #2's wheelchair and started pushing her quickly down the hall and then spun her around and started pushing her quickly back to dining room. Unknown Resident #2 asked, What are you gonna do, push me into somebody? Resident #4 stepped around wheelchair, facing Unknown Resident #2 and attempted to grab her. Staff stepped in between both residents and attempted to redirect them. Unknown Resident #2 stated, I'm gonna kill her. Resident #4 left staff and rushed back to Unknown Resident #2 and grabbed a hand full of hair from the top of her head and continued to pull it. Resident #4 would not let it go. RN supervisor entered unit a few minutes later and was informed of incident. Signed by S10EMP. Further review of Resident #4's current Care Plan dated 05/25/2025 revealed the following, in part:Intervention: 1 on 1 observation 05/26/2025-06/09/2025. Multiple attempts were made throughout the survey to contact S10EMP, which were unsuccessful. Resident #6Review of Resident #6's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #6's admission MDS with an ARD of 04/23/2025 revealed Resident #6 had a BIMS of 5, which indicated she had severe cognitive impairment. Review of Resident #6's Incident Report dated 06/09/2025 at 4:10 p.m. revealed the following, in part:Resident: Resident #6Incident location: dining roomIncident description: Resident #6 was standing up in the common area with the use of her rolling walker talking to Resident #4 when Resident #4 told Resident #6 to shut up, and pushed Resident #6 backwards causing resident to stumble backwards. Resident #6 hit her head against the wall and fell to the floor.Immediate action taken: Resident #6 assessed for injuries, none noted. Resident #6 complained of pain to her lower back at this time. Tylenol administered for pain. Staff assisted Resident #6 up off the floor and into a chair. Range of motion performed and within normal limits. Neuro Checks initiated. Vitals obtained. S13NP notified and RP notified. Further review of Resident #4's Nurse's Notes revealed the following, in part:On 06/09/2025 at 11:15 p.m.-Late entry for 4:10 p.m. Resident #4 was talking with Resident #6 in the dining room area when she pushed Resident #6. Signed by S9EMP. On 07/10/2025 at 8:47 a.m., an interview was conducted with S9EMP. She stated she was working on 06/09/2025. She stated Resident #6 was standing up talking and Resident #4 turned around told her to shut up and shoved her. She stated there was no forewarning and no triggers noted. She stated Resident #6 fell and hit her head. She stated Resident #6 stated she contacted S13NP. She stated S13NP gave an order for Tylenol for Resident #6's complaint of head pain and stated to monitor Resident #6 with neurological checks. She stated the incident between Resident #4 and #6 would be considered abuse. She stated after this incident, Resident #4 had a staff member assigned to her 1:1 monitoring for 2-3 days. On 07/10/2025 at 3:30 p.m., an interview was conducted with S23EMP. She stated she was working on 06/09/2025. She stated Resident #4 stood up and shoved Resident #6 into the wall. She stated Resident #6 hit her head and then fell to the ground. She stated Resident #6's facial expressions showed fear and Resident #6 kept telling staff to call her husband. She stated it happened so fast she couldn't do anything to prevent Resident #4 from pushing Resident #6. She stated since the nurse witnessed it, she did not report the incident to anyone. She stated she was told by S1ADM not to intervene because they didn't know what triggered Resident #4. She stated S1ADM told staff to avoid trying to stop it, and not to scream or pull at Resident #4 because she might get more aggressive. She stated if a resident shoved another resident it was abuse. Further review of Resident #4's current Care Plan revealed the following, in part:Intervention: Sent to ER for evaluation/treatment dated 06/09/2025. 1:1 close monitoring initiated on 06/09/2025. Resident #1Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE]. Review of Residen

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure all alleged allegations involving physical and psychological abuse were reported immediately, but not later than 2 hours after the allegation was made, to the State Survey Agency, for 7 (#R1, #1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2) of 9 (#R1, #1, #3, #4, #5, #6, #7, Unknown Resident #1, and Unknown Resident #2) residents reviewed for abuse. This deficient practice resulted in an Immediate Jeopardy situation on 02/22/2025, when the facility failed to report allegations of abuse to the State Agency. On 02/22/2025, Resident #4 hit Resident #R1. On 03/25/2025, Resident #4 attempted to pull Unknown Resident #1 out of her wheelchair by her feet. On 04/17/2025, Resident #4 hit Resident #3. On 5/20/2025, Resident #4 pushed Resident #5, causing her to fall then Resident #4 hit Resident #5 in the face. On 05/25/2025, Resident #4 grabbed Unknown Resident #2's hair and pulled it and wouldn't let go. On 06/09/2025, Resident #4 told Resident #6 to shut up and pushed Resident #6 backwards causing her to stumble and hit her head against the wall and fall to the floor. On 06/16/2025, the nurse heard a scream and a wheelchair alarm go off and a second scream and she observed Resident #1 lying on her left side on the floor by the bed in a fetal position, and observed Resident #4 standing at the end of the bed next to Resident #1's wheelchair with the seat pad in her hands. Record review revealed none of the above incidents were reported to the State Agency. Interview with S1ADM revealed he was aware of the incidents above and none were reported to the State Agency. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Residents #R1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2, it could be determined a reasonable person would have experienced psychosocial harm as a result of Resident #4's abusive behaviors since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. S1ADM was notified of the Immediate Jeopardy situation on 07/11/2025 at 11:10 a.m. This deficient practice continued at a potential for more than minimal harm for the other 166 residents residing in the facility. Findings:Cross Reference F600 and F835 Review of the facility's policy dated 03/25/2023 and titled, Abuse- Prevention and Prohibition Policy and Procedure, revealed the following, in part: II. Procedures:7. Reporting/Response: The facility employee or covered individual who becomes aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator. The Administrator shall immediately initiate a self-reported incident report to the State Survey Agency and the facility's local law enforcement agency, but not less than 2 hours after forming the suspicion of a crime if the alleged violation involves abuse (physical, sexual, verbal, or mental) or results in serious bodily injury. On 07/10/2025 at 9:20 a.m., review of the facility's self-reported incidents dated January 2025 through July 2025 revealed no incidents of resident to resident abuse reported to State Agency. Resident #R1Review of Resident #R1's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #4's Nurse's Notes revealed the following, in part:02/22/2025 at 4:42 p.m.-While doing medication pass Resident #4 was in another residents room and Resident #R1 (Resident #4's husband) was standing at doorway. I asked Resident #4 to follow me to her room and she exited with the other residents blanket rolled up in her arms. Resident #R1 attempted to take it from her and give it back to the other resident, and when she followed him out she hit him in his back. Signed, S4EMP. On 07/10/2025 at 9:55 a.m., an interview was conducted with S4EMP. She stated she observed the incident between Resident #4 and #R1 on 02/22/2025. She stated she would consider this incident resident to resident physical abuse. She stated she reported the incident but did not recall who she reported it to. She stated the facility's protocol was to notify the direct supervisor immediately after a witnessed incident. Unknown Resident #1Review of Resident #4's Nurse's Notes revealed the following, in part: On 03/25/2025 at 7:10 p.m.-Resident #4 noted attempting to take residents from the community area against their will. Unable to redirect, she is becoming verbally aggressive. Resident #4 noted tearing padding off a residents wheelchair, when redirection attempted she grabbed Unknown Resident #1 by both feet and began trying to pull her out of her chair by her feet. Unknown Resident #1 is fearful and showing physical as well as expressing verbal signs of stress. Resident #4 then walked away and took a facility chair making attempts to leave with the chair but while sitting in it. Signed by S30FEMP. On 07/10/2025 at 9:38 a.m., a telephone interview was conducted with S30FEMP. She stated she observed the incident above between Resident #4 and Unknown Resident #1 on 03/25/2025. She stated she informed S1ADM of the incident after it happened. Resident #3Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #3's Incident report dated 04/17/2025 at 3:00 p.m.Person Preparing Report: S30FEMPNursing description: Resident #3 witnessed by hall staff sitting in the community living room area watching television when Resident #4 walked over to Resident #3 and said something indecipherable and then began hitting Resident #3. Resident #3 in no way instigated the interaction. Resident #3 reported she did not do or say anything to the other resident. No injuries noted. On 07/08/2025 at 10:28 a.m., a telephone interview was conducted with S30FEMP. She stated she witnessed the incident between Resident #3 and Resident #4 which occurred on 04/17/2025. She stated Resident #3 was sitting in her wheelchair facing the window. She stated Resident #4 wrapped her arms around Resident #3's neck then began pulling her backwards, choking her. She stated S1ADM was present during the incident. She stated when S5EMP attempted to break up the residents, S1ADM instructed S5EMP to take her hands off of Resident #4. She stated for any allegations of abuse or witnessed abuse, she would notify S1ADM, S2DON, or S3ADON. On 07/08/2025 at 3:44 p.m., an interview was conducted with S5EMP. She stated she witnessed the incident between Resident #3 and Resident #4 which occurred on 04/17/2025. She stated she attempted to pull Resident #4's arms away from Resident #3's neck but was told to let her be by S1ADM, who was present at the time of the incident. S5EMP stated this incident was resident to resident abuse. She stated for any allegations of abuse or witnessed abuse, she would notify the nurse or administrative staff. Resident #5Review of Resident #5's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #5's Incident Report dated 05/20/2025 at 6:00p.m., revealed the following, in part:Incident Location: Resident's RoomNursing description: The CNA reported that she heard a commotion coming from one of the resident's room. She went into Resident #5's room and noted Resident #5 and Resident #4 were on the floor. Spilled cup of water also noted on the floor near the residents along with their clothes noted wet.Resident Description: Resident #5 stated she fell.Was the incident witnessed: NoImmediate Action Taken: Resident's #4 and #5 were immediately separated. The CNA removed Resident #4 from this Resident #5's room and walked Resident #4 back to her own room. Resident #5 was assessed for injuries, no apparent injuries noted. Vitals obtained. Neuro checks initiated. ROM performed, Resident #5 complained of pain in her right hip. On call NP notified. New order obtained for stat x-ray ordered to bilateral hips/pelvis. Resident #5's RP notified. Review of Incident Witness Statement revealed the following, in part: Witness Name: S5EMPResidents Involved: Resident #4 and Resident #5Date of Incident: 05/20/20251. Provide a brief description of what happened: I was helping another resident and turned around and saw Resident #5 and Resident #4's hands up in the air, middle of doorway, going back and forth. Resident #5 was yelling stop. I called for help and as I entered room, Resident #4 and #5 were on the floor. I grabbed Resident #4 and she swung at Resident #5 on the side of face. 2. Are you aware of an injury? No3. Where did the incident take place? Resident #5's room4. What actions did you take immediately? Running to get Resident #4 out of room [ROOM NUMBER]. Did anyone else other than you witness the incident? No On 07/08/2025 at 3:44 p.m., an interview was conducted with S5EMP. She stated she was working on 05/20/2025 and witnessed the incident between Resident #4 and Resident #5. She stated Resident #4 pushed then hit Resident #5. She stated she notified the nurse, S18EMP. She stated Resident #5 complained of pain after the incident and an x-ray was ordered. She stated for any allegations of abuse or witnessed abuse, she would notify the nurse or administrative staff. On 07/09/2025 at 12:00 p.m., an interview was conducted with S18EMP. She stated she was not in the locked dementia unit at the time of the incident between Resident #4 and Resident #5. She stated when she arrived on the unit, she was notified of what happened. She stated both residents were already separated and in their rooms. She stated she completed an assessment on Resident #5, and Resident #5 complained of hip pain. She stated she notified the Nurse Practitioner on call and Resident #5's family. She stated an x-ray was ordered. She stated Resident #5 stated, that lady came in my room, why was she in my room? She stated she reported the incident to Administration. She stated for any allegations of abuse or witnessed abuse, she would notify S1ADM or S2DON. Unknown Resident #2Review of Resident #4's Nurse's Notes revealed the following, in part:On 05/26/2025 at 7:47 p.m. -Late entry for 4:30 p.m.- Resident #4 agitated at Unknown Resident #2, continuously calling staff lil N***** girls. Resident #4 jumped up out of chair and rushed over to Unknown Resident #2 yelling, Ok you are being obnoxious and I've had enough! Resident #4 abruptly grabbed Unknown Resident #2's wheelchair and started pushing Unknown Resident #2 quickly down the hall and then spun Unknown Resident #2 around and started pushing Unknown Resident #2 quickly back to dining room. Unknown Resident #2 asked, What are you gonna do, push me into somebody? Resident #4 stepped around wheelchair, facing Unknown Resident #2 and attempted to grab Unknown Resident #2. Staff stepped in between both residents and attempted to redirect them. Unknown Resident #2 stated, I'm gonna kill her. Resident #4 left staff and rushed back to Unknown Resident #2 and grabbed a hand full of hair from the top of Unknown Resident #2's head and continued to pull it. Resident #4 would not let it go. RN supervisor entered unit a few minutes later and was informed of incident. Signed by S10EMP. Multiple attempts were made throughout the survey to contact S10EMP with no success. Resident #6Review of Resident #6's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #6's Incident Report dated 06/09/2025 at 4:10 p.m. revealed the following, in part: Resident: Resident #6, incident location was in the dining roomIncident description: Resident #6 was standing up in the common area with the use of her rolling walker talking to Resident #4 when Resident #4 told Resident #6 to shut up and pushed Resident #6 backwards causing Resident #6 to stumble backwards. Resident #6 hit her head against the wall and fell to the floor.Immediate action taken: Resident #6 assessed for injuries, none noted. Resident #6 complained of pain to her lower back at this time. Tylenol administered for pain. Staff assisted Resident #6 up off the floor and into a chair. Range of motion performed and within normal limits. Neuro Checks initiated. Vitals obtained. S13NP notified and RP notified. On 07/10/2025 at 8:47 a.m., an interview was conducted with S9EMP. She stated she was working on 06/09/2025 and witnessed the incident on 06/09/2025 when Resident #4 pushed Resident #6. She stated she would consider it abuse. She stated she reported it to S3ADON as soon as the incident occurred. On 07/10/2025 at 1:00 p.m., an interview was conducted with S3ADON. She stated S9EMP notified her of the incident between Resident #4 and Resident #6 on 06/09/2025. She stated she immediately notified S1ADM. Resident #1 Review of Resident #1's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #1's Incident Report dated 06/16/2025 at 2:50 p.m., revealed the following, in part: Unwitnessed fall, Date: 06/16/2025 2:50 p.m.Nursing Description: Nurse was on the hall when she heard a scream and then heard a chair alarm sounding off. Upon entering the room Resident #1 noted lying on left side with large hematoma to forehead and swelling and discoloration under left eye. Upon range of motion assessment Resident #1 noted with swelling to right knee.Resident Description: Resident #1 unable to give descriptionWas this incident witnessed: No Review of Resident #1's Nurse's Notes revealed the following, in part:06/16/2025 at 2:50 p.m.- S7EMP heard a scream and then heard a chair alarm sounding off. Upon entering the room, Resident #1 noted lying on left side. Resident #1's wheelchair was next to Resident #1 with seatbelt unbuckled. Resident #1 assessed for injuries. Resident #1 noted with large hematoma to left side of forehead with swelling and redness under Resident #1's left eye. Resident #1 appeared to be very agitated and scared. Nurse attempted to give Resident #1 Tylenol for pain but Resident #1 refused. NP notified, received order to send to ER. Acadian ambulance called for transfer to ER per family request. Nurse sat in room with Resident #1 until ambulance arrived and Resident #1 calmed down. Upon entering the room, nurse noticed two other residents present in close proximity in the room with the resident as well as the upper part of resident's high-back wheelchair was not in the correct position with seatbelt unbuckled. Signed by S7EMP. On 07/08/2025 at 1:15 p.m., an interview was conducted with S7EMP. She stated she was working on 06/16/2025. She confirmed the incident with Resident #1 on 06/16/2025 where Resident #1 was found on the floor out of her wheelchair with Resident #4 standing beside her. She stated she noticed Resident #1 had a large hematoma on the left side of Resident #1's head starting at the hairline and extending to her cheekbone. She stated Resident #1 was crying. She stated she called Administration and informed them she needed assistance immediately due to an unwitnessed incident. She stated she told her supervisors she suspected Resident #4 had pulled Resident #1 out of the wheelchair. She stated she was told since she did not have proof, she did not need to say that. On 07/08/2025 at 3:44 p.m., an interview was conducted with S5EMP. She stated she was familiar with Resident #1 and was assigned to her on 06/16/2025. She confirmed the incident with Resident #1 on 06/16/2025 where Resident #1 was found on the floor out of her wheelchair with Resident #4 standing beside Resident #1. She stated Administration was made aware of this by S7EMP. She stated Resident #4 attempted to push Resident #1 out of her wheelchair three other times that she witnessed. She stated Resident #4 had a known history to target Resident #1. She stated she suspected Resident #4 had pulled Resident #1 out of her wheelchair on 06/16/2025, but was told not to talk about it by administrative staff. She stated for any allegations of abuse or witnessed abuse, she would notify the nurse or administrative staff. On 07/10/2025 at 1:28 p.m., an interview was conducted with S1ADM. He stated staff were expected to immediately report any allegations of abuse or witnessed abuse to him. He stated his responsibility for reporting abuse was to report any allegations of abuse or abuse concerns to State Agency within 2 hours. He stated he was aware of the incidents on 02/22/2025, 03/25/2025, 04/17/2025, 05/20/2025, 05/26/2025, 06/09/2025, and 06/16/2025 involving Resident #4. S1ADM stated he was present on 04/17/2025 when the incident occurred between Resident #3 and Resident #4. He stated Resident #4 grabbed Resident #3 around the shoulders, not around the neck, as staff stated. He stated the incident only lasted for 2 seconds. He stated he was notified of the incident on 05/26/2025 of Resident #4 pulling another residents hair. He stated after reviewing camera footage, he could tell Resident #4's hand was by the other resident, but could not confirm she pulled the resident's hair. He stated again, this only lasted 2 seconds. He stated he was aware on 06/16/2025, Resident #1 was found in front of Resident #1's wheelchair lying on her left side. He stated he was aware Resident #4 was observed to be beside Resident #1's wheelchair at that time. He stated there was presently no video camera footage saved to be reviewed for the incidents listed above. He stated based on State guidance in 2024, it was up to the facility to decide if an incident was abuse. He stated abuse was to be reported if the action was willful and caused injury or pain. He stated due to Resident #4's poor cognition, her actions were not willful, therefore none of the incidents listed above would be considered abuse, and he was not required to report them to State Agency. The Immediate Jeopardy was removed on 07/11/2025 at 3:23 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Plan of Removal F609 - The provider allegedly failed to ensure all allegations of physical and psychosocial abuse was reported to the state agency and within the appropriate timeframe.I. Corrective actions were taken for the residents affected by the alleged deficient practice by:a. Administrator in-serviced on facility self-reported incident reporting, reporting timeline and abuse in-service timing requirements by Regional Director of Operations on 07/11/2025.b. Staff in-service initiated per Staff Developer on 07/10/2025 on abuse prevention and reporting to include reporting timeline, appropriate resident supervision and one-to-one supervision procedures. In-service will be done with all staff prior to starting their next scheduled shift and will be ongoing until completed. Any staff member will not be allowed to work until training has been completed.2. All residents who reside in the facilities secure unit have the potential to be affected by the alleged deficient practice.a. Staff in-service Initiated per Staff Developer on 07/10/2025 on abuse prevention and reporting to include reporting timeline, appropriate resident supervision and one-to-one supervision procedures. In-service will be done with all staff prior to starting their next scheduled shift and will be ongoing until completed. No staff member will be allowed to work until training has been completed.3. Measures put in place to ensure the alleged deficient practice will not recur are:a. Administrator in-serviced on facility self-reported incident reporting, reporting timeline and abuse in-service timing requirements by Regional Director of Operations 07/11/2025. 4. The facility plans to monitor its performance to ensure solutions are achieved and sustained by (monitoring started on 07/11/2025 as observed by Surveyors):a. Regional Director of Operations will conduct audit 3 times per week to ensure all reportable incidents have been reported correctly. Audit will involve review of incident log and behavior notes. Audit will begin on 07/11/2025 and will be ongoing. b. Administrator or designee will interview 3 residents daily to ensure facility is aware of all potential instances of abuse or neglect. Interviews will begin on 07/11/2025 and will be ongoing.c. Ongoing issues to be discussed in daily meeting that occurs Monday through Friday. Discussion started on 07/11/2025.d. Failure to comply will result in progressive disciplinary action.5. The facility will ascertain substantial compliance by 07/11/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interviews, the facility failed to ensure a resident received adequate supervision to prevent incidents for 1 (#4) of 10 (#1, #2, #3, #4, #5, #6, #7, #R1, Unknown Resident #1, and Unknown Resident #2) residents review for incidents. This deficient practice resulted in an Immediate Jeopardy situation on 05/26/2025, when Resident #4, a cognitively impaired resident with a history of aggressive behaviors and was assessed to need 1:1 supervision, was left unattended by staff. Resident #4 was placed on 1:1 supervision from 05/26/2025 through 06/09/2025. On 05/26/2025, Resident #4 was observed grabbing and pulling Unknown Resident #2's hair. On 06/02/2025, Resident #4 grabbed Resident #1's wheelchair, spun her around forcefully and began telling her she was bothering her. Interviews with staff revealed Resident #4 was not receiving 1:1 supervision at that time. On 06/09/2025, 1:1 supervision was removed and later that day, Resident #4 was involved in another incident where she pushed Resident #6 into the wall, causing her to hit her head. Resident #4 was placed back on 1:1 close monitoring following the incident on 06/09/2025. On 06/11/2025, Resident #4 was found in an empty resident's room at 12:21 a.m., attempting to get in bed. Interviews with staff revealed Resident #4 did not have 1:1 supervision during the 10:00 p.m. to 6:00 a.m. shifts. On 06/16/2025, Resident #1 had an incident where she was found lying on the floor in front of her wheelchair, on her left side. Resident #4 was found standing beside Resident #1's wheelchair, with no staff present with Resident #4. Resident #1 acquired a right femur fracture and facial soft tissue hematoma which extended into left frontal scalp. Due to Resident #1's age, she was unable to undergo surgery, and she was transferred to an inpatient hospice facility, where she passed away on 06/25/2025. Staff interviews revealed Resident #4 did not have 1:1 supervision at the time of the incident on 06/16/2025. Staff interviews revealed Resident #4 was not provided with consistent 1:1 supervision during the day until after Resident #1's incident on 06/16/2025. On 07/09/2025 at 5:30 a.m., an observation was made of Resident #4. She was lying in her bed with her eyes closed. There was no staff present providing 1:1 supervision. S1ADM was notified of the Immediate Jeopardy situation on 07/11/2025 at 11:10 a.m. This deficient practice continued at a potential for more than minimal harm for the other 24 residents residing in the locked dementia unit and any resident who would require 1:1 supervision. Findings: Cross Reference F600 and F835 Review of Resident #4's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, Dementia with Agitation, Major Depressive Disorder, and Anxiety. Review of Resident #4's Quarterly MDS with an ARD of 05/14/2025 revealed a BIMS of 2, which indicated Resident #4 had severe cognitive impairment. Further review revealed Resident #4 was ambulatory and required supervision with ADL's. Review of Resident #4's current Physician Orders revealed the following, in part:03/19/2025-Admit to memory care; secure unit monitoring Review of Resident #4's current Care Plan revealed the following, in part:Problem: Resident #4 went into another resident's room and urinated on the floor, turning on/off others lights. 03/26/25- Resident #4 has been taking other residents food, throwing food at staff, hitting staff members, yelling at other residents, and pushing furniture while other residents are on it. Resident #4 can be difficult to redirect. 03/27/25- Resident #4 has been taking family members belongings and refusing to give them back. Resident #4 attacked a CNA when the resident could not open window.Intervention: Every 30 minute checks for behavior x 24 hours, initiated 05/20/2025. Redirect as needed. Resident #4 separated on 05/20/2025. 1 on 1 observation 05/26/2025-06/09/2025. Sent to ER for evaluation/treatment dated 06/09/2025. 1:1 close monitoring initiated on 06/09/2025. Review of Resident #4's Nurse's Notes revealed the following, in part:On 05/26/2025 at 7:47 p.m. - 4:30 p.m.-Resident #4 agitated at another resident continuously calling staff lil N***** girls. Resident #4 jumped up out of chair and rushed over to another resident yelling, Ok you are being obnoxious and I've had enough! Resident #4 abruptly grabbed Unknown Resident #2's wheelchair and started pushing Unknown Resident #2 quickly down the hall and then spun Unknown Resident #2 around and started pushing Unknown Resident #2 quickly back to dining room. Unknown Resident #2 asked, What are you gonna do, push me into somebody? Resident #4 stepped around wheelchair, facing Unknown Resident #2 and attempted to grab Unknown Resident #2. Staff stepped in between both residents and attempted to redirect them. Unknown Resident #2 stated, I'm gonna kill her. Resident #4 left staff and rushed back to Unknown Resident #2 and grabbed a hand full of hair from the top of Unknown Resident #2's head and continued to pull it. Resident #4 would not let it go. RN supervisor entered unit a few minutes later and was informed of incident. Signed by S10EMP. On 06/02/2025 at 3:23 p.m. -Resident approached Resident #1, who she saw was wheeling herself in her wheelchair down the hallway and grabbed the handles of the wheelchair swinging Resident #1 around with force and trying to push Resident #1 down the hallway. Staff immediately redirected Resident #4 away from Resident #1 and encouraged her to not worry about Resident #1, Resident #4 stated she just makes me so angry. Staff was able to redirect Resident #4 out of situation. Will continue to monitor. Signed by S11EMP. On 06/09/2025 at 11:15 p.m.-Late entry for 4:10 p.m. Resident #4 was talking with Resident #6 in the dining room area when she pushed Resident #6. Signed by S9EMP. On 06/11/2025 at 12:21 a.m. -Resident #4 found up and in another room attempting to get in bed. Brought back to her room and assisted into her room without incident. Will continue to monitor. Signed by S8EMP. On 06/16/2025 at 2:50 p.m. -When nurse entered the room due to an incident of another resident having an unwitnessed fall with injuries, Resident #4 was noted standing next to the injured resident's wheelchair with a pad in her hand folding it in the seat of the wheelchair. No other staff present. Resident #4 was removed from room by staff. Signed by S7EMP. Review of Resident #4's Nurse Practitioner Notes revealed the following, in part: On 04/18/2025- Resident #4 had an aggressive episode in which she attacked 3 other residents on the secured Dementia Unit. Resident #4 appears to be a danger to others as she is impulsive and frequently become aggressive despite recent change in psychotropic medications. Recent inpatient psychiatric evaluation and treatment noted. Physician Emergency Certificate (PEC) written today as Resident #4 appears to be a danger to others. Signed by S13NP. On 06/20/2025- Resident #4 continues to have intermittent agitation and aggressive behavior noted. Resident #4 continues to be aggressive with other residents, especially in the evening time, despite psychotropic medication regimen. Discussed recent behaviors with Psychiatrist.Assessment/Plan: Resident #4 with another altercation with elderly resident and nursing staff overnight. Will have Resident #4 seen at inpatient psychiatric facility. Resident #4 will be transferred to the emergency room today. Signed by S13NP. On 07/10/2025 at 9:00 a.m., an interview was conducted with S22EMP. She stated Resident #4 was on 1:1 supervision. She stated the 1:1 supervision for Resident #4 started 3-4 weeks ago, after a resident-to-resident incident. She stated she was unsure of the exact date. She stated 1:1 supervision required a staff member to be with the resident at all times. On 07/09/2025 at 5:06 a.m., an interview was conducted with S15EMP. She stated she worked the 10:00 p.m. to 6:00 p.m. shifts on the locked dementia unit. She stated Resident #4 had never been on 1:1 supervision during her shifts. She stated she went into Resident #4's room every 15-20 minutes to check on her during her shift but did not provide 1:1 supervision. On 07/09/2025 at 5:13 a.m., an interview was conducted with S16EMP. She stated she picked up a 10:00 p.m. to 6:00 a.m. shift a few times a month. She stated Resident #4 received 1:1 supervision during the day, but not during the 10:00 p.m. to 6:00 a.m. shift. On 07/09/2025 at 5:30 a.m., an observation was made of Resident #4 laying in her bed with her eyes closed. No staff was present in the room providing 1:1 monitoring. On 07/10/2025 at 9:15 a.m., an interview was conducted with S24EMP. She reviewed the staff schedules dated 05/26/2025 through 05/30/2025. She confirmed she worked the 6:00 a.m. to 2:00 p.m. shifts on the locked dementia care on those dates, and Resident #4 did not receive 1:1 supervision. She stated Resident #4 had been receiving 1:1 supervision for about 3-4 weeks, after a resident-to-resident incident. She stated 1:1 supervision required a staff member to be with the resident at all times. Throughout survey, multiple attempts were made to contact S10EMP regarding the 05/26/2025 incident with no success. On 07/10/2025 at 12:20 p.m., an interview was conducted with S11EMP. She stated she was working on the locked dementia unit on 06/02/2025. She stated Resident #1 was rolling herself down the hallways back and forth. She stated Resident #4 was sitting in the common area in a chair when she jumped up out of her chair, and quickly went to Resident #1's wheelchair, grabbed the handles, and aggressively turned Resident #1's wheelchair so that Resident #1 was facing her. She stated Resident #4 then sternly told Resident #1 to stop doing that. She stated if Resident #1 would not have had her seatbelt buckled at the time, Resident #1 would have been slung out of her wheelchair. She stated Resident #4 was not on 1:1 supervision at that time. She stated Resident #4's 1:1 supervision started a few weeks ago. She stated Resident #4 had been incredibly aggressive since she was admitted to the facility. She stated the physician had attempted to change Resident #4's medications, sent her to emergency room and Behavior Health Facility to attempt to manage her aggression but none of the interventions had been effective. On 07/10/2025 at 8:47 a.m., an interview was conducted with S9EMP. She stated she was working on 06/09/2025. She stated Resident #6 was standing up talking and Resident #4 turned around told her to shut up and shoved her. She stated there was no forewarning and no triggers noted. She stated Resident #6 fell and hit her head. She stated Resident #6 stated she contacted S13NP. She stated S13NP gave an order for Tylenol for Resident #6's complaint of head pain and stated to monitor Resident #6 with neurological checks. She stated the incident between Resident #4 and #6 would be considered abuse. She stated after this incident, Resident #4 had a staff member assigned to her 1:1 monitoring for 2-3 days. On 07/10/2025 at 4:58 p.m., an interview was conducted with S8EMP. She stated she was working on 06/11/2025 at 12:21 a.m. when she found Resident #4 in an empty resident's room attempting to get in the bed. She stated Resident #4 was redirected back to her room. She stated Resident #4 was not receiving 1:1 supervision at that time. On 07/08/2025 at 1:15 p.m., an interview was conducted with S7EMP. She stated she was working on 06/16/2025. She stated she was in the front part of the hallway by the nurses' station around 2:50 p.m. and heard a scream. She stated when she entered the room, she saw Resident #1 lying on her left side on the floor by the bed, in a fetal position. She stated Resident #4 was standing at the end of the bed next to Resident #1's wheelchair with no staff members present and a seat pad was in Resident #4's hands. She stated she assessed Resident #1 and then noticed Resident #1 had a large hematoma on the left side of Resident #1's head starting at the hairline and extending to her cheekbone and Resident #1's right knee was swollen. She stated Resident #1 was crying. She stated she called Administration and informed them she needed assistance immediately and there had been an unwitnessed incident. She stated Resident #1 was transferred to the hospital and her family was notified of the incident. She stated she called Resident #1's family to check on her while she was in the hospital and was told Resident #1 had a broken Right Femur and multiple other injuries. She stated the family told her she was not a candidate for surgery and was placed on hospice for comfort measures. She stated Resident #4 was supposed to be receiving 1:1 supervision prior to 06/16/2025 but was not. On 07/08/2025 at 3:44 p.m., an interview was conducted with S5EMP. She stated she was familiar with Resident #1 and was assigned to her on 06/16/2025. She stated on 06/16/2025, the nurse called out from a resident's room for assistance, and she went into the room. She stated Resident #1 was lying on the ground, on her left side, in front of Resident #1's wheelchair. She stated Resident #4 was touching Resident #1's wheelchair, and Resident #4 was holding the seat pad of Resident #1's wheelchair. She stated Resident #4 was supposed to have been receiving 1:1 supervision due to her aggressive behavior at the time of Resident #1's incident on 06/16/2025 but was not. On 07/10/2025 at 11:30 a.m., an interview was conducted with S21EMP. She stated Resident #4 had several resident-to-resident incidents. She stated Resident #4's 1:1 supervision had been inconsistent up until 06/17/2025, after Resident #1's incident. She stated she could not keep the residents safe when Resident #4 was not on 1:1 supervision. On 07/11/2025 at 12:20 p.m., an interview was conducted with S29CP. She stated she was responsible for updating care plans for incidents which occurred in the facility. She stated all incidents were discussed in the morning meeting with administrative staff, then S3ADON would tell her what intervention to add to the care plans. She stated the morning meetings consisted of S1ADM, S2DON, S3ADON, S17SS, and the care plan nurses. She stated S3ADON told her to add the 1:1 supervision intervention to Resident #4's care plan on 05/26/2025. She stated she was not responsible to ensure the intervention was implemented. She stated S3ADON was responsible for implementing care plan interventions for incidents. On 07/11/2025 at 12:28 p.m., an interview was conducted with S3ADON. She stated she was responsible for the facility's incidents. She stated incidents were talked about in the morning meeting with administrative staff. She stated when an intervention was added to a care plan, such as 1:1 supervision, one of the administrative staff who were in the morning meeting would relay the information to the floor staff. She stated there was no one staff responsible for this. She stated Resident #4 was placed on 1:1 supervision from 05/26/2025-06/09/2025, then ongoing on 06/09/2025. She stated she was unsure which staff member relayed this information to the Resident #4's direct care staff. She stated she did not know why Resident #4's 1:1 supervision was not implemented at that time, but it should have been. On 07/10/2025 at 2:05 p.m., an interview was conducted with S2DON. She stated S1ADM was responsible for monitoring Resident #4 to ensure she received 1:1 supervision. On 07/10/2025 at 1:28 p.m., an interview was conducted with S1ADM. He stated Resident #4 had a lot of aggressive behaviors. He stated Resident #4 would be calm then in a flip of a switch become aggressive. He stated Resident #4's triggers could not be determined. He stated after an incident on 05/26/2025 with another resident, Resident #4 was placed on 1:1 supervision. He stated Resident #4 did well on 1:1 supervision and it was removed on 06/09/2025. He stated after the 1:1 supervision was removed, Resident #4 had another incident on 06/09/2025, so ongoing 1:1 supervision was initiated. He stated he was aware on 06/16/2025, Resident #1 was found in front of Resident #1's wheelchair lying on her left side, with swelling to the left side of Resident #1's face and right knee. He stated he was aware Resident #4 was found to be beside Resident #1's wheelchair at that time. He confirmed Resident #4 should have been receiving 1:1 supervision and was not at the time of the incident with Resident #1. He confirmed Resident #4 should have been receiving 1:1 supervision beginning on 05/26/2025. He stated when a resident was on 1:1 supervision, he expected staff to be with the resident when the resident was awake and out of their room. The Immediate Jeopardy was removed on 07/11/2025 at 3:23 p.m., as confirmed by onsite verification through observations, interviews, and record reviews. The facility implemented an acceptable Plan of Removal (POR) prior to the survey exit. Plan of RemovalF689- The facility allegedly failed to ensure staff provided adequate supervision to resident #4. A cognitively impaired resident with known physically and verbally abusive behavior.1. All residents who reside in the facilities secure unit have the potential to be affected by the alleged deficient practice.a. Starting on 07/11/2025, the DON will review behavior notes daily and ensure any resident needing 1:1 supervision is appropriately placed on the monitoring. Review will continue ongoing until completed.b. As of 07/11/2025, there currently is one resident on 1:1 supervision.2. Measures put in place to ensure the alleged deficient practice will not recur are:a. Resident was placed on 24 hour one-to-one staff supervision on 07/09/2025 at 5:00 p.m. and will remain on one-to-one supervision until the facility is able to find placement at another facility.b. Staff in-service initiated per Staff Developer on 07/10/2025 on abuse prevention, appropriate resident supervision and one-to-one supervision procedures. In-service will be done with all staff prior to starting their next scheduled shift and will be ongoing until completed. No staff member will be allowed to work until training has been completed.3. The facility plans to monitor its performance to ensure solutions are achieved and sustained by (monitoring started on 07/11/2025 as observed by Surveyors):a. Starting on 07/11/2025, the NFA or designee will perform facility rounds at random 3 times a week to ensure residents are receiving appropriate supervision. Facility rounds will occur ongoing until completed.b. Starting on 07/11/2025, the NFA or designee will perform facility rounds at random 3 times a week to ensure residents on 1:1 supervision is being monitored appropriately. Facility rounds will occur ongoing until completed.c. Starting on 07/11/2025, DON or designee will review behavior notes daily to ensure residents are assessed and supervised appropriately ongoing until completed.d. Ongoing issues to be discussed in weekly high-risk meeting with IDT. d. Failure to comply will result in progressive disciplinary action. 4. The likeliness of harm to any resident due to supervision no longer existed as of 07/11/2025 when Resident #4 was placed on 24 hour 1:1 supervision. The facility will ascertain substantial compliance by 07/11/2025.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 7 (#R1, #1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2) of 9 (#R1, #1, #3, #4, #5, #6, #7, Unknown Resident #1, and Unknown Resident #2) sampled residents. The facility failed to:1. Protect Resident's #R1, #1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2 from physical and psychosocial abuse by Resident #4;2. Report allegations of physical and psychosocial abuse by Resident #4 to the State Agency in the required timeframe; and3. Ensure Resident #4 received consistent adequate staff supervision to manage the resident's known verbally and physically abusive behaviors.This deficient practice resulted in an Immediate Jeopardy situation on 02/22/2025, when Resident #4, a cognitively impaired resident, hit Resident #R1. Resident #4 exhibited continued aggressive and abusive behaviors, and was transferred to the facility's locked dementia care unit on 03/25/2025. On 03/25/2025, Resident #4 was observed grabbing Unknown Resident #1 by the feet and attempting to pull the resident out of their wheelchair. Unknown Resident #1 was observed by a former employee to be fearful, displaying physical and verbal signs of stress, including crying and repeatedly making a swatting motion with her hands. The IJ continued on 04/17/2025, when Resident #4 interlocked her arms around Resident #3's throat then began pulling back, choking her. The IJ continued on 05/20/2025, when Resident #4 pushed Resident #5, causing Resident #5 to fall to the floor. Resident #4 then hit Resident #5 in her face. Resident #5 complained of hip pain after the incident. Resident #5's family requested Resident #5 be moved out of the locked dementia care unit for safety, which resulted in Resident #5 crying for days. The IJ continued on 05/26/2025, when Resident #4 grabbed Unknown Resident #2's hair, pulled it, and would not let go. On 05/26/2025, Resident #4 was placed on 1:1 supervision until 06/09/2025. However, staff interviews revealed during that time Resident #4 received inconsistent 1:1 supervision. On 06/09/2025 after 1:1 supervision was removed, Resident #4 pushed Resident #6 into the wall, causing Resident #6 to hit her head against the wall. Resident #6 complained of a headache after the incident and required administration of Tylenol for pain management. Resident #4 was placed back on continuous 1:1 supervision on 06/09/2025. On 06/16/2025, Resident #1 was found in a resident's room lying on her left side in a fetal position. Resident #4 was observed standing on the right side of Resident #1's wheelchair with Resident #1's wheelchair pad in her hand, and no staff present with Resident #4. Resident #1 was noted to have swelling to the left side of her face and right knee. Resident #1 was transferred to the hospital where it was determined she had a right femur fracture and a left facial hematoma. Due to Resident #1's age, she was unable to undergo surgery and was ultimately transferred to an inpatient hospice facility where she passed away on 06/25/2025. Staff interviews revealed Resident #4 did not have 1:1 monitoring during the 10:00 p.m. to 6:00 a.m. shifts, and Resident #4 was not provided with consistent 1:1 monitoring during the day until after Resident #1's incident on 06/16/2025. On 07/09/2025 at 5:30 a.m., an observation was made of Resident #4. She was lying in her bed with no staff present at bedside. Record review and interview with S1ADM revealed S1ADM was aware of each of the above incidents with Resident #4, but none of the above incidents were reported to State Agency. As a result of the investigation, despite there not being a significant decline in mental or physical functioning for Residents #R1, #3, #5, #6, Unknown Resident #1, and Unknown Resident #2, it could be determined a reasonable person would have experienced psychosocial harm as a result of Resident #4's abusive behaviors since a reasonable person would not expect to be treated in this manner in their own home or a health care facility. S1ADM was notified of the Immediate Jeopardy situation on 07/11/2025 at 11:10 a.m. This deficient practice continued at a potential for more than minimal harm for the other 167 residents residing in the facility. Findings:Cross reference F600, F609, and F689 Review of the facility's policy dated 03/25/2023 and titled, Abuse-Prevention and ProhibitionPolicy and Procedure, revealed the following, in part:Purpose:Each resident has the right to be free from abuse. 3. Physical Abuse may include hitting, slapping, pinching, biting, shoving, and kicking. 4. Mental Abuse includes, but is not limited to, harassment.There may be some situations in which the resident is unable to express him/herself due to a medical condition and/or impairment, cannot relate what has occurred, or may not express outward signs of physical harm, pain, or mental anguish. A lack of response by the resident does not mean that mental abuse did not occur. II. Procedures:7. Reporting/Response: The facility employee or covered individual who becomes aware of abuse or neglect, including injuries of unknown source or alleged misappropriation of resident property, shall immediately report the matter to the facility administrator. The Administrator shall immediately initiate a self-reported incident report to the State Agency and the facility's local law enforcement agency, but not less than 2 hours after forming the suspicion of a crime if the alleged violation involves abuse (physical, sexual, verbal, or mental) or results in serious bodily injury. Resident #R1Review of Resident #R1's clinical record revealed he was admitted to the facility on [DATE]. Review of Resident #R1's Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date (ARD) of 07/02/2025 revealed a Brief Interview for Mental Status (BIMS) of 5, which indicated Resident #R1 had severe cognitive impairment. Resident #4Review of Resident #4's clinical record revealed she was admitted to the facility on [DATE] with diagnoses which included, Dementia with Agitation, Major Depressive Disorder, and Anxiety. Review of Resident #4's Quarterly MDS with an ARD of 05/14/2025 revealed a BIMS of 2, which indicated Resident #4 had severe cognitive impairment. Further review revealed Resident #4 was ambulatory and required supervision with ADL's. Review of Resident #4's Nurse's Notes revealed the following, in part: 02/22/2025 at 4:42 p.m.-While doing medication pass, Resident #4 was in another resident's room and Resident #R1 (Resident #4's husband) was standing at doorway. I asked Resident #4 to follow me to her room and Resident #4's exited with the other resident's blanket rolled up in her arms. Resident #R1 attempted to take it from her and give it back to the other resident, and when she followed Resident #R1 out she hit Resident #R1 in his back. Signed, S4EMP. On 07/10/2025 at 9:55 a.m., an interview was conducted with S4EMP. She stated she observed the incident between Resident #4 and #R1 on 02/22/2025. She stated prior to the incident, Resident #4 wandered into another resident's room and stole the blanket off the bed. She stated Resident #R1 attempted to take the blanket from Resident #4 and return it to the bed. She stated Resident #4 then became enraged and hit #R1 on the back. She stated she would consider this incident resident to resident physical abuse. She stated she reported the incident but did not recall who she reported it to. She stated the facility's protocol was to notify the direct supervisor immediately after a witnessed incident. Further review of Resident #4's Nurse's Notes revealed the following, in part:On 03/09/2025 at 3:11 p.m. - Resident #4 went to end of hall and grabbed a wet floor sign. Resident #4 got combative when CNA tried to get her to put the sign down and hit CNA. Signed by S12EMP. On 03/11/2025 at 4:21 p.m.-Resident #4 took an employee's purse/bag, staff attempted to redirect resident and retrieve bag, Resident #4 became combative kicking and hitting the nurse in the chest. Resident #4's husband attempted to talk to the resident and get the bag. The Resident #4 was resistant to him as well but finally let go of the bag. Resident #4 was provided time to calm down. Staff applied non-slip socks for safety as Resident #4 is wondering around the facility without shoes and only one sock on that she is bending over trying to remove. Signed by S6EMP. Review of Resident #4's current Physician Orders revealed the following, in part:03/19/2025-Admit to memory care; secure unit monitoring Review of Resident #4's admission and discharge report revealed Resident #4 was transferred to an inpatient psychiatric facility on 03/12/2025 and returned to the facility on [DATE], when Resident #4 was placed on the locked dementia unit. Review of Resident #4's current Care Plan revealed the following, in part:Problem: Resident#4 went into another resident's room and urinated on the floor, turning on/off others lights. 03/26/25- Resident #4 has been taking other residents food, throwing food at staff, hitting staff members, yelling at other residents, and pushing furniture while other residents are on it. Resident #4 can be difficult to redirect. 03/27/25- Resident #4 has been taking family members belongings and refusing to give them back. Resident #4 attacked a CNA when she could not open window. Unknown Resident #1Further review of Resident #4's Nurse's Notes revealed the following, in part:On 03/25/2025 at 7:10 p.m.-Resident #4 noted attempting to take residents from the community area against their will. Unable to redirect, she is becoming verbally aggressive. Resident #4 noted tearing padding off a residents wheelchair, when redirection attempted she grabbed Unknown Resident #1 by both feet and began trying to pull Unknown Resident #1 out of her chair by her feet. Unknown Resident #1 is fearful and showing physical as well as expressing verbal signs of stress. Resident #4 then walked away and took a facility chair making attempts to leave with the chair but while sitting in it. Signed by S30FEMP. On 03/25/2025 at 7:19 p.m. - Resident #4 noted making attempts to snatch the same resident, Unknown Resident #1, out of the top of her chair by the shirt. When redirected, Resident #4 became physically aggressive and pushed the couch in the community living room while another resident was sitting on it. Resident #4 continues to act out verbally and physically against staff and fellow residents. Signed by a former employee. On 07/10/2025 at 9:38 a.m., a telephone interview was conducted with S30FEMP. She stated she was working on 03/25/2025. She stated Resident #4 attempted to pull another resident out of her wheelchair by her feet. She stated she remembered the resident had a seatbelt in place but was unable to recall which resident it was. She stated the incident was unprovoked. She stated she was close by when it occurred and was able to intervene immediately and separated Resident #4 from the resident in the wheelchair before any injuries occurred. She stated after the incident, Unknown Resident #1 was scared, crying, and kept doing a swatting motion with her hands. She stated she informed S1ADM and S2DON frequently of her concerns for the safety of the other residents due to Resident #4's aggressive behavior. She stated she told S1ADM and S2DON, Resident #4 would become violent with no warning, attacked staff and other residents, and could not be redirected. She stated when Resident #4 was transferred to the locked dementia unit, she felt like she was not able to keep the other resident's safe due to Resident #4's aggressive behaviors. She stated after the incident on 03/25/2025, she went to S1ADM's office and told him she could not work under the current conditions of the unit because she could not protect the other residents from Resident #4. She stated S1ADM told her to do what she had to do, so she put in her 2 weeks' notice. Further review of Resident #4's Nurse's Notes revealed the following, in part:On 03/26/2025 at 12:05 p.m. - During lunch Resident #4 walked over to nurse's desk and removed the top from another resident's food and attempted to pick up the food with her hands. The nurse attempted to redirect Resident #4 and Resident #4 became angry and grabbed a handful of greens and threw them at the nurse and grabbed the bowl of pie and hit the nurse with the pie. Resident #4 swung at nurse multiple times. Resident #4 then lost balance and fell on the floor. Resident #4 did not hit her head. While on the floor, Resident #4 attempted to kick nurse multiple times. Nurse was able to remain holding Resident #4's hand while the CNA went to get assistance. S1ADM and S13NP notified of the Resident #4's aggressive behavior. Signed by S7EMP. On 03/27/2025 at 5:30 p.m.-Late Entry-Resident #4 was attempting to open a window with intent to elope. The CNA sitting directly next to the window turned her head to see what was going on and asked Resident #4 what she was doing and to not do that to the window. Resident #4 immediately turned and began grabbing and hitting the CNA in her head and face. The CNA yelled for assistance I went over to get the resident to stop. Resident #4 then became aggressive towards me. Resident #4 was very difficult to redirect but after some time she walked away but remained agitated until she went to bed. The situation was reported to S1ADM and her responsible party. Signed by S30FEMP. On 04/16/2025 at 12:15 p.m. -Resident #4 took papers from nurse's desk. Nurse attempted to retrieve papers from Resident #4. Resident #4 became aggressive and pulled nurse's hair and kicked nurse in the stomach. Resident #4 then lost balance trying to kick nurse a second time and fell. Resident #4 did not hit head, no apparent injuries noted. Resident #4 assisted off of the floor by staff. Resident #4 refused vital signs. S13NP and RP notified. Signed by S7EMP. Resident #3Review of Resident #3's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #3's Quarterly MDS with an ARD of 06/11/2025 revealed a BIMS of 9, which indicated Resident #3 had moderate cognitive impairment. Review of Resident #3's Incident report dated 04/17/2025 at 3:00 p.m.Incident Description: Nursing description-Resident #3 witnessed by hall staff sitting in the community living room area watching television when Resident #4 walked over to Resident #3 and said something indecipherable and then began hitting Resident #3. Resident #3 in no way instigated the interaction. Resident #3 reported she did not do or say anything to Resident #4. No injuries noted. Review of Resident #3's Nurse's Notes revealed the following, in part:04/18/2025 at 1:06 p.m. -Shift Summary: Following report received at shift change, went to visually assess Resident #3 related to incident earlier on previous shift. Assessed Resident #3 for pain and any potential injuries. Resident #3 denied any pain (but specifically to head, neck and back) and no visual markings or bruises noted. Resident #3's speech clear and appropriate. Upon Resident #3 getting up for the day, resident came and sat by this nurse and described earlier incident, Resident #3 continues to deny any pain or discomfort with associated incident. Resident #3 does not appear in any mental anguish, states she is alright but she will not forget what happened to her. Will continue to monitor. Signed by S6EMP. On 04/17/2025 9:49 p.m. -Resident #4 exhibited verbal and physical aggression this shift. Resident #4 was pushing Resident #1 down the hall and Resident #1 was asking Resident #4 to stop. Staff asked Resident #4 not to push Resident #1 as she didn't want to be pushed and Resident #4 became verbally aggressive and threatening toward staff. As I attempted to administer medication to Resident #1, Resident #4 reached out and grabbed the medication which was crushed in pudding. She then laughed and went to the sink to wash her hands. I went off the unit to report the incident to the administrator. Upon returning to the unit, Resident #4 was noted yelling and sitting on top of Resident #1 while aggressively squeezing her hands and pushing them down where they were also crushed between the sides of the resident's legs and the arm rest of her wheelchair. Resident #4 was verbally and physically aggressive with staff as they tried to convince her to get off of Resident #1. I called for the administrator to come assist us. When S1ADM arrived, Resident #4 stood up and continued being verbally aggressive while she walked over to Resident #3. Resident #4 leaned down and spoke aggressively to Resident #3 and when Resident #3 started to speak, Resident #4 began attacking her. Resident #4 was noted standing behind Resident #3 using both hands balled into fists and striking her repeatedly in the head. When staff turned to intervene, Resident #4 leaned over the resident and wrapped both arms around Resident #3's neck squeezing it. As staff attempted to remove Resident #3 from Resident #4's clutch, Resident #4 attempted to stop us from moving Resident #3 and had her hands around the resident's neck. Resident #4 began slapping and grabbing at Resident #3's face. We were finally able to block Resident #4 from Resident #3 and Resident #4 walked away to Resident #1. Resident #4 attempted to push Resident #1 in her wheelchair but staff were able to stand in front of the wheelchair and hold it still. Resident #4 then began pulling on the trunk support contraption and tearing the protective foam padding off of it. Resident #4 continued to try to get Resident #1's wheelchair away from staff but became more frustrated and began pushing tables around the dining area. Resident #4 walked around to the other side of the dining room in order to pull a table out of the way so she would have access to the back of Resident #1's wheelchair. Once behind the wheelchair, she made more attempts to pull the chair from the grasp of staff. When she was unable to, she grabbed the high back wheelchair handles while putting her foot on the rear tippers and pulled aggressively to tip the wheelchair backwards. Two staff members remained in place holding Resident #1's wheelchair so it could not be tipped. Resident #4 finally walked away, remaining quite agitated. Resident #4 continued to speak aggressively to other residents and staff but stopped being physically aggressive at that point. Signed by S30FEMP. On 07/08/2025 at 3:44 p.m. an interview was conducted with S5EMP. She stated she witnessed Resident #4 choke Resident #3 a few months ago. She stated Resident #4's elbows were around the front of Resident #3's neck. She stated she attempted to pull Resident #4's arms away from Resident #3's neck but was told to let her be by S1ADM, who was present at the time of the incident. She stated S30FEMP witnessed the incident as well. S5EMP stated this incident was resident to resident abuse. She stated for any allegations of abuse or witnessed abuse, she would notify the nurse or administrative staff. On 07/08/2025 at 10:28 a.m., a telephone interview was conducted with S30FEMP. She stated she witnessed the incident between Resident #3 and Resident #4 which occurred on 04/17/2025. She stated Resident #3 was sitting in her wheelchair facing the window. She stated Resident #4 wrapped her arms around Resident #3's neck then began pulling Resident #3 backwards. She stated when S5EMP attempted to break up the residents, S1ADM instructed S5EMP to take her hands off of Resident #4. She stated Resident #4 then walked calmly toward Resident #1, stood behind her wheelchair and began trying to tip over her wheelchair from the back and the side. She stated the assistant administrator intervened, sitting on one armrest to prevent the wheelchair from tipping. She stated she continued trying to redirect Resident #4, but it was ineffective as it usually was. She stated Resident #4 eventually walked away, sat on the couch, and cried. Review of Resident #4's Nurse Practitioner Notes revealed the following, in part: On 04/18/2025- Resident #4 had an aggressive episode in which she attacked 3 other residents on the secured Dementia Unit. Resident #4 appears to be a danger to others as she is impulsive and frequently becomes aggressive despite recent change in psychotropic medications. Recent inpatient psychiatric evaluation and treatment noted. Physician Emergency Certificate (PEC) written today as Resident #4 appears to be a danger to others. Signed by S13NP. Resident #5Review of Resident #5's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #5's Quarterly MDS with an ARD of 06/11/2025 revealed a BIMS score of 11, which indicated Resident #5 had moderate cognitive impairment. Review of the facility's Incident Log revealed Resident #5 had an unwitnessed fall on 05/20/2025 at 6:00p.m. Review of Resident #5's Incident Report dated 05/20/2025 at 6:00 p.m. revealed the following, in part:Incident Location: Resident's RoomNursing description: The CNA reported that she heard a commotion coming from one of the resident's room. She went into Resident #5's room and noted Resident #5 and Resident #4 were on the floor. Spilled cup of water also noted on the floor near the residents along with their clothes noted wet.Resident Description: Resident #5 stated she fell.Was the incident witnessed: NoImmediate Action Taken: Residents were immediately separated. The CNA removed Resident #4 from Resident #5's room and walked Resident #4 back to her own room. Resident #5 was assessed for injuries, no apparent injuries noted. Resident #5 complained of pain in her right hip. New order obtained for stat x-ray ordered to bilateral hips/pelvis. Review of Incident Witness Statement revealed the following, in part: Witness Name: S5EMPResidents Involved: Resident #4 and Resident #5Date of Incident: 05/20/20251. Provide a brief description of what happened: I was helping another resident and turned around and saw Resident #5 and Resident #4's hands up in the air, middle of doorway, going back and forth. Resident #5 was yelling stop. I called for help and as I entered room, Resident #4 and #5 were on the floor. I grabbed Resident #4 and she swung at Resident #5 on the side of face. 2. Are you aware of an injury? No3. Where did the incident take place? Resident #5's room4. What actions did you take immediately? Running to get Resident #4 out of room [ROOM NUMBER]. Did anyone else other than you witness the incident? No Review of Resident #5's Social Services Note dated 05/23/2025 revealed the following, in part:05/23/2025 at 3:12 p.m.: S17SS went to speak with Resident #5 on the afternoon of 05/23/2025. Upon entering resident room she was visibly distraught and talking with the nurse. Resident #5 said that she was feeling like she was being taken away from her home. When asked about a prior incident that occurred, Resident #5 stated that she didn't know. She said she was very confused because she couldn't remember how the lady hit her or what happened. Resident #5 repeated she was very confused and couldn't remember anything about a woman hitting her and started getting upset more. Resident #5 then changed the subject back to wanting to go back to her room on the memory care unit. Resident #5 said she was happy there and safe there and needs to go back. Signed by S17SS. On 07/08/2025 at 8:48 a.m., an interview was conducted with Resident #3. She stated she recalled when her friend, Resident #5, was attacked by Resident #4. She stated Resident #5 was walking down the hall when Resident #4 pushed Resident #5 to the floor and began hitting Resident #5. She stated Resident #5 told her she was scared to death and did not treat anyone poorly to deserve being treated like that. On 07/08/2025 at 3:27 p.m., an interview was conducted with Resident #5. Resident #5 stated she previously resided on another hall at the facility. She stated she was involved in an altercation with another resident during which she was hit. She stated her family was worried about her safety after the incident and requested a room change. She stated she did not speak to the other resident before being hit. She stated she did not know the name of the resident that hit her. She was unable to recall when the incident took place. She stated she did not remember if she was injured. On 07/08/2025 at 3:44 p.m., an interview was conducted with S5EMP. She stated she was working on 05/20/2025 and witnessed the incident between Resident #4 and Resident #5. She stated she heard Resident #4 yelling at Resident #5 to get out of her room. She stated she saw Resident #4 push Resident #5 from behind. She stated Resident #5 fell down, then Resident #4 fell down as well. She stated while on the floor, Resident #4 was swinging at Resident #5, and Resident #5 had her hands in the air trying to protect herself. She stated she immediately tried removing Resident #4 away from Resident #5, and Resident #4 swung, hitting Resident #5 on the side of her face. She stated she separated the residents and reported the incident to S18EMP. She stated Resident #5 complained of pain after the incident and an x-ray was ordered. She stated she told Administration about Resident #4's aggression and abuse of the other residents but they did not do anything to stop or prevent it. She stated Resident #4 was sent out to a behavioral hospital after the incident, but it did not help. She stated Resident #4's behavior was the same when she returned to the facility. On 07/09/2025 at 12:00 p.m., an interview was conducted with S18EMP. She stated she was not in the locked dementia unit at the time of the incident between Resident #4 and Resident #5. She stated when she arrived on the unit, she was notified of what happened. She stated both residents were already separated and in their rooms. She stated she completed an assessment on Resident #5, and Resident #5 complained of hip pain. She stated she notified the Nurse Practitioner on call and Resident #5's family. She stated an x-ray was ordered. She stated Resident #5 stated, that lady came in my room, why was she in my room? She stated she reported the incident to Administration. She stated for any allegations of abuse or witnessed abuse, she would notify S1ADM or S2DON. On 07/09/2025 at 9:55 a.m., an interview was conducted with Resident #5's family member. He stated he was informed Resident #5 had a fall on 05/20/2025 at 7:42 p.m. resulting in hip pain. He stated through his own discussions with staff, he learned the incident was not just a fall, instead it was an altercation with Resident #4. He stated he visited Resident #5 at the facility the following day to check on her. He stated during their visit Resident #5 was paranoid, frequently stating I didn't push her, she pushed me. I don't want to be pushed around again. He stated this prompted him to discuss the incident with S1ADM. He stated when he discussed the incident with S1ADM, S1ADM refused to show him the camera footage, with the reason of him not being Resident #5's Power of Attorney (POA). He stated S1ADM also denied another resident was involved in the incident. He stated he arranged to become Resident #5's POA the same day. He stated when he presented the paperwork to S1ADM, he would not accept it and still would not let him see the camera footage. He stated S1ADM contacted corporate, who agreed to acknowledge the POA and let him see the footage. He stated when he was allowed to watch the camera footage, 2 of the 3 videos had already been deleted. He stated S1ADM did not provide a reason for the deletion. He stated he was initially told the footage was available for 7 days, and it had not yet been that long. He stated when he reviewed the camera footage, it revealed the incident occurred on 05/20/2025 at 7:15 p.m. He stated Resident #5 was followed to her room by Resident #4 at the start of the footage. He stated it appeared Resident #5 was pushed out of the doorway, then the video stopped. He stated Resident #5 never had any altercations with any other residents. He stated after he was made aware the incident involved Resident #4, he requested Resident #5 be moved to another room off the locked dementia unit. He stated if Resident #5 was fully cognitive, she would also classify it as abuse since she had vision impairment causing her to only see 3-4 feet in front of her, and would not be able to defend herself. On 07/10/2025 at 3:35 p.m., an interview was conducted with S17SS. She stated she saw Resident #5 within 72 hours of the incident and room change. She stated Resident #5 cried for days following the incident. Further review of Resident #4's current Care Plan revealed the following, in part:Goal: Resident #4 will have fewer episodes of behavior by review date of 08/12/2025.Intervention: Every 30 minute checks for behavior x 24 hours, initiated 05/20/2025. Redirect as needed. Resident #4 separated on 05/20/2025. Unknown Resident #2Review of Resident #4's Nurse's Notes revealed the following, in part:On 05/26/2025 at 7:47 p.m. - 4:30 p.m.-Resident #4 agitated at another resident continuously calling staff lil N***** girls. Resident #4 jumped up out of chair and rushed over to another resident yelling, Ok you are being obnoxious and I've had enough! Resident #4 abruptly grabbed Unknown Resident #2's wheelchair and started pushing Unknown Resident #2 quickly down the hall and then spun Unknown Resident #2 around and started pushing Unknown Resident #2 quickly back to dining room. Unknown Resident #2 asked, What are you gonna do, push me into somebody? Resident #4 stepped around wheelchair, facing Unknown Resident #2 and attempted to grab Unknown Resident #2. Staff stepped in between both residents and attempted to redirect them. Unknown Resident #2 stated, I'm gonna kill her. Resident #4 left staff and rushed back to Unknown Resident #2 and grabbed a hand full of hair from the top of Unknown Resident #2's head and continued to pull it. Resident #4 would not let it go. RN supervisor entered unit a few minutes later and was informed of incident. Signed by S10EMP. Further review of Resident #4's current Care Plan revealed the following, in part:Intervention: 1 on 1 observation 05/26/2025-06/09/2025. Multiple attempts were made throughout the survey to identify the resident in this nurse's note, however, this resident was unable to be identified. On 07/10/2025 at 9:15 a.m., an interview was conducted with S24EMP. She reviewed the staff schedules dated 05/26/2025 through 05/30/2025. She confirmed she worked the 6:00 a.m. to 2:00 p.m. shifts on the locked dementia unit on those dates, and Resident #4 did not have 1:1 monitoring. She stated Resident #4 had been receiving 1:1 monitoring for about 3-4 weeks from today, after a resident to resident incident. She stated she could not recall after which resident to resident incident though. She stated 1:1 monitoring required a staff member to be present with the resident at all times. Resident #6Review of Resident #6's clinical record revealed she was admitted to the facility on [DATE]. Review of Resident #6's admission MDS with an ARD of 04/23/2025 revealed she had a BIMS of 5, which indicated Resident #6 had severe cognitive impairment. Review of Resident #6's Incident Report dated 06/09/2025 at 4:10 p.m. revealed the following, in part: Resident: Resident #6 Incident location: dining roomIncident description: Resident #6 was standing up in the common area with the use of her rolling walker talking to Resident #4 when Resident #4 told Resident #6 to shut up and pushed Resident #6 backwards causing Resident #6 to stumble backwards. Resident #6 hit her head against the wall and fell to the floor.Immediate action taken: Resident #6 assessed for injuries, none noted. Resident #6 complained of pain to her lower back at this time. Tylenol administered for pain. S13NP notified and RP notified. Further review of Resident #4's Nurse's Notes revealed the following, in part:On 06/09/2025 at 11:15 p.m.-Late entry for 4:10 p.m. Resident #4 was talking with Resident #6 in the dining room area when she pushed Resident #6. Signed by S9EMP. On 07/10/2025 at 8:47 a.m., an interview was conducted with S9EMP. She stated she was working on 06/09/2025. She stated Resident #6 was standing up talking and Resident #4 turned around told her to shu

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review, the facility failed to protect the residents right to be free from verbal abuse for 1 (#1) of 4 (#1, #2, #3, and #4) residents reviewed for abuse. The facility failed to ensure Resident #1 was free from verbal abuse by S4CNA and S5CNA. This deficient Practice resulted in an Immediate Jeopardy situation on 01/22/2025 at 4:52 p.m. for Resident #1, a cognitively impaired resident who required staff assistance for care, when S5CNA was observed in video footage verbally abusing Resident #1 while providing care. On 01/29/2025 at 3:51 p.m., S4CNA was observed in video footage verbally abusing Resident #1 while providing care. On 01/30/2025 at 3:46 p.m., S4CNA was again observed in video footage verbally abusing Resident #1 while providing care. S4CNA and S5CNA continued to provide care to Resident #1 and other residents in the facility until S1ADM was notified of an allegation of abuse on 02/04/2025. It could be determined a reasonable person would suffer serious psychosocial harm after being repeatedly verbally abused by staff who the resident was dependent upon to provide care. The facility implemented corrective actions on 02/04/2025, which were completed on 02/21/2025 prior to the State Agency's investigation on 02/24/2025, thus it was determined to be a Past Noncompliance citation. Findings: Review of facility's policy titled, Abuse- Prevention and Prohibition Policy and Procedure dated 03/25/2023 revealed, in part: Purpose: Each resident has the right to be free from abuse. Policy: To provide a safe, abuse-free environment for all residents. I.) Types of abuse: 1. Verbal Abuse- is the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families or within their hearing distance or sight, regardless of the resident's age, ability to comprehend, or disability. Review of Resident #1's Clinical Record revealed she was admitted to the facility on [DATE] with diagnoses which included, in part, Alzheimer's Disease and Dementia. Review of Resident #1's most recent Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 12/31/2024, indicated the resident was unable to conduct a Brief Interview of Mental Status (BIMS) due to the resident rarely or never being understood. Further review of section H0300 and H0400 revealed Resident #1 was frequently incontinent of bowel and bladder. An interview was conducted with Resident #1's Representative (RP) on 02/24/2025 at 3:26 p.m. She stated on 02/04/2025, she observed body language to suggest yelling and chastising from staff through a camera installed in Resident #1's room that was concerning for abuse. She stated she contacted S7SW and reported the abuse. She stated she had a meeting with S1ADM and S7SW on 02/06/2025 to show them the video and audio footage. She reported S1ADM confirmed S4CNA and S5CNA were the accused staff members. Resident #1's RP reported Resident #1 would have felt scared, intimidated or anxious from the verbal abuse if she had not been diagnosed with Dementia. An interview was conducted with S7SW on 02/25/2025 at 1:44 p.m. S7SW stated she received a call from Resident #1's RP on 02/04/2025 around 2:00 p.m. stating staff were verbally abusing Resident #1. S7SW reported Resident #1's RP brought the video footage to the facility on [DATE] for S1ADM and S7SW to observe. S7SW confirmed S4CNA and S5CNA were heard yelling and chastising Resident #1 in the video and it was considered verbal abuse. She stated any reasonable person would feel hurt, scared, or isolated after verbal abuse. She further confirmed a victim of verbal abuse could have psychosocial outcomes such as agitation, restlessness or wandering. S7SW confirmed receiving a verbal in-services on 02/07/2025 on abuse, neglect, abuse reporting, consequences of failing to report abuse and consequences if abuse was substantiated. An observation of video footage of Resident #1's room was conducted on 02/25/2025 at 4:00 p.m. with S1ADM. The video footage with audio was reviewed and revealed the following: 01/22/2025 at 4:52 p.m., S5CNA entering Resident #1's room, turning on the lights and yelling at Resident #1 who was in bed, stating in a demeaning tone, I know you did not take those pants off. Resident #1 responded in a confused tone, Did I take these pants off? S5CNA yelled in an aggressive and chastising tone at Resident #1, Yes, you took those pants off, and oh you're in trouble! S5CNA pulled the covers off Resident #1 aggressively and walked toward the room entrance doorway yelling in the hallway loudly, Y'all, she took her pants off again! Resident #1 remained in bed mumbling incoherently in a sadden tone. 01/29/2025 at 3:51 p.m., S4CNA entered Resident #1's room with gloves on and a brief in her hand. Resident #1 was in bed. She yelled aggressively at Resident #1, Come over here. Get up with all that sh*t on the bed. Look at all that sh*t. S4CNA yelled demandingly several more times at the resident to get up. Resident #1 remained lying in bed and confusingly asked, Who did that? S4CNA yelled, chastising Resident #1, You did that sh*t on the bed! S4CNA assisted Resident #1 into a sitting position, Resident #1 stood from the bed and responded I'm hurting while ambulating to the bathroom. S4CNA yells at Resident #1, Go to the bathroom! 01/30/2025 at 3:46 p.m., S4CNA entered Resident #1's room and turned the light on. She began yelling at Resident #1 who was lying in bed, Why you pulling those clothes off, why you pulling those clothes off? S4CNA yells not uh, indicating no in a scolding tone to Resident #1. Resident #1 was mumbling incoherently and still lying in bed. S4CNA then yells in a disrespectful demanding tone, Let's get up as she attempted to abruptly get Resident #1's pants back on her while she was lying in bed. S4CNA in a rough demanding tone stated Get up, let's go! Once Resident #1's pants were on and Resident #1 stood next to the bed, the CNA yelled in a demeaning tone, I just cleaned up this sh*t. You aint gonna do that on me! Resident #1 stood in front of the entrance to the bathroom and S4CNA yelled in a demanding tone, Sit down, put your shoes on! Resident #1 sat back on her bed and attempted to lay down. S4CNA tells her in an irritated voice, not uh (indicating no), put your shoes on. Got sh*t on all this! An interview was conducted with S1ADM on 02/25/2025 at 4:30 p.m. S1ADM stated he was first aware of the allegations of abuse on 02/04/2025 around 2:00 p.m. He stated he immediately suspended the accused staff until investigation was completed and opened a SIMS report. He confirmed he observed video footage from Resident #1's representative on 02/06/2025. He stated S4CNA and S5CNA were immediately terminated after observation of the video footage with audio revealing the CNAs verbally abused Resident #1. He stated he contacted the ombudsman and law enforcement and a report was filed. He stated 100% of the facility's staff were in-serviced on abuse, neglect, abuse reporting, consequences of failing to report abuse and consequences if abuse was substantiated. S1ADM stated he and S2AADM interviewed all residents which S4CNA and S5CNA care for. He stated no residents had signs of abuse, and no concerns arose from the interviews. He reported S2AADM was interviewing three residents per week for four weeks to inquire if residents had experienced abuse or witnessed abuse in the facility. He confirmed any resident who was a victim of verbal abuse could be frightened or perturbed. Review of the facility's special care form revealed S2ADDM had monitored three residents a week for abuse in the facility beginning 02/10/2025 which would be completed in four weeks. Throughout the survey from 02/24/2025 through 02/26/2025 observations, record reviews, staff interviews revealed they received training on the facility's abuse policies and procedures, reporting of abuse, consequences of not reporting abuse and consequences if abuse was substantiated. Interviews revealed staff were knowledgeable of the types of abuse and how and when, and why to report abuse to administration immediately. The facility had implemented the following actions to correct the deficient practice: 1. Corrective action taken by: a. Removed accused employees from resident care and suspended pending investigation. b. Contacted Ombudsman to provide facility additional in-servicing/training. c. All staff in-serviced regarding abuse, caring for resistant and combative residents and signs and symptoms of staff burnout. The following topics are to be covered: i. Types of abuse: mental, physical, verbal, misappropriation of funds and neglect. ii. Abuse reporting; facility staff's responsibility to report immediately to the administrator. Administrator's responsibility to report to State Agency and the local authority the timeframes for reporting. iii. Consequences for failing to report abuse or suspected abuse. iv. Consequences if allegation is substantiated v. Abuse investigations require the immediate suspension vi. Caring for resistant and combative residents vii. Signs and symptoms of staff burnout **In-servicing began on 02/04/2025 and completed on 02/19/2025** 2. All residents have the potential to be affected by the alleged deficient practice. 3. The measure that will be put in place or a system change that will be made to ensure that the deficient practice not recurred are: a. Accused staff members were terminated. b. All residents on Hall A were interviewed by Assistant Administrator and Social Services Director on 02/07/2025. c. Corrective action plan to be initiated requiring the administrator or designee to interview 3 residents per week starting 02/10/2025. During this interview the administrator or designee is to inquire whether the resident has experienced abuse or witnessed abuse while living at the facility. The interviews are to be recorded on a special care form. Interviews are to be conducted for 4 weeks or until substantial compliance is achieved. The outcomes of the interviews are to be discussed in the daily stand-up meeting with the interdisciplinary team. The interdisciplinary team is to discuss corrective action plan weekly in the Quality Assurance Committee meeting. d. The Director of Nursing or designee will observe staff's provision of peri-care and/or dressing, for signs or symptoms of abuse, of cognitively impaired and/or nonverbal residents, no less than 5 times per week for a minimum of 4 weeks starting week of 02/10/2025. The observations are to be recorded on a special care document. The special care document is to be reviewed in the daily stand up meeting with the interdisciplinary team. The interdisciplinary team is to review the corrective action plan weekly in the quality assurance committee. The facility plans to monitor its performance to ensure solutions are achieved and sustained by: an interdisciplinary team to review the outcomes of audits in the weekly Quality Assurance Committee. 4. The facility plans to monitor its performance to ensure solutions are achieved and sustained by: a. Interdisciplinary team to review the outcomes of audits in the weekly Quality Assurance Committee meeting to ensure continued compliance. b. Quality Assurance Committee will continue to meet weekly to discuss audits until substantial compliance is achieved and quarterly thereafter. 5. Corrective action will be completed by 02/21/2025.