Based on interviews, record review, and policy review, the facility failed to prevent one Resident (#193), who had a history of agitation, aggression, and physical abuse of staff, from punching four Residents (#147, #83, #122, and #192), who had severe cognitive impairment, from a total sample of 38 residents. 1. On 2/13/24, Resident #193 punched Resident #147; 2. On 3/16/24 and 3/20/24, Resident #193 punched Resident #83; 3. On 3/16/24 and 3/20/24, Resident #193 punched Resident #192; and 4. On 3/18/24, Resident #193 punched Resident #122. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, by another person. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised 1/2024, indicated but was not limited to: Procedure: -Abuse is defined as, but not limited to, willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Resident to Resident altercation is defined as a physical or verbal act between two residents with or without resulting injury. -Employees are obligated, as a condition of employment, to report immediately to their supervisors or the administrator, any observed or suspected incidents of abuse when they have reasonable cause to do so. -The reporting is necessary in order that the nursing home can inform the alleged violations to the Department of Public Health prior to preliminary investigation as required and to protect the Resident from harm during the investigation of any such allegations. -The Administrator shall immediately take any and all protective actions necessary to prevent further harm to residents. Resident #193 was admitted to the facility in June 2023 with diagnoses including dementia. Review of the medical record indicated Resident #193 has a history of agitation, aggression, and physically assaulting staff since admission to the facility. Review of a Nursing progress note, dated 11/9/23, indicated Resident #193 exhibited increased agitation, combativeness and punched a Certified Nursing Assistant (CNA) in the face when attempting to provide care. On 11/14/23, Resident #193 was evaluated at the hospital and diagnosed with a urinary tract infection and metabolic encephalopathy. Review of the Minimum Data Set (MDS) assessment, dated 2/22/24, indicated a staff assessment of Resident's mental status identifying he/she had both long- and short-term memory problems, severely impaired skills for daily decision making, exhibited physical behaviors toward others such as hitting, kicking, pushing, scratching, and grabbing, and wandering. Review of Resident #193's Mood/Behavior Care Plan, dated 6/27/23, indicated, but was not limited to the following interventions: -Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). -If I become agitated, please try to assess for any unmet needs and redirect me with activities I enjoy; this will help calm me. Ensure that I am not in pain. Go slow with my care. Speak calmly to me while providing care. I enjoy conversations pertaining to my family. I light up when you talk to me about my granddaughter. -If I become physically and/or verbally abusive: assess whether the behavior endangers myself and/or others. Intervene as necessary. -Redirect me as needed and if that doesn't work, then just leave me alone if it is safe to do and return at a later time. -When I become physically and/or verbally abusive: keep distance between resident and others (e.g. staff, other residents, visitors). -When I become physically and/or verbally abusive: STOP and try task later. Do not force to do task. Review of the medical record indicated an interdisciplinary care plan meeting was held on 3/13/24. However, the current mood/behavior care plan was reviewed and renewed with no new interventions. Review of a psychiatric consultant Nurse Practitioner's note, dated 2/20/24, indicated Resident #193 was seen for aggressive behavior. The NP indicated a possibility that the Resident was annoyed by another resident's screaming. Recommendations included an increase in a medication used to treat akathisia (psychomotor restlessness), continue with supportive care, monitor for signs and symptoms of depression and notify the consultant provider with any changes. Further review of Resident #193's medical record indicated Resident #193 physically assaulted four residents on six occasions from 2/13/24 to 3/20/24 as follows: 1. Resident #147 was admitted to the facility with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated 3/1/24, indicated Resident #147 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, and required assistance from staff for all activities of daily living. Review of the medical record indicated on 2/13/24 at 6:30 P.M., while seated at a table in the unit dining room, Resident #147 was punched in the face by Resident #193. Review of the facility's Event Reports (for Residents #147 and #193), dated 2/13/24, indicated on 2/13/24 at 6:30 P.M., a Certified Nursing Assistant (CNA) observed Resident #193 approach Resident #147 while he/she was seated at a table in the unit dining room and punch him/her on the right side of the face, unprovoked. New interventions included 15-minute checks for 72 hours, and redirect the resident as needed. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. During an interview on 3/19/24 at 9:45 A.M., Resident #147 was unable to recall the incident that occurred on 2/13/24. 2. Resident #83 was admitted to the facility with diagnoses including dementia with agitation and anxiety. Review of the MDS assessment, dated 1/5/24, indicated Resident #83 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, required supervision only for ambulation on the unit, wandered, and had verbal behavioral symptoms directed toward others. Review of Resident #83's Mood/Behavior Care Plan, dated 1/20/22, indicated, but was not limited to the following: -Problem: I am at risk for behaviors and/or mood issues secondary to Alzheimer's disease, dementia, anxiety, depression, paranoia. -Approach: I can be paranoid in my thinking and believe that people are trying to hold me hostage or do harm to me. -Goal: To have a sense of happiness, calmness, and my mood to be regulated so that I can enjoy the time I spend with my family when they visit and enjoy the interactions with staff and other residents (target date: 4/18/24). a. Review of the facility's Event Reports (for both Resident #83 and #193), dated 3/16/24, indicated on 3/16/24 at 10:15 A.M. a CNA observed Resident #193 punch Resident #83 in the back twice as the Resident walked by him/her in the unit hallway. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on one-to-one (1:1) for the safety of others. b. Review of the facility's Event Reports (for both Resident #83 and #193), dated 3/20/24, indicated on 3/20/24 at 2:50 P.M., Resident #193 entered Resident #83's room and slapped him/her in the face. The report indicated a new intervention of redirection and Resident #193 was placed on 1:1. 3. Resident #192 was admitted to the facility with diagnoses including dementia and depression. Review of the MDS assessment, dated 1/19/24, indicated Resident #192 was unable to complete the BIMS assessment. Staff assessed that the Resident had both long- and short-term memory problems, severely impaired skills for daily decision making, physical and verbal behavior toward others and wandering behavior. Review of Resident #192's Mood/Behavior Care Plan, dated 4/29/23, indicated, but was not limited to the following: -Problem: I am at risk for behaviors and/or mood issues secondary to my Alzheimer's disease, dementia, and depression. -Approach: Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). -Goal: To have a sense of happiness, calmness, and my mood will be regulated so that I can enjoy the time I spend with my family when they visit and enjoy the interactions with staff and other residents (target date: 5/2/24). a. Review of the facility's Event Reports (for both Resident #192 and #193), dated 3/16/24, indicated on 3/16/24 at approximately 5:00 P.M., Resident #193, while being supervised by CNA #5 for 1:1, entered Resident #192's room and struck him/her in the chest with a closed fist while he/she was resting in bed. The CNA's witness statement indicated she followed Resident #193 into Resident #192's room and observed him/her hit the Resident with a closed fist in the upper chest area. The statement indicated she was able to stop the Resident by leading him/her out of the room. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. The Surveyor was unable to interview CNA #5 as she did not respond to the Department of Public Health's telephone message request for an interview. b. Review of the facility's Event Reports (for both Resident #192 and #193), dated 3/20/24, and review of the medical record indicated on 3/20/24 at 3:00 P.M., the facility Social Worker (SW) was doing rounds on the unit, and observed Resident #193 sitting on the edge of Resident #192's bed repeatedly striking him/her on the chest. The SW removed Resident #193 from Resident #192's bed and called for assistance of a CNA. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. The Resident was placed on 1:1, redirection as needed, and urinalysis and culture and sensitivity were ordered. During an interview on 3/21/24 at 9:00 A.M., Resident #192's family member said that her loved one was hit by a resident the other day and she was called by facility staff last night to inform her that her loved one was hit again by the same resident. She said Resident #192 makes loud vocalizations frequently and staff think that may be a trigger for the Resident. She said she doesn't want her loved one to get hit again. 4. Resident #122 was admitted to the facility with diagnoses including dementia, depression, and anxiety. The Resident was receiving Hospice services. Review of the MDS assessment, dated 1/4/24, indicated Resident #122 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, and required assistance with all activities of daily living. Review of Resident #122's Mood/Behavior Care Plan, dated 9/4/23, indicated, but was not limited to the following: -Problem: I am at risk for behaviors and/or mood issues secondary to my dementia, depression and anxiety. -Approach: Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents); At times, I don't like being alone. I can become anxious and restless and yell out. -Goal: To have a sense of happiness, calmness, and my mood to be regulated so that I can enjoy the time I spend with my family when they visit and enjoy the interactions with staff and other residents this quarter (target date: 4/11/24). Review of the facility's Event Reports (for both Resident #122 and #193), dated 3/18/24, indicated on 3/18/24 at 3:15 P.M., Resident #122 was yelling out with distressing behavior and told a Nurse that he/she was thrown to the floor and punched two times in the back. Increased anxiety and shaking were noted. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on 1:1, and redirect the Resident. During an interview on 3/21/24 at 2:10 P.M., Unit Manager #5 said Resident #193 has a history of aggression and assaulting facility staff. She said they have tried redirection, which really hasn't worked for a long time, every 15-minute checks (the staff go by the room and check on the resident), administration of as-needed (prn) antidepressant medication, and prn 1:1. The Unit Manager said prn 1:1 is only authorized by the Nursing Supervisor or Assistant Director of Nursing (ADON) and is when someone sits with a resident when they are behavioral, and once they are calm, the person leaves and the resident is unsupervised. She said 15-minute checks and prn 1:1 was not effective in preventing Resident #193 from punching Residents #147, #83, #192, #122 multiple times. Unit Manager #5 said Resident #193's behavior may be due to a urinary tract infection (UTI) and they are waiting for test results before implementing any interventions. During an interview on 3/21/24 at 2:40 P.M., the Assistant Director of Nursing (ADON) reviewed facility Event Reports for Residents #193, #147, #83, #192 and #122. She said Resident #193's behavior is unpredictable, and 15-minute checks and 1:1 was not effective in preventing Resident #193 from punching the Residents. She said the Resident is triggered by noise, and have considered moving his/her room, but he/she would be disruptive to others. The ADON said that when Resident #193 was at the hospital on 3/16/24, a urinalysis was negative for a UTI. She said the physician ordered another test and they are waiting for results. She said his/her behaviors may be due to a urinary tract infection (UTI), but they are waiting for the results before implementing any interventions. During interviews on 3/22/24 at 9:25 A.M. and 9:55 A.M., the Medical Director and the surveyor reviewed Resident #193's resident to resident altercations. He said after reviewing Resident #193's medical record, he consulted with the Resident's attending physician, and has decided to send the Resident out to the hospital for evaluation of his/her behaviors and psychiatric status. During an interview on 3/22/24 at 10:05 A.M., Social Worker #1 (SW# 1) said when Resident #193 was admitted to the facility, he/she would get nervous and combative with care only. She said the Resident had no aggression toward other residents until 2/13/24, when the Resident punched Resident #147. SW #1 said Resident #193's behavior has escalated over the past week and a half. She said they are waiting for test results to see if the Resident has a UTI, which may cause his/her behaviors. She said the Resident used to respond to redirection and would be calmed by talking about his/her family, but now he/she has just a blank stare. She said she had not contacted the facility's consultant psychiatric service provider for guidance related to managing Resident #193's behavior. SW #1 said there have been no updates or revisions to the Resident's care plan to prevent the resident from assaulting other residents. During an interview on 3/22/24 12:20 P.M., Nurse #7 said that she was working on 3/16/24 when a CNA told her that Resident #193 hit Resident #83 in the back. She said Resident #193 was redirected to his/her room; she notified the Supervisor and the Resident was placed on an as needed 1:1. Nurse #7 said she heard that Resident #193 hit another Resident in the afternoon and Resident #193 was sent out to the hospital. She said when she came back to work on the 17th, the Resident was not on a 1:1 and she didn't think of asking if he/she should be put back on a 1:1. She said she feels bad, because he/she hit someone else on 3/18/24. She said the Resident was started on continuous 1:1 last night. Nurse #7 said Resident #193's lab results came back positive for a UTI, but the physician is waiting for the culture and sensitivity results before prescribing treatment. During a telephone interview on 3/26/24 at 1:22 P.M., the consultant psychiatric Nurse Practitioner #1 (NP #1) said she has seen Resident #193 on several occasions for psychiatric medication management since his/her admission to the facility. She said the Resident's baseline behaviors include agitation, aggression and pacing behaviors. She said the Resident started a new medication, Rexulti (used to treat agitation associated with dementia) in December 2023 to address agitation and aggressive behaviors. NP #1 said she last saw Resident #193 on 2/20/24 upon staff request for aggressive behavior, medication review, breakthrough agitation, and an incident in which the Resident hit a peer and she recommended a dose increase to Benztropine (used to treat psychomotor restlessness). NP #1 said neither she nor her office was made aware of the Resident's multiple physical altercations with peers following the 2/13/24 altercation. She said the facility can contact her directly via her cell phone or email, or her office 24/7 and a clinician would contact them to set up a telehealth consult with the staff and Resident. She said if they had contacted her regarding the change in the Resident's violent behavior, she would have recommended they call 911 and have the Resident evaluated at the hospital.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, record reviews, and policy review, the facility failed to implement their abuse policy for prevention, protection and reporting to the Department of Public Health (DPH) for four Residents (#147, #83, #192, and #122), out of a total sample of 38 residents. Specifically, the facility failed to implement their policy: 1. For Resident #147, when he/she was struck by a peer on [DATE]. 2. For Resident #83, when he/she was struck by a peer on [DATE] and [DATE]. 3. For Resident #192, when he/she was struck by a peer on [DATE] and [DATE]. 4. For Resident #122, when he/she was struck by a peer on [DATE]. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, by another person. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised 1/2024, indicated but was not limited to: Procedure: -Abuse is defined as, but not limited to, willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Resident to Resident altercation is defined as a physical or verbal act between two residents with or without resulting injury. -Employees are obligated, as a condition of employment, to report immediately to their supervisors or the administrator, any observed or suspected incidents of abuse when they have reasonable cause to do so. -The reporting is necessary in order that the nursing home can inform the alleged violations to the Department of Public Health prior to preliminary investigation as required and to protect the Resident from harm during the investigation of any such allegations. -Administrator must immediately report allegations of abuse to the Department of Public Health's Division of Health Care Quality within two hours and do so via online reporting system. -The Administrator shall immediately take any and all protective actions necessary to prevent further harm to residents. Resident #193 was admitted to the facility in [DATE] with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated a staff assessment of the Resident's mental status identified that he/she had both long- and short-term memory problems, severely impaired skills for daily decision making, exhibited physical behaviors toward others such as hitting, kicking, pushing, scratching and grabbing, and wandering. Review of the medical record indicated Resident #193 has a history of agitation, aggression and physically assaulting staff since admission to the facility. Review of Resident #193's medical record indicated Resident #193 physically assaulted four residents on six occasions from [DATE] to [DATE] as follows: 1. Resident #147 was admitted to the facility with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #147 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, and required assistance from staff for all activities of daily living. Review of the medical record indicated on [DATE] at 6:30 P.M., while seated at a table in the unit dining room, Resident #147 was punched in the face by Resident #193. Review of the facility's Event Reports (for Residents #147 and #193), dated [DATE], indicated on [DATE] at 6:30 P.M., a Certified Nursing Assistant (CNA) observed Resident #193 approach Resident #147 while he/she was seated at a table in the unit dining room and punch him/her on the right side of the face, unprovoked. New interventions included 15-minute checks for 72 hours, and redirect the resident as needed. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Review of the Health Care Facility Reporting System (HCFRS-system used in Massachusetts by facilities to report suspected abuse/misappropriation) on [DATE], indicated the facility submitted a report on [DATE] as a resident-to-resident altercation between Resident #193 and Resident #147, and not resident-to-resident abuse, and did not report within two hours as required. No protective measures were put in place to protect any residents from Resident #193's aggressive behavior once 15-minute checks expired after 72 hours. 2. Resident #83 was admitted to the facility with diagnoses including dementia with agitation and anxiety. Review of the MDS assessment, dated [DATE], indicated Resident #83 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 3 out of 15, required supervision only for ambulation on the unit, wandered, and had verbal behavioral symptoms directed toward others. a. Review of the facility's Event Reports (for both Resident #83 and #193), dated [DATE], indicated on [DATE] at 10:15 A.M. a CNA observed Resident #193 punch Resident #83 in the back twice as the Resident walked by him/her in the unit hallway. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on one-to-one (1:1) for the safety of others. b. Review of the facility's Event Reports (for both Resident #83 and #193), dated [DATE], indicated on [DATE] at 2:50 P.M., Resident #193 entered Resident #83's room and slapped him/her in the face. The report indicated a new intervention of redirection and Resident #193 was placed on 1:1. Review of the HCFRS on [DATE], failed to indicate the facility submitted a report for the resident-to-resident abuse between Resident #193 and Resident #83 that occurred on [DATE] and [DATE]. During an interview on [DATE] at 2:10 P.M., Unit Manager #5 said Resident #193 did not have a prn 1:1 in place and was not on 15-minute checks at the time the incident occurred. No ongoing protective measures were put in place to protect any residents from Resident #193's aggressive behavior. 3. Resident #192 was admitted to the facility with diagnoses including dementia and depression. Review of the MDS assessment, dated [DATE], indicated Resident #192 was unable to complete the BIMS assessment. Staff assessed that the Resident had both long- and short-term memory problems, severely impaired skills for daily decision making, physical and verbal behavior toward others and wandering behavior. a. Review of the facility's Event Reports (for both Resident #192 and #193), dated [DATE], indicated on [DATE] at approximately 5:00 P.M., Resident #193, while being supervised by CNA #5 for 1:1, entered Resident #192's room and struck him/her in the chest with a closed fist while he/she was resting in bed. The CNA's witness statement indicated she followed Resident #193 into Resident #192's room and observed him/her hit the Resident with a closed fist in the upper chest area. The statement indicated she was able to stop the Resident by leading him/her out of the room. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. b. Review of the facility's Event Reports (for both Resident #192 and #193), dated [DATE], and review of the medical record indicated on [DATE] at 3:00 P.M., the facility Social Worker (SW) was doing round on the unit, and observed Resident #193 sitting on the edge of Resident #192's bed repeatedly striking him/her on the chest. The SW removed Resident #193 from Resident #192's bed, and called for assistance of a CNA. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. The Resident was placed on 1:1, redirection as needed, and urinalysis and culture and sensitivity were ordered. Review of the HCFRS on [DATE], failed to indicate the facility submitted a report for the resident-to-resident abuse between Resident #193 and Resident #192 that occurred on [DATE] and [DATE]. No ongoing protective measures were put in place to protect any residents from Resident #193's aggressive behavior. 4. Resident #122 was admitted to the facility with diagnoses including dementia, depression and anxiety. The Resident was receiving Hospice services. Review of the MDS assessment, dated [DATE], indicated Resident #122 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, and required assistance with all activities of daily living. Review of the facility's Event Reports (for both Resident #122 and #193), dated [DATE], indicated on [DATE] at 3:15 P.M., Resident #122 was yelling out with distressing behavior and told a Nurse that he/she was thrown to the floor and punched two times in the back. Increased anxiety and shaking were noted. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on 1:1 and redirect the Resident. Review of the HCFRS on [DATE], failed to indicate the facility submitted a report for the resident-to-resident abuse between Resident #193 and Resident #122 that occurred on [DATE]. During an interview on [DATE] at 2:40 P.M., the Assistant Director of Nursing (ADON) reviewed the facility Event Reports for Residents #193, #147, #83, #192 and #122. She said Resident #193's behavior is unpredictable, and 15-minute checks and prn 1:1 was not effective in protecting any residents from being punched by Resident #193. During an interview on [DATE] at 8:10 A.M., the Administrator and ADON said they were confused on the definition of abuse as it relates to cognitively impaired residents, and after reviewing the incidents, the Administrator said all of the incidents are considered abuse and should have been reported within two hours.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to implement protective interventions to prevent further instances of abuse, resulting in psychosocial distress for four cognitively impaired Residents (#147, #83, #122, and #192), in a total sample of 38 residents. Using the reasonable person concept, a person would experience emotional distress after being hit, unprovoked, by another person. Findings include: Review of the facility's policy titled Resident Abuse, Mistreatment, and Neglect Policy and Procedure, last revised 1/2024, indicated but was not limited to: Procedure: -Abuse is defined as, but not limited to, willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. -Resident to Resident altercation is defined as a physical or verbal act between two residents with or without resulting injury. -The reporting is necessary in order that the nursing home can inform the alleged violations to the Department of Public Health prior to preliminary investigation as required and to protect the Resident from harm during the investigation of any such allegations. -The Administrator shall immediately take any and all protective actions necessary to prevent further harm to residents. Resident #193 was admitted to the facility in [DATE] with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated a staff assessment of the Resident's mental status identifying he/she had both long- and short-term memory problems, severely impaired skills for daily decision making, exhibited physical behaviors toward others such as hitting, kicking, pushing, scratching and grabbing, and wandering. Review of the medical record indicated Resident #193 has a history of agitation, aggression, and physically assaulting staff since admission to the facility. Review of Resident #193's Mood/Behavior Care Plan, dated [DATE], indicated but was not limited to the following interventions: -Avoid over-stimulation (e.g. noise, crowding, other physically aggressive residents) -If I become agitated, please try to assess for any unmet needs and redirect me with activities I enjoy; this will help calm me. Ensure that I am not in pain. Go slow with my care. Speak calmly to me while providing care. I enjoy conversations pertaining to my family. I light up when you talk to me about my granddaughter. -If I become physically and/or verbally abusive: assess whether the behavior endangers myself and/or others. Intervene as necessary. -Redirect me as needed and if that doesn't work, then just leave me alone if it is safe to do and return at a later time. -When I become physically and/or verbally abusive: keep distance between resident and others (e.g. staff, other residents, visitors). -When I become physically and/or verbally abusive: STOP and try task later. Do not force to do task. Review of a psychiatric consultant Nurse Practitioner's note, dated [DATE], indicated Resident #193 was seen for agitation and combativeness. Recommendations included but were not limited to monitoring and document changes in mood, behavior, mental status and cognition and contact the psychiatric service provider with any changes. Further review of Resident #193's medical record indicated Resident #193 physically assaulted four residents on six occasions from [DATE] to [DATE] as follows: 1. Resident #147 was admitted to the facility with diagnoses including dementia. Review of the Minimum Data Set (MDS) assessment, dated [DATE], indicated Resident #147 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of 11 out of 15, and required assistance from staff for all activities of daily living. Review of the medical record indicated on [DATE] at 6:30 P.M., while seated at a table in the unit dining room, Resident #147 was punched in the face by Resident #193. Review of the facility's Event Reports (for Residents #147 and #193), dated [DATE], indicated on [DATE] at 6:30 P.M., a Certified Nursing Assistant (CNA) observed Resident #193 approach Resident #147 while he/she was seated at a table in the unit dining room and punch him/her on the right side of the face, unprovoked. New interventions included 15-minute checks for 72 hours, and redirect the resident as needed. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. During an interview on [DATE] at 2:10 P.M., Unit Manager #5 said as needed (prn) one to one (1:1) supervision is only authorized by the Nursing Supervisor or Assistant Director of Nursing (ADON) and is when someone sits with a resident when they are behavioral, and once they are calm, the person leaves and the resident is unsupervised No protective measures were put in place to protect any residents from Resident #193's aggressive behavior once 15-minute checks expired after 72 hours. 2. Resident #83 was admitted to the facility with diagnoses including dementia with agitation and anxiety. Review of the MDS assessment, dated [DATE], indicated Resident #83 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, required supervision only for ambulation on the unit, wandered, and had verbal behavioral symptoms directed toward others. Review of the facility's Event Reports (for both Resident #83 and #193), dated [DATE], indicated on [DATE] at 10:15 A.M. a CNA observed Resident #193 punch Resident #83 in the back twice as the Resident walked by him/her in the unit hallway. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on one-to-one (1:1) for the safety of others. The report failed to indicate any protective measures were in place at the time of the incident to prevent Resident #83 from being punched by Resident #193. During an interview on [DATE] at 2:10 P.M., Unit Manager #5 said Resident #193 did not have a prn 1:1 in place and was not on 15-minute checks at the time the incident occurred. 3. Resident #192 was admitted to the facility with diagnoses including dementia and depression. Review of the MDS assessment, dated [DATE], indicated Resident #192 was unable to complete the BIMS assessment. Staff assessed that the Resident had both long- and short-term memory problems, severely impaired skills for daily decision making, physical and verbal behavior toward others and wandering behavior. Review of the facility's Event Reports (for both Resident #192 and #193), dated [DATE], indicated on [DATE] at approximately 5:00 P.M., Resident #193, while being supervised by CNA #5 for 1:1, entered Resident #192's room and struck him/her in the chest with a closed fist while he/she was resting in bed. The CNA's witness statement indicated she followed Resident #193 into Resident #192's room and observed him/her hit the Resident with a closed fist in the upper chest area. The statement indicated she was able to stop the Resident by leading him/her out of the room. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. The Surveyor was unable to interview CNA #5 as she did not respond to the Department of Public Health's telephone message request for an interview. Review of hospital documentation, dated [DATE], indicated Resident #193 was evaluated for altered mental status and aggressive behavior due to dementia. A head CAT scan (computed tomography scan) and laboratory tests were performed which showed no abnormalities. The Resident was discharged and arrived at the facility at 11:50 P.M. on [DATE]. Review of Resident #193's medical record failed to indicate 1:1 supervision was resumed upon his/her return to the facility, and no other protective measures were put in place to protect any residents from Resident #193's aggressive behavior. During an interview on [DATE] at 12:20 P.M., Nurse #7 said when Resident #193 returned from the hospital on [DATE], the 1:1 was not resumed. 4. Resident #122 was admitted to the facility with diagnoses including dementia, depression and anxiety. The Resident was receiving Hospice services. Review of the MDS assessment, dated [DATE], indicated Resident #122 had severe cognitive impairment as evidenced by a BIMS score of 3 out of 15, and required assistance with all activities of daily living. Review of the facility's Event Reports (for both Resident #122 and #193), dated [DATE], indicated on [DATE] at 3:15 P.M., Resident #122 was yelling out with distressing behavior and told a Nurse that he/she was thrown to the floor and punched two times in the back. Increased anxiety and shaking were noted. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. Resident #193 was placed on 1:1, and redirect the Resident. The report failed to indicate any protective measures were in place at the time of the incident to prevent Resident #122 from being punched by Resident #193. During an interview on [DATE] at 2:10 P.M., Unit Manager #5 said Resident #193 did not have a prn 1:1 in place and was not on 15-minute checks at the time of the incident. 5. Review of the facility's Event Reports (for both Resident #83 and #193), dated [DATE], indicated on [DATE] at 2:50 P.M., Resident #193 entered Resident #83's room and slapped him/her in the face. The report indicated a new intervention of redirection and Resident #193 was placed on 1:1. The report failed to indicate any protective measures were in place at the time of the incident to prevent Resident #83 from being slapped by Resident #193. During an interview on [DATE] at 2:10 P.M., Unit Manager #5 said Resident #193 did not have a prn 1:1 in place and was not on 15-minute checks at the time of the incident. 6. Review of the facility's Event Reports (for both Resident #192 and #193), dated [DATE], and review of the medical record indicated that on [DATE] at 3:00 P.M., the facility Social Worker (SW) was doing rounds on the unit, and observed Resident #193 sitting on the edge of Resident #192's bed repeatedly striking him/her on the chest. The SW removed Resident #193 from Resident #192's bed, and called for assistance of a CNA. The report indicated Resident #193's behavioral symptoms put others at risk for significant injury. The Resident was placed on 1:1, redirection as needed, and urinalysis and culture and sensitivity were ordered. The report failed to indicate any protective measures were in place at the time of the incident to prevent Resident #192 from being punched by Resident #193. During an interview on [DATE] at 2:10 P.M., Unit Manager #5 said Resident #193 has a history of aggression and assaulting facility staff. She said they have tried redirection, which really hasn't worked for a long time, every 15-minute checks (the staff go by the room and check on the resident), administration of prn antidepressant medication, and prn 1:1. She said 15-minute checks and prn 1:1 was not effective in preventing Resident #193 from punching Residents #147, #83, #192, #122 multiple times. Unit Manager #5 said Resident #193's behavior may be due to a urinary tract infection (UTI) and they are waiting for test results before implementing any interventions. During an interview on [DATE] at 2:40 P.M., the Assistant Director of Nursing (ADON) reviewed the facility's Event Reports for Residents #193, #147, #83, #192, and #122. She said Resident #193's behavior is unpredictable, and 15-minute checks and 1:1 was not effective in preventing Resident #193 from punching the Residents. She said the Resident is triggered by noise, and have considered moving his/her room, but he/she would be disruptive to others. The ADON said that when Resident #193 was at the hospital on [DATE], a urinalysis was negative for a UTI. She said the physician ordered another test and they are waiting for results. She said his/her behaviors may be due to a urinary tract infection (UTI), but they are waiting for the results before implementing any interventions. During an interview on [DATE] at 10:05 A.M., Social Worker #1 (SW# 1) said when Resident #193 was admitted to the facility, he/she would get nervous and combative with care only. She said the Resident had no aggression toward other residents until [DATE], when the Resident punched Resident #147. SW #1 said Resident #193's behavior has escalated over the past week and a half. She said the Resident used to respond to redirection and would be calmed by talking about his/her family, but now he/she has just a blank stare. She said they are waiting to update the Resident's care plan with new interventions until they receive test results to see if the Resident has a UTI, which may cause his/her behaviors. During an interview on [DATE] at 12:20 P.M., Nurse #7 said Resident #193 was started on continuous a 1:1 last night, more than five weeks after Resident #193 first struck a fellow Resident.