**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.02(H) Based on record review and interview; the facility failed to report an incident related to elopement for Resident 15. The sample size was 2 and the facility census was 34. Findings are: Review of the facility policy Elopement Emergency, undated revealed the following: -once a resident leaves facility grounds it was considered an elopement, -upon return to the facility, the resident would be assessed for injuries, -the resident's provider would be notified, -the charge nurse would document all events that transpired prior to the elopement through the residents return assessment including how the elopement occurred, if the alarm sounded, and the time the Director of Nursing (DON), Administrator, and Provider were notified, -Adult Protective Services (APS) would be notified within 24 hours (unless injury and medical treatment needed must be within 2 hours), -the Administrator, DON, and Social Service Director (SSD) would complete an investigation within 5 working days, -if a resident was not wearing a wander guard one would be placed, -residents that were at risk of elopement or had a wander guard device would be left unattended outside of the facility, and -nursing would monitor and document the resident for 48 hours after the elopement. Review of Resident 15's Minimum Data Set (MDS- a federally mandated assessment tool used in care planning) dated 7/25/23 revealed the following: -the resident was admitted on [DATE], -had severe cognitive impairment, -had diagnoses of high blood pressure, arthritis, and dementia, -behaviors included hallucinations, delusions, and daily wandering, -required moderate assistance with toileting and dressing and supervision with transfers and ambulation, and -a wander guard alarm was not in use. Review of the facility form Wandering Risk Scale dated 7/29/23 revealed the resident was found to be at high risk for wandering. Review of the facility form Morse Fall Scale dated 7/29/23 revealed the resident was found to be at high risk for falling. Review of the resident's Progress Notes an entry dated 8/15/23 at 3:58 PM revealed the resident was found outside of the building by themself, the resident went back inside easily with staff assistance, and a wander guard was placed. Further review revealed no documentation that the DON, Administrator, Provider or that APS had been notified. Review of the resident's Care Plan last revised on 10/24/23 revealed on 8/18/23 the resident wandered outside by themself, and a wander guard was placed on the resident's wrist was handwritten in. Interview on 8/7/24 at 3:30 PM with the Administrator confirmed the elopement was not reported to the State Agency.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** LICENSURE REFERENCE NUMBER 175 NAC 12-006.09 Based on record review and interview; the facility failed to ensure Transportation Personal maintained current Cardiopulmonary Resuscitation (CPR-emergency procedures performed if a person stops breathing or their heart stops) credentials. This had the potential to affect 2 Residents 34 and 25) of 23 total sampled residents. The facility census was 34. Findings are: A. Review of the facility policy Emergency Procedure-Cardiopulmonary Resuscitation with a revision date of 2/2018 revealed a policy statement which indicated personnel were to have completed training on the initiation of CPR for victims of sudden cardiac arrest (the sudden loss of all heart activity due to an irregular heart rhythm). The policy further indicated if a resident was found unresponsive and was not breathing, a certified staff member should initiate CPR unless it was known that a Do Not Resuscitate (DNR- (physician order which instructs staff not to perform CPR if a resident would stop breathing or if their heart would stop beating) order was in place. If the resident's DNR status was unclear, CPR was to be initiated until the resident's status was determined. Training was to be provided/required biannually by a certified instructor and staff were to provide the facility with current CPR card with completion. B. Review of Resident 34's Nursing Progress Note dated [DATE] at 11:30 AM revealed the resident was transferred to the facility per the facility van with the Social Service Director (SSD)-M driving. Review of the resident's Advanced Medical Directives (a written document that tells your health care provider who should speak for you and what medical decisions they should make for you) dated [DATE] revealed the resident wanted CPR for a witnessed arrest of heart or respirations. C. Review of Resident 25's Nursing Progress Notes dated [DATE] at 11:00 AM revealed the resident was transported by SSD-M to the facility from the hospital in the facility van. Review of Resident 25's Advanced Medical Directives dated [DATE] revealed the resident had requested CPR for witnessed arrest of the heart or respirations. D. Review of a current roster of staff who were listed as course participants in the CPR training dated [DATE] revealed no evidence SSD-M was listed as having received CPR certification. E. Interview on [DATE] at 10:37 AM with the Director of Nursing (DON) indicated a CPR certified staff member should always be available for any residents who indicated they wanted to receive CPR with a witnessed cardiac arrest and/or who had stopped breathing. F. Interview with SSD-M on [DATE] at 11:12 AM confirmed SSD-M was not CPR certified when SSD-M transported Residents 34 and 25 in the facility van.

Licensure Reference Number 175 NAC 12-006.09(H) Based on record review and interview, the facility failed to have a diagnosis in place to support the use of an antipsychotic (medication that affects behavior, mood, thoughts, perception, and is used to manage psychotic disorders) medication for Resident 25. The sample size was 5 and the facility census was 34. Findings are: Review of the undated facility policy Restraints-Physical or Chemical revealed the following: - Residents had the right to be free from any chemical of physical restraint imposed for the purpose of discipline or convenience and not required to treat the resident's medical symptoms. -An example of a chemical restraints included but was not limited to, psychoactive (mind or consciousness altering) medications or any other medication class ordered for the purpose of discipline or convenience and not required to treat medical symptoms. Review of the undated facility policy Psychotropic Medication Review and Gradual Dose Reduction revealed the following: -All antipsychotic medications were reviewed upon admission and quarterly to reduce unnecessary drugs and adverse drug reactions. Review of Resident 25's Minimum Data Set (MDS-federally mandated comprehensive assessment used to develop resident care plans) dated 6/10/24 revealed the following: -The resident had diagnoses of dementia -The resident had taken Antipsychotic medication daily, Review of Resident 25's Care Plan with a revision date of 6/10/24 revealed the following: -The resident had a diagnosis of dementia without behavioral, psychotic, or mood disturbance. -The resident had severe cognitive impairment and displayed inattention and disorganized thinking. -The resident was taking antipsychotic medication, and staff were to monitor for adverse reactions. Review of Resident 25's Medication Administration Record dated August 2024 revealed the resident was taking the antipsychotic medication Quetiapine Fumurate 25 milligrams daily at bedtime. During an interview on 8/7/24 at 3:35 PM the Director of Nursing confirmed the facility did not have a diagnosis in place for the use of the antipsychotic medication for Resident 25.

Licensure Reference Number 175 NAC 12-006.09B Based on record review and interview; the facility failed to ensure Resident 2's Pre-admission Screening and Resident Review (PASARR-federally mandate screen performed to identify Mental Disorders (MD), Intellectual Disability (ID), or Related Disorders (RD) and to ensure appropriate facility placement with appropriate services), accurately reflected a potential MD. The sample size was 1 and the facility census was 30. Findings are: Record review of the facility policy dated 6/12/23 revealed the facility performed PASARR screening for all new admissions and readmission to the facility to screen for MD, ID, or RD, and new PASARR screening would be completed to reflect antipsychotic (medication used to treat psychotic disorders) medication use. Record review of Resident 2's PASARR dated 1/19/18 revealed the resident has no MD including depression or delusional disorders. Record review of Resident 2's Psychoactive Medication Review dated 4/17/23 revealed the resident took the antipsychotic medication Seroquel for a delusional disorder and hallucinations and antidepressant (medication used to treat depression, anxiety, and chronic pain) medication Duloxetine for treatment of depression, and the antidepressant medication Trazadone for insomnia. Record review of Resident 2's Minimum Data Set (MDS-federally mandated comprehensive assessment used for the development of resident Care Plans) dated 4/25/23 indicated the resident had a diagnosis of depression, displayed verbal behaviors 1-3 days in the preceding week, and took antipsychotic and antidepressant medication 7 out of 7 of the preceding 7 days. Record review of Resident 2's Care Plan with a revision date of 5/1/23 revealed the resident was delusional, had a delusional disorder diagnosis, and took antipsychotic and antidepressant medication. Interview on 6/21/23 at 8:44 AM the facility Administrator confirmed the facility did not have a PASARR for Resident 2 that accurately reflected a potential Mental Disorder and the use of antipsychotic medication.

Licensure Reference Number 175 NAC 12-006.09C Based on record review and interview; the facility failed to address insulin use on the care plan for 1 (Resident 27) of 19 total sampled residents. The facility census was 30. Findings are: Record review of Resident 27's diagnosis list revealed a diagnosis for type 2 diabetes mellitus. Record review of the resident's Medication Administration Records (MAR) for March 2022 and April 2022 revealed the resident had an order for insulin detemir, a medication used to help control blood sugar. Record review of the resident's Comprehensive Care Plan, initiated 9/27/21, revealed no documentation to address the use of insulin. Interview on 4/5/22 at 9:20 AM with Registered Nurse/Minimum Data Set (a federally mandated comprehensive assessment tool utilized to develop resident care plans) Coordinator (RN/MDS-L) confirmed that the use of insulin was not addressed on the plan of care.

Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview, the facility failed to assess, monitor and notify the physician in a timely manner when a change in condition was identified for 1 (Resident 4) of 1 sampled residents related to ongoing loose stools. The facility census was 30. Findings are: A. Review of the facility policy Change in a Resident's Condition or Status with revision date of 5/2017 revealed the facility was to notify the physician promptly of significant changes in the resident's medical/mental condition and/or status. Further review of the policy revealed a significant change was classified as a decline in the resident's status that would not normally resolve itself without intervention or by implementing standard clinical interventions. B. Review of Resident 4's MDS (Minimum Data Set, a federally mandated comprehensive assessment tool used for care planning) dated 1/11/22 revealed diagnoses of non-traumatic brain dysfunction, Alzheimer's disease, anemia and Non-Alzheimer's dementia. The following was assessed regarding the resident; -severely impaired cognition; -behaviors which included delusions, physical and verbal behaviors directed at others; resistance with cares and wandering; -required extensive staff assistance with toilet use and personal hygiene; and -always incontinent of bowel and bladder. Review of a Nursing Progress Note dated 2/4/22 at 10:33 AM revealed the resident's bowel elimination patterns were regular. Review of a Nursing Progress Note dated 3/1/22 at 7:42 AM revealed the resident's bowel elimination remained regular with a bowel movement every day or every other day. Review of a Nursing Progress Note dated 3/14/22 at 3:42 PM revealed the resident continued to have loose stools. Review of a Nursing Progress Note dated 3/17/22 at 3:52 AM revealed the staff reported the resident had watery loose stools. Review of a Bowel Elimination report from 3/1/22 to 3/31/22 revealed the resident was having loose/diarrhea stools on the Day Shift on 3/4, 3/5, 3/7, 3/10, 3/11, 3/12, 3/13, 3/14 (x2), 3/18, 3/20, 3/21, 3/22, 3/24, 3/25, and 3/29/22 (15 out of 31 days). The resident had loose/diarrhea stools on the evening shift on 3/11, 3/14, 3/16, 3/19, 3/25, 3/27, 3/29 and 3/30/22 (8 out of 31 days) and on the night shift on 3/3 and 3/16/22. The resident had loose/diarrhea stools a total of 21 out of 31 days. Review of a Nursing Progress Note/Communication with the Physician dated 3/30/22 (27 days after staff started documenting the resident's loose/diarrhea stools) at 3:34 PM revealed the resident's physician was notified the resident was having continuous large, loose stools, multiple times a day. The note further indicated the resident did not have orders for a routine laxative. Review of the resident's medical record revealed no evidence staff provided further monitoring and/or assessment of Resident 4 or that interventions were developed and/or implemented to address the resident's continuous loose stools. Interview with the Director of Nursing (DON) on 4/4/22 at 2:49 PM confirmed there was no documentation to indicate staff provided further monitoring/assessment of Resident 4 or that interventions were put into place to address the loose stools. In addition, the DON verified staff should have notified the resident's physician in a timelier manner and in accordance with the facility policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.09D Based on record review and interview; the facility failed to ensure orders for as needed psychotropic (medication taken to exert an effect on the brain and/or nervous system) medications for Residents 19 and 21 were limited to 14 days in duration, a specific duration time was identified and that ongoing evaluations were completed regarding continuation of the medications. The sample size was 5 and the facility census was 30. Findings are: A. Review of Resident 19's Minimum Data Set (MDS- a federally mandated assessment used in the development of the resident Care Plan) dated 3/1/22 revealed the following; -diagnoses of anxiety, depression, psychosis, delusions, heart failure, kidney disease, hypertension, and chronic lung disease, -rejected care daily, and -received antianxiety medication 2 of the previous 7 days. Review of Resident 19's Medication Administration Record (MAR) dated 4/22 revealed the resident had an order initiated on 2/22/18 for Xanax (medication taken for the treatment of anxiety) 0.25 miligrams (mg) as needed up to 3 times daily with no prescribed duration for use. Review of Resident 19's Psychoactive Medication Review dated 1/17/22 revealed no evidence of an ordered duration of use for the as needed Xanax. B. Review of Resident 21's MDS dated [DATE] revealed diagnoses of delusional disorder, dementia, depression and anxiety. The resident had behaviors which included delusions, verbal behaviors directed at others, other behavioral symptoms not directed at others, rejection of cares and wandering. In addition, the resident received an antipsychotic medication 7 out of the last 7 days of the look back period and an antianxiety medication 2 out of the last 7 days. Review of the resident's MAR dated 4/22 revealed the resident had an order dated 1/19/21 for Lorazepam (medication used to treat anxiety) 0.5 mg every 2 hours as needed for anxiety and comfort with no prescribed duration for use. Review of the resident's Psychoactive Medication Review dated 2/21/22 revealed no evidence the Lorazepam was evaluated by the physician to determine need for continued use. C. Interview with the Director of Nursing (DON) on 4/4/22 at 2:49 PM revealed the facility failed to assure ongoing assessment and evaluation of Resident 19's Xanax and Resident 21's Lorazepam were completed to monitor for therapeutic benefits and potential adverse side effects to determine need for continued use of the medications and/or the medications had a specified duration date for use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.05(9) Based on record review and interview; the facility failed to protect Residents 1, 10, 19, and 23 after allegations of potential abuse and neglect. The sample size was 5 and the facility census was 30. Findings are: A. Review of the facility Resident Abuse and Neglect policy dated 1/2/2020 revealed the following; -all employees of the facility are responsible to protect and prevent resident abuse from occurring. This included resident to resident, resident to staff and staff to resident abuse; -resident abuse included an intentional or negligent act or omission which resulted in mistreatment, neglect, misappropriation of resident's property, physical, mental, verbal or sexual abuse, or involuntary seclusion of a resident; -the facility would not employ or continue to employ anyone that had a history of documented resident abuse or had subsequently been found guilty of any abuse; -staff would report their knowledge or allegation without fear of reprisal; -if abuse or suspected abuse occurred the Charge Nurse, Director of Nursing (DON), Social Services, and the Administrator would be immediately notified: -an immediate investigation would be conducted; and -the appropriate state and local agencies would be called immediately, whether the facility felt the allegation was substantiated or unsubstantiated. B. An interview on 3/30/22 at 10:38 AM with Resident 23 revealed a staff member had told the resident to wet the bed rather than call for assistance to get up during the night. The resident reported this concern to the facility. Review of Resident 23's Care Plan dated 3/10/22 revealed the following; -recent right arm and right hip fractures and surgery; -bladder problems that required staff monitoring; -required extensive assistance of 1 or 2 staff for toileting, dressing, and personal hygiene; and -staff were to assist with toileting. Review of Resident 23's Grievance, Concern, and Suggestion Form dated 3/14/22 revealed the following; -when the resident called for assistance to the bathroom staff reported not having time to assist the resident to the bathroom; and -when the resident called again 45 minutes later, the same staff member offered the bed pan and instructed the resident to wet self the remainder of the night. Interview on 4/4/22 at 2:13 PM with the DON confirmed no staff were restricted from direct care or educated on abuse despite Resident 23's allegation of potential abuse, and the facility did not have a system in place to protect the residents during the course of the investigation, of the resident allegation on 3/14/22. C. An interview on 3/30/22 at 9:04 AM with Resident 19 revealed one staff member had hurt the resident. Resident 19 chose not to share the staff members name at the time of the interview but referred to the staff member as a Nurse Aide (NA). Review of the facility Vocalized Complaints form dated 12/1/21 revealed Resident 19 reported a NA picked up the resident and threw them against the wall. Further review revealed this occurred during rolling the resident in bed for bed pan use. Review of Resident 19's Care Plan dated 12/9/21 revealed the following; -the resident required total assistance with bed mobility and transfers; -was unable to stand, bear weight, transfer, or walk; and -required a mechanical lift for all transfers. Interview on 4/4/22 at 2:13 PM with the DON confirmed that no staff were restricted from direct care or educated on abuse despite Resident's 19's allegation of potential abuse, and the facility did not have a system in place to protect residents during the course of investigation, of the resident allegation on 12/1/21. D. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/29/22 revealed diagnoses of stroke, anemia, heart failure, hemiplegia (paralysis of one side of the body), chronic pain syndrome and anxiety. The following was assessed regarding Resident 1: -was cognitively intact; -no behaviors; and -required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of a Nursing Progress Note dated 1/3/22 at 2:02 AM revealed a late entry for 1/2/22 which indicated Licensed Practical Nurse (LPN)-O was called to the resident's room by NA-N as the resident had complained of not being able to breath. Resident 1 was wearing oxygen and was trying to remove. The resident requested assistance to the bathroom. Staff assisted the resident into the bathroom and when cares were completed transferred the resident back into the recliner. Resident 1 reported at this time, the resident did not want NA-N back in the resident's room again. Review of a Grievance, Concern and Suggestion Form dated 1/3/22 revealed the resident had turned on the call light as the resident needed to use the bathroom. NA-N responded to the call light, but threw a fit about the resident's positioning in the recliner. Resident 1 repeatedly requested assistance to the bathroom. NA-N left the room to obtain the help of a second staff and returned with LPN-O. The resident told the staff the resident needed to use the bathroom but they continued to argue with the resident about positioning in the recliner. The staff did finally assist the resident, but the resident reported the staff were mean. E. Review of Resident 10's MDS dated [DATE] revealed diagnoses of non-specified intellectual disability and non-traumatic brain dysfunction. The resident's cognition was severely impaired and the resident had behaviors which included hallucinations, delusions, physical and verbal behaviors directed at others and rejection of cares. Resident 10 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene and had occasional urinary incontinence. Review of a Grievance, Concern and Suggestion Form dated 12/7/21 revealed Resident 10 had told NA-P the resident was glad (gender) wasn't here as (gender) had grabbed the resident's hands and hurt the resident. F. During an interview on 4/4/22 at 2:43 PM, the DON confirmed the following: -both Resident 1 and 10 had histories of delusions and hallucinations and after initial review of the resident's grievances, the DON did not feel the residents had been abused or that an abuse investigation was warranted and made no attempt to investigate the allegations further; -despite Resident 1's allegation LPN-O and NA-N had been mean to the resident and the resident did not want NA-N back in the resident's room, both staff continued to work and to provide direct care to the residents; -did not investigate Resident 10's allegation regarding someone grabbing the resident's hands and hurting the resident; and -failed to develop and/or implement interventions to assure Resident 1 and 10's safety after their allegations of potential staff to resident abuse.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Licensure Reference Number 175 NAC 12-006.02(8) Based on record review and interview; the facility failed to report, complete a thorough investigation and then submit the results of the investigation to the State Agency within the required time frames for Residents 1, 10, 19, and 23 after allegations of potential abuse and neglect. The sample size was 5 and the facility census was 30. Findings are: A. Review of the facility Resident Abuse and Neglect policy dated 1/2/2020 revealed the following; -all employees of the facility are responsible to protect and prevent resident abuse from occurring. This included resident to resident, resident to staff and staff to resident abuse. - Resident abuse included an intentional or negligent act or omission which resulted in mistreatment, neglect, misappropriation of resident's property, physical, mental, verbal or sexual abuse, or involuntary seclusion of a resident -the facility would not employ or continue to employ anyone that had a history of documented resident abuse or had subsequently been found guilty of any abuse. -staff would report their knowledge or allegation without fear of reprisal, -if abuse or suspected abused occurred the Charge Nurse, the Director of Nursing (DON), Social Services, and A dministrator would be immediately notified, -an immediate investigation would be conducted, and -the appropriate state and local agencies would be called immediately, whether the facility felt the allegation was substantiated or unsubstantiated. B. An interview on 3/30/22 at 10:38 AM with Resident 23 revealed a staff member had told the resident to wet the bed rather than call for assistance to get up during the night. The resident reported this concern to the facility. Review of Resident 23's Care Plan dated 3/10/22 revealed the following; -the resident had recent right arm and right hip fractures and surgery, -the resident had bladder problems that required staff monitoring, -the resident required extensive assistance of 1 or 2 staff for toileting, dressing, and personal hygiene, and -staff were to assist with toileting. Review of Resident 23's Grievance, Concern, and Suggestion Form dated 3/14/22 revealed the following; -when the resident called for assistance to the bathroom staff reported not having time to assist the resident to the bathroom, -when the resident called again 45 minutes later the same staff member offered the bed pan and instructed the resident to wet self the remainder of the night. Interview on 4/4/22 at 2:13 PM with the DON confirmed that allegations of potential abuse by Resident 23 were not reported to the appropriate State Agency and a thorough investigation was not submitted in the required time frames. C. An interview on 3/30/22 at 9:04 AM with Resident 19 revealed that a staff member hurt the resident. Resident 19 chose not to share the staff members name at the time of the interview but referred to the staff member as a Nurse Aide (NA). Review of the facility Vocalized Complaints form dated 12/1/21 Resident 19 reported that a Nurse Aide picked up the resident and threw them against the wall. Further review revealed this occurred during rolling the resident in bed for bed pan use. Review of Resident 19's Care Plan dated 12/9/21 revealed the following; -the resident required total assistance with bed mobility and transfers, -was unable to stand, bear weight, transfer, or walk, and -required a mechanical lift for all transfers. Interview on 4/4/22 at 2:13 PM with the Director of Nursing (DON) confirmed that allegations of potential abuse by Resident 19 were not reported to the appropriate State Agency and a thorough investigation was not submitted in the required time frames. D. Review of Resident 1's Minimum Data Set (MDS-a federally mandated comprehensive assessment tool used for care planning) dated 3/29/22 revealed diagnoses of stroke, anemia, heart failure, hemiplegia (paralysis of one side of the body), chronic pain syndrome and anxiety. The following was assessed regarding Resident 1: -was cognitively intact; -no behaviors; and -required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene. Review of a Nursing Progress Note dated 1/3/22 at 2:02 AM revealed a late entry for 1/2/22 which indicated Licensed Practical Nurse (LPN)-O was called to the resident's room by NA-N as the resident had complained of not being able to breath. Resident 1 was wearing oxygen and was trying to remove as the resident needed assistance to the bathroom. Staff assisted the resident into the bathroom and when cares were completed transferred the resident back into the recliner. Resident 1 reported at this time, the resident did not want NA-N back in the resident's room again. Review of a Grievance, Concern and Suggestion Form dated 1/3/22 revealed the resident had turned on the call light as the resident needed to use the bathroom. NA-N responded to the call light, but threw a fit about the resident's positioning in the recliner. Resident 1 repeatedly requested assistance to the bathroom. NA-N left the room to obtain the help of a second staff and returned with LPN-O. The resident told the staff the resident needed to use the bathroom but they continued to argue with the resident about positioning in the recliner. The staff did finally assist the resident, but the resident reported the staff were mean. During an interview on 4/4/22 at 2:43 PM, the DON confirmed the following: -Resident 1 had a history of delusions and hallucinations and after reviewing the resident's grievance, the DON interviewed the resident. The DON felt the resident was more concerned about having enough toilet paper as opposed to potential abuse and did not feel any further investigation was warranted; -the DON had not questioned Resident 1 regarding the resident's allegation staff were mean or about the resident not wanting NA-N back in the resident's room; and -despite the residents' allegation of potential staff to resident abuse, the allegation was not reported, a thorough investigation was not initiated and/or completed and the results of the investigations sent to the State Agency within the required time frame. E. Review of Resident 10's MDS dated [DATE] revealed diagnoses of non-specified intellectual disability and non-traumatic brain dysfunction. The resident's cognition was severely impaired and the resident had behaviors which included hallucinations, delusions, physical and verbal behaviors directed at others and rejection of cares. Resident 10 required extensive assistance with bed mobility, transfers, dressing, toilet use and personal hygiene and had occasional urinary incontinence. Review of a Grievance, Concern and Suggestion Form dated 12/7/21 revealed Resident 10 had told NA-P the resident was glad that (gender) wasn't here as (gender) had grabbed the resident's hands and hurt the resident. During an interview on 4/4/22 at 2:43 AM, the DON confirmed the following: -Resident 10 had a history of delusions and hallucinations. The DON interviewed the resident and after review of the resident's grievance, the DON did not feel the resident had been abused or that an abuse investigation was needed. The DON made no attempt to investigate the allegation further even though the resident identified someone had grabbed the resident's hand and hurt the resident; and -despite the resident's allegations of potential staff to resident abuse, the allegations were not reported, a thorough investigation initiated and/or completed and the results of the investigation sent to the State Agency within the required time frame.