**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, resident, staff, resident representative, and Nurse Practitioner (NP) interviews, the facility failed to protect the resident's right to be free from abuse for 4 of 30 residents reviewed for abuse (Resident #32, Resident #59, Resident #86, and Resident #125). On 05/09/25, Resident #32 was heard yelling for help when Resident #154 entered Resident #32's room and grabbed her by the neck and pinned her against the wall. Resident #32 was noted to be swatting at Resident #154 to free herself. Resident #154 sustained scratches to left ear. On 04/20/25, Resident #154 balled up his fist and hit Resident #86 in the mouth. Resident #86 sustained a cut to her upper lip with bleeding. On 04/17/25, Resident #32 was heard yelling for help when Resident #154 entered Resident #32's room and grabbed her arm and pulled it. When staff arrived, Resident #32 was noted to be swatting at Resident #154 in an attempt to free herself. Resident #154 sustained scratches to left eye and left lip. On 08/16/24, Resident #156 hit Resident #125 on the left shoulder and placed his hands around her neck causing a 2-centimeter by 2-centimeter (cm) reddened area to Resident #125's left shoulder. The facility also failed to protect the resident's right to be free from sexual abuse for 1 of 30 residents reviewed for abuse (Resident #59). On 08/29/24, Resident #156 and Resident #59 were observed in the hallway. Resident #156 had one hand down the front of Resident #59's brief, and one hand down the back of Resident #59's brief. A reasonable person would expect to be protected from abuse in their own home and would expect to experience mental anguish with feelings such as fear, humiliation, anxiety, anger, and depressed mood after experiencing physical or sexual abuse. This deficient practice was for 4 of 30 residents reviewed for abuse (Resident #32, Resident #59, Resident #86, and Resident #125). Immediate jeopardy began on 05/09/25 when Resident #32 was in her bedroom when Resident #154 entered her room, grabbed her by the neck, and had her pinned against the wall in the corner. The immediate jeopardy was removed on 08/10/25 when the facility implemented an acceptable credible allegation for immediate jeopardy removal. The facility remained out of compliance at a lower scope and severity level of E (no actual harm with potential for more than minimal harm that is not immediate jeopardy) for the following examples: 1b (Resident #86), 1c (Resident #32), 2a (Resident #59), and 2b (Resident #125) to ensure education and monitoring systems put into place are effective. Findings included: 1a. Resident #32 was admitted to facility on 09/24/24 and resided in a locked memory care unit. Resident #32's diagnoses included Alzheimer's disease, dementia in other diseases with behavioral disturbance, generalized anxiety disorder, and depression. A review of Resident #32's quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #32 was severely cognitively impaired, required supervision for all activities of daily living (ADLs), and used a walker for ambulation. Resident #32 received antipsychotics and antidepressants daily. Resident #32 was coded for having adequate hearing and vision, usually able to make herself understood, and able to understand others. A review of Resident #32's care plan initiated 10/14/24 revealed plan for diagnosis of anxiety. Stated goal was Resident #32 would show decreased signs of anxiety. Interventions included allow Resident #32 to verbalize her feelings, monitor for changes in mood, and monitor for adverse reactions to anxiety medications. Hospital discharge instructions prior to admission to facility dated 09/20/24 revealed Resident #154 was admitted to the hospital on [DATE] for evaluation of increased confusion and hallucinations. Resident #154's hospital discharge note indicated a sitter was required during hospital stay but was discontinued 48 hours prior to discharge. Resident #154 required medication for agitation up to 24 hours prior to discharge from the hospital. Behavioral disturbances noted in the hospital discharge note included agitation. Discharge instructions were to continue current medications as ordered after discharge. Resident #154 initially admitted to the facility on [DATE] and readmitted on [DATE]. Resident #154 discharged from facility to hospital on [DATE]. Resident #154's diagnoses included unspecified dementia with other behavioral disturbances, depression, generalized anxiety disorder, and insomnia due to other mental disorders. A review of Resident #154's care plans revealed a plan initiated 10/14/24 which noted Resident #154 was verbally and physically aggressive with others (cursing and yelling at staff and other residents, threatening staff, combative with staff). The stated goal was Resident #154 would have little to no episodes of behavior during the next review period. Interventions included: allow resident time to calm down in a safe and quiet place when agitation occurred, redirect Resident #154 when behaviors occurred, notify the provider of mood or behavioral changes, document behaviors, monitor Resident #154 for medication side effects, and notify the psychiatric provider as needed. Another care plan was initiated on 03/24/25 for Resident #154's psychotropic drug use related to the diagnosis of dementia with behavioral disturbance. The stated goal was Resident #154 will have no negative events associated with psychotropic medications. Interventions included monitor Resident #154 for adverse reactions such as sedation and notify the provider of adverse reactions. Another care plan initiated 04/18/25 stated Resident #154 was the aggressor in a resident-to-resident altercation. The stated goal was Resident #154 would exhibit no symptoms of agitation resulting in altercations. Interventions included notify the provider for changes in mood or increased agitation, monitor behaviors during activities and while around other residents, redirect Resident #154, and provide 1:1 support as needed. Physician orders for Resident #154 revealed Resident #154 received the following medications: An order written 09/23/24 for mirtazapine (an antidepressant) 7.5 milligrams by mouth daily at bedtime. An order written 11/11/24 for escitalopram (an antidepressant) 20 milligrams by mouth daily. An order written 04/21/25 for valproic acid delayed release tablet (an anticonvulsant used as a mood stabilizer) 250 milligrams by daily at 12:00 PM and 500 milligrams by mouth daily at bedtime. An order written 04/25/25 for quetiapine (an antipsychotic) 75 milligrams by mouth daily in the AM and 100 milligrams by mouth daily in the PM. An order written 04/30/25 for haloperidol (an antipsychotic) solution 5 milligrams per milliliter. Administer 1 milliliter (equals 5 milligrams) injection intramuscularly (in the muscle) daily as needed for increased anxiety, behaviors causing danger to self or others, or aggressiveness for 14 days.A Psychiatric Nurse Practitioner consultation note dated 02/11/25 for Resident #154 was reviewed. The consultation note stated Resident #154 had been assessed due to increased anxiety and agitation on 02/11/25. Assessment of Resident #154 revealed he appeared anxious and restless. Staff reported Resident #154 was agitated, exit seeking, yelled and cursed at staff, was combative with staff, and had attempted to aggress on other residents. The note revealed Resident #154's agitation was ongoing from 02/07/25 through the Psychiatric Nurse Practitioner's assessment date of 02/11/25. The Psychiatric Nurse Practitioner's recommendations from assessment were to increase Resident #154's daily dose of quetiapine (an antipsychotic medication). A review of Resident #154's quarterly MDS dated [DATE] revealed Resident #154 was severely cognitively impaired. Resident #154 coded for having behaviors 1 to 3 days in the 7-day look-back period. These behaviors included: Physical behavioral symptoms directed toward others, verbal behavioral symptoms directed toward others, and other behavioral symptoms not directed toward others Resident #154 was not coded for refusal of care or wandering. Resident #154 received antipsychotic medications daily, antidepressant medications daily, and anticonvulsant (used as a mood stabilizer) medications daily. Resident #154 required partial assistance with ADL and walked independently. Resident #154 coded as having impaired vision (required large print), no hearing deficits, and clear speech. A facility incident report dated 05/09/25 at 4:50 PM was completed for Resident #32. Nurse #2 completed the incident report because of the resident-to-resident altercation involving Resident #154. The incident report revealed Resident #32 was in her room when Resident #154 entered Resident #32's room and cornered Resident #32 with hands around her neck. The incident report noted Resident #32 exhibited fear after the incident. Interventions used for Resident #32 after the altercation included redirection and simplifying the environment. A progress note dated 05/09/25 at 4:39 PM written by the Infection Preventionist revealed Resident #32's Representative was notified of altercation of Resident #154 in Resident #32's room with hands around Resident #32's neck. A review of skin assessment completed by the Infection Preventionist, dated 05/09/25 for Resident #32 revealed no bruising or injury noted after 05/09/25 incident. A progress note dated 05/10/25 at 12:50 PM written by Director of Nursing (DON) revealed daily body audits were added for 3 days because of altercation with Resident #154. A progress note dated 05/10/25 at 4:34 PM written by Nurse #2 stated a body audit was performed and no injury was noted. Resident #32 noted to be in a pleasant mood in facility dayroom at time of assessment. No other notes related to the incident or further body audits were documented in Resident #32's progress notes. An interview with Resident #32 was conducted on 08/06/25 at 2:24 PM. The surveyor asked Resident #32 if she recalled the incident involving Resident #154. Resident #32 stated Oh yes, I remember. Resident #32 (who was 84-years-old) then verbalized, I don't know why an older man would want to do to a little girl, I was so young, and he touched me all over. Resident #32 then verbalized to this day, I am still scared of older men. A telephone interview was attempted on 08/08/25 at 1:13 PM with Resident #32's Representative. Resident Representative was unwilling to be interviewed. A facility incident report dated 05/09/25 at 4:31 PM was completed by Nurse #2 for Resident #154. The incident report revealed Resident #154 entered Resident #32's room, grabbed Resident #32's by the neck, and pinned Resident #32 in the corner of the room with her back against the wall. Resident #32 was noted to be hitting Resident #154 in an attempt to free herself. Resident #154 sustained scratches to left ear. Resident #154 noted to be wandering unit prior to the incident. Wandering recorded as occurred daily for Resident #154 and intruded on the privacy or activity of others. Resident #154 noted entering another resident's room immediately after the incident. Interventions included redirection and a simplified environment. The incident report noted Resident #154 was transferred to the hospital on [DATE] related to multiple resident altercations. A handwritten untimed statement dated 05/09/25 written by Nurse Aide (NA) #1 revealed NA #1 heard Resident #32 yelling help me from Resident #32's room. NA #1 entered Resident #32's room and observed Resident #154 had Resident #32 by the neck. NA #1 reported Resident #32 and Resident #154 were separated, and nurse notified. A telephone interview was attempted with NA #1 on 08/08/25 at 9:22 AM. NA #1 was not available for interview. A progress note dated 05/09/25 at 4:31 PM written by the Infection Preventionist revealed Resident #154 had an altercation with another resident in the other resident's room. Resident #154 was noted with his hands around Resident #32's neck. Resident #154 entered another resident's room after staff redirected him out of Resident #32's room. The Administrator and Resident #154's Representative notified. A progress note dated 05/09/25 at 6:07 PM written by the Infection Preventionist noted the on-call provider was notified of the altercation and Resident #154 exited the building at 6:01 PM via Emergency Medical Services for the hospital.An interview with Nurse #2 was conducted on 08/08/25 at 11:43 AM. Nurse #2 was assigned to Resident #32 and Resident #154 on 05/09/25. Nurse #2 stated on 05/09/25, Resident #32 was heard calling for help from her bedroom. Nurse #2 reported NA #1 responded to Resident #32's room and witnessed Resident #154 in front of Resident #32 who was pinned with back against the wall in the inner corner of the room. NA #1 reported to Nurse #2 he observed both of Resident #154's hands around her neck. Nurse #2 stated Resident #32 and Resident #154 were separated when staff arrived at room. The Infection Preventionist was also on the unit at the time and responded to the incident. Nurse #2 stated Resident #32 was assessed for injury and none were noted. Resident #154 assessed for injury and superficial scratches to the left ear noted. The scratches to Resident #154's ear did not require treatment. Nurse #2 reported Resident #32 was not crying but was shaking after the altercation. Nurse #2 recalled Resident #32 was in the dayroom after the altercation and appeared distraught but could not indicate what distraught meant. Nurse #2 could not recall if Resident #32 verbalized anything to her at the time of the incident. Nurse #2 stated Resident #154 continued to be agitated after the incident. Nurse #2 verbalized Resident #154 had a history of aggression to other residents. When Resident #154 continued to be agitated, the on-call provider was notified and a 1-time order for medication was administered to Resident #154. Nurse #2 could not recall what medication was administered. Resident #154 transferred to the hospital due to continued agitation for an involuntary psychiatric hold. Nurse #2 stated Resident #32 and Resident #154's responsible parties were notified of the altercation.An interview with the facility Nurse Practitioner (NP) was conducted on 08/07/25 at 1:18 PM. The NP stated if a resident had increased agitation, they were evaluated to rule-out physical cause of agitation. The NP indicated labs such as urinalysis would be collected to rule out infection. If a resident would not calm down, the on-call or on-duty NP would order a 1-time dose of medication, then would reassess effectiveness. The NP recalled Resident #154 and stated the Psychiatric Nurse Practitioner took over Resident #154's care because of his ongoing behaviors. The NP reported that the Psychiatric Nurse Practitioner would discuss any medication changes with the NP. The NP knew several medication changes had occurred for Resident #154, and he continued to have periods of agitation even with medication changes. The NP reported that Resident #154 had a long history of violent behaviors and family had reported to the facility that he had been aggressive at home prior to his first hospitalization. The NP was off duty on the date 05/09/25 but was notified of the altercation between Resident #32 and Resident #154 the next day. A telephone interview with the Psychiatric Nurse Practitioner was conducted on 08/07/25 at 1:17 PM. The Psychiatric Nurse Practitioner recalled Resident #154 well. The Psychiatric Nurse Practitioner verbalized Resident #154 had severe aggressive behaviors and was a lot to manage. The Psychiatric Nurse Practitioner stated Resident #154 was not appropriate for the facility, but Resident #154 was a family member of a facility staff member, so they kept him. The Psychiatric Nurse Practitioner had discussed with administrative staff it was unsafe to leave Resident #154 in the facility because of his behavior and verbalized it placed others at risk for significant harm. On 05/09/25 when Resident #154 was transferred to the hospital, the Psychiatric Nurse Practitioner spoke with hospital staff prior to Resident #154 being discharged back to the facility. The Psychiatric Nurse Practitioner reported during a team discussion on 05/09/25 that Resident #154 would be accepted back to the facility, but they would have to manage him aggressively with medication such as haloperidol (an antipsychotic medication), which they would not normally order because of his severe behaviors. However, Resident #154 did not return to the facility. A statement written by Social Worker dated 04/23/25 at 11:30 AM revealed that Social Worker was notified on that date that Resident #154's family had disclosed to provider that Resident #154 had a history of physical aggression. This physical aggression was reported by family to the point of almost murdering his first wife and being put in prison. Resident #154 was hospitalized and family expressed that hospital staff met with family and told family that resident needed to be in a geriatric psychiatric inpatient unit. Statement also revealed family was not in agreement with that placement due to concern family could not visit Resident #154. Family also reported that prior to Resident #154 being hospitalized on [DATE], Resident #154 was aggressive at home. An interview with the Social Worker was conducted on 08/08/25 at 11:55 AM. The Social Worker stated that after any resident-to-resident altercation, staff assessed residents involved for injury, nursing staff would perform body audits for 3 days, head trauma protocol if indicated, and notify the provider. The Social Worker performed monitoring for Resident #32 after the altercation for several days and Resident #32 did not recall the altercation. The Social Worker was not aware of any trauma in Resident #32's past. The Social Worker verbalized because of Resident #32's inability to recall the incident, it was determined there were no adverse effects from the altercation. The Social Worker did not produce any documentation of Resident #32's assessment after the incident. The Social Worker verbalized that she became aware from family on 04/23/25 that Resident #154 had a history of violent behavior and had reportedly almost murdered his first wife. The Social Worker stated they were not aware of any history of aggression when Resident #154 was admitted . The Social Worker reported Resident #154 transferred to the hospital on [DATE] due to continued agitation and was involuntarily committed. An interview with the DON was conducted on 08/08/25 at 12:05 PM. The DON indicated the staff reported the altercation between Resident #32 and Resident #154 at the time it occurred. The DON indicated the incident was investigated thoroughly, neither Resident #32 nor Resident #154 had any significant injuries. The DON verbalized when resident-to-resident altercations occurred, staff would separate the residents involved, move them to a safe location, assess each resident for injury, place a resident 1:1 for safety, and notify the DON and the Administrator. The DON stated that Resident #154 was placed 1:1 for safety after the incident until he transferred to the hospital about an hour later. The DON stated if the residents involved sustained significant injury, the medical provider would also be notified. An interview with the Administrator was conducted on 08/08/25 at 12:10 PM. The Administrator stated the facility followed the State Operating Manual for abuse allegation investigation. The Administrator verbalized due to both Resident #32 and Resident #154 being severely cognitively impaired, it was determined there was no willful intent from Resident #154 to harm Resident #32 therefore it would not constitute abuse. The Administrator stated the Social Worker assessed Resident #32 for several days after the incident and Resident #32 could not recall the altercation. The Administrator stated that Resident #154 had ongoing behaviors and would have location tracking (30-minute checks) initiated if agitated until calm. Resident #154 was placed 1:1 for safety after the incident until he transferred to the hospital two hours later and was involuntarily committed due to his aggressive behaviors. The Administrator reiterated that without willful intent, she felt no abuse had occurred. The Administrator was notified of immediate jeopardy on 08/08/25 at 5:59 PM. The facility provided the following IJ removal plan:Identify those recipients who have suffered, or are likely to suffer, a serious adverse outcome as a result of the noncompliance:The identification of the residents is the following: Resident #154 was discharged from the facility on 05/09/25 for involuntary commitment to the hospital and did not return to the facility. On 05/09/25 at 4:30 PM it was observed by a NA #1 Resident #154 had walked into Resident #32's room where an altercation occurred. Resident #154 had grabbed resident #32 by the neck. At the time of the altercation staff immediately separated the residents and assisted Resident #154 back to his room.Incident on 05/09/25 with Resident #154 and Resident #32. Resident #32 had no injury noted on her body according to the incident report. Resident #32 was assessed by Nurse #2 at the time of the altercation and was noted to be fearful. NA #1 provided 1:1, and redirection until Resident #32 was calm and displayed no further signs of fear. Resident #32 currently does not recall incident due to having severely impaired cognition and is at baseline with her psychosocial wellbeing. Incident on 04/20/25 with Resident #154 and Resident #86. Resident #86 stated Resident #154 hit her due to no one witnessing the incident. Resident #86 sustained a cut to her upper lip. Resident #86 was and is currently at baseline for her psychosocial well-being. Incident on 04/17/25 with Resident #154 and Resident #32. Resident #32's arm was pulled by Resident #154. No injury was noted to Resident #32 who was assessed to be at baseline with her psychosocial wellbeing. Resident #154 was noted with small scratch under left eye and small reddened area to lower left side of lip. No other injuries were noted. Both residents were immediately separated, provided a calm environment, and monitored for any distress. On 08/29/24 Resident #156 was observed by nurse placing both his hands in Resident #59's brief. Residents were separated immediately, and skin audit was performed and no injuries noted to Resident #59. One-on-one caregiver assigned to monitor Resident #156. Resident #59 had no distress noted and accepted a snack during one-on-one visit with her. Resident #59 was placed on hourly checks to ensure no emotional distress and there was no distress noted. Resident #59 is currently at baseline with her psychosocial wellbeing. On 08/16/24 Resident #156 was observed hitting Resident #125 on the left shoulder and then placed his hands around Resident #125's neck. Resident #156 was assisted back to his room, provided a calm environment, and was administered his bedtime medications to calm him. Resident #125 sustained a reddened area to left shoulder which measured 2 centimeters by 2 centimeters. There were no visible injuries noted around the resident's neck and was noted to be at baseline for her psychosocial well-being and currently is as well. Specify the action the entity will take to alter the process or system failure to prevent a serious adverse outcome from occurring or recurring, and when the action will be complete. [NAME] Oak Manor - [NAME] Mountain will ensure to protect severely cognitively impaired residents from resident-to-resident abuse. Corrective Actions: Current residents in the memory care unit (rooms 313-326) were potentially at risk for adverse outcome from resident-to-resident abuse. An audit of current resident care plans was completed on 08/08/25 by the Administrator and Social Services Director to identify potential residents who could present with aggressive behaviors. Beginning 08/08/25 at 11:00 PM the identified residents were placed on location and behavioral mood status monitoring every 30 minutes. On 08/08/25 the DON educated nurses and NAs working on the memory care unit on how to complete the new location and behavior tracking for the identified high-risk residents who had potential for aggressive behaviors. The nurses and NAs were also educated about steps to take if a resident exhibited anxious or aggressive behavior. 30-minute monitoring will be completed by either an NA or nurse assigned to the memory care unit. Monitoring will be reviewed by the management nurse Monday through Friday, and the charge nurse on duty for 7:00 AM to 3:00 PM shift on Saturday and Sunday. Beginning on 08/08/25 at 3:00 PM, the facility increased staff numbers in the memory unit by 2 NAs on 1st shift (7:00 AM to 3:00 PM) and 2nd shift (3:00 PM to 11:00 PM) and 1 NA on 3rd shift (11:00 PM to 7:00 AM), bringing the total staff to 5 NAs on 1st and 2nd shifts and 2 NAs on 3rd shift. On 08/08/25 the Staffing Coordinator was notified by the DON and Administrator that additional staffing would be implemented in the memory care unit. This staffing ratio would continue indefinitely. On 08/08/25 the DON educated NAs and nurses on the memory care unit that staffing numbers would be increased. This provided additional monitoring for residents on the memory care unit who had the potential for aggressive behaviors, to prevent further resident-to-resident altercations. Until additional activity personnel are hired, the Activities Director will be assigned to the memory care unit Monday through Friday 8:00 AM to 4:00 PM to provide activities and one-on-one interactions as needed. Beginning on 08/09/25 the facility will assign 1 additional nurse from Monday through Friday, which would total 2 nurses assigned to the memory care unit on the weekdays. During the weekend, a minimum of 1 nurse and 1 medication aide would be assigned to the memory care unit during the weekends. On 08/08/25 the Administrator notified the staffing coordinator to schedule the additional nurses. On 08/08/25, the DON educated the additional nurses assigned to the memory care unit on ensuring the 30-minute checks were completed. Nurses who worked in the memory care unit were notified staffing numbers were increased to provide additional monitoring for residents who had potential for aggressive behaviors to prevent further resident-to-resident altercations. All current staff members were re-educated on the abuse protocol which included the identification of resident-to-resident abuse, reporting abuse, and investigating the abuse thoroughly to prevent further abuse. The re-education also included behavioral training to deescalate aggressive behaviors. Nurses and NAs assigned to the memory care unit were educated on performing 30-minute checks for the high-risk residents with the potential for aggressive behaviors. Staff were also educated how to deescalate behaviors, to provide 1:1 care for any resident demonstrating anxious or aggressive behaviors, and to report the behavior to the provider if interventions were unsuccessful. The reeducation was completed by Nursing Administration, department directors for Nursing, Social Services, Therapy, Activities, Maintenance, Dietary, and Housekeeping. The reeducation was completed on 08/08/25 in person and by telephone. Newly hired staff would receive this training during their job specific orientation with the Staff Development Coordinator or Social Services Director. Nursing Administration and Social Services Directors would monitor by checking the 24-hour reports to ensure no resident-to-resident altercations or abuse occurred, and the location/behavioral mood monitoring had been completed. All corrective actions were implemented by 08/10/25.Alleged date of immediate jeopardy removal: 08/10/25.The facility's IJ removal plan was validated on 08/12/25 by the following: A review of staff inservices from 08/08/25 related to reporting of abuse and neglect. Inservices reviewed were for all staff from every department. The inservice included a description of types of abuse, identifying signs of abuse, and what is considered reportable. Interviews with facility staff from each department revealed they had received education on abuse and neglect and reporting physical and sexual abuse and neglect on 08/08/25. Staff interviewed discussed different scenarios and were able to describe types of abuse, and what steps they would take in the event of resident-to-resident altercation, abuse, or neglect. Staff stated if abuse or neglect had been witnessed, suspected, or reported, they would immediately separate the residents, call additional staff for help, and would not leave the residents alone to verify their safety from further abuse. Staff verbalized a nurse would be notified immediately to complete assessment of the residents involved. Staff interviewed described the process for notification of administrative staff of incidents of abuse or neglect. Staff stated all high-risk residents for aggressive behaviors had been identified, and every 30-minute location tracking was performed by one assigned staff every shift. If a resident aggressed toward a peer, resident would be placed 1:1 staffing for safety. Facility staff stated no further resident-to-resident altercations had occurred. A review of facility orientation education for new hires included education on facility abuse and neglect policy and reporting abuse and neglect. A review of staff assignment sheets revealed the staff had been increased on the memory care unit. An assigned staff was noted each shift to complete the 30-minute location tracking for each high-risk resident. A review of high-risk resident location tracking data sheets revealed every 30-minute tracking for each high-risk resident had begun on 08/08/25 at 11:00 PM and remained ongoing through 08/12/25. Staff verbalized 30-minute tracking would continue indefinitely. Interview with the Administrator and DON revealed they had received training from their corporate staff regarding abuse and neglect, sexual behaviors, and protocols for reporting abuse and neglect to the appropriate agencies. Staff had been educated in person or via telephone, and all staff were able to demonstrate their understanding of the education they had received. The facility's immediate jeopardy removal date was validated as 08/10/25. The following examples were cited at a lower scope and severity of E: b. Resident #86 was admitted to facility on 11/08/2024 and resided on a locked memory care unit. Resident #86's diagnoses included unspecified dementia with other behavioral disturbance, generalized anxiety disorder, and depression. A review of Resident #86's quarterly MDS dated [DATE] revealed Resident #86 was severely cognitively impaired, required supervision for all activities of daily living (ADL), and used a walker for ambulation. Resident #86 received antianxiety and antidepressants daily. Resident #86 was coded for having adequate hearing and vision, usually able to make herself understood, and able to understand others. Resident #86's care plan initiated 11/26/24 revealed a plan for the diagnosis of anxiety. The stated goal was Resident #86 would show decreased signs of anxiety. Interventions included allow Resident #86 to verbalize her feelings, monitor for changes in mood, and monitor for adverse reactions to anxiety medications. Resident #86 also had a plan for diagnosis of depression dated 11/26/24 and revised 07/28/25. The stated goal was Resident #86 would show decreased signs of depression. Interventions included allow Resident #86 to verbalize her feelings, monitor for changes in mood, and monitor for adverse reactions to antidepressant medications. A facility incident report dated 04/20/25 at 9:02 PM for Resident #86 was completed by Nurse #2 because of a resident-to-resident altercation with Resident #154. The incident report revealed Resident #86 was in her room when Resident #154 entered Resident #86's room and had fist balled up making contact with Resident #86's face. Incident report described the injury to Resident #86 as small area to upper lip with small amount of blood. Bleeding stopped. No swelling noted. No complaints of pain or discomfort. The incident report noted Resident #86 exhibited anger during the incident. Interventions for Resident #86 included redirection, location tracking, and simplifying the environ[TRUNCATED]