**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the residents were free from physical abuse for two (Resident #2 and Resident #3) of six residents reviewed for abuse. 1. The facility failed to ensure Resident #2 was not attacked by Resident #1 with a pencil on 08/11/25 causing slight bleeding and the facility failed to ensure Resident #2 was not hit over the head by Resident #1 with a metal object on 08/15/25, no physical injury, causing Resident #2 to be afraid of Resident #1.2. The facility failed to ensure Resident #1 did not slap Resident #3 on the back on 08/20/25.3. The facility failed to ensure a nurse, on 09/01/25, when pushing Resident #3 in her wheelchair to her room, did not tell the resident it hurt the nurses her back to push her and the nurse was going to need a forklift to move Resident #3An Immediate Jeopardy (IJ) situation was identified on 08/30/25. While the IJ was removed on 09/02/25, the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. These failures could place residents at risk of continued abuse, injury, hospitalization, trauma, and psychosocial injury.The findings include:Review of Resident #1's face sheet dated 08/30/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including schizophrenia (a chronic mental illness characterized by a combination of positive, negative, and cognitive symptoms that significantly impair a person's daily functioning and social relationships), schizoaffective disorder, bipolar type (a mental health condition that combines symptoms of schizophrenia and bipolar disorder (a chronic mental health condition characterized by extreme mood swings between episodes of mania (highs) and depression (lows) ), and unspecified dementia (a general term for a group of conditions that cause a progressive decline in cognitive abilities, such as memory, thinking, reasoning, and judgment), severe, with anxiety (a severe form of unspecified dementia with the added symptom of anxiety).Review of Resident #1's care plan reflected focus;1. 07/08/25 Resident #1 had a behavior problem aggressive r/t schizophrenia and had potential to be physically aggressive r/t schizophrenia2. 07/08/25 Resident #1 had potential to be physically aggressive r/t schizophrenia3. 07/08/25 Resident #1 had potential to be verbally aggressive r/t schizophrenia and DementiaResident #1's MDS Nursing Home Comprehensive dated 06/16/25 reflected a BIMS score of 00 indicating severe cognitive impairment. Section A1510 Level II Preadmission Screening and Resident Review (PASRR) Conditions reflected serious mental illness. Section A1805 Entered From reflected Inpatient Psychiatric Facility (psychiatric hospital or unit). Review of Resident #2's face sheet dated 08/30/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses including Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline), schizophrenia, unspecified dementia, unspecified severity, with other behavioral disturbance (a description combining symptoms of schizophrenia with unspecified dementia and a behavioral disturbance). Review of Resident #2's care plan reflected focus;1. 07/30/24 Resident #2 was PASRR level 2 d/t schizophrenia and major depressive disorder, recurrent2. 12/26/24 Resident #2 had potential to be physically aggressive (throwing cups, trash) r/t schizophrenia and TBI3. 12/26/24 Resident #2 had potential to be verbally aggressive calling staff bitches and niggers r/t schizophrenia and TBI4. 01/15/24 Resident #2 had a communication problem r/t HOH and used an amplifier. 5. 01/15/24 Resident #2 had a mood problem r/t schizoaffective disorder. Resident #2's Quarterly MDS dated [DATE] reflected a BIMS score of 12 indicating moderate cognitive impairment. Review of Resident #3's face sheet dated 09/02/25 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including major depressive disorder (mental health condition characterized by persistent feelings of sadness, loss of interest, and other symptoms that significantly interfere with daily life), unspecified psychosis not due to a substance or known physiological condition (psychotic symptoms (like hallucinations or delusions) but a specific diagnosis cannot be made because there isn't enough information or the symptoms don't fit another established category), and schizoaffective disorder, depressive type (a mental health condition that combines symptoms of schizophrenia with those of major depression).Review of Resident #3's care plan reflected focus dated 08/31/25 reflected Resident #3 had potential to be verbally aggressive, shouting at staff or other residents r/t dementia, mental or emotional illness. Resident #3's MDS Quarterly assessment dated [DATE] reflected in section A1805 Resident #3 entered the facility from inpatient psychiatric hospital. Review of Resident #3's brief interview for mental status reflected a BIMS score of 00, indicating severe cognitive impairment.Observed Resident #1, Resident #2, and Resident #3 in the secured unit of the facility. Observation of Resident #1's right hand reflected no marks on his skin. Record review Resident #1 progress note dated 08/11/25 by LPN A reflected, Resident was sitting at the dining room table with several other residents when he started to stick his middle finger up at that the TV. The Resident next to him asked him politely not to do that and then he proceeded to say some cuss words and pull his pencil out of his pocket [and struck] the other resident a few times in his arm. Lorazepam given at this time. [name of NP notified and ordered risperidone 0.5mg bid at this time and said to go ahead and try to send him for eval Record review of Resident #1 progress note dated 08/11/25 by LPN A reflected, Weekly Skin Check Summary Resident is in facility and available for scheduled skin check. Resident allowed clinician to complete today's skin check. Resident does not have any skin or wound issues.Record review of Resident #1 progress noted dated 08/11/25 by RN reflected, this resident run after the CNA down to the office so mad and pushed hard the door and hit the CNA on her chest. CNA took his pen and gave it to this nurse. He got mad and kicked the nurse so hard on her thigh. reason why resident not to have pen on his possession was that he stabbed a resident on his hand several times. noted he has more pens and pencils and was confiscated. his reason for having those pens and pencils was to use to stab the gorilla.Record review of Resident #1 progress note dated 08/14/25 by LPN A reflected, start of Shift 6 Am resident was hitting the wall and yelling in his room. Nurse attempted to offer him a snack/ Drink He refused. He was then asked if he wanted to go [outside] and walk around in the [courtyard] he refused at this time as well. Resident said he was going back to sleep. Never went back to sleep. lab staff came in to draw his labs but he refused and hit nurse at this time. Was then yelling [and] cussing at everyone who walked by and the nurse. Saying thing in Spanish and English. Saying everyone was calling him names. No one was.Record review of Resident #1 progress note dated 08/14/25 by ADON reflected, Resident continues to pace up and down the hallway most of the morning, Keeps saying some [inappropriate] things to other resident and staff. Hit nurse again when I was trying to redirect him about punching air around other people he could hit someone. he [got flustered] with another resident saying that someone one was gonna fight them and that he needed to get up and fight back. [Offered] him more food he has refused at this time. Offered him to go outside [which] he did for about 5 mins but came back in. Offered for him sit with nurse and watch the movie on TV he did for a few minutes but got up several time in a 15 min period. Has changed [changed] 4 times since 6 am. He is now laying in his bed resting at this time.Record review of Resident #1 progress note dated 08/15/25 by ADON reflected, Resident was outside with another resident, they started cussing at each other and [Resident #1] hit the other resident in the head with an object. No injuries were noted. DON aware.Record review of Resident #1 progress note dated 08/17/25 by LPN A reflected, Resident has been cussing the staff out most of the morning. Very aggressive toward staff and other resident. Swing his arm and trying to box everyone who walks by. Yelling at the TV again, [Yelling] at other resident and staff when he walks by. Started bang on the door to the other unit saying he saw his wife and that she needs to come to see him now. When asked to move away from the door. He became even more aggressive. Ativan was given with him morning medication. No effective at this time. We have offered him several snack/ drinks. Offered to let him go for a walk out in the [courtyard] witch he did but was still aggressive. put him back on one on one for now. Attempted to contact [psych NP] no answer at this time. Also notified DON at this time.Record review of Resident #1's progress notes reflected no 1:1 monitoring (a healthcare intervention where a single, qualified staff member continuously provides direct, visual observation of a high-risk patient to ensure their safety and prevent harm. This method is implemented for patients exhibiting behaviors or conditions such as cognitive impairment, high suicide risk, aggressive tendencies, or other safety threats, requiring constant, immediate intervention) put in place for Resident #1. Record review of Resident #2's progress reflected no note of incident with a pencil and Resident #1 on 08/11/25.Record review of Resident 2's progress note dated 08/11/24 by LPN A reflected, Right hand (back) - has 3 small puncture wounds to his right wrist and hand area. Review of Resident #2's progress note type wound dated 08/12/25 by LPN A reflected, Wound Location/Wound Description: Right hand (back) - Small wounds to his wrist and hand [from] a pencil. Wound Number: 1 Status: This wound/skin condition is not resolved/healed. Resident is in facility and available for scheduled wound assessment/wound care. There were no family and/or friends present during today's wound care/assessment. The resident allowed clinician to complete wound/skin condition weekly assessment and treatment. This wound was acquired while a resident of this facility.Review of Resident #2's progress note type incident dated 08/12/25 by LPN A reflected, Residents [RP] was notified by DON today about incident for yesterday. He was very thankful for the call and [stated] that the resident handled the situation very well.Review of Resident #2's progress note type incident dated 08/15/25 by LPN A reflected Resident was outside with another resident, they started cussing at each other, The other resident did hit [Resident #2] in the head with an object, no injuries were noted. DON was made aware.Review of Resident #2's progress note type wound dated 08/19/25 by DON reflected late entry, Weekly Wound Observation Summary Note: Wound Location/Wound Description: Right hand (back) - Small wounds to his wrist and hand form a pencil. Wound Number: 1 Status: This wound/skin condition has resolved/healed. Review of facility Behaviors Documentation Chart Memory Care Unit reflected the following:08/11/15 Resident #1 threw a pencil across from his room to hall. Very aggressive.08/13/25 Resident #1 he was being behavioral issues w/staff & residents. Hitting walls not [listening] 08/15/25 Resident #1 [Resident #1] & [Resident #2] outside [Resident #1] hit [Resident #2] in the head08/15/25 Resident #1 Didn't hit/kick anyone but continues to punch/kick the air08/17/25 Resident #1 slapped & then kicked my left hand (I had asked him to give me the weapons he had)08/17/25 Resident #1 5:30 am in room beating on the wall08/20/25 Resident #1 walked by [Resident #3] and slapped him on the back.08/25/25 Resident #2 [Resident #1 purposely bumped into [Resident] when passing in the hallInterview on 08/30/25 at 11:00 am with Resident #2 reflected Resident #1 grabbed a mental rod and hit him in the head and another time he stabbed him with a pencil and when he was stabbed with the pencil it drew blood. He reflected he told the DON that he wanted to press charges, but she called his RP, and his RP told him to calm down. He said he and Resident #1 were not allowed to walk in the courtyard together at the same time. Resident #1 said it was wrong for Resident #1 to have stabbed him and hit him and he should not have to be afraid of someone here. He said it hurt both times when Resident #1 hit him.Interview on 08/30/25 at 7:20 pm with Resident #2 reflected he was in the courtyard area alone with Resident #1 and he went to Resident #1 cursing him and asked Resident #1 why Resident #1 stabbed him with the pencil and Resident #1 pulled up an iron rod and hit him with it. He wanted to know if the DON was going to call the police and report Resident #1.Attempted interview on 08/30/25 at 11:15 am with Resident #1. Resident #1's responses to questions were unintelligible.Attempted interview on 08/30/25 at 11:15 am with Resident #3. Resident #3 was not interviewable. Interview on 08/30/25 at 11:44 am with CNA B reflected Resident #1 had calmed down some after the incident with Resident #1 and Resident #2 and the pencil. She said staff was alert around Resident #1 all the time because he attacked Resident #2. She said she was working at the time of the pencil incident but did not see it happen. She said Resident #2 was upset about the incident when Resident #1 attacked Resident #2 with the pencil and believed Resident #2 was still upset about the incident. She said (date unknown) on one occasion at dinner Resident #1 and Resident #2 were yelling at each other and she jumped up and got between them. She said she was not there with the situation with Resident #1 and Resident #2 and the iron bar. She said she was concerned about Resident #1 hitting residents. She said Resident #2 asked her if he should press charges. She said that Resident #1 was on 1:1 monitoring a couple of shifts. She said the Administrator and DON were aware of the incident with the pencil. Interview on 08/30/25 at 12:28 pm with facility Psych NP reflected there was no problem with Resident #1, but he has had his issues. She said she was aware of the incident with the pencil and Resident #2 but Resident #2 was scrapped with a pencil and it was a superficial injury taken care of with soap and water. She only knows of the incident with the pencil and that was the only incident that was reported to her. She was not aware of any issues with Resident #1 yelling at staff, hitting staff, or yelling or hitting other residents. She said Resident #1 was put on 1:1 after the incident with the pencil and Resident #2 but did not know for how long and when she saw it was a superficial scratch, she felt she was given wrong information, and the nurse overreacted. She said could not speak on anything else involving Resident #1 because she was not aware of any other issues and was not informed about Resident #1 hitting Resident #2 with a metal object. She was not aware of any additional behaviors involving Resident #1 and other residents. She said if there was problem with a resident and another resident at the facility the DON would notify her. Interview on 08/30/25 at 1:13 pm with CNA C reflected she was not at the facility when the incident occurred between Resident #1 and Resident #2 and the pencil. She said she was concerned because Resident #2 was not the same anymore, he seems scared. She said the other day Resident #1 was coming at Resident #2 for no reason and Resident #2 was backing up scarred. She said the other residents are getting hit for not reason and none of the residents hit other people. She said she wrote resident behaviors on a behaviors chart, and she reported the behavior to the nurse. She said the behavior chart was for CNAs only and it was their personal log to keep documentation of what was happening. She did not know if the DON was aware of the behavioral chart, and she did not know when it started. She said she felt like Resident #1 was still aggressive and she did not feel like 1:1 would help. She said she felt like telling Resident #1 to stop his behaviors was useless, but she did not think he was malicious. She had not directly told the DON about Resident #1's behaviors. She said her chain of command was to tell the nurse and the nurse relayed it to the DON. She said she would consider the situation between Resident #1 and Resident #2 abuse because Resident #1 was known to be kind of violent and Resident #2 was scarred when he walked around the secured unit because Resident #1 physically harmed Resident #2 twice. She has observed Resident #1 hit Resident #3 in the back. Resident #3 was going to his room and Resident #1 hit him in the back. When Resident #3 was hit by Resident #1 he jolted forward and Resident #3 turned around, but Resident #1 was laughing and walked away. Resident #3 was not physically harmed when he was hit in the back by Resident #1.Interview on 08/30/25 at 1:48 pm with LVP A reflected she was the charge nurse on duty on 08/11/25 and witnessed the incident with the pencil between Resident #1 and Resident #2. She said she was charting next to the table where both Resident #1 and Resident #2 were sitting together. She was watching them because Resident #1 got upset at the TV and started cursing at the TV and giving the finger to the TV and Resident #2 said don't do that. Resident #1 had a pencil in his hand and took his pencil and struck Resident #2 three times on the back on one time on the top of Resident #1's right hand. She Resident #2 no longer had marks on his hand. She said he bled very little and after she cleaned them there was no additional bleeding. She said Resident #1 was placed on 1:1 but did not know how long he was monitored 1:1. She said they did not document Resident #1's 1:1 monitoring. She said Resident #2 was very calm about the incident but annoyed and he said it should not have happened and he was irritated. She said she had not seen Resident #1 hit other residents. She saw him swing at other residents but never make physical contact. She said she spoke with the Psych NP about the issue with the pencil and told her Resident #1 continued to have behaviors. She said she told the Psych NP he was cussing, had delusions, and was screaming at staff. She said she told the DON about the incident with the pencil and the DON told her she was going to tell the Administrator. LNP A said she had been trained by the facility in abuse and neglect, and she would consider the incident with the pencil between Resident #1 and Resident #2 to be abuse. She said if one resident hit another resident it was abuse. Interview on 09/02/25 at 6:02 pm with the ADON via phone reflected on 08/15/25 she was passing pills to other residents and saw Resident #1 and Resident #2 outside and she asked a staff member (staff member unknown) to let them inside. She said that Resident #2 told her he was going toward Resident #1 and was cursing at Resident #1 asking him why he hit him with a pencil and Resident #1 hit him in the head. She did not see Resident #1 hit Resident #2 with an object. She said she went outside with Resident #2 and Resident #2 pointed to a yard decoration (an yard decoration with a frog on it) that was lying on the ground and told her Resident #1 hit him in the head with it to it. She said she was frustrated because of issues with Resident #1's behavior and showed the DON to object and said Resident #2 said that Resident #2 hit him with it. She said that Resident #2 was scared of Resident #1. She said she was not present on 08/11/25 during the incident with Resident #1 and Resident #2 and the pencil but she saw the wound on his arm and said there were two little stab wounds from the pencil and it incident did draw blood. She said Resident #2 was kind of afraid of Resident #1 because he tried to stay away from Resident #1. She said Resident #2 did not say he was afraid of Resident #1, but she said Resident #2 was watchful and kept his eyes on Resident #1 because there have been incidents where Resident #1 had hit the nurses. She did feel like Resident #2 was let down because she told the DON that Resident #1 was not stable, and Resident #1 had a lot of behaviors when they changed Resident #1's medication. Resident #1 had a lot of behaviors when he was taken off his medications and she told both the Administrator and the DON. She said she reported Resident #1's cussing at staff and residents and punch and kicking the air behind the staff and residents. Interview on 09/02/25 at 9:04 pm with the LP reflected she was aware of the incident with Resident #1 and Resident #2 and the pencil, and she understood that it was originally reported as a worse situation than it was. She understood that Resident #2 was scratched with a pencil by Resident #1 and did not leave any marks on his arm. She said that she had not observed any behaviors out of the ordinary with Resident #1, but he had been inappropriate trying to kiss staff. She said that a resident going towards another resident with a pencil, no matter the extent of the injury, was abuse. She said she would have wanted to hear Resident #1's behaviors on staying up all night and hitting the walls. She said he probably should have been on 1:1 monitoring based upon his behaviors. Interview on 08/30/25 at 2:35 pm with the DON reflected she was aware of the incident between Resident #1 and Resident #2 and the pencil. It was her understanding that Resident #2 was at the table and Resident #1 walked by and kind of scratched Resident #2 with a pencil. She said the charge nurse removed the pencil from Resident #1. She said the facility trained her on abuse and neglect. She said that the secured unit was a special unit and the residents in that unit had behaviors but even though they are in that unit, they should be safe. She said Resident #1's act towards Resident #2 was an aggressive act toward another resident. She said the fact that Resident #1's pencil made contact with Resident #2's skin had never been in question. She said she notified the Administrator, the Abuse and Neglect Coordinator, as soon as she was aware of the incident. She agreed the facility policy read that abuse meant the willful infliction of injury and given this definition, the incident was abuse. She said the Psych NP was notified and Resident #1 was placed on 1:1 monitoring. She said there was not an order for 1:1 monitoring. She said when a resident had an altercation with another resident policy was to implement 1:1 monitoring to make sure everyone was protected. She said she did not know exactly how long Resident #1 was on 1:1 monitoring, maybe through the next night or next day. She said that Resident #1 should have been continued on 1:1 monitoring until given the behaviors that were reflected in his progress notes and on the behavioral chart. She said that she knew Resident #1 had aggressive behaviors and they were working on a medication change. She said Resident #1 had not had any aggressive behaviors toward her. She said Resident #1 should have been on 1:1 monitoring until his medication changes reflected his behavior was stabilized. She said she was not aware that Resident #1 hit Resident #2 in the head with a metal object, staff did not tell her. She said she was not aware of either the Behaviors Documentation Cart Memory Care Unit or many of Resident #1's behaviors documented in that chart. She said she did know that both residents were outside alone unsupervised on 08/15/25 when Resident #2 said Resident #1 hit him with a metal object. She said staff told her that Resident #1 and Resident #2 were outside alone, and Resident #2 was cursing at Resident #1, but was not aware that Resident #1 hit Resident #2 with anything even though it was in Resident #1's progress notes. Interview on 08/30/25 at 3:57 pm with the Administrator reflected she was aware of the situation between Resident #1 and Resident #2 and the pencil that occurred on 08/11/25. She heard about it from her DON. She did not know about the incident with Resident #1 and Resident #2 and the metal object that occurred on 08/15/25. She said they did place Resident #1 on 1:1 monitoring after the 08/11/25 incident but there were no 1:1 monitoring logs, and it was not recorded in the eMAR resident progress notes. She said she did not see it as abuse herself personally because Resident #1 was going through medication adjustment, and he was reacting to a lot of things, and he was not himself. She said she did not see any intent in his actions towards Resident #2 because she did not think Resident #1 knew what he was doing and did not see his action as willful but now looking back on the criteria it was abuse. Review of facility Abuse Prohibition Policy reviewed on 06/02/25 reflected INTENT:This protocol was intended to assist in the prevention of abuse, neglect and misappropriation of property. Each resident has the right to be free from abuse, mistreatment, neglect, corporal punishment, involuntary seclusion and financial abuse.POLICY:The facility will prohibit neglect, mental or physical abuse, including involuntary seclusion and the misappropriation of property or finances of residents. The facility will designate a qualified staff member to oversee the abuse prohibition program.DEFINITIONS:Abuse means the willful infliction of injury, withholding or misappropriating property or money, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish.Physical abuse includes, hitting, slapping, kicking, shoving, pinching and controlling behavior through corporal punishment.Abuse Prohibition Program:The facility's abuse prevention program includes the following components:screening, training, prevention, identification, investigation, protection and reporting/response.Prevention:Residents, families and staff will be able to report concerns, incidents and grievances without fear of retribution, staff will be instructed to report any signs of stress from individuals involved with the residents that may lead to abuse/neglect and intervene appropriately, facility staff will immediately correct and intervene in reported or identified situations in which abuse/neglect is at risk for occurring, residents identified as exhibiting abusive behaviors will be reviewed and have their treatment plans modified as appropriate.Identification:Any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately, the facility will track all occurrences, trends or patterns that could potentially constitute abuse or neglect, the facility supervisory staff will monitor behavior of staff members/residents to identify potential for abuse, neglect, and misappropriation of resident funds. Protection: All residents will be immediately protected from harm, all allegations involving staff will necessitate suspension without pay, pending investigation, if the allegation is substantiated, the employee will be terminated immediately without pay retroactive to the date of removal from employment. If the allegation is not substantiated, the employee will be reinstated with retroactive pay, if another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the facility's primary concern. Resident to Resident Incidents: The following guidelines will be implemented when resident to resident incidences occur:1. The staff observing the incident will immediately separate the residents involved2. The charge nurse will assess the victim to determine any injury3. Physician and family of both victim and perpetrator will be notified of incident.4. An incident report will be completed for the perpetrator and the victim5. The Abuse Coordinator will be immediately contacted.6. The interdisciplinary team will make the determination on what course of action needs to be taken with the perpetrator such as, but not limited to the following - immediate discharge from the facility due to potential for harm to other residents, can the behavior be controlled by location monitoring and need for referral to a psychologist/psychiatrist. The family and physician of the perpetrator will be notified of the next step.7. If the perpetrator is placed on location monitoring, staff will be instructed on reason for monitoring and targeted behaviors being monitored.8. If the perpetrator is on a behavioral contract, facility staff will be in serviced accordingly, and the resident and family will be notified of consequences.9. If the perpetrator continues to exhibit inappropriate behaviors/or violates the behaviors identified on the behavioral contract, staff will immediately notify the Administrator /DON10. The team will conduct an emergency review to determine further course of action such as immediate discharge11. The victim will be seen by Social Services to determine further psychological support needed as well as follow up with physician/family12. The Ombudsman will be notified of incident /allegations as appropriate.This was determined to be an Immediate Jeopardy (IJ) on 08/30/25 at 6:28 pm. The Administrator was notified at 6:28 p.m. The ADM was provided with the IJ template on 08/30/25 at 6:28 p.m.The following Plan of Removal submitted by the facility was accepted on 09/01/25 at 8:05 am. PLAN OF REMOVALPlan of RemovalOn 08/30/2025, an Immediate Jeopardy was identified at the facility due to a resident-to-resident abuse allegation.Action StepsThe following immediate actions were implemented Resident #1 was placed under 1:1 supervision immediately. Resident's care plan updated to reflect changes in monitoring. The 1:1 will remain in place until the IDT will be held on 9/2/2025, including physician, psychiatric input determines that it is safe to discontinue the cadence of supervision. If this is not deemed attainable, the facility will explore opportunities for discharging resident to an alternate setting. IDT meeting will be held weekly to discuss resident #1. Resident #1 was seen by psych services on 8/18, 8/26 and will continue with weekly visits until behaviors are improved.Residents 2 and 3 were assessed by DON for evidence of injury.Resident #2 was seen by the psych NP via telemedicine for evaluation of impact. A trauma informed assessment was completed on residents 1, 2 and 3. Care Plans updated for resident 1, 2, and 3. No negative outcomes found in resident assessment. Nursing Administration conducted resident record review, resident interviews to determine that no other residents were affected by the deficient practice. Direct care staff are trained on resident care plans through a combination of orientation, ongoing in-service education, and real-time instruction from licensed nursing staff. During orientation, staff receives instruction on individualized resident needs, the purpose of the care plan, and how their daily assignments connect to the plan of care. Supervisors and charge nurses review care plan updates with staff as changes occur, and education is reinforced during shift huddles, staff inservicing, etc. This ensures staff understand their role in implementing interventions outlined in each resident's care plan. Each incident was reported to HHSC via self-report email template. The incident for 8/11 was emailed on 8/30 @ 10:25PM. The incident for 8/15 was emailed 8/31 at 7:57am. The return emails from HHSC sending us the intake number has not been received yet. It typically takes 24-48 hours from time of submission.Start Date: 08/30/2025Completion Date:8/30/2025Responsible: Director of Nursing (DON), AdministratorFollowing the notification of immediacy, the Administrator and Director of Nursing received immediate elaborate retraining on abuse reporting requirements, the facility's abuse policy, and leadership responsibilities in responding to allegations. To validate that the retraining was effective and sustained, the Regional [TRUNCATED]