**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to protect Resident #2's right to be free from physical, mental, and verbal abuse by Resident #1. The facility failed to protect Resident #1 from abuse by Resident #2. Residents had an established and repeated facility wide known history of disputes, both verbal and attempted physical alterations. On 10/09/2024, both residents were in the same room unattended by staff and video footage revealed Resident #1 used his cane to hit Resident #2 on the head. Resident #2 was sent to the hospital by EMS and received 10 staples to his head for a 2 cm laceration. An IJ was identified on 10/12/24. The IJ template was provided to the facility on [DATE] at 1:45 PM. While the IJ was removed on 10/18/24, the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure placed residents at risk for abuse, injuries, and pain. Findings included: Review of Resident #1's face sheet, dated 10/11/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included diffuse traumatic brain injury (occurs when the brain is injured by blunt force, causing the brain's nerve fibers to shear of tear), depression and heart failure. Review of Resident #1's quarterly MDS assessment, dated 08/27/24, reflected a BIMS score of 15 indicating intake cognition. On 10/11/24 at 12:30 pm observed Resident #1 ambulating using a wheelchair and had a cane with him, but neither device was listed in his MDS. Review of Resident #1's quarterly care plan reflected: Focus dated 03/18/24 Resident #1 had potential to have verbal and physical aggression related to anger. Goal - the resident will demonstrate effective coping skills through the review date and the resident will not harm self or others through the review, date initiated 03/18/24, revision on 09/04/24, and target date 12/03/24. Interventions: Behavior plan in place with Resident - date initiated 03/18/24 4. Get staff to mitigate any negative encounter and remove self from confrontation with Resident #2. 5. Avoid contact with Resident #2 and not seek confrontation with Resident #2, and 6. Monitor verbal or physical aggression every shift and document observed behavior attempted in behavior log On 10/11/24 at 12:30 pm observed Resident #1 ambulating using a wheelchair and had a cane with him, but neither device was listed in his care plan. Review of Resident #2's face sheet, dated 10/11/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar type (which features bouts of mania and sometimes depression), and diffuse trauma brain injury (occurs when the brain is injured by blunt force, causing the brain's nerve fibers to shear of tear). Review of Resident #2's quarterly MDS assessment, dated 08/27/24, reflected a BIMS score of 14 indicating intact cognition. On 10/10/2024 at 4:18 pm observed Resident #2 in a wheelchair but this was not listed in his MDS. Review of Resident #2s quarterly care plan reflected: Focus: 3. Resident #2 had behavior problems as a result of schizoaffective disorder - yelling, racial slurs, name calling 4. 09/04/24 aggressive behaviors date initiated 12/15/23 revision on 09/05/24 Goals: 2. Resident #2 will have less than daily behaviors hitting self. Impulsiveness, racial slurs by review date Date initialed 12/15/23, revision date 03/04/24, and target date 12/09/24 Interventions: 4. administer medication as ordered, monitor/document for side effects and effectiveness date initialed 12/15/23 5. anticipate and meet the resident's needs dated initiated 12/15/23 6. Behavior plan in place: 6. Resident #2 will smoke in separate smoking area from Resident #1 and will be provided supervision on that break 7. Resident #1 will avoid contact with Resident #2 and if they meet in person, Resident #1 will not say provoking things to Resident #2 or have physical altercation. Resident will alert staff if he feels unsafe or if he feels unsafe or if Resident #2 threatens him for immediate interventions date initiated 09/23/24 8. document any behaviors and interventions in clinical record as they occur date initiated 01/26/24 9. medication review by psych date initiated 02/15/24 10. monitor behavior episodes and attempt to determine underlying causes, consider location, time of day, persons involved, and situation and document behavior and potential causes date initiated 12/15/23 11. Weekly discussion regarding social services date initiated 01/26/24 On 10/10/24 at 4:18 pm observed Resident #2 in a wheelchair, but this was not listed in his care plan. Resident #1 Review of Resident #1's progress note dated 03/17/24 revealed Resident #1 observed with another resident speaking harshly and using foul language, stating he was, Going to kick [Resident #2's] ass and making physical motions to indicate his intent. The nurse positioned herself in between the two residents and remained in between them at all times to prevent physical contact. Resident #1 refused to move away from Resident #2. Resident #1 repeatedly moved himself closer to Resident #2 even when asked not to and he was continuing to taunt and threaten Resident #1. Nurse removed Resident #2 from the area and brought him with her to monitor Staff was made aware of the situation and alerted to keep residents apart due to aggressive behaviors. DON and Administrator notified of situation. Review of Resident #1's progress note dated 04/05/24 reflected after dinner Resident #1 went outside behind the building and laid down on the grass. Staff attempted to talk to Resident #1, and he stated that he was going to come back inside but that he planned to stay out there until something was done to Resident #2. A call was placed to administrator and PMHNP and she recommended to call non-emergency police and see if they could talk him into coming inside. Police arrived and spoke with Resident #1, and he did come inside. The police asked the nurse what the plan was to keep him away from the man [Resident #2] Resident #1 was mad at. The plan was to place Resident #1 on every 15-minute checks to ensure he does not go near Resident #2 and smoke Resident #1 and Resident #2 away from each other. Review of Resident #1's progress note dated 08/08/24 reflected nurse went to dining room due to hear Resident #1 yelling. Upon entering the dining room Resident #1 was in his wheelchair yelling at a CNA about Resident #2. It was alleged that Resident #1 spit in the face of Resident #2. Resident #1 stated, yeah I spit on him because he [Resident #2] cusses at me. Resident was spoken to and encouraged to calm down and stop yelling and not to spit on others regardless of their activity. PMHNP, DON, and Administrator notified. Review of Resident #1's progress note dated 08/24/24 reflected Resident #1 was returned to facility by the police, police said they found him across the street where he called 911. Nurse asked resident what happened, and Resident #1 said he had called 911 because he was tired of having Resident #2, feeling like he can say anything he wants to me and I won't take it anymore so I went across the street and called the police on my phone. Nurse assured resident that measures have been taken to resolve this situation and will continue plan of care. Review of Resident #1's progress note dated 09/04/24 reflected CNA informed the nurse of an altercation between Resident #1 and Resident #2 in which Resident #2 kicked Resident #1's wheelchair and Resident #1 hit Resident #2 on the knee with his cane. Review of Resident #1's progress note dated 09/23/24 reflected nurse spoke with Resident #1 regarding issues he was having with Resident #2. Resident #1 stated he is not going to seek out Resident #2 and initiate behaviors, however, if Resident #2 provoked him he intended to finish it. Resident #1 was asked what he meant by this statement and Resident #1 stated that if Resident #2 provoked him he would, get him back. The nurse, who was the done DON, who wrote the progress note stated she also spoke with the PMHNP to initiate a behavioral care plan and contacted the ombudsman for assistance in developing a behavior plan. Review of Resident #1's progress note dated 10/09/24 reflected Resident #1 was assessed because of an altercation with Resident #2. Resident #1 stated that he had been hit in the face by Resident #2. Resident #1 assessed and found with no visible injury related to the incident. Note reflected there is a 2X1 (unit of measure not noted) slightly reddened area noted to the left side of residents left eye. Resident stated that Resident #2 hit him in the face, and he hit Resident #2 with his cane on the top of Resident #2's head. Resident #1 stated that the reddened area does not hurt, and he wasn't sure if that was related to the incident. Resident #2 Review of Resident #2's progress note dated 09/04/24 6:23 PM reflected ambulance arrived at the facility and stated that they were called by resident #2. The nurse asked the resident why he called the ambulance and Resident #2 stated he got into an altercation with Resident #1 in the smoking area and his right knee hurt. Assessment of knee revealed no wound, no bleeding, or inflammation noted to the knee. Resident #2 insisted on being sent out and stated, if you don't let me go I'll cause hell to everyone here. The responsible party, ADON, DON, medical director, and Administrator were informed. Note reflected, will continue plan of care. Review of Resident #2's progress note dated 09/04/24 7:36 PM reflected police officer arrived at the facility and insisted on speaking to Resident #1 because of a report an altercation between him and Resident #2. Resident #2 called the police. There were no staff present when the altercation occurred. Review of Resident #2's progress note dated 09/11/24 reflected Resident #2 continued 1 on 1 monitoring (reason for 1 on 1 monitoring not explained in note). Review of Resident #2's progress note dated 09/23/24 6:00 PM reflected resident seen for follow up virtual visit with PMHNP, Resident #2 was placed 1 on 1 due to having multiple on/off behaviors of aggression/ agitation with other residents. Medication had been adjusted over the last two weeks. Resident #2 currently denies being a harm to himself or others. Staff reported that he has not had any noted agitation/aggression with him during one-to-one period and he denied harm to himself or others. Will discontinue 1 on 1 at this time and follow up with resident with face-to-face visit within one week. Review of Resident #2's progress note dated 09/23/24 8:00 PM reflected nurse spoke with resident regarding issues he was having with Resident #1. Resident #2 stated that he felt safe at this time and will do his best to stay away from Resident #1, the resident with whom he was having trouble with. The nurse spoke with the PMHNP regarding the safety of Resident #2 and she stated she had completed an assessment of him and the situation and in her opinion Resident #2 was not a danger to himself or others at this time. The facility was to provide a separate smoking areas Resident #1 and Resident #2 and to keep them separated as much as possible. The note reflected a discussion with the PMHNP to initiate a behavioral care plan and contact with the ombudsman for assistance in developing a behavior plan. Review of Resident #2's progress note dated 10/09/24 by LVN A reflected she heard someone yelling and went into the sunroom and noticed Resident #1 sitting behind resident #2. Resident #1 had his cane raised in the air. Resident #2 was leaning over and he had blood dripping from the top of his head. A second nurse (not identified in the note) went to get the DON, Administrator, and called 911. When the LVN A walked into the sunroom Resident #1 said Resident #2 hit him in the face and he hit Resident #2 on his head with his cane. Resident #2 stated Resident #1 called him a son of a bitch and told him not to talk about his mother. Resident #1 stated Resident #2 hit him in the face, and he hit Resident #2 with his cane. The police came and talked to Resident #2. Review of police report dated 10/09/24 reflected the DON advised the officer that Resident #1 and Resident #2 got into an altercation. DON stated that she was unaware of how the situation started but advised that Resident #1 and Resident #2 had several instances of verbal altercations and stated that they didn't like each other. Resident #2 had an open laceration on his head that was being treated. Resident #2 stated he and Resident #1 were in the sunroom by the smoking area when the incident occurred. Resident #2 said Resident #1 called him a son of a bitch which then caused him to punch Resident #1 using his right arm with a closed fist in the nose. The officer asked Resident #2 how hard he tried to punch Resident #1 and he said, As hard as he could. Resident #2 then stated that's when Resident #2 used his walking cane to hit him in the head, causing the open laceration. The officer observed the laceration on Resident #2's head. Resident #2 was transported to the hospital. The officer contacted the Administrator who provided him with camera footage of the incident. In the camera footage, the officer observed Resident #1 and Resident #2 in the sunroom by the smoking area. The officer observed that Resident #2 blocked the doorway path, trying to prevent Resident #1 from going to the smoking area. Resident #1 pulled on Resident #2's wheelchair, trying to pull him away from the door, and Resident #1 threw a closed fisted punch (unsure if it connected with Resident #2), to which Resident #1 retaliated by hitting Resident #1 on the head with his walking cane. Resident #1 was asked to give his side of the story and he said Resident #2 wasn't supposed to be in that particular smoking area and Resident #1 was trying to get Resident #2 to leave by pulling on his wheelchair. Resident #1 stated they exchanged words and then got hit by Resident #2 under his left eye, which then caused him to hit Resident #2 with his cane. The officer then asked how hard he tried to hit Resident #1 and Resident #2 responded, saying, Well, it was enough to make him bleed. The officer observed redness under Resident #1's left eye. In an interview on 10/11/24 at 12:30 pm with Resident #1, he revealed the issues with Resident #2 had been ongoing for a while and Resident #2 had hit and kicked him several times. Resident #2 said he told Resident #1 he would knock him in the head if he did it again and that is what he did. Resident #1 said he warned Resident #2 a couple of days earlier and Resident #1 had been to the Administrator's office thirteen times and said that if Resident #2 hit him, he was going to hit Resident #2. Resident #1 said that Resident #2 was not supposed to be in the smoking area, and he told Resident #2 you are not supposed to be in the smoking area and Resident #2 hit across his face so Resident #2 knocked him in the head with his cane. In an interview on 10/11/24 at 4:18 pm with Resident #2, he revealed Resident #2 hit him over the head with a cane and it made him bleed. Interview on 10/11/24 at 1:04 pm, CNA B who revealed as far as she knew, Resident #1 and Resident #2 did not get along. Resident #2 called Resident #1 white trailer trash and Resident #1 did not let that go. CNA B said she observed Resident #1 and Resident #2 argue and they were separated. Resident #1 was on 1 on 1 because of an altercation with Resident #2. CNA B said when Resident #1 saw Resident #2, Resident #1 was on the defense. Staff were all supposed to keep an eye on Resident #1 and Resident #2. Sometimes Resident #2 would come into the group smoking area and Resident #1 would get upset and tell Resident #2 he could not be in that smoking area. CNA B said because of Resident #2's brain injury she was not sure if he understood he could not be in the community smoking area. CNA B said Resident #2 did not verbalize that he knew that he was not supposed to be in the community smoking area, and he did not ½ of the stuff he was told. Interview on 10/11/24 at 2:27 pm with CNA C revealed staff told Resident #2 multiple times he could not be in the same area with Resident #1 because they always, bumped heads. Resident #2 was supposed to smoke on another hallway, but he insisted, everyday on going to the other hallway to smoke. CNA revealed Resident #2 went over to the community smoking area 15 or thirty minutes before the smoking time began. CNA C revealed Resident #2 went where he wanted to go and would say things to antagonize other people. Interview on 10/11/23 at 3:05 pm with CNA D revealed Resident #1 and Resident #2 should not have been alone and the Administrator did not want them to cross paths. Resident #1 was an aggressor and he and Resident #2 should not have been in a space together, alone, without supervision. Resident #2 would try to enter the community smoking area and she would tell Resident #2 you cannot be in this smoking area, and I will take you to smoke when I am finished here. CNA D revealed this happened several times a week. She said she reported this to the DON and ADON. She said she told the ADON and the DON it would be best if someone took Resident #2 out when she took the others out. If Resident #2 came out to the community smoking area, Resident #1 would cuss at Resident #2 and tell him you are not supposed to be out here and you are not allowed to be around me. Resident #2 could be on the complete opposite side of the building but if Resident #1 saw Resident #2, Resident #1, would see red. Interview on 10/11/24 at 4:59 pm with the ADON revealed they did their best to keep Resident #1 and Resident #2 apart. They were assigned separate smoking and eating areas. Resident #2 would go wherever he really wanted to go. There was a staff in-service that instructed that Resident #1 and Resident #2 should be kept separated. Resident #1 made it very clear he did not like Resident #2. The ADON said there was concern about them getting into an altercation, but she felt like the staff was keeping them separated. Interview on 10/11/24 at 12:30 pm DON who revealed Resident #1 and Resident #2 were in an altercation in the sunroom. Resident #1 came up behind Resident #2 and grabbed Resident #2's wheelchair and tried to pull Resident #2 away from the smoking area door. The video of the incident has no audio. Resident #1 hit Resident #2 over the head with his cane. There was no staff member present. There was a plan in place where Resident #2 was not supposed to be smoking at the same time as Resident #1. The residents were not supposed to be together. The staff had been in-serviced on keeping Resident #1 and Resident #2 separated, and it was care planned for each resident. The staff was aware of the residents' poor relationship. The residents were not on 1 to 1 supervision. The Residents had previous verbal altercations and one previous physical altercation. The DON thought the men did not like each other. Both men had a diagnosis of traumatic brain injury. Resident #2 received a significant injury to his head, a 2 cm laceration, when he was hit by Resident #1 with Resident #1's cane. The DON said Resident #2 could be impulsive. Review of the facility's abuse and neglect policy, undated 01/01/23, reflected: The purpose of this policy is to ensure that each resident has the right to be free from any type of abuse The facility staff will adhere to the policies and procedures and will follow the guidelines in the written policy and procedure. The facility administrator is the appointed abuse coordinator and in his/her absence a designee with be appointed. Abuse is willful infliction of injury or negligent, unreasonable confinement, intimidation, or punishment with resulting physical or emotional harm or pain to a resident. Resident will not be subjected to abuse by anyone including but not limited to community staff, other residents The administrator and or designee are responsible for maintaining all facility policies that prohibit abuse, neglect, and misappropriation of funds/personal belongings. In the event of a resident-to-resident abuse, the facility will immediately protect the resident being abused and all other residents in the facility. If the initial determination is that the perpetrator is a threat to the health and safety of the residents in the facility as determined by the attending physician/or other physician, the resident will be discharged as soon as possible. During the time that the perpetrator has not been discharged , the facility will monitor this resident one-on-one to protect all other residents. The ADM was notified on 10/12/24 at 1:45 PM that an Immediate Jeopardy had been identified due to the above failures and an IJ template was provided. The following POR was accepted on 10/17/24 at 4:05 PM: Plan of Removal On 10/12/2024 the surveyor provided an Immediate Jeopardy template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate jeopardy to the resident health and safety. Removal of Immediacy Plan PLAN OF REMOVAL FOR IMMEDIATE JEOPARDY Impact Statement Abuse The resident has the right to be free from abuse, neglect misappropriation of resident property as defined in this subpart. This includes but is not limited to freedom from corporal punishment involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Identify residents who could be affected All residents who came into contact with Resident #1 had the potential to be affected by this alleged deficient practice. All residents who come into contact with resident #2 has the potential to be affected by this alleged deficient practice. Problem The facility failed to keep the residents free from abuse. Action Taken Resident #1 was placed on 1:1 and remained 1:1 until discharge. Resident #2 was placed on 1:1 until cleared by Psychology Nurse Practitioner. Administrator and Director of Nursing were in-serviced by Regional [NAME] President of Operations on 10-12-2024 to include keeping resident within eyesight at all times and maintaining resident safety. Staff members assigned to 1:1 will be in-serviced by Director of Nursing and/or designee on responsibilities to include keeping resident within eyesight at all times and maintaining resident safety. This in-service will occur prior to the start of each 1:1 shift. This will continue while resident remains 1:1. The administrator will oversee actions taken. Safe Surveys were conducted by administrative nurses/designee with alert and oriented residents to determine if there were any residents who did not feel safe in the facility. Safe survey did not reveal any additional resident that cause fear or abuse. Verification of completion on 10-12-2024 was done by the Administrator. For those non-alert and non-oriented residents all nurses have been educated on 10-13-24 to monitor for changes in behavior and skin during weekly skin assessments for non-verbal signs and symptoms of abuse this will continue indefinitely. All new nurses will be trained during orientation. The Director of Nursing and/or designee began educating all staff on the facility's Abuse and Neglect policy on 10-12-2024. All staff will be educated prior to their next assigned shift. Training will continue until all staff have been educated by 10-13-2024. All new staff will be trained during orientation. Agency staff are not used in the facility. The Director of Nursing and/or designee began educating all clinical staff on following resident #2 plan of care on 10-12-2024. All clinical staff will be educated prior to their next assigned shift. Training will continue until all clinical staff have been educated by 10-13-2024. All new clinical staff will be trained during orientation. Agency staff are not used in the facility. Involvement of Medical Director and Quality Assurance Ad HOC QA meeting held with the medical director on 10-12-2024 to review all aspects of Immediate Jeopardy and Initial Plan of removal. QA meetings are held on a monthly basis and all allegations, incidents, and accidents will be reviewed during the QA meeting. The next QA meeting will be 11-12-2024. This will be an ongoing process. Monitoring: Reviewed facility documentation that Resident #1 was placed on 1:1 and remained 1:1 until he was discharged from the facility on 10/11/24. Reviewed documents that Resident #2 was placed on 1:1 until cleared by Psychology Nurse Practitioner. Resident #2 1:1 monitoring still continued at time of investigator exit. Reviewed facility Safe Surveys that were conducted by administrative nurses/designee with alert and oriented residents to determine if there were any residents who did not feel safe in the facility. The reviewed safe surveys did not reveal any additional resident that caused fear or abuse. On 10/18/2024 reviewed nursing staff in-services dated 10/13/23 that provided education for non-alert and non-oriented residents to monitor for changes in behavior and skin during weekly skin assessments for non-verbal signs and symptoms of abuse. On 10/18/24 reviewed in-services that provided education for all staff on the facility's Abuse and Neglect policy dated 10/13/24 including types of abuse, reporting, who the facility abuse and neglect coordinator was, and signs of abuse. On 10/18/24 reviewed in-serves confirming DON trained and informed staff that 1 to 1 for resident is 24-7 and the staff were trained to make sure resident was in eyesight for safety. Staff members assigned to 1:1 will be in-serviced by Director of Nursing and/or designee on responsibilities to include keeping resident within eyesight at all times and maintaining resident safety. Staff interviewed confirmed this in-service occurred prior to the start of each 1:1 shift and will continue while resident remains 1:1. In an interview with the DON on 10/18/24 11:40 AM the DON stated all training was completed with staff on 10/13/24 on abuse neglect. Any PRN staff will be trained prior to working shift they are scheduled for. She trained and informed staff that 1 to 1 for resident is 24-7 and the staff were trained to make sure resident was in eyesight for safety. In an interview on 10/18/24 2:15 PM with RVP he stated he in-serviced the Administrator and the DON on 10/12/24 on facility abuse neglect policy. In an interview with the DON on 10/18/24 at 11:40 PM she revealed she was in-serviced by the RVP on different types of abuse/neglect including types of abuse (mental, physical, and verbal) and to report to the Administrator immediately if she ever witnessed any abuse. In an interview on 10/18/24 2:15 PM with RVP he stated he in-serviced the Administrator and DON regarding 1:1 supervision to include keeping resident within eyesight at all times and maintaining resident safety. In an interview on 10-18-2024 at 12:15 PM with CNA E she stated she had been 1 to 1 with Resident #2 since 8:00 AM that morning and will continue to be 1 to 1 until the end of her shift at 10:00 PM. CNA E stated that Resident #2 was to have 1 to 1 24-7. CNA E stated she had signed off on training by the DON on 10-16-2024 on abuse and neglect training and understood that during the 1 to 1 for Resident #2 she needed to make sure he was always in view(eyesight) for the resident safety. She was trained on abuse neglect and knew the different types (mental, physical, and verbal), the signs of abuse (bruises and emotional changes or indicators) and knew to report immediately to the abuse coordinator (ADM) if ever witnessed. During interviews on 10/18/24 from 11:40 AM - 3:50 PM, one RN, three LVNs, and five CNAs (from different shifts) all stated they were in-serviced and abuse and neglect. All were able to state that the Administrator was the Abuse and Neglect Coordinator and give examples of different types of abuse such as physical, verbal, emotional, and psychosocial. All stated if they saw a resident being abused by a staff member, another resident, or a family member they would intervene to ensure the resident was in a safe space and would notify the Administrator immediately. They all stated if the Administrator or DON was not immediately available, they would call the HHSC hotline (and were able to report where the number was posted). They all stated it was important to notify the Administrator because a thorough investigation was necessary to ensure residents safety, and report to the appropriate agencies. Reviewed documentation of Ad HAC QA meeting attended by the DON, Administrator, the MD, confirming review all aspects of Immediate Jeopardy and Initial Plan of removal including in-serving in progress and procedural changes made moving forward. While the IJ was removed on 10/18/24 at 5:00 PM, the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observations, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for two (Resident #1 and Resident #2) of ten residents reviewed for care plans. The facility failed to implement a comprehensive care plan for Resident #1 and Resident #2 with attainable interventions in place addressing the repeated facility wide known history of disputes between the two Residents. An incident occurred on 10/09/24 where video footage revealed R#1 used his cane to hit Resident #2 on the head. Resident #2 was sent to the hospital by EMS and received 10 staples to his head for a 2 cm laceration. An IJ was identified on 10/16/24. The IJ template was provided to the facility on [DATE] at 12:48 PM. While the IJ was removed on 10/18/24, the facility remained out of compliance at a scope of pattern and severity of no actual harm with potential for more than minimal harm that is not immediate jeopardy. This failure placed residents at risk for not including measurable objectives and timetables to meet residents' medical, nursing, and mental and psychosocial needs to ensure resident safety. Findings included: Review of Resident #1's face sheet, dated 10/11/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included diffuse traumatic brain injury (occurs when the brain is injured by blunt force, causing the brain's nerve fibers to shear of tear (a force that acts in opposite directions, causing a tear or deformation)), depression, and heart failure. Review of Resident #1's quarterly MDS assessment, dated 08/27/24, reflected a BIMS score of 15 indicating intake cognition No information was provided in section E regarding Resident #1's behavior and did not include information about physical or verbal behaviors directed at others. On 10/10/24 at 12:20 pm observed Resident #1 ambulated using a wheelchair and he had a cane, but neither device was listed in his MDS. Review of Resident #1's quarterly care plan reflected: Focus dated 03/18/24 Resident #1 had potential to have verbal and physical aggression related to anger. Goal - the resident will demonstrate effective coping skills through the review date and the resident will not harm self or others through the review, date initiated 03/18/24, revision on 09/04/24, and target date 12/03/24 Interventions: Behavior plan in place with Resident - date initiated 03/18/24 1. Get staff to mitigate any negative encounter and remove self from confrontation with Resident #2. 2. Avoid contact with Resident #2 and not seek confrontation with Resident #2, and 3. Monitor verbal or physical aggression every shift and document observed behavior attempted in behavior log Review of Resident #1's progress note dated 03/17/24 revealed Resident #1 observed with another resident speaking harshly and using foul language, stating he was, Going to kick [Resident #2's] ass and making physical motions to indicate his intent. The nurse positioned herself in between the two residents and remained in between them at all times to prevent physical contact. Resident #1 refused to move away from Resident #2. Resident #1 repeatedly moved himself closer to Resident #2 even when asked not to and he was continuing to taunt and threaten Resident #2. Nurse removed Resident #2 from the area and brought him with her to monitor Staff was made aware of the situation and alerted to keep residents apart due to aggressive behaviors. DON and Administrator notified of situation. Review of Resident #1's progress note dated 03/18/24 reflected social worker followed up with resident to address an altercation with Resident #2 that happened over the weekend. Resident shared his version of the story. Social worker listened and provided ways to avoid altercations. Resident listened and agreed. Review of Resident #1's progress note dated 03/25/24 social worker and administrator spoke with resident regarding a conflict he had previously with Resident #2. Resident stated that he needed time space to deal with his feelings. Resident will be given time and space as requested. Social worker will follow up with Resident #1 weekly to check on him. Review of Resident #1's progress note dated 04/05/24 reflected social worker spoke with resident to follow up. Resident shared that he and another resident [Resident #2] made amends. Resident #1 stated that he forgave Resident #2 because he had to do it for himself. Review of Resident #1's progress note dated 04/05/24 reflected after dinner Resident #1 went outside behind the building and laid down on the grass. Staff attempted to talk to Resident #1 and he stated that he was going to come back inside but that he planned to stay out there until something was done to Resident #2. A call was placed to administrator and PMHNP and she recommended to call non-emergency police and see if they could talk him into coming inside. Police arrived and spoke with Resident #1 and he did come inside. The police asked the nurse what the plan was to keep him away from the man [Resident #2] Resident #1 was mad at. The plan was to place Resident #1 on every 15-minute checks to ensure he does not go near Resident #2 and smoke Resident #1 and Resident #2 away from each other. Review of Resident #1's progress note dated 08/08/24 reflected nurse went to dining room because she heard Resident #1 yelling. Upon entering the dining room Resident #1 was in his wheelchair yelling at a CNA about Resident #2. It was alleged that Resident #1 spit in the face of Resident #2. Resident #1 stated, yeah I spit on him because he [Resident #2] cusses at me. Resident was spoken to and encouraged to calm down and stop yelling and not to spit on others regardless of their activity, PMHNP, DON, and Administrator notified. Review of Resident #1's progress note dated 08/24/24 reflected Resident #1 was returned to facility by the police, police said they found him across the street where he called 911. Nurse asked resident what happened, and Resident #1 said he had called 911 because he was tired of having Resident #2, feeling like he can say anything he wants to me and I won't take it anymore so I went across the street and called the police on my phone. Nurse assured resident that measures have been taken to resolve this situation and will continue plan of care. Review of Resident #1's progress note dated 09/04/24 reflected CNA informed the nurse of an altercation between Resident #1 and Resident #2 in which Resident #2 kicked Resident #1's wheelchair and Resident #1 hit Resident #2 on the knee with his cane. Review of Resident #1's progress note dated 09/23/24 reflected resident was seen by PMHNP by virtual visit. R had had incident where he was kicked and hit by Resident #2 and he hit Resident #2 with his cane. Both residents had to be separated and were taken to their rooms. PMHNP discussed the incident with Resident #1 and he stated facility staff seem to be keeping Resident #2 away from him so Resident #1 felt safe. Resident #1 said that he felt if the facility staff let him [Resident #2] loose Resident #2 would go back to being himself. Resident #1 said Resident #2 hit him five times, cursed at him 10 times, and shot the finger at him until he had no choice but to result to violence. The note reflected the DON was told about the conversation and the DON agreed to put a plan in place to help Resident #1 feel safe and to prevent further incidents. Review of Resident #1's progress note dated 09/23/24 reflected nurse spoke with Resident #1 regarding issues he was having with Resident #2. Resident #1 stated he is not going to seek out Resident #2 and initiate behaviors, however, if Resident #2 provokes him he intends to finish it. Resident #1as asked what he meant by this statement and Resident #1 stated that if Resident #2 provoked him he would, get him back. The nurse, DON, who wrote the progress note stated she also spoke with the PMHNP to initiate a behavioral care plan at this time and contacted the ombudsman for assistance in developing a behavior plan. Review of Resident #1's progress note dated 10/09/24 reflected Resident #1 was assessed because of an altercation with Resident #2. Resident #1 stated that he had been hit in the face by Resident #2. Resident #1 assessed and found with no visible injury related to the incident. Note reflected there is a 2X1 (unit of measure not noted)) slightly reddened area noted to the left side of residents left eye. Resident stated that Resident #2 hit him in the face and he hit Resident #2 with his cane on the top of Resident #2's head. Resident #1 stated that the reddened area did not hurt and he wasn't sure if that was related to the incident. Review of Resident #1's progress note dated 10/10/24 reflected social worker followed up with Resident #1 and discussed his feelings. Request for placement was made to various nursing facilities, but placement for Resident #1 was declined by facilities due to Resident #1's aggressive behavior. He was accepted to a group home. Review of Resident #1's initial assessment visit on 04/03/24 with PMHNP reflected Resident #1 admitted to mental health conditions, depression and stated someone had insulted him three times (resident not identified). Anxiety: Patient endorsed current symptoms of excessive worry and denies symptoms of restlessness, irritability/agitation, impaired concentration, panic attacks and anticipatory worry/impending doom. Severity level is 2 (Minimal). Review of Resident #1's visit on 05/15/24 with PMHNP reflected Resident admitted to being mad. He stated I was assaulted 4xs [by Resident #2] and, they are still bringing him [Resident #2] around me and right now I'm after him [Resident #2]. Resident #1 stated if he's not around [Resident #2] I'm happy. Review of Resident #1's visit on 05/20/24 with PMHNP reflected Resident #1, Admits to being agitated due to feeling he has been disrespected by another resident [Resident #2]. Received call from facility the past weekend due to resident going outside and refusing to come back in due to not wanting to be around resident [Resident #2] he feels he was disrespected by. Review of Resident #1's visit on 07/31/24 with PMHNP reflected, staff reports resident made a [shank] out of foil and is carrying a cane as a weapon. Patient endorses current symptoms of excessive worry, irritability/agitation and impaired concentration and admits to anxiety and agitation due to, wanting a cane. Review of Resident #1's visit on 08/13/24 with PMHNP reflected, staff reports that patient had an incident where he left the facility and went to a park to look for a stick. Review of Resident #1's visit on 08/25/24 with PMHNP reflected Resident #1 stated he did well as long as another resident [Resident #2] that he has had incidents with stayed away from him and, Resident #1, Becomes agitated when he sees the resident [Resident #2] that he has problems with. Review of Resident #1's visit on 10/06/24 with PMHNP reflected reason for referral anger, physical aggression. Review of Resident #1's visit on 10/09/24 with PMHNP reflected reason for referral, Anger, physical aggression. Patient seen today for a new problem. At staff request for continued unstable symptoms that have showed limited improvement. PMHNP visit reflected Resident #1 was seen for a follow up visit due to behaviors that lead to an altercation with another resident [Resident #2]. When asked about the altercation he stated that it was the sixth time he has [Resident #2] hit me or kicked me, in the past he, brought blood on me. I was going to the smoke area, and he was in the way, and I pulled Resident #2's chair and told him he was not supposed to go out there. I was tired of going and getting someone, so I held him back this time and told him you are not going out there you are not supposed to be out there. They want me to get someone every time he goes out there, he said I was here first and that is when he hit me and I hit him back. He thinks he can hit people and cuss them with no recourse. The visit reflected that the PMHNP asked him when you see Resident #2 does that make you angry and Resident #1 responded, yes because every time he comes around I have to watch him. A few days ago he kicked at me, but I didn't notify anyone. He is constantly shooting the finger and cussing me. When asked if he was aware that the resident went to the emergency room with a head injury Resident #2 stated, well, he hit me first and between me and you I am tired and fed up with him so I hit him. Resident #1 said he was anxious when he was around Resident #2 and the facility staff knew he [Resident #2] was mean and cruel, vial and violent. Resident #2 expected everyone to move out of his way and kept getting by with it and, that is the reason he keeps doing it. It's on my mind and I can't forget what hes done to me. I can't stand to be around him. We used to get along he was banned from the smoking area in the past I tried to get him and help him and he still hit me and I don't want to be around him period. Review of Resident #1's visit on 10/01/24 with MSW, LCSW reflected service provided, new referral, reason for referral anger, physical aggression. Patient [Resident #1] described an altercation between him and another resident [Resident #2]. Review of Resident #1's visit on 10/08/24 with MSW, LCSW reflected current risk factors, Aggressive Behavior: Current and History, Mental Status Examination Affect: Angry, Anxious, Agitated. Review of Resident #2's face sheet, dated 10/11/24, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses that included schizoaffective disorder, bipolar type (which features bouts of mania and sometimes depression), and diffuse trauma brain injury (occurs when the brain is injured by blunt force, causing the brain's nerve fibers to shear of tear). Review of Resident #2's quarterly MDS assessment, dated 08/27/24, reflected a BIMS score of 14 indicating intact cognition. No information was provided in section E regarding potential indicators of Psychosis. No information was provided in section E regarding Resident #1's behaviors, physical or verbal, directed at others or other behavioral symptoms not directed toward others (e.g., hitting or scratching self). On 10/10/24 at 4:18 pm observed Resident #2 in a wheelchair. No wheelchair was listed in his MDS. Review of Resident #2's quarterly care plan reflected: Focus: 1. Resident #2 had behavior problems as a result of schizoaffective disorder - yelling, racial slurs, name calling 2. 09/04/24 aggressive behaviors date initiated 12/15/23 revision on 09/05/24 Goals: 1. Resident #2 will have less than daily behaviors hitting self. Impulsiveness, racial slurs by review date Date initialed 12/15/23, revision date 03/04/24, and target date 12/09/24 Interventions: 1. administer medication as ordered, monitor/document for side effects and effectiveness date initialed 12/15/23 2. anticipate and meet the resident's needs dated initiated 12/15/23 3. Behavior plan in place: 1. Resident #2 will smoke in separate smoking area from Resident #1 and will be provided supervision on that break Resident #1 will avoid contact with Resident #2 and if they meet in person, Resident #1 will not say provoking things to Resident #2 or have physical altercation. Resident will alert staff if he feels unsafe or if he feels unsafe or if Resident #2 threatens him for immediate interventions date initiated 09/23/24 2. document any behaviors and interventions in clinical record as they occur date initiated 01/26/24 3. medication review by psych date initiated 02/15/24 4. monitor behavior episodes and attempt to determine underlying causes, consider location, time of day, persons involved, and situation and document behavior and potential causes date initiated 12/15/23 5. Weekly discussion regarding social services date initiated 01/26/24 Review of Resident #2's progress note dated 09/04/24 6:23 PM reflected ambulance arrived at the facility and stated that they were called by resident #2. The nurse asked the resident why he called and Resident #2 stated he got into an altercation with Resident #1 in the smoking area and his right knee hurt. Assessment of knee revealed no wound, no bleeding or inflammation noted to the knee. Resident #2 insisted on being sent out and stated, if you don't let me go I'll cause hell to everyone here. The responsible party, ADON, DON, medical director, and Administrator were informed. Note reflected, will continue plan of care. Review of Resident #2's progress note dated 09/04/24 7:36 PM reflected police officer arrived at the facility and insisted on speaking to Resident #1 because of a report an altercation between him and Resident #2. Resident #2 called the police. There were no staff present when the altercation occurred. Review of Resident #2's progress note dated 09/11/24 reflected Resident #2 continued 1 on 1 monitoring (reason for 1 on 1 monitoring not explained in note). Review of Resident #2's progress note dated 09/23/24 6:00 PM reflected resident seen for follow up virtual visit with PMHNP, Resident #2 was placed 1 on 1 due to having multiple on/off behaviors of aggression/ agitation with other residents. Medication had been adjusted over the last two weeks. He currently denies being a harm to himself or others. Staff reports that he has not had any noted agitation/aggression with him during one-to-one period and he denied harm to himself or others. Will discontinue 1 on 1 at this time and follow up with resident with face-to-face visit within one week. Review of Resident #2's progress note dated 09/23/24 8:00 PM reflected nurse spoke with resident regarding issues he was having with Resident #1. Resident #2 stated that he felt safe at this time and will do his best to stay away from Resident #1, the resident with whom he was having trouble with. The nurse spoke with the PMHNP regarding the safety of Resident #2 and she stated she had completed an assessment of him and the situation and in her opinion Resident #2 was not a danger to himself or others at this time. The facility was to provide a separate smoking areas Resident #1 and Resident #2 and to keep them separated as much as possible. The note reflected a discussion with the PMHNP to initiate a behavioral care plan and contact with the ombudsman for assistance in developing a behavior plan. Review of Resident #2's progress note dated 10/09/24 by LVN A reflected she heard someone yelling and went into the sunroom and noticed Resident #1 sitting behind resident #2. Resident #1 had his cane raised in the air. Resident #2 was leaning over and he had blood dripping from the top of his head. A second nurse (not identified in the note) went to get the DON, Administrator, and called 911. When the LVN A walked into the sunroom Resident #1 said Resident #2 hit him in the face and he hit Resident #2 on his head with his cane. Resident #2 stated Resident #1 called him a son of a bitch and told him not to talk about his mother. Resident #1 stated Resident #2 hit him in the face, and he hit Resident #2 with his cane. The police came and talked to Resident #2. Review of Resident #2's visit on 01/10/24 with PMHNP reflected reason for referral issues with trauma. Mania: Resident #2 endorsed current symptoms of grandiosity and easily distracted. Anxiety: Resident #2 endorsed symptoms of excessive worry, irritability/agitation and anticipatory worry/impeding doom. Cognitive impairment: Resident #2 endorsed current symptoms of forgetfulness, confusion, mood/personality change and difficulties with activities of daily living. Review of Resident #2's visit on 01/24/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity and easily distracted. Review of Resident #2's visit on 02/06/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity and easily distracted and hyper-focused behavior. Review of Resident #2's visit on 02/28/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity and easily distracted, impulsive actions and hyper-focused behavior. Resident #2 endorsed symptoms of decreased concentration. MSE mood - anxious, depressed. Review of Resident #2's visit on 03/10/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity, impulsive actions and hyper-focused behavior, and history of easily distracted. MSE mood - anxious, depressed. Review of Resident #2's visit on 04/03/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity, easily distracted and impulsive actions. Anxiety: resident #2 endorsed current symptoms of excess worry and irritability/agitation. MSE anxious, depressed, short-term memory mildly impaired. Review of Resident #2's visit on 04/08/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity, pressured speech/hyper-verbosity and easily distracted. Psychosis: Resident #2 endorsed current symptoms of delusions. He reports that another resident threw a 20oz. Coke at him and he responded by hitting her back. Resident #2 admitted to feeling own and depressed and being anxious. He denied being a harm to himself or anyone else. Resident #2 endorsed current symptoms of sad moods and decreased concentration. Review of Resident #2's visit on 04/24/24 with PMHNP reflected Mania: Resident #2 endorsed current symptoms of grandiosity, pressured speech/hyper-verbosity and easily distracted. Psychosis: Resident #2 endorses current symptoms of delusions. Review of Resident #2's visit on 05/07/24 with PMHNP reflected Resident #2 endorsed current symptoms of decreased concentration. Mania: Resident #2 endorsed current symptoms of grandiosity, pressured speech/hyper-verbosity and easily distracted. Anxiety: Resident #2 endorsed current symptom of impaired concentration. Cognitive Impairment: Resident #2 endorsed current symptoms of mood/personality change. Psychosis: Resident #2 endorsed current symptoms of delusions. MSE: Mood anxious, depressed, short-term memory mildly impaired. Review of Resident #2's visit on 05/20/24 with PMHNP reflected Resident #2 endorsed current symptom of decreased concentration. Manie: Resident #2 endorsed current symptom of grandiosity, pressured speech/hyper-verbosity and easily distracted. Anxiety: Resident #2 endorsed current symptoms of impaired concentration. Cognitive impairment: Resident #2 endorsed current symptom of mood/personality change. Psychosis: Resident #2 endorsed current symptoms of delusions and responding to internal stimuli. MSE: Mood anxious, depressed, short-term memory mildly impaired. Review of Resident #2's visit on 06/02/24 with PMHNP reflected Resident #2 endorsed current symptoms of decreased concentration. Mania: Resident #2 endorsed symptoms of grandiosity and easily distracted. Cognitive impairment: Resident #2 endorsed current symptoms of forgetfulness mood/personality change. Psychosis: Resident #2 endorsed symptoms of delusions. MSE: Mood anxious, depressed, short-term memory mildly impaired. Review of Resident #2's visit on 01/24/24 with MSW, LCSW reflected Resident #2 was referred due to his anger outbursts and inappropriate remarks such as racial slurs. Brief psychiatric rating scale reflected BPRS current ratings: Disorientation - moderately severe Grandiosity - moderately severe Review of Resident #2's visit on 02/14/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 02/20/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 02/28/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 03/05/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 03/12/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 03/20/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Resident #2 discussed the incident that happened over the weekend and he processed his feeling for anger. Review of Resident #2's visit on 03/25/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 04/02/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, behavior, conduct problems, depression, anxiety, and confusion Review of Resident #2's visit on 04/23/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, depression, anxiety, and confusion Resident #2 seemed to be having difficulty managing emptions and longed to be discharged and reside with family. Review of Resident #2's visit on 04/30/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, depression, anxiety, and confusion Review of Resident #2's visit on 05/08/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, depression, anxiety, and confusion Review of Resident #2's visit on 05/14/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Disorientation - moderately severe Symptoms Present - anger, depression, anxiety, and confusion Resident #2 discussed the incident he had with, another staff. He processed his feelings of anger. Resident #2 noted how he could have handled things, differently. He listed triggers that made him angry. Review of Resident #2's visit on 05/21/24 with MSW, LCSW reflected history of current illness: Resident #2 was referred due to his anger outbursts and inappropriate remarks, such as racial slurs. Grandiosity moderately severe no change, hostility moderate - increase, and excitement - increase. Review of Resident #2's visit on 05/28/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Review of Resident #2's visit on 06/06/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe Resident #2 reported feelings of anger when speaking about the incident that happened. Review of Resident #2's visit on 06/12/24 with MSW, LCSW reflected current and a history of aggressive behavior. MSE reflected affect (immediate emotional expression) - sad, anxious mood - depressed, elevated (an abnormal heightened emotional stat, such as euphoria or extreme happiness) Grandiosity - moderately severe On 10/11/24 at 12:30 observed Resident #1 ambulating using a wheelchair and had a cane with him. On 10/11/24 at 4:18 pm observed Resident #2 in a wheelchair. Interview on 10/11/24 at 1:04 pm with CNA B revealed as far as she knew, Resident #1 and Resident #2 did not get along. Resident #2 called Resident #1 white[TRUNCATED]

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident was free from abuse for 5 (Residents #2, #3, #4, #5 and #6) of 5 residents reviewed for abuse. The facility failed to ensure Resident #2, #3, #4, #5 and #6 were protected from physical and verbal abuse including verbally and physically aggressive behavior, such as physically punching, cursing, insulting, and intimidation from Resident #1. As a result of the facility's failures Residents #2, #3, #4, #5 and #6 suffered continual negative psychosocial outcomes including crying, fear and anxiety, feelings of hopelessness, and withdrawal from former social patterns. An IJ was identified on 07/15/23. The IJ template was provided to the facility on [DATE] at 8:30 PM. While the IJ was removed on 07/16/23 at 4:36 PM, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not immediate to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure caused actual harm to 5 residents and placed all residents in the facility at risk for physical abuse, verbal abuse, severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Record review of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: epilepsy (seizures), cerebral infarction (stroke), hemiplegia (partial paralysis), insomnia, depression, repeated falls, mood disorder, and anxiety. Record review of Resident #1's quarterly MDS , dated 05/30/2023 revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed toward others; this indicated that these behaviors were not present. Record review of Resident #1's care plan dated 06/01/23 revealed Resident #1 is/has potential to be physically aggressive. 04/13/21 physical altercation with roommate, 04/24/23 physical altercationnwith another resident no injuries, 07/09/23 physical altercation with another resident, no injuries, 07/12/22 physical altercationn with another resident, no injuries. Interventions included monitor, document, report as needed any symptoms of Resident #1 posing danger to self and other. It further revealed that Resident #1 had physically assaulted Resident # 2 on 07/9/23 and Resident #3 on 07/09/23. Record review of Resident #1's progress notes, printed 07/15/23 revealed: 07/10/23 1:42 PM Nurse note authored by LPN A: During report off going nurse made me aware of this resident involved in an altercation after finishing lunch. This resident slapped Resident #2. 07/10/23 10:02 PM Nurse note authored by LVN A: Resident is to remain one on one until 1:00 PM on 07/10.23. Resident is in his room this time with a nurse. No behavioral problems noted at this time. 07/12/23 12:14 PM Nurse note authored by LVN A: was told by another resident that this resident hit Resident #3 on the left side of his head when he was coming in from smoking without provocation. I went and asked Resident #3 what happened and he stated that I didn't do anything to him. He just hit me. I asked Resident why he hit Resident #3 and he stated he called me a bastard. Call placed to DR A and new order received and noted to place resident one on one and get a physic evaluation. Resident brother stated that his brother needed help because he had angry issue. Resident was placed one on one as per orders and call placed to the psychiatrist. 07/12/23 8:00 PM Nurse note authored by LVN A: Resident remains one on one throughout shift. No behaviors noted. Record review of the facility's incident list, printed on 07/15/23 revealed abuse reports for the progress notes reviewed above. Record review of faciliy abuse report dated 07/09/23 revealed Resident #1 was sitting at table table eating lunch when Resident #2 was moving past him. Resident #2 stopped and began saying something to Resident #1'. After a moment Resident #1 turned around and slapped Resident #2. Record review of facility abuse report dated 07/12/23 revealed Resident #3 was out in the smoking area when Resident #1 brought his arm up and slapped Resident #3. Record review of Resident #2's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including traumatic brain injury, intermittent explosive disorder (unpredictable outbursts of anger), falls, dementia, anxiety, and depression. Record review of Resident #2's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 09, which indicated the resident's cognition was moderately impaired. Record review of Resident #3's undated face sheet revealed that he was an [AGE] year-old male admitted [DATE] with diagnoses including major depressive disorder and anxiety disorder. Record review of Resident #3's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record review of Resident #4's undated face sheet revealed that he was a [AGE] year-old female admitted [DATE] with diagnoses of schizophrenia and homelessness. Record review of Resident 4's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed no score which indicated unable to determine resident # 4's cognition. Record review of Resident #5's undated face sheet revealed a [AGE] year-old female originally admitted [DATE] with diagnoses including: type 2 diabetes, obesity, hepatitis C, dementia, bipolar disorder, and absence of left leg below the knee. Record review of Resident #5's most recent MDS dates 05/31/23 revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record review of Resident #6's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including: type 2 diabetes, anxiety, bipolar disorder, stroke causing partial paralysis, repeated falls, and Parkinson's. Record review of Resident #6's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact. An interview on 07/15/23 at 11:26 AM revealed the interim DON stated Resident #1 slapped Resident # 2 on 07-09-23 and Resident # 3 on 07-12-23. Resident #1 was placed back on 1 on 1 but could not recall the date placed on 1 on 1 or the reason Resident #1 was removed from 1 on 1 after the first incident but could not give an exact date Interim DON stated she was not at the facility when the two incidents occurred but stated Resident #1 had a history of being physically and verbally abusive with other residents. An interview on 07/15/23 at 12:45 PM revealed the Administrator stated Resident #1 punched Resident #2 on 7-9-23 and Resident # 3 on 7-12-23 in the face. Resident #1 was placed on 1 on 1 after the first incident on 7-9-23 The Administrator was unable to provide an exact date Resident #1 was taken off 1 on 1 after the first incident. Resident # 1 was not experiencing any behaviors after being placed on 1 on 1. An interview on 07/15/23 at 1:30 PM revealed Resident #5 stated she did not feel safe at the facility. Resident #5 stated she is fearful of being hit by Resident #1. Resident #5 stated that Resident # 1 had hit Resident #3 and Resident #4 and she did not like living at the facility in fear. Resident #5 stated she is not happy with Resident #1 getting away with the things he is doing. Resident #5 stated a couple of weeks ago (could not recall exact date and time) Resident #1 raised his cell phone over his head as he was going to hit her. Resident # 1 was using profanity towards her and making fun of her having one leg. Resident #5 stated she was in fear of Resident #1 that he will eventually hit and harm her. Resident # 5 stated she just wanted to enjoy being at the facility again without fear. An interview on 07/15/23 at 1:45 PM revealed Resident #6 stated he was not happy at the facility and in fear of Resident # 1. Resident #6 stated Resident # 1 had hit Resident #2 and Resident #3 and nothing had been done about it. Resident #6 stated he was in fear of safety and not comfortable being around Resident #1. Resident #1 hit his friend Resident #3 on the side of his face with his fist. Resident #3 was trying to come back inside from being outside and Resident #1 was blocking the door to come inside. Resident #3 was trying to go around Resident #1 when Resident #1 physically hit Resident #3 in the face. Resident #6 stated he did not believe the facility was not doing anything about Resident #1's behavior towards residents. An interview on 07/15/23 at 1:55 PM revealed Resident #4 stated she witnessed Resident #1 hit Resident #3. Resident #4 stated on 7-12-23 she was standing out taking a smoke break and Resident #3 was trying to come back inside and Resident #1 was in front of the door and punched Resident #3 for nothing. Resident #4 stated she was scared for her safety as Resident #1 may one day hit her for nothing. Resident #4 stated the facility need to do something about Resident #1 hitting people and that was not the only time he had hit someone. Resident #1 hit Resident #2 was what she was told by other residents at the facility. Resident #4 stated after witnessing Resident # 1 verbally and physically abuse Resident #3 she was in fear of being safe. An interview on 07/15/23 at 2:15 PM revealed Resident #3 stated he was hit by Resident # 1 when he came back into the building. Resident #3 stated Resident #1 punched him on the left side of his face with his fist. Resident #3 stated he asked Resident #1 could he move so he could go in and when he tried to go around him that's when Resident #1 hit him. Resident # 3 stated he had a headache for a couple of days and had not felt safe since the incident. Resident #3 stated he did not feel comfortable with Resident #1 and was in fear of Resident # 1 hitting him again. Resident # 3 stated the incident had mentally affected him as he was embarrassed for being hit in the face for no reason. Resident #3 stated he did not feel protected with Resident #1 at the facility and that he did not want to come out of his room hardly. An interview on 07/15/23 at 3:00 PM revealed Resident #2 stated he was hit by the big black man on the side of his face. Resident #2 stated he was in the dining room and did not know why he hit him. Resident #2 stated he did not feel safe because he is in a wheelchair and not able to take up for himself. Resident #2 did not further elaborate on the incident. An interview on 07/15/23 at 3:15 PM revealed Resident #1 would not talk or communicate what happened with the incidents. Several attempts were made to obtain an interview with Resident #1 was unsuccessful. Resident # 2 wheeled by Resident #1's room in wheelchair and Resident #1 seen Resident # 2 in the hallway from the room and Resident # 1 looked at surveylor and stated he hit him real hard several times. Attempted again to interview Resident #1 and Resident #1 no longer responded. An interview on 07/15/23 at 3:42 PM revealed LVN B stated that she heard about the incidents with Resident #1 but she was not in the facility when they occurred. LVN B stated Resident # 1 had a history of being physically and verbally abusive with residents. LVN B could not give a date when Resident #1 was removed from 1 on 1 previous. An interview on 07/15/23 at 4:10 PM revealed RN Supervisor stated he was not in the facility with the incident with Resident #3 but was in the facility with the incident with Resident #2. The incident with Resident # 2 happened on 07/09/23 in the dining room. RN Supervisor stated he did not witness the incident but assessed Resident #2. Resident #2 stated the big black guy had hit him and he did not know the reason why. RN Supervisor spoke with Resident #1 and he told him that he hit Resident #2. Resident # 1 stated that Resident #2 was pouring sugar on the ground and going back and forth to Resident #1's table messing with him and Resident # 1 hit Resident # 2. RN Supervisor stated all the behaviors have been seen last two weeks. An interview on 07/15/23 at 4:45 PM was attempted with LVN A left a voice mail to return the call. An interview on 07/15/23 at 4:55 PM revealed CNA A stated she was monitoring the cigarette smoke break and not monitoring a 1 on 1 with Resident # 1. CNA A stated she did not know Resident #1 was assigned to 1 on 1. CNA A stated she was lighting a resident's cigarette and was told by Resident # 4 that Resident # 1 hit Resident #3. CNA A stated that Resident #4 stated Resident #1 hit that man for nothing. An Interview on 07/15/23 at 5:17 PM revealed LVN C stated he was on dining room duty monitoring the residents eat when he heard a loud sound. LVN C stated he did not see the hit and Resident #2 told him that he had gone to Resident #1 table by accident and that's when Resident # 1 hit him. Record review of inservice on abuse dated 07/12/23 all staff completed the training Record review of of safe surveys dated 07/12/23 completed by all residents. Record review of the facility abuse policy, dated 02/1/17, revised 01/27/23; The purpose of this policy is to ensure each resident has the right to be free from any type of Abuse, Neglect, Intimidation, Involuntary Seclusion/Confinement, and or Misappropriation of property. The facility staff will adhere to the policies and procedures and will follow the guidelines in written policy and procedure. The facility administrator is the appointed Abuse Coordinator, and in his/her absence a designee will be appointed. Residents will not be subjected to abuse by anyone, including, but not limited to community staff, other residents, consultants, volunteers, staff of other agencies serving the residents, family members or legal guardians, care taker, friends, or other individuals. On 07/15/23 at 8:30 PM the Administrator and Interim DON were informed that an Immediate Jeopardy (IJ) for abuse was identified and were provided the Immediate Jeopardy template. On 07/16/23 at 4:36 PM the following plan of removal was accepted: Impact Statement Abuse The resident has the right to be free from abuse, neglect, misappropriation of resident property as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Identify residents who could be affected All residents who encounter Resident #1 have the potential to be affected by this alleged deficient practice. Problem The facility failed to prevent ongoing aggressive behaviors from Resident #1. Action Taken Resident #1 was 1:1 on 7-15-2023 and will remain 1:1 until Resident #1 transfers to alternate facility. Facility has alternate placement for Resident #1 with transfer date of 7/17/2023. Alternate placement has been secured for Resident #1. Staff members will be assigned and notified of assignment to include always keeping resident within eyesight. Education was provided by Interim Director of Clinical Services and/or designees on 7-15-2023. Staff were educated in person and via telephone for staff that was not present. The administrator will oversee actions taken. Psych services was consulted on 7-15-2023 to evaluate Resident #1 to determine a course of treatment to assist with inappropriate behaviors by Assistant Director of Clinical Services. Safe Surveys were conducted by administrative nurses/designee with alert and oriented residents to determine if there were any residents who did not feel safe in the facility on 7-16-2023. Alert and oriented is defined by the resident's being alert and oriented to person, place, time and event. Verification of completion was done by the Administrator on 7-16-2023. Safe surveys included Are you fearful of other residents? Have you witnessed aggressive behavior by other residents? Safe survey did not reveal any additional resident that cause fear or abuse. Regional Director of Clinical Operations educated administrator and Interim Director of Nursing on reporting of abuse and neglect allegations on 7-15-2023. The Interim Director of Nursing and/or designee began educating all staff on the facility's Abuse and Neglect policy on 7-15-2023. All staff will be educated prior to their next assigned shift. Training will continue until all staff have been educated either in person by Interim DCO or ADCO on 7-16-2023. Interim DCO and Administrator will verify education has been completed prior to their next assigned shift. The Interim Director of Nursing and/or designee educated staff on completion of incident reports on 7-16-2023. All nurses will be educated prior to their next assigned shift. Training will continue until all nurses have been educated. This training will be part of any new hire orientation for nurses. Involvement of Medical Director and Quality Assurance Ad HOC QA meeting held with the medical director on 7-15-2023 at 9:19 pm to review all aspects of Immediate Jeopardy and Initial Plan of removal. QAPI meetings are held on a monthly basis and all allegations of physical aggression by Resident #1, incidents, and accidents will be reviewed during the QAPI meeting. This will be an ongoing process. POR monitoring . An observation on 07/16/23 at 11:00 AM revealed Resident #1 in a 1-to-1 with a CNA B in his room. An observation on 07/16/23 at 11:45 AM revealed Resident #1 in a 1-to-1 with a CNA B in his room. An observation on 07/16/23 at 12:30 PM revealed Resident #1 in a 1-to-1 with a CNA B in his room. An interview on 07/17/23 at 11:00 AM revealed LVN B stated she trained on Abuse & Neglect on 07/16/23. LVN B know the signs of abuse who to report to, and make sure Residents are safe. LVN B gave five types of abuse identified and one example of neglect. An interview on 07/17/23 at 11:13 AM revealed the Housekeeping Supervisor stated he know the signs abuse to the Administrator if suspected. The Housekeeping Supervisor stated abuse and neglect training are held weekly and he gave an example of neglect. An interview on -7/17/23 at 11:22 AM revealed CNA C received the training to report to Administrator if abuse is suspected. CNA C gave examples of abuse. An observation on 07/17/23 at 1:56 PM revealed Resident #1 in a 1-to-1 with a CNA B in his room An interview on 07/17/23 at 1:58 PM revealed LVN A was called by phone on 07/16/23 to complete training on incident documentation on abuse. LVN A know to report to the Administrator and gave examples of abuse. An interview on 07/17/23 at 2:07 PM revealed The Receptionist was trained on abuse and neglect. The Receptionist know to report any suspected abuse to the Administrator and DON. Record review of the medical records safe surveys were conducted on 07/17/23. In addition, psych services were consulted according to the medical records. On 07/16/23 The Administrator and interim DON was informed the IJ was removed 07/16/23 at 4:36 PM. However, the facility remained out of compliance at actual harm that is not immediate and a scope of a pattern due to the facility's need to monitor the evaluate the effectiveness of their plan of removal.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure the resident was free from abuse for 4 (Residents #2, #3, #4, and #5) of 5 residents reviewed for abuse. The facility failed to ensure Resident #2, #3, #4, and #5 were protected from verbal abuse including verbally aggressive behavior, such as screaming, cursing, bossing around/demanding, insulting to race or ethnic group and intimidating from Resident #1; and sexually lewd behavior and questions; including urination in cups at breakfast from Resident #6. As a result of the facility's failures Residents #2, #3, #4, and #5 suffered continual negative psychosocial outcomes including crying, fear and anxiety, feelings of hopelessness, and withdrawal from former social patterns. An IJ was identified on 03/11/23. The IJ template was provided to the facility on [DATE] at 6:45 pm. While the IJ was removed on 03/13/23 at 4:45 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure caused actual harm to 4 residents and placed all residents in the facility at risk for severe negative psychosocial outcomes which could prevent them from achieving their highest practicable physical, mental, and psychosocial well-being. Findings included: Abuse neglect and exploitation policy Record review of the facility abuse policy, dated 2/1/17, revised 1/1/23; right to be free from any type of abuse . Residents will not be subjected to abuse by anyone including other residents This includes physical, verbal, sexual (including indecent exposure), physical/chemical restraint Record review of Resident #1's undated face sheet revealed a [AGE] year-old male admitted to the facility 10/23/21 with diagnoses including: epilepsy (seizures), cerebral infarction (stroke), hemiplegia (partial paralysis), insomnia, depression, repeated falls, mood disorder, and anxiety. Record review of Resident #1's quarterly MDS , dated 12/09/22 revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, and other behavioral symptoms not directed toward others; this indicated that these behaviors were not present. Record review of Resident #1's undated care plan revealed: he has a history of high-risk heterosexual behaviors, makes sexual advances towards female staff members and grabs their private parts and touches them inappropriately. Intervention included monitoring every shift and redirecting. It further revealed that Resident #1 has a potential to be physically aggressive, he assaulted his roommate 04/13/21. Record review of Resident #1's progress notes, printed 03/13/23 revealed: 03/09/23 9:23 pm behavior note: Resident had several issues today where he hit this nurse and other staff . hit this nurse four times 10/28/22 8:18 am nurse note: Resident in hall way and called another female resident a bitch 08/01/22 12:47 pm nurse note: resident and another got in altercation and were hitting each other outside in smoking area, 07/13/22 6:30 am nurse note: resident angry called nurse a bitch and demanded she come to his room now, 07/12/22 1:09 pm nurse note: housekeeper saw Resident #1 in another resident room and asked him to leave and he started hitting her with a wash cloth and refused to stop when asked 07/10/22 10:15 am nurse note: Resident #1 pointing at vagina of staff stating I want that pussy and I'm watching your ass , 07/03/22 1:40 am behavior note: Resident #1 tried to reach down CNA top, tried to kiss her while she changed his brief, This is a frequent behavior from resident 05/26/22 11:45 am nurse note: resident in dining room blaring music, said fuck you when nurse asked him to lower volume, only lowered it after several requests, record review of facility incident list printed 03/13/23 showed no incident report on this date 05/26/22 8:20 am behavior note: wanted to smoke, tried to hit staff with wheelchair, told female resident to shut her mouth and called her a fat bitch, note states this is not the first time he behaved like this 4/13/21 Note Text: CNA reported to this nurse that this resident bumped into his roommate's wheelchair and hit resident with his fist. Both residents became physically aggressive towards each other. Resident denies physical altercation, but roommate states resident punched him after moving his wheelchair off of his leg, roommate states he hit resident back after he was hit, residents separated at this time resident moved to another room, Dr. notified, and family member notified, Will continue to monitor. Record review of the facility's incident list, printed on 03/13/23 revealed no incident reports no incident report for any of the progress notes reviewed above. Record review of the grievance log shows Resident #1 was in an altercation with another resident on 03/08/22. Record review of Resident #2's undated face sheet revealed a [AGE] year-old female originally admitted [DATE] with diagnoses including: type 2 diabetes, obesity, hepatitis C, dementia, bipolar disorder, and absence of left leg below the knee. Record review of Resident #2's most recent MDS date 01/30/23 revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record review of Resident #3's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including: type 2 diabetes, depression, dementia, and anxiety. Record review of Resident #3's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 14, which indicated the resident's cognition was intact. Record review of Resident #4's undated face sheet revealed that she was a [AGE] year-old female first admitted to the facility on [DATE], and most recently admitted on [DATE] with diagnoses including: Chronic post-traumatic stress disorder, major depressive disorder, obesity, hemiplegia and hemiparesis (paralysis) following cerebral infarction (stroke), and obesity. Record review of Resident #4's significant change MDS, dated [DATE], revealed: Section C for Brief Interview for Mental Status score revealed a score of 15, which indicated the resident's cognition was intact. Record review of Resident #5's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including: type 2 diabetes, anxiety, bipolar disorder, stroke causing partial paralysis, repeated falls, and Parkinson's. Record review of Resident #5's quarterly MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was intact. Record review of Resident #6's undated face sheet revealed that he was a [AGE] year-old male admitted [DATE] with diagnoses including traumatic brain injury, intermittent explosive disorder (unpredictable outbursts of anger), falls, dementia, anxiety, and depression. Record review of Resident #6's admission MDS dated [DATE] revealed: Section C for Brief Interview for Mental Status score revealed a score of 11, which indicated the resident's cognition was moderately impaired. Section E Behavior Symptom - presence and frequency revealed a 0 for physical behavioral symptoms directed toward others, verbal behavioral symptoms directed towards others, which indicated that the behavior did not occur and 1 for other behavioral symptoms not directed toward others; this indicated that these behaviors occurred 1 to 3 days. It further indicated on E0500 Impact on the resident was marked as 0 indicating behaviors did not impact the resident. On section E0600 Impact on Others was marked 0 indicating the behaviors did not impact other residents. Record review of Resident #6's undated care plan revealed The resident has a behavior problem related to inappropriate behaviors, cusses, talks inappropriate to staff, throws urine on floor, turns over bedside table when laying in bed; Resident will place himself on the floor to urinate and defecate on floor. Resident will inappropriately touch staff at times. Intervene as necessary to protect the rights and safety of others. Approach/Speak in a calm manner. Divert attention. Remove from situation and take to alternate location as needed. Minimize potential for the resident's disruptive behaviors inappropriate touching and urinating in cups by offering tasks which divert attention such as puzzles. Record review of Resident #6's progress notes, printed 3/11/23 revealed: Nurses note dated 3/6/23 9:46 pm resident removed his brief and threw it on the floor, also urinated in cup and threw it on the floor Nurses note dated 3/6/23 12:19 pm resident was banging on walls all morning long, continues cussing at staff Nurses note dated 3/4/23 12:39 pm resident yelling and cursing at staff Nurses note dated 3/3/23 1:19 pm resident yelling, banging on walls, cursing at staff Nurses note dated 3/3/23 3:37 am resident banging on walls Nurses note dated 3/2/23 10:49 am resident banging on walls, yelling, cursing staff, calling them bitch Nurses note dated 2/27/23 12:16 pm resident banging on walls and yelling Nurses note dated 2/26/23 11:05 am resident in sunroom with female resident and proceeded to pee in cup, educated, stated he did not care Nurses note dated 2/24/23 12:52 pm resident in dining room attempting to urinate in flower vase Nurses note dated 2/24/23 9:07 am resident banging on walls, bed pulled from wall, pouring urine on floor, roommate stated all night long pouring urine on floor, nurse went to tell him to stop banging on the walls he stated you bitch, you bitch I will punch you in your fucking face Nurses note dated 2/22/23 1:59 pm resident peeing in hallway Nurses note dated 2/10/23 12:11 pm yelling at housekeeper to suck his penis and calling her a bitch. Nurses note dated 2/8/23 Note Text: Resident was in the dining room for breakfast and he was trying to pee in a plastic cup like he did yesterday. He was taken out and taken to his room. Nurses note dated 2/7/23 Note Text: Resident was cursing the CNA this morning calling her a Bitch. Following her down the hallway. He then started yelling at another CNA and I informed him to stop. Resident went into the dining room and peed in a glass and poured it in the floor Resident #6 was not interviewable. In an interview and observation on 03/10/23 at 3:37 pm with Resident #4, she stated, Resident #1 is angry she was elected to the Resident Council and not him. She stated she felt harassed by him since she arrived in December. She stated he was also hostile towards her and she constantly feared encountering Resident #1. He also called her a fat cow, she told administrator two or three weeks ago, who told him not to do it anymore, but she said he harasses her and she tries to avoid him at all times. He plays his music so loud that it disrupts her sleep and rest and the music is vulgar. He cranks it in the dining room and common areas too. He was in a resident room and raised his hand to hit a little lady in a wheelchair who has severe dementia until Resident #4 intervened verbally. While surveyor was speaking with Resident #4, Resident #1 approached to try to listen in to the conversation and ended up kicking the back of Resident #4's wheelchair. Staff that were outside in the smoking area did not intervene when Resident #1 approached Surveyor and Resident #4 during interview. She stated Resident #1 continues to harass her, call her names and cause her distress. She stated it began when he made sexual advances towards her that she declined. Resident #4 said he has brought her to tears at times and that she has to walk on eggshells and try to avoid contact with Resident #1. When Resident #4 was describing the interactions with Resident #1 she appeared distressed and her eyes watered. At times her voice trembled as she recounted specific details. She stated that her room was directly across the hall from his room, and he blares vulgar music in common areas and in his room (which disrupts her). Resident #4 stated she told the ADM about the inappropriate advances and him calling her names and nothing changed. She also stated she was tired of Resident #6 being disruptive, which included him urinating on her chair in the dining room, urinating in cups in the dining room, and constant banging on walls and screaming and cursing. In an interview and observation on 03/13/23 at 6:43 pm with Resident #4, she stated that she liked her roommate and that she was upset because Resident #1 was across the hall, but it was very hard that her tormentor is across the hall because it was a reminder of my abuse and the only time I feel 100% safe is when he is in his bed. She stated she felt safe when he was in bed because he was partially paralyzed and not able to get out of bed without staff assistance While being interviewed outside in the smoking area, Resident #1 was outside with one aide watching the 7 residents outside; as Resident #4 was speaking with surveyor, Resident #1 wheeled over to within 2 feet of Resident #4 and no staff intervened. Resident #4 stated that if she made an allegation of abuse that she would be moved from her room, which greatly upset Resident #4 because she stated she helps her roommate and cares for her. In an interview and observation on 03/10/23 at 3:37 pm with Resident #5 stated Resident #1 blares loud music and he feels bullied by Resident #1 and 2 other residents also bullied him, all of whom hang out. One of the reasons he resigned from the office on the Resident Council to which he was elected after less than 1 week is intimidation by Resident #1. He stated that he does not attend social events anymore due to fear of running across Resident #1. He stated he would enjoy these activities if Resident #1 were not present. Resident #5 stated that he is disgusted by the behavior of Resident #6 and that he doesn't belong at the facility with all of his sexually lewd talk and inappropriate behaviors such as urinating in the dining room. During the interview with Resident #5 his voice trembled and his hands started to shake when he described encounters with Resident #1 and his ongoing fear of being bullied by Resident #1 and the other 2 residents that bullied him. In an interview and observation on 03/10/23 at 3:37 pm with Resident # 3 he stated that Resident #1 threw a bottle of hot sauce on his face in the dining room in front of everyone; he stated a staff member even took pictures, but the staff member was no longer here. He stated this occurred a few months ago, possibly December or January. He stated that Resident #6 was asking sexually inappropriate questions about Resident #3's grandchildren. He stated Resident #6 makes sexually inappropriate comments on a daily basis. He further stated that Resident #6's inappropriate behavior was ignored by staff. When he was describing the sexually inappropriate speech and behavior of Resident #6, he lowered his voice to almost a whisper. When he discussed Resident #1 throwing the bottle of hot sauce on him and constant blaring of inappropriate music his voice became elevated and his face turned red. He reiterated that Resident #1 disrupted the calm environment. On 03/11/23 at 12:00 pm during an interview with Interim DON the results of the safe surveys were reviewed and an additional victim of verbal abuse, Resident #2 was identified as being fearful of Resident #1. In an interview and observation on 03/11/23 at 3:00 pm with Resident #2 she stated that Resident #1 has on 5 or 6 occasions called Resident #2 names such as 1 legged bitch and fat slob. This verbal abuse started about a year ago, and she stated she has told the prior administrator, the current interim administrator, and the interim director of nurses and all said they would talk to him. She won't cry in front of him but goes to her room and sobs uncontrollably. This has caused her to change directions any time she sees him, avoid activities when he is present and causes her ongoing anxiety. She cried after each event. She also witnessed him and another resident almost come to blows (engage in physical aggression). When she was being interviewed, Resident #2 appeared tearful and agitated. She was emotional as she spoke. In an interview with Resident #1 on 03/11/23 at 9:25 am he stated that Resident #4 doesn't do her job as an elected official on the Resident Council like he did when he [NAME] the position; she hasn't been here 6 months and he has been here over 2 years. He complained the whole cabinet was appointed by her and all of them are [NAME] (all positions are elected per DON). He stated she doesn't care about Black residents. When he was on the council he got up and did rounds on all of the residents in the facility. He stated, I admit, I called her a pig, one time. He stated she doesn't like Black people, but he doesn't know if it just him. He also admitted throwing a bottle of hot sauce at another resident. In an interview on 03/09/23 at 2:00 pm with the DON and ADM, the Adm stated that Resident #1 called Resident #4 a fat pig. He stated he spoke to Resident #1 and told him he could not talk to people like that and the resident apologized and stated he would not do it again. In an interview on 03/10/23 at 8:30 am with the DON and ADM, the DON stated that the three residents who were the victims of abuse all had psychological diagnoses and asked where does Resident #1's rights stop; DON stated that is how he was raised . The ADM stated that Resident #5 was a music teacher and is just sensitive. He further stated he did not get involved with petty disputes between residents. They both denied knowledge of Resident #1 throwing a bottle of hot sauce at Resident #3, which caused it to shatter on his beard. They stated Resident #6 had these behaviors, such as sexually inappropriate comments and banging on the walls all nights, and urinating in public places. DON stated he apologized when she spoke to him, but then resumed the behaviors; she did stated that Resident #6 knew what he was doing and continued the behaviors. On 03/11/23 at 6:45 pm the Interim DON and Interim Administrator were informed that an Immediate Jeopardy (IJ) for abuse was identified and were provided the Immediate Jeopardy template. On 03/13/23 at 4:45 pm the following plan of removal was accepted: Impact Statement F600 Abuse The resident has the right to be free from abuse, neglect misappropriation of resident property as defined in this subpart. This includes but is not limited to freedom from corporal punishment involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. Identify residents who could be affected All residents who came into contact with Residents #1 and #6 have the potential to be affected by this alleged deficient practice Problem F600- The facility failed to prevent ongoing verbally aggressive behaviors, such as screaming, cursing, bossing around/demanding, insulting race or ethnic group, intimidating, sexually lewd behavior and questions; including urinating in cups at breakfast by 2 residents resulting in 4 residents reporting secluding in rooms and/or avoiding activities previously enjoyed. Action Taken Resident #1 was placed on 1:1 on 3/10/23 and it will be ongoing until residents exhibit improved behaviors or alternate placement is arranged; the Interim Direct of Nurse will ensure the resident remains on 1:1. Beginning 3/10/23 at 5pm Staff members will be assigned and notified of assignment to include always keeping resident within eyesight. The interim administrator will oversee actions taken. Resident #6 was placed on 1:1 on 3/10/23 Resident will remain 1:1 until behaviors are improved or alternate placement is arranged; the Interim Direct of Nurse will ensure the resident remains on 1:1. Beginning 3/10/23 at 5pm Staff members will be assigned and notified of assignment to include always keeping resident within eyesight. The interim administrator will oversee actions taken. Psych services were consulted on 3/11/23 to evaluate both Resident #1 and Resident #6 to determine a course of treatment to assist with alleged inappropriate behaviors. Psych services will provide counseling on 3/12/23. Psych services will be care planned on 3/12/23 by the Regional Clinical Reimbursement Coordinator. Verified by Corporate Clinical Reimbursement Specialist. Psych services were consulted on 3/11/23 to evaluate Residents #2, #3, #4, and #5 to assist with any alleged psychosocial distress from behaviors by Residents #1 and #6. Psych services will provide counseling on 3/12/23. Psych services will be care planned on 3/12/23 by the Regional Clinical Reimbursement Coordinator. Verified by Corporate Clinical Reimbursement Specialist. Safe Surveys were conducted by administrative nurses on 3/11/23 with all alert and oriented residents to determine if there were any residents who did not feel safe in the facility. Verification of completion was done by the Interim Administrator. Two residents reported that they did not feel safe, the individuals that they are reportedly fearful of are on 1:1 observation and have been evaluated by psych services and will be seen at least weekly for 4 weeks. Regional Director of Clinical Operations educated Interim administrator and Interim Director of Nursing on reporting of abuse and neglect allegations on 3/11/23. The Interim Director of Nursing and/or designee began educating all staff on the facility's Abuse and Neglect policy on 3/11/23. All staff will be educated prior to their next assigned shift. Training will continue until all staff has been educated. This training will be part of any new hire orientation on the next schedule orientation 3/14/23. The Interim Director of Nursing and/or designee began educating nurses on when to complete an Incident Report on 3/11/23. All nurses will be educated prior to their next assigned shift. Training will continue until all nurses have been educated. This training will be part of any new hire orientation for nurses. This training will be part of any new hire orientation on the next schedule orientation 3/14/23. Involvement of Medical Director and Quality Assurance Ad HOC QA meeting held with the medical director on 03/11/23 at 7:38 pm to review all aspects of Immediate Jeopardy and Initial Plan of removal. QAPI meetings are held on a monthly basis and all allegations, incidents, and accidents will be reviewed during the QAPI meeting. This will be an ongoing process. POR monitoring . An observation on 03/12/23 at 11:15 am revealed Resident #1 at the facility entrance sitting in a wheelchair being assisted by a cna in a 1 to 1 with the resident. An observation on 03/12/23 at 11:20 am revealed Resident #6 in the sunroom sitting in a wheelchair playing a board game assisted by a cna in a 1 to 1 with the resident. An observation on 03/12/23 at 11:45 am revealed Resident #1 in a 1 to 1 with a CNA in his room. An observation on 03/12/23 at 1:00 pm revealed Resident #6 in the sunroom sitting in a wheelchair playing a board game assisted by a cna in a 1 to 1 with the resident. An observation on 03/12/23 at 1:10 pm revealed Resident #1 in a 1 to 1 with a CNA in his room. An observation on 03/13/23 at 6:00 pm revealed Resident #6 was outdoors with a CNA taking a walk one on one. An observation on 03/13/23 at 6:15 pm revealed Resident #1 was observed with CNA one-on-one walking down the hall An interview on 03/13/23 at 6:32 pm revealed that CMA A was able to answer questions regarding abuse, reporting and resident on resident abuse; stated in-service today on abuse. An interview on 03/13/23 at 6:36 pm revealed LVN B was able to answer questions related to abuse, reporting, verbal abuse, and resident abusing other residents and stated she was in-serviced this weekend. Record review of the medical records safe surveys were conducted on 03/11/23. In addition, psyc services were consulted according to the medical records. Based on observation, interview and record review the plan of removal was implemented and the IJ was removed on 03/13/23 at 4:45 pm, the facility remained out of compliance at a scope of pattern and a severity level of actual harm to resident health or safety due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.