**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility failed to keep six residents (#6, #3, #5, #7, #10 and #11) free from resident to resident physical abuse of nine residents reviewed out of 13 sample residents. The facility failed to ensure there was an effective plan to monitor, or provide increased oversight and effective interventions to protect residents from Resident #6's behavior. Resident #6 physically assaulted at least three residents, between 3/19/23 and 6/11/23. Four additional residents complained of Resident #6's behavior in the facility's abuse investigations. This included Resident #3 who told a staff member during an interview that he had been hit by Resident #6. There was no further investigation of this allegation. The residents involved in the allegations reported pain, fear of Resident #6 hitting them again, feelings of being attacked and frustration with Resident #6's behavior. There was no plan to provide supervision or monitoring of Resident #6's behaviors, except after the third known altercation when the facility implemented monitoring in the smoking area. Physical Altercation 3/19/23, Resident #6 struck Resident #5 causing pain and fear Record review and interviews revealed Resident #6 struck Resident #5 on the arm four times on 3/19/23. The incident was witnessed by staff and residents. Resident #5 was interviewed and said Resident #6 hit her in the arm with a closed fist and with her knuckles. She said it was painful. Resident #5 said she tried to stay away from Resident #6, and she was fearful Resident #6 would hit her again. Review of the facility investigation revealed Resident #5 said on 3/19/23, that she felt Resident #6 would hit her again and she, worries for her safety. Eight staff members interviewed during the facility investigation reported the resident was mean, aggressive, rough or disrespectful to staff. This included being punched and scratched by Resident #6. No plan for increased supervision or monitoring was developed for Resident #6. Physical altercation 5/8/23, Resident #6 struck Resident #7 Record review and interviews revealed Resident #6 struck Resident #7 in the hallway of the facility on 5/8/23 at 6:10 p.m. Interviews revealed Resident #6 and Resident #7 were in the front lobby. Resident #6 and Resident #7 had words, Resident #6 flipped Resident #7 off. Resident #7 headed away down the hall, but Resident #6 followed her down the hall to the nurses station where Resident #6 slapped Resident #7. Resident #7 said she felt attacked. Resident #7 said she was fine, but hoped it would not happen again. Her interview on 5/9/23 in the facility investigation documented she did not feel safe in the facility. She said, not until you know people, it is not safe to be around them and people feel free to hit people around here. No plan for increased supervision or monitoring was documented for Resident #6. Physical altercation 6/11/23, Resident #6 struck Resident #7 again and Resident #7 struck Resident #6 in response Record review and interviews revealed residents and staff had witnessed a physical altercation between Resident #6 and Resident #7 on 6/11/23. Resident #6 was observed hitting Resident #7 multiple times and yelling at her in the smoking area. Resident #7 turned and swung back at Resident #6, slapping her in the face. A red mark was left on Resident #6's left cheek. Staff attempted to escort Resident #6 from the area, but she continued to scream and hit the staff. Resident #7 was not interviewed until three days later on 6/14/23. She said she was concerned that Resident #6 was going to hit a resident who could not defend themselves. Furthermore, the facility's interviews with staff and residents on 6/11/23, documented multiple residents had stated Resident #6 shakes her fists at people, she was physically aggressive and threatening to other residents and two residents said she had hit them previously. There was no follow up by the facility to further investigate the information relayed in interviews to ensure the safety of residents in the facility. Additionally, the facility failed to: -Ensure Resident #11 was free from physical abuse from Resident #10; and, -Ensure Resident #10 was free from verbal abuse from Resident #11. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation, Reporting and Investigating policy, revised September 2022, was received from the nursing home administrator (NHA) on 6/27/3 at 1:44 p.m. It documented in pertinent part, If abuse, neglect, exploitation or misappropriation is suspected, the suspicion must be reported to the administrator immediately and to other officials according to state law. All allegations are thoroughly investigated. The administrator is responsible for determining what actions are needed for protection of the residents. II. Substantiated physical abuse, 3/19/23, Resident #6 struck Resident #5 A. Facility investigation The abuse investigation dated 3/19/23 was reviewed on 6/26/23. The investigation documented on 3/19/23 at 10:00 a.m., Resident #6 hit Resident #5. Staff and residents witnessed the abuse and the physical abuse was substantiated. A typed document from a staff member, undated, documented she was taking Resident #6 outside to smoke. The staff member asked the resident if she had her cigarettes. Resident #6 gave the staff member a derogatory gesture with her finger. Resident #5 was seated outside. Resident #5 told Resident #6 to be nice. Resident #6 then went over to Resident #5 and began punching her in the arm. A second typed document dated 3/19/23 at 9:55 a.m. documented Resident #5 had gone down to the therapy gym and reported that Resident #6 had hit her in the arm four times. It documented the residents were told to stay away from each other. A document dated 3/19/23 at 10:00 a.m., written by a staff member and signed by Resident #5, documented Resident #5 was seated outside. Resident #6 was being combative with the nurse. Resident #5 told Resident #6 to be nice. Resident #6 then went over to Resident #5 and struck her four times. Resident #5 said she was afraid Resident #6 would strike her again and worried about her safety. The facility reported to the State Agency as Resident #5 was worried about her safety if she was around the assailant. An undated, handwritten note from a resident, who was a witness, documented Resident #6 had socked Resident #5. The note documented Resident #5 told Resident #6 not to hit her and Resident #6 flipped her off (using her middle finger in an offensive way). Residents and staff were not interviewed until the next day on 3/20/23. A resident interview documented Resident #6 cursed at the staff and was verbally rude. Resident #6 hits people if they get too close or if someone tells her no. The resident said she had not seen her hit anyone. The resident said people need to just leave her alone. Eight staff interviews on 3/20/23, documented Resident #6 was mean, aggressive and rough. The staff said Resident #6 scratched and pinched them. A social service note in the investigation file documented on 3/22/23 at 12:42 p.m., documented Resident #5 was not afraid as long as she could maintain her distance from Resident #6. The social worker told Resident #5 she should not have been in Resident #6's space. -However, according to witnesses and the investigation, Resident #5 was seated outside and Resident #6 approached Resident #5 and began hitting her. A follow up message by the State Agency on 4/19/23 asked the facility if Resident #5 was fearful of the assailant. The facility responded on 4/21/23 and said Resident #5 was worried about her safety if she was around the assailant. B. Resident #6 1. Resident status Resident #6, under age [AGE], was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO) diagnoses included vascular dementia, cerebral vascular accident (stroke) with frontal lobe executive function deficit (brain loses ability to control thoughts, emotions and behavior), aphasia (loss of ability to understand or express speech) and pseudobulbar affect (involuntary laughing or crying). The 3/27/23 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status score (BIMS) with a score of three out of 15. She required limited one person assistance with bed mobility and transfers and extensive one person assistance with dressing, toileting and personal hygiene. She had physical and verbal aggression toward others, including hitting, scratching, threatening and screaming. The assessment documented her behavior significantly disrupted care and the living environment. 2. Record review The physical aggression care plan initiated 11/14/22 documented Resident #6 had a history of aggression per her medical power of attorney, raising her fists, slapping, biting, cursing, flipping her middle finger at you, growling, and slapping her hand against her forehead when she was frustrated. The goal was that she would not harm herself or others. Interventions included, administer medications per physician orders, initiated 11/14/22, allow her time to verbalize dissatisfaction initiated 3/20/23, allow resident to calm down and re approach in a few minutes, and assess her needs initiated 3/20/23, call her MPOA (medical power of attorney) initiated 3/20/23. Resident #6 will need to be a supervised smoker due to exhibiting aggressive behavior towards others while in the smoking area. She has issues with impulse control and strikes out when she is angry. Having her as a supervised smoker will allow staff to be close by if or when she gets angry and staff will be able to intervene quicker, initiated 6/12/23. Inform Resident #6 that inappropriate behavior is not accepted. If she becomes frustrated with redirection, staff is to back away, allow her to calm down and re-approach when she is calm, initiated 3/20/23. Medication review by MD (medical doctor), psychiatrist and pharmacist routinely or PRN (as needed), psychiatric evaluation as needed, initiated 5/9/23. Monitor her for triggers to aggressive behavior, initiated 3/20/23, offer one to one activity or social services for support and companionship initiated 5/9/23, provide positive feedback for appropriate behavior, initiated 11/14/23. A second physical aggression care plan, initiated 3/20/23, documented Resident #6 has the potential to be physically aggressive related to poor impulse control and past history of trauma and neglect. The goal was that Resident #6 will not harm herself or others, interventions included, communication: provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of source of agitation, assist to set goals for more pleasant behavior, encouraging seeking out of staff members when agitated. Triggers for physical aggression include: staff asking for her to give up food and drink (she remains nothing by mouth, and is at risk of choking), when she is touched or when others brush by her, when she is asked to wait when wanting something and when frustrated. Resident's behaviors are de-escalated by giving her space, explaining to her in detail and in a manner she can understand as to why she cannot have food and drink, allowing the resident to make choices and not reaching for her or the item she is holding. Psychiatric/Psychogeriatric consult as indicated/as she allows. Will be sending referrals for the resident to attend day activities through a day program. When she becomes agitated intervene before agitation escalates; Guide her away from source of distress (if she allows); Engage calmly in conversation; If response is aggressive towards staff, staff are to walk calmly away and approach later. The resident had a supervised smoking care plan, initiated 10/14/22. It documented encourage resident not to go smoke with cold temperatures below 20 degrees (Fahrenheit), notify charge nurse immediately if it is suspected resident has violated facility smoking policy, observe clothing and skin for signs of cigarette burns, smoking assessment quarterly and as needed, smoking materials are to be kept by staff, educate resident and family regarding smoking policy. -While the care plan had many interventions that could help the staff with caring for her, it did not include a plan to supervise or monitor Resident #6 to protect the other residents with her known aggressive behavior. The other residents in the facility did not know her triggers, how to de-escalate her, assess her needs or calm her down. The other residents could not guide her away or tell her when her behavior was not appropriate. The interventions did not help the other residents if Resident #6 became aggressive. The facility placed on supervised smoking three months later in June 2023 due to her behavior in the smoking area, but this did not protect residents at any other time in or around the facility. There were no interventions aimed at the protection of other residents. Resident #6 continued to physically abuse additional residents (see below). The medication administration record (MAR) and treatment administration record (TAR) for June 2023 were reviewed. The only behavior tracking on the MAR and TAR was for signs of depression, as the resident was on an antidepressant. There was no tracking of her physical aggression or other behaviors. An SBAR (situation, background, assessment, recommendation), dated 3/19/23, documented the Resident #6 had been physically aggressive. It documented that it was unknown if this had occurred before. C. Resident #5 1. Resident status Resident #5, under age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the June 2023 CPO diagnoses included traumatic brain injury and major depression. The 5/6/23 MDS assessment revealed the resident was cognitively intact with a brief interview for mental status score (BIMS) with a score of 15 of 15. She required supervision with bed mobility, transfers, toileting and personal hygiene. She required limited one person assistance with dressing. The assessment documented she had no behaviors. 2. Resident interview Resident #5 was interviewed on 6/27/23 at 1:11 p.m. She said Resident #6 hit her in the arm with a closed fist and with her knuckles. She said her arm was painful for a while. Resident #5 said she had tried to stay away from Resident #6 and she was fearful Resident #6 would hit her again. 3. Record review An SBAR dated 3/19/23 documented Resident #5 had no injury and no pain. The physician was notified at 3:00 p.m. -It did not document what time the assessment occurred. A pain assessment dated [DATE] at 11:37 p.m. (more than two hours after the altercation) documented the resident had pain at a level of 1 (out of 10, with 10 being the worst pain on the scale). The assessment documented Tylenol and rest made the pain better. -According to the resident interview (see above), she experienced pain for a while and continued to have fear. III. Substantiated physical abuse 5/8/23, Resident #6 struck Resident #7 A. Facility investigation The investigation revealed on 5/8/23 at around 6:10 p.m. Resident #6 was holding a cigarette in the front lobby. Resident #7 told Resident #6 not to light the cigarette in the facility. Resident #6 flipped Resident #7 off. Resident #7 left the lobby and headed down the hall to the nurses station. Resident #6 followed her. According to a witness, Resident #6 followed her down the hall to the nurses station where Resident #6 hit Resident #7 in the right arm and a staff member was there. Resident #7 said she felt attacked. Resident #7 said she was fine, but hoped it would not happen again. Resident #7's interview on 5/9/23 in the facility investigation file documented she did not feel safe in the facility. She said, not until you know people, it is not safe to be around them, and people feel free to hit people around here. At some point, an undated note by the social worker documented on the resident's statement that she felt safe. The facility substantiated the abuse. A nurse note investigation documented Resident #7's left arm was assessed and there was no injury. An SBAR dated 5/8/23 documented it was unknown if this happened before, the physician for Resident #7 was notified at 11:55 p.m. and said to monitor for safety. There were no injuries to her left harm. -However, the physician was notified five hours after the altercation, a pain evaluation was not indicated and the left arm had no injuries, even though she was hit on the right arm. In the investigation file, an email to the nursing home administrator (NHA) on 5/8/23 at 7:43 p.m. documented the event, both residents have hashed it out, but we are keeping them in line of sight to ensure safety. -However, it was unclear from the care plan, investigation or resident's electronic medical records (EMR) how long the residents were kept in line of sight. Resident and staff interviews the next day on 5/9/23 documented no further information except for one resident who said he had witnessed Resident #6 flipping off Resident #7. An IDT (interdisciplinary note) note dated 5/9/23 at 10:13 a.m. documented Resident #7 had increased aggression. Resident #7 had recently broken up with a love interest and that may be contributing to her aggression. The plan was to offer her some one-on-one activities or social service visits and request a psychological evaluation. Social services would provide support as needed. -Despite the facility's documented knowledge of the resident's increased aggression, there were no new interventions to keep other residents safe. No monitoring or supervision for the increased aggression. The care plan documented, medication review by physician, psychiatrists and pharmacist routinely or PRN, psychiatric evaluation as needed and offer one-to-one activity or social services for support and companionship initiated 5/9/23. -It remained unclear in the investigation file, the care plan and the EMR what the facility was doing to protect Resident #6, and other residents. Resident #6 had a known history of aggression, prior to admission according to the medical power of attorney as referenced in the care plan. She had two known altercations at the facility at this time and the social worker documented she had increased aggression. There was no monitoring or supervision of Resident #6 and the increased physical aggression. B. Resident #7 Resident #7, age [AGE], was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO) diagnoses included chronic pain and depression. The 4/30/23 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status score (BIMS) with a score of 12 of 15. She required supervision with bed mobility and transfers. Resident #7 required limited one person assistance with dressing, and extensive one person assistance with toileting and personal hygiene. The assessment documented she had no behaviors, but did show signs of depression and feeling down. IV. Substantiated physical abuse 6/11/23, Resident #6 struck Resident #7 again, Resident #7 struck Resident #6 in response A. Facility investigation The investigation file revealed residents and staff had witnessed a physical altercation between Resident #6 and Resident #7 on 6/11/23 in the smoking area. Resident #6 was observed hitting Resident #7 multiple times and yelling at her in the smoking area. Resident #7 turned and swung back at Resident #6, slapping her in the face. A red mark was left on Resident #6's left cheek. Staff attempted to escort Resident #6 from the area, but she continued to scream and hit the staff. Resident #7 was interviewed three days later on 6/14/23. She said Resident #6 was handing out cigarettes to other residents and asking them for cigarettes. Resident #7 told her she was not supposed to do that. Resident #6 flipped her off and began to curse at her. Resident #6 started to go toward Resident #7 and then Resident #6 punched Resident #7 in the right shoulder. Resident #7 said Resident #6 then came at her again. Resident #7 said she blocked her and slapped her. Resident #7 said she could hear the staff coming to help intervene. She said Resident #6 kept coming at her and she tried to back up in her wheelchair, but she was not that fast. She said, I did not feel like there was anywhere for me to go. She said staff did then intervene but Resident #6 began to hit them as well. Resident #7 said in her interview on 6/14/23 her shoulder was a bit sore but there were no marks. Resident #7 she was concerned that Resident #6 was going to hit a resident who could not defend themselves. A skin assessment on 6/11/23 documented Resident #6 had a red mark on her left cheek. An SBAR dated 6/11/23 for Resident #6 documented there was a physical altercation, the resident was physically aggressive, it was unknown if this had occurred before and a pain assessment was not applicable. A second pain assessment on 6/11/23 at 6:57 p.m. documented Resident #6 had no signs of pain. An SBAR dated 6/11/23 for Resident #7 documented it was unknown if this occurred before, the resident was in an altercation with another resident, witnessed by staff and the resident had no pain or injuries. A pain assessment dated [DATE] at 4:59 p.m. documented Resident #7 had pain at level 4 out of 10. The resident said she rarely had pain in the last five days. The resident received Tylenol. The nurse documented the resident had chronic back pain and not pain from the incident. An email from SSD to the NHA dated 6/15/23 at 6:01 p.m. documented she was unable to obtain any details on the altercation from Resident #6 due to her aphasia. Social services documented Resident #6 was going to be a supervised smoker due to her behavior and because she was asking others for cigarettes. The email documented the social services department would reach out to see if Resident #6 wanted to visit or if she would do group therapy. A staff member who witnessed the altercation on 6/11/23 documented another resident had come to get her due to two residents fighting outside. The staff member observed Resident #6 hitting Resident #7 multiple times and yelling. Resident #7 then turned and hit Resident #6 in the face. Resident #6 continued to try and go after Resident #7 even as the staff tried to remove her from the area. Resident #7 was observed screaming and hitting the nurse. The facility interviews in the investigation file for staff and residents were reviewed for the 6/11/23 altercation. The interviews were signed by the by the social service manager (SSM), for the altercation on 6/11/23, documented the following: Certified nurse aide (CNA) #4, in an undated interview, documented Resident #6 and Resident #7 had been in an altercation before. -The facility did not clarify or investigate if that was the known incident on 5/8/23 or a new incident. On 6/12/23, Resident #10 complained Resident #6 stood up and shook her fist at people. -There was no further investigation, or interview regarding whether Resident #10 was fearful. On 6/12/23, Resident #8 said Resident #6 shook her fist at people and mainly hit staff, but she would hit anyone. -There were no further interviews or investigation as to whether Resident #8 was fearful. On 6/12/23, Resident #13 said Resident #6 would stand up and shake her fists when she was angry. -There were no further interviews or investigation as to whether Resident #13 was fearful. On 6/12/23, Resident #5 said she had witnessed Resident #6 being physically aggressive and threatening to other residents and Resident #6 had hit her before. -There was no further investigation by the facility regarding when Resident #5 was hit or if the resident was referencing the known altercation on 3/19/23 (see above). On 6/12/23, Resident #3 said he had witnessed Resident #6 being physically aggressive and threatening to other residents. Resident #6 shook her fists at other residents. He said Resident #6 had hit him before. The resident said it did not hurt. -However, in an interview on 6/27/23, Resident #3 said that it did hurt (see below). -There was no follow up documented, no investigation of abuse or reporting to the State Agency. On 6/6/23 at 12:33 p.m. (during the survey) the social service director (SSD) documented Resident #6 was on supervised smoking due to her behaviors while smoking and staff would continue to help redirect her behaviors. The SSD documented Resident #6 had been responding better to redirection from social services. B. Resident #3 1. Resident status Resident #3, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the June 2023 CPO diagnoses included multiple sclerosis, seizures, pain, rheumatoid arthritis, scoliosis with cervical fusion, depression and anxiety. The 4/19/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 of 15. He required extensive two person assistance with bed mobility. He required extensive one person assistance with transfers, dressing, toileting and personal hygiene. Resident #3 had no behavior concerns. 2. Resident interview and observation Resident #3 was interviewed on 6/27/23 at 12:30 p.m. Resident #3 was sitting in his electric wheelchair in his room. His neck was flexed forward with his chin toward his chest. He said he had surgery on his spine a few years ago and he was unable to lift his head upright as a result. Resident #3 said he was familiar with Resident #6. He said Resident #6 had hit him, more than once, probably three times. He said he reported it to the social worker and nurses. He said when Resident #6 got angry, like when the staff did not give her what she wanted, she would flip them off and curse at them. He said for example, if they did not take her out to smoke. He said she would threaten other residents when she would shake her fist at them. Resident #3 said she hits hard. He said it hurt, especially the first time she did it. He did not recall the dates of the physical abuse. Resident #3 could not recall if there was bruising. He said he steered clear of her if she came near him. The resident said he was not fearful, but he was frustrated with her behavior and having to make sure he was not near her. Resident #3 said Resident #6 and Resident #7 have had fights more than once. V. Staff interviews The NHA, social service director (SSD), assistant director of nursing (ADON) and nurse consultant (NC) were interviewed on 6/26/23 at 2:45 p.m. regarding the last physical abuse altercation on 6/11/23. The NHA said the physical abuse on 6/11/23 between Resident #6 and Resident #7 was substantiated. She said Resident #6 hit Resident #7 in the smoking area. She said Resident #6's behaviors were always in the smoking area, so the facility had made her a supervised smoker. She said Resident #7 did hit Resident #6 back in the face and then Resident #6 hit the nurse as the staff attempted to separate them. The NHA and SSD said they did not know what the plan was to keep the other residents safe from Resident #6 or whether any increased supervision or monitoring had been provided previously. The NHA said the facility had made Resident #6 a supervised smoker due to the altercations. -However, the supervised smoking care plan was initiated on 10/14/22 so she was supposed to be supervised prior to the resident altercations. The SSD said the plan for Resident #6 after this altercation was she would need to be a supervised smoker due to her behavior in the smoking area. The SSD said Resident #6's behavior was many times around smoking but not always. The SSD clarified before this incident, Resident #6 would be given one cigarette at a time to smoke and her lighter. She said Resident #6 would give away her cigarettes. She said the staff take her out and monitor her. The SSD did not know why Resident #6 was not monitored in the smoking area after the first altercation on 3/19/23 and when she was supposed to be supervised smoking according to her plan of care. The SSD said after the second known altercation on 5/8/23, which was not in the smoking area, the plan was to offer anger management and group therapy classes to Resident #6. The SSD said she did not feel her behavior was aggression but her way of communicating. The NHA said she had not seen the interviews with the staff and other residents conducted as part of the 6/11/23 investigation. The NHA said she should have reviewed and investigated the staff and resident interviews. She said all interviews should be dated. The NHA and the SSD said they did not recall any investigations regarding Resident #3 and they did have one for Resident #5 from March 2023. -However, they were unable to say, based on the documented interview, whether Resident #5 was referring to the 3/19/23 altercation or another one. The NHA said she could not determine from the staff interview whether CNA #4 was referring to a known altercation between Resident #6 and Resident #7 or a new one. The NHA said the SSM had done the interviews. She said she would investigate the concerns in resident interviews for Residents #3, #5, #8, #10 and #13. The SSM was interviewed on 6/26/23 at 3:30 p.m. She said she had done the interviews with staff and residents on 6/11/23. She said she had been trained on interviewing. The SSM said she should have asked Resident #3 more information like the date of the physical abuse. She said she should have notified the NHA about the interview with Resident #3 and Resident #5. The SSM said she should have asked more questions and clarified with the residents their concerns for Resident #8, #10 and #13. She said she was distracted with multiple requests by the staff. She said in the future she would tell the staff she was busy and focus on investigations. The SSM said there were no behaviors by Resident #7 in the smoking area, except for the two altercations with Resident #6. The SSM said resident behaviors were tracked on the resident's TAR or MAR and reviewed at the weekly psychotropic meeting. She said Resident #7 did not have behaviors and she would provide a copy of the behavior tracking for Resident #6. The NHA was interviewed on 6/27/23 at 10:45 a.m. She said she had spoken to CNA #4 regarding her interview 6/11/23 and clarification the comment Resident #6 and Resident #7 had been in a scuffle before. She said the CNA was referring to the known incident in May 2023. The NHA said the CNA was not asked any further clarifying questions at the time of the interview. She said the human resources (HR) staff had done the interview with CNA #4. The ADON and director of nursing (DON) were interviewed on 6/27/23 at 11:04 a.m. The ADON said on 6/11/23 Resident #6 and Resident #7 had an altercation. Resident #6 approached Resident #7 and tried to grab her cigarette. She said then Resident #7 slapped her. She said the resident had interactions in the smoking area before but she did not think it was physical. The DON said the plan to keep residents safe was to have Resident #6 supervised while smoking. He said he was not familiar with the investigations but he said Resident #3 and Resident #5 were not verbally or physically aggressive. He said the residents in the smoking area were capable of reporting altercations, therefore he did not think there were altercations that had not been investigated. The DON said behaviors were tracked on the resident's MAR or TAR. He reviewed the MAR and TAR for Resident #6. He said there was no tracking of her aggressive behaviors. He said there was nothing tracked about[TRUNCATED]