Based on observation, interview, and record review, the facility failed to ensure services were provided to residents with dementia to prevent resident-to-resident altercations for 2 of 3 residents reviewed for dementia. (Resident C, Resident D) This deficient practice resulted in Resident D experiencing a fall and sustaining an acute fracture of the right upper arm bone with moderate displacement and rotation. Finding includes: During an interview on 1/9/24 at 10:30 a.m., the Director of Nursing (DON) and Executive Director indicated a physical altercation occurred on 1/5/24 between Resident D and Resident C on a secured unit. The DON indicated a stop sign was positioned across the threshold to the bedroom of Resident C and usually was effective to prevent Resident D from entering the room. The DON indicated Resident D, the victim, entered the bedroom of Resident C by traveling underneath the stop sign. The DON indicated Resident C was pulling on the right upper arm of Resident D to get Resident D out of her room when a physical therapist walked by and told Resident C not to pull on the arm of Resident D. The DON indicated Resident C let go of Resident D and Resident D fell to the floor. The DON indicated Resident D was sent to the hospital and a right arm fracture was identified; however, surgery was not performed because Resident D was receiving hospice services. During an interview on 1/10/24 at 9:50 a.m., a family friend of Resident D indicated she was aware of the altercation between the two women. The resident was observed sleeping, at that time, and had her right arm folded up against her chest with no splint in place. The friend indicated it was unlike the resident to be so lethargic. She indicated the resident's daughters were flying in today to see their mother because she believed the fracture would cause a more rapid decline in her health and death would be soon. During an interview on 1/10/24 at 11:57 a.m., PT 1 indicated he was walking up towards the nurses station when he heard someone yelling, Don't! Stop it! He looked around and happened to be right outside of Resident C's room and saw her actively pulling Resident D onto the floor. She was pulling at her by her waist area which caused Resident D to fall between the bed and the front of the wheelchair. Resident C continued to yell at the patient while she was on the floor. He further indicated that he did know through communication with staff that Resident C had a tendency to wander and he knew to approach Resident C carefully because she can be foul-tempered. 1 On 1/9/24 at 11:30 a.m., Resident C's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, dementia with agitation, dementia with psychotic disturbance, dementia with mood disturbance, unspecified dementia with psychotic disturbance, psychotic disorder with delusions, mood disorder, pseudobulbar affect, unspecified dementia with behavioral disturbance, and cognitive communication deficit. The Annual Minimum Data Set (MDS) assessment, dated 8/25/23, indicated the resident was severely cognitively impaired and had Alzheimer's disease and psychotic disorder. The assessment indicated there were no physical behaviors during the assessment period. The most current care plan for agitation, dated 9/25/23, indicated Resident C exhibited aggressive behaviors when other residents entered her bedroom without permission and included the following interventions: -staff will do rounds on the unit to ensure all of the residents are in the correct rooms and beds to assist residents not becoming agitated when peers enter into the wrong room, -staff to check resident's room often to ensure peers are not wandering into her room, -a stop sign is to be placed on the resident doorway to prevent others from entering into her room, -the resident was moved to a room closer to the nursing station to increase supervision, and -the resident preferred her door to be closed at all times and this would deter peers from entering her room. The Quarterly MDS assessment, dated 11/18/23, indicated the resident was severely cognitively impaired, utilized a wheelchair for locomotion, and had Alzheimer's disease, dementia, and psychotic disorder. The assessment indicated there were no physical behaviors during the assessment period. Resident C's progress notes, dated from 6/30/23 through 1/3/24, indicated Resident C was the perpetrator in three resident-to-resident altercations. A nursing progress note, dated 1/3/24 at 9:37 a.m., indicated the stop sign did not effectively prevent an unknown resident from entering the room of Resident C without permission, a resident-to-resident verbal altercation occurred, and Resident C attempted to make physical contact with the arm of the unknown resident. The progress note did not include documentation to show new, effective interventions were implemented to prevent further resident-to-resident altercations. A nursing progress note, dated 1/5/24 at 3:59 p.m., indicated the stop sign did not effectively prevent Resident D from entering the room of Resident C without permission, Resident C perpetrated a resident-to-resident physical altercation with Resident D that resulted in Resident D falling to the floor and sustaining a right upper arm fracture with dislocation and rotation. The progress note did not include documentation to show new, effective interventions were implemented to prevent further resident-to-resident altercations. The progress notes and plans of care, dated between 1/5/24 and 1/7/24 at 4:27 p.m., did not include documentation to show new, effective interventions were implemented to prevent further resident-to-resident altercations. 2. On 1/9/24 at 11:25 a.m., Resident D was observed sleeping in her bed with her right arm folded up and over her chest. On 1/9/23 at 11:32 a.m., Resident D's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, displaced fracture of upper end of right humerus (bone in the upper arm), severe unspecified dementia, low back pain, unspecified pain, and cognitive communication deficit. A Significant Changed MDS assessment, dated 9/20/23, indicated severe cognitive impairment to make decisions regarding tasks of daily life, had wandering behaviors 1-3 days during the assessment period that significantly intruded on the privacy of others, and the resident had 1 fall with no injuries since the prior assessment. A Quarterly MDS assessment, dated 12/13/23, indicated Resident D experienced severe cognitive impairment to make decisions regarding tasks of daily life, utilized a wheelchair for locomotion, and had 1 fall since the prior assessment with no injury. A Facility Observation Detail List Report, dated 1/6/24 at 4:37 p.m., indicated the resident was transferred to the emergency room due to having a fracture of the head of the humerus. A Radiology Report, dated 1/6/24, indicated there was an acute fracture involving the neck of the right humerus with moderate displacement of greater than 1 cm (centimeter), with humeral head rotation. The boney structures appear osteopenia. On 1/10/24 at 2:45 p.m., the DON provided the facility policy, Fall Management, revised 8/2022, and indicated it was the policy currently being used. A review of the policy included, but was not limited to, it is the policy that residents residing within the facility receive adequate supervision. On 1/10/24 at 2:45 p.m., the DON provided the facility policy, Resident Rights, updated on 3/15/17, and indicated it was the policy currently being used. A review of the policy indicated, . Safe Environment . You have the right to a safe . environment . including but not limited to receiving treatment for daily living safely . This citation relates to Complaint IN00425646. 3.1-37(a)