**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, resident interview, and facility policy review the facility failed to protect residents from resident to resident altercations which included sexual gestures, physical touching, grabbing, and attempted hitting by Resident #51 for four of five residents reviewed for abuse (Resident #1, Resident #4, Resident #17, Resident #37), and also unidentified residents. The facility reported a census of 49 residents. Findings include: The admission Minimum Data Set (MDS) assessment for Resident #51 dated 11/12/21 revealed the resident scored 3 out of 15 on a Brief Interview for Mental Status (BIMS) exam, which indicated the resident had severely impaired cognition. Per this assessment, Resident #51 displayed delusions, other behavioral symptoms not directed towards others, and wandered which significantly intruded on the privacy or activities of others. The MDS for Resident #51 dated 5/4/22 documented the resident again scored 3 out of 15 on a BIMS exam. Per this assessment, the resident required limited assistance of one person to walk in their room and in the corridor, and had fluctuating behaviors of inattention and disorganized thinking. It had also been documented per the assessment that Resident #51 had delusions, displayed physical behaviors directed towards others, verbal behaviors directed towards others, and other behavioral symptoms not directed towards others. Diagnoses for Resident #51 included dementia with behavioral disturbance and hypertension. The Care Plan dated 5/17/22 documented, I have a behavior problem wandering, refusal of cares, physically aggressive, verbally aggressive, and inappropriate advances r/t (related to) Dementia with Behavioral disturbances. Interventions, all dated 5/17/22, included the following: a. Administer medications as ordered. Monitor/document for side effects and effectiveness. b. Anticipate and meet my needs. c. Assist in developing more appropriate methods of coping and interacting. Encourage me to express my feelings appropriately. d. Caregivers to provided opportunity for positive interaction/attention. Speak/stop/talk with me as passing by. e. If reasonable, discuss The resident's behavior. Explain/reinforce why behavior is inappropriate and/or unacceptable to the resident. f. 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. g. Praise any indication of The resident's progress/improvement in behavior. The Wandering Risk assessment dated [DATE] identified Resident #51 at moderate risk for wandering. The Incident Note dated 11/7/2021 at 11:30 PM documented, Resident had wandered into [Resident #1's] room and had been told to leave room by her. He would not until two staff members redirected him back to his room. He had only a brief and gripper socks on. The CNA (Certified Nursing Assistant) Note dated 11/8/2021 at 3:43 AM authored by Staff P, Certified Nursing Assistant (CNA) documented, Resident had wondered <sic> into female residents room. When found was sitting on bed with female resident in only a brief and was trying to touch female resident. Female resident had asked multiple times for him to leave her room and he didn't comply. (The resident mentioned in this note had been later identified by Staff P as Resident #1. The Nurses Note for Resident #1, dated 11/10/21 at 6:43 AM, stated the resident called staff to her room and asked if that man next door was in the dining area. The staff member informed her he was and the resident stated she was frightened of him and hardly slept the previous night because she worried he would come back into her room. The Nurses Note for Resident #2 dated 11/16/2021 at 7:49 PM documented, Resident complains that male resident across the hall continues to enter her room and not leave. Resident expresses concern that fellow resident has entered into the hall in his shorts and is afraid that he will enter her room dressed in only shorts. Resident states can you not just make him stay out of our rooms? He frightens us and we are not able to sleep from worrying about him coming in our rooms while we are sleeping. The CNA Note dated 11/17/2021 at 3:47 AM (in Resident #51's record) documented, Resident up wondering <sic> in room and outside room since 0200 (2:00 AM). Going in room [Room Number where Resident #2 resided] and resident scared of him going in in the middle of the night. Reported to nurse. Review of a Psychosocial Note for Resident #2 dated 11/24/2021 at 11:28 AM documented, in part, Nursing reviewed recent medication changes. Mild improvement with the increase in her Buspar; however, [Resident #2] voiced anxiety secondary to new male resident coming into her room and the room next to her. She denies being scared but states she does not like that he awakens her at night generally from the noise he is causing and she feels bad for the staff. She voiced that she plans to go visit family for Thanksgiving but is concerned what I will come back to. The [Hospital Name] note for Telemedicine, encounter date 12/7/21, revealed, in part, the following: a. He [Resident #51] was found wandering naked in the hallway the first night at the facility. He was awake most of the night .He slept after wandering into a female peers room just wearing underwear and gripper socks. He was told to leave the room by the peer, but would not leave until 2 staff members redirected him back to his room. He again wandered into a female residents room the next night and was found sitting on her bed in his brief, and was trying to touch her and would not leave despite her asking him to do so. b. The next day and the next night [Resident #51] again entered the room of a female peer. He was not easily redirected on one of these occasions. c. [Resident #51] went into female peers room during the night 11/17/21 who was afraid of him. He wandered all second shift that day, looking for a phone and a way out. d. [Resident #51] needed to be redirected from the rooms of 2 female residents 3 different times on 11/19/21 day shift. e. On 11/20, he was in another resident's room who is a fall risk trying to assist the resident and then he was trying to get in the med room and told a female resident they were getting married and she was terrified. On 11/22 night he was wandering the halls in his underwear trying to enter other rooms. f. On 11/30 pm he was wandering in other rooms in his underwear. g. On 12/4, he was again going in other rooms and putting himself on the floor .He was later on the floor naked with his hands on his penis in front of 2 female resident's rooms. The CNA Note dated 12/5/2021 at 3:01 PM documented, aide ask me to help her get him dress an off the floor. he was lying on floor naked and had his hands on his penis. in front of 2 female resident rooms. their doors was open. assist him in dressing assist to bed. The Behavior Note dated 12/14/2021 at 8:38 AM documented, This staff member was on my way to the [section of facility] charting room to file papers. At this time I witnessed [Resident Initials] standing in the hall between his room and 2 other female resident rooms with his pants and brief pulled down. Facility nurse was with him trying to help pull up his brief and take him to his room. The CNA note dated 12/14/21 at 8:12 PM documented, Resident would not stop trying to get into other residents rooms. Resident kept saying open the son of a [expletive] resident was hitting staff, punching, kicking, and biting. The Behavior Note dated 12/21/2021 at 9:00 AM documented, While making rounds Nurse noticed that resident was walking in another female's resident room without any clothing on. Female resident was upset stating, I'm sick and tired of this. This has been an ongoing situation, and something needs to be done about it! Nurse grabbed a blanket to wrap around the naked resident and redirected him back to his room. The Behavior Note authored by the Activities Director dated 12/28/21 at 3:05 PM documented, This staff was in the [NAME] Center to put a move on for resident's there. This staff observed resident [Resident #51] lifting up [Resident #4's] Leg. Referring to her as [Name Redacted]. Staff did move [Resident #4] to the counter area to have a snack. Staff just reminded resident [Resident #51] not to touch other's. [Resident #4] was moved several times so that they were not in the same area. This resident also put his hands on [Resident #37's].) wheelchair handles. He then took his right hand just inside her top. (Resident #37) grabbed his hand and shoved it away and stated he is evil. This staff removed [Resident #37] from that area. (Identities of residents involved had later been confirmed during interview with the Activities Director). The Nurses Note dated 12/28/2021 at 3:36 PM documented, Return call rec'd from ARNP (Advanced Registered Nurse Practitioner) office et spoke with [Name Redacted] who states message from [NP] states that she would need to see the frequency of behaviors before a PRN (as needed) would be given et suggested calling daughter [Name Redacted] to sit with resident. This RN (Registered Nurse) reiterated that resident had placed hand down a female resident's blouse et that had been grabbing another female resident's leg et (and) that this would be considered inappropriate sexual contact. [Name Redacted] states she will message ARNP back et that ARNP would likely phone facility. This RN passed information onto floor nurse, [Initials]. The CNA Note dated 12/28/2021 at 9:08 PM documented, Resident has been touching female residents inappropriately <sic>, they touched a female residents breast area, put his hand in their bra, female resident yanked his hand out of their. Resident has also been rubbing the legs near the crotch area and arms of a different female resident. Staff moved the female resident many times, he just followed. Resident has been trying to get into other residents rooms in his depend, resident grabbed a female residents hand and tried to hit them. Resident was kicking, biting, hitting staff. Review of documentation for a Facility Reported Incident for Resident #51 dated 12/28/21, not signed, documented, This nurse received a report the evening of 12/28/2021 that the resident had had an increase in behaviors and staff was finding it difficult to redirect him. Staff reported that resident was propelling himself in his walker and was looking for his wife. Resident was calling out, [Name Redacted] his wife's name. This resident then approached a female resident and put his hand down her shirt. Resident was approached by staff told that the behavior was inappropriate yet he continued to seek out his wife. He then approached another female resident who was in a wheelchair and began rubbing her leg. Resident was again asked to stop and told that behavior was inappropriate. Resident continued to seek out female residents but did not touch any other residents. This nurse was at the building from approximately 1700-1745 (5:00 PM-5:45 PM) and at that time the resident was sitting on his walker seat in the dining area away from other residents and was being monitored closely by staff. While this nurse was present this resident attempted to go into another resident room and was easily redirected back to his room. At the time this nurse left the facility resident was in his room. This nurse received a call later that evening from facility staff stating that resident had grabbed the wrist of a female resident and swung at her. Staff intervened and the female resident was not injured. The Behavior Note dated 12/29/2021 at 6:30 AM documented, This nurse received report from nursing staff that resident was being combative and had blocked himself in another resident's room and he was naked. Prior to blocking himself in a room he was combative with staff, striking them and scratching them. At this time staff has been unable to redirect resident. The Behavior Note for Resident #51 dated 12/29/2021 at 7:25 AM documented, This RN (Registered Nurse) went down to [Specific Part of facility) after being told resident was naked in a female resident's room et she was reporting being scared. This RN approached resident who was naked in female resident's bathroom. This RN attempted to redirect resident et discuss his need to exit her room et go into his room to use bathroom as well as the need to get dressed et not walk around facility naked. Resident was raising voice at this RN, stating that he would not leave the room like this. The [Hospital Name] note for Telemedicine, encounter date 1/4/22, revealed, He [Resident #51] has been taking his medications. His aggressive behaviors continued and escalated 12/29/21 with some new behaviors of trying to touch staff and female residents inappropriately. He was taken to the local ER (Emergency Room) on 12/29 with hopes of transfer to [Hospital], nut there were no beds available. Behaviors continued 12/30. He sleeps in the nude and always has, He was naked in a female resident's room [ROOM NUMBER]/30 night, and could not be redirected. He would not let go of the walker and it hit him in the face and he struck a staff member in the face. The Nurses Note dated 5/29/22 at 7:47 PM documented the Nurse heard female resident confined to bed yelling and entered room to find this resident in female residents room, and [staff] convinced resident to sit on seat of walker and rolled resident out of female resident's room. The Nurses Note dated 5/30/22 at 9:23 PM documented, Resident was found coming out of female resident [Initials Redacted] room and going into her neighbors [Initials Redacted] room. Resident was redirected to his room and nurse assisted resident with taking his shoes off and laying in his bed. Resident asked nurse to turn out the light so he could rest. The Nurses Note dated 5/31/22 at 8:56 PM documented, Resident opened door and entered female residents, [Initials Redacted], room. Resident [Initials Redacted] was very upset and stated that she is scared of him and that this is not fair. She should be able to lay down and sleep at night without being frightened that a man will enter her room. Resident was redirected and allowed nurse to escort him to his room and get him ready for bed. Once in bed resident told the nurse goodnight and asked that his light be turned off. The Nurses Note dated 5/31/2022 at 9:05 for Resident #25, who's initials matched those of the resident in the note dated 5/31/22 at 8:56 PM, documented, Male resident, [Initials matching Resident #51] entered resident's room while she was in bed. Resident was very upset and stated that she is scared of him and that this is not fair. She should be able to lay down and sleep at night without being frightened that a man will enter her room. Male resident was redirected and removed from resident's room. Resident calmed down some when nurse assured her that he would not be back in her room tonight and that nurse would watch over him for the remainder of this shift and make certain that he does not leave his room again. The Incident Report authored by Staff H, Licensed Practical Nurse (LPN) dated 6/16/22 at 7:28PM documented per the Incident Description, This nurse heard female resident yelling and went to see what was happening. Resident had female residents [later identified as Resident #17's] walker and when she tried to get her walker back he grabbed her by the front of her shirt and twisted pulling her to him. This nurse was able to get resident to let go of female resident and release her walker. Resident became very angry with nurse and started trying to bite and hit nurse. Review of the Witness Statement portion of the form documented Resident #19 had witnessed the incident, and the statement documented, He just come in and snatched her walker from her, and then he grabbed her by the shirt and I started yelling. Resident asked what they, all of us ladies, are supposed to do if he tries to hurt us. We are all really scared of him. He beats on you girls all the time. The Nurses Note for Resident #17 dated 6/16/2022 at 6:28 PM documented, This nurse heard female resident yelling and went to see what was happening. Male resident had female residents walker and when she tried to get her walker back he grabbed her by the front of her shirt and twisted pulling her to him. This nurse was able to get male resident to let go of female resident and release her walker. Resident was very angry with male resident and stated what would happen if I rared back and punched him as hard as I could? We should not have to put up with him behaving that way. On 7/7/22 at 3:22 PM, when queried if Resident #51 had been physically aggressive to staff and residents,Staff H, LPN, explained Resident #51 had been physically aggressive with one the week before he had been transferred. Per Staff H, he had taken [Resident #17's] walker, grabbed her by the shirt, and had yanked her up to him. Staff H reported there was no doubt if they had not gotten there faster he would have hit her. Staff H acknowledged there had been need to get the resident out of many female resident rooms at night. When queried if the resident walked, Staff H responded sort of, yeah, and said the resident could move quickly. When she [Resident #17] had tried to take her walker back, Resident #51 had grabbed her by the shirt, twisted her shirt pulling her to him, and the other resident [Resident #19] had been screaming. Per Staff H, that night the resident had been looking for his keys, had wanted his wife to bring his keys, and wanted to get out of the facility. Per Staff H, it was something different each time, and they knew that certain things triggered the resident. Staff H explained she knew residents were scared of Resident #51 because they would see him beat on the staff. On 7/12/22 at 12:21 PM, when queried about Resident #51's behaviors, the Social Worker explained mostly recently the resident's behaviors had been discussed because the resident had gone into a female resident room across the hall, both female residents had been spoken with and one had said they were afraid of Resident #51 because he kept coming in, and the other said they were ready to bop him. Per the Social Worker, the resident had been going in other people's rooms and did grab [Resident #17] by the collar and didn't hurt her. The Social Worker further explained Resident #51 had gone across the hall, and it sounded like he had been looking for a walker. Resident #17 had been outside of Resident #19's room, and from what Resident #17 told the Social Worker, Resident #51 continued to approach her, she said don't come in this room, and Resident #51 had kept coming towards her. Resident #19 had yelled for help and someone came down, and by that time Resident #51 had Resident #17's collar. The Social Worker explained she had spoken with Resident #17 the next day, and Resident #17 had been mad. Resident #19, who was in her chair, asked what would have happened if I would have kicked him? Per the Social Worker, Resident #19 could not get out of her chair, and it was scary for her. The Social Worker explained when Resident #51 had first come, he had been going into rooms around his room and had wandering behaviors, described by the Social Worker as kind of off and on. At times, the resident would get medication and be better and sleep a lot .When the resident's Seroquel (antipsychotic) medication had been adjusted the resident had experienced more and more behaviors. Per the Social Worker, discussion had occurred with the resident's family, staff, and departments head and it had been determined another placement was needed. When queried if the resident had displayed sexual behaviors, the Social Worker explained the only thing they had been aware of had been what was charted, described by the Social Worker as trying to put his hands down someone's shirt or grab. When queried about non-medical interventions that had been implemented for Resident #51, the Social Worker explained that when the resident had been in a specific part of the facility, stop signs had been put on doors or something outside the resident's room so he know where his room was located. The Social Worker also explained that the resident's family member frequently visited, and per the Social Worker it seemed like later in the day when those things had been happening. The Social Worker explained the resident liked ice cream and that was something that had been tried, the resident had been taken in to the bathroom, and Resident #51 liked to tinker with things, however the resident's attention span had been short and it was difficult to find things to engage the resident for longer periods of time. When queried about increased monitoring, the Social Worker explained she did not remember anything that was care planned, and the other thing done most recently was an alarm to the resident's door so if he went out it would ring like a doorbell. The Social Worker explained they believed when the resident had been in a different part of the facility this had been tried also, and when the resident opened their door a tab would be set off so they would go check on him. The Social Worker did not recall careplanning anything about increased checks for the resident, however stated this could have occurred and they did not recall. Per the Social Worker, the resident generally understood what had been said, had been somewhat hard of hearing, always did things his way, had moderate cognitive deficit, and could not follow cues really easily. On 7/12/22 at 12:42 PM, when queried about Resident #51's behaviors, Staff I, Certified Medication Aide (CMA) explained the resident hit, pinched, and cussed at staff. When queried about behaviors towards residents, Staff I explained she had never seen this but had heard. Staff I acknowledged the resident wandered, went into resident rooms, and was not always able to be redirected. When queried where they would look to know how to address behaviors, Staff I responded as a CMA the only thing she could see was in the nurses notes section in the POS, then she could read the notes other people had put in. When queried if CNAs could access the Care Plan, Staff I responded they could see it on their tablets. When queried if Resident #51 had been ambulatory, Staff I explained the resident did walk, and also acknowledged the resident had been cognitively impaired. On 7/12/22 at 3:07 PM, Staff J,CMA, had been queried about Resident #51, and explained he would do sexual things to some of the residents. Per Staff J, she thought it had been [Name Redacted], and the resident had his hands in her shirt. Staff J explained the resident had been in one part of the facility then moved to South Hall. Staff J explained the resident had been ambulatory and the ladies back (in the back part of the facility) in the corner had been afraid of him. Per Staff J, Resident #51 had been back in that corner and would go in and out of their rooms and they were scared. Staff J explained Resident #19 had been scared of him. When queried if Resident #51 had been able to be redirected, Staff J explained sometimes. Staff J acknowledged the resident wandered, and acknowledged the resident wandered around without clothing. Per Staff J, alarms had been put on his door so they knew when he came out. When queried if there had been enough staff to respond to it, Staff J explained not always and they would find the resident in others rooms, or they would turn their lights on, or would just holler out to get help. On 7/12/22 at 3:18 PM, Staff N, CNA, explained about two weeks before the resident left the facility she had been down the East Hall, had come out of the room to get supplies, and had heard someone screaming. Per Staff N, this had been Resident #19. Resident #51 had been sitting on her (Resident #19's) toilet and had bowel movement all over the floor, Staff N explained the resident had been crying and screaming. Per Staff N, other residents had been scared of Resident #51. Staff N further explained Resident #51 had been sexually inappropriate with other residents, so he was moved up front, and that may have helped for a little bit. Per Staff N, the resident should not have been at the facility as the facility was not the place for him, and per Staff N the facility could not handle him. On 7/12/22 at 3:44 PM, when queried about Resident #51, Staff O, CNA explained when the resident was first back (towards back of the facility) they had dealt with the resident. Staff O explained he had grabbed a resident's (later identified as Resident #37's) breast and had gone into the bra. Staff O explained she had reported it. Per Staff O, [Resident #51] would always go into Resident #1 and Resident #2's rooms. Per Staff O, Resident #51 had gone into Resident #31's room naked, and would also be very combative with staff. Staff O explained she did not think the facility was the place for him, and also explained the resident had been terrified of him. Per Staff O, the resident had wandered, and would wander into everybody's room. Per Staff O, she had witnessed the incident with Resident #37, and also with Resident #17. Staff O reported Resident #17 had wanted to hit the resident because she had been scared. Staff O further explained some kind of tape barrier had been put on Resident #1's and Resident #2's doors, but that did not help as Resident #51 had gotten under it. When queried about increased supervision for the resident, Staff O explained the resident got a fall mat once and a bed alarm, may have had checks, and did not have one to one supervision. On 7/13/22 at 8:00 AM, when queried if residents had come into her room, Resident #19 explained Resident #51 lived across the hall and down one. Per Resident #19, Resident #51 would come in and she would yell at him that this was not his room and he needed to leave. Per Resident #19, he did not, said he needed to pee, and went into the bathroom. Resident #19 further explained they had started yelling for nurses and had pushed the button too and it had been the middle of the night. When queried how this had made the resident feel, Resident #19 explained it had made them feel kind of frightened, and they didn't know what to expect. Per Resident #19, the were frightened and angry at the same time, and explained the question of what was he [Resident #51] going to do and why's he coming in here. Per Resident #19, Resident #51 used to try to go into another resident's room across the hall and whenever she would see the resident doing that, she would call a nurse aide as he had no business being in there. Per Resident #19, she felt Resident #19 didn't know where he was or what he was doing. When queried if she had ever seen Resident #51 push, pull, or grab others, Resident #19 acknowledged a nurse had been trying to keep the resident out of another resident's room and Resident #51 had kept hitting at their arm. Resident #19 denied the resident acting in that manner towards other residents, and stated she felt the resident should be in a place other than the facility because they could not watch [Resident #51] all the time. Per Resident #19, she had spoken with facility staff about how she felt, and further explained we spend big bucks to stay here and would like to feel safe. On 7/13/22 at 4:00 PM, when queried about Resident #51's behaviors, Staff P, CNA, explained the resident could be combative and sometimes really sweet. Per Staff P, the resident would wander the halls, would go in other resident rooms, and use other resident's bathroom. When queried about documentation she had written that Resident #51 had touched another resident, Staff P identified the resident as Resident #1. When queried where Resident #51 had been trying to touch the resident [Resident #1], Staff P explained Resident #1 had reported Resident #51 had been trying to touch her, and she had just saw him on the bed. When queried if the resident had been accepting of redirection, Staff P reported sometimes the resident would accept redirection, and that day he did. On 7/14/22 at 8:45 AM, the Activities Director explained Resident #51 would roam around on his wheeled walker. When queried about the events she had documented in the progress note on 12/28/21 at 3:05 PM, the Activities Director explained she thought they were either getting people or bringing people back from the activity, Resident #4 had been sitting, and Resident #51 had the resident's leg up. Per the Activities Director, you could just tell on Resident #4's face that the resident did not like that. The Activities Director explained Resident #51 had been moved, she had gone to get Resident #4 some pop, and when she went back Resident #51 had been over with Resident #37 and had his hand really close to the resident's breast. The Activities Director explained Resident #37 had told the resident to get out, and the resident's hand had been over the Resident #37's shirt really close to the resident's breast. Per the Activities Director, Resident #37 had told him to stop and the resident had been removed. On 7/14/22 at 1:36 PM, the Infection Preventionist explained they had been the facility's Director of Nursing (DON) until January or February of 2022. When queried if the resident had displayed any physical behaviors towards residents, the Infection Preventionist explained Resident #51 had touched or put his hand down the shirt of one of the female residents, identified as Resident #37. Per the Infection Preventionist, Resident #51 had been rubbing the leg of Resident #4, and most recently she had been made aware of an issue with Resident #17 when she had been in Resident #19's room. When queried about the documentation of resident to resident touching in November, the Infection Preventionist explained she had known the resident had gone into a few female resident rooms in a brief, and had not been aware that he had been trying to touch her. When queried as to what actions staff were to have taken if this type of incident occurred, the Infection Preventionist explained if it had been a CNA they were to tell the charge nurse, and the information next would be reported to the DON to see how they needed to proceed. The Infection Preventionist explained they could not remember if they had been notified about the touching, and she did not recall that Resident #51 had tried to touch another resident. Per the Infection Preventionist, Resident #51 had walked, had wandered, and explained the following interventions had been attempted: one to one with staff, activities offered, changed medications, and eventually the resident's room had been moved to another hallway. Per the Infection Preventionist, stop signs had been placed in front of doors to keep the resident from going into the two closest rooms to where the resident had been located. The Infection Preventionist acknowledged most of the interventions had been unsuccessful, explained the one to one had not been a formal arrangement, and people would just spend a lot of time sitting with the resident in his room, talked to him, and made sure they had their eyes on him. The Infection Preventionist explained the following about the Facility Reported Incident: The Infection Preventionist remembered it had been reported Resident #51 had put his hand down Resident #37's shirt and had groped/touched her breast, and had gone up to Resident #4 when she had been at the table and had been rubbing her leg. The Infection Preventionist further reported that the resident often time would come out without clothes, slept without clothes, and a couple of times did lay on the floor or stand and touched himself inappropriately. When asked if this behavior had ever taken place within view of other residents, the Infection Preventionist responded she believed it had, by Residents #1 and Resident #2. Per the Infection Preventionist, a lot of nights on second shift the resident had an informal one to one because the resident's behaviors escalated in the evening, and the more you approached the resident, he became aggre[TRUNCATED]