**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews during the Recertification Survey and the Abbreviated Survey (Complaint # NY 00263584) completed on 7/1/2021, the facility failed to ensure resident rights to be free from abuse for two of two residents reviewed for abuse (Resident #23 and Resident #157). Specifically, Resident #23 who was identified with aggressive behavior, pushed a wandering resident (Resident #157) when Resident #157 grabbed and shook Resident #23's arm. Resident #157 fell to the floor and sustained two lacerations to the back of the head. Subsequently Resident #157 was sent to the hospital with a change in mental status and the two lacerations to the back of the head required five staples. Furthermore, Resident #157 was not adequately supervised upon return from the hospital the next day and entered Resident #23's room when Resident #23 punched Resident #157 in the face causing the resident to sustain a bloody nose with bruising and cuts to the face. This resulted in actual harm to Resident #157 that is not Immediate Jeopardy. The finding is: The Facility Freedom from Abuse, Mistreatment, Neglect and Exploitation policy dated 4/1/1991 and revised on 11/2018 documented that abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm or pain or mental anguish or deprivation by an individual of goods or services that are necessary to attain or maintain physical, mental and psychosocial well-being. Inflictions of abuse can include but are not limited to the following: Physical Abuse includes hitting, slapping, pinching and kicking. 1) Resident #157 was admitted to the facility with diagnoses of Dementia with Behavioral Disturbance, Major Depressive Disorder and Seizure Disorder. The Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #157's BIMS score was 4, indicating severely impaired cognition. The nurses progress note dated 8/30/2020 documented that at 1:40 PM, Resident #157 was found lying on their back in the doorway to their room, assisted from the floor by staff to the wheelchair. Resident #157 had two lacerations to the scalp; one measuring 1.5 centimeter (cm) in length, the other measuring 1 cm in length. The lacerations were cleaned with normal saline, bacitracin and steri strips were applied and were covered with a clean dressing as ordered. The supervisor, physician and family were notified. Resident #157 had complaints of pain from the laceration on the head and Tylenol was given. Neuro checks for every shift for 24 hours as ordered by physician. The Physician's Orders dated 8/30/2020 documented Bacitracin 500 unit/Gram (gm) ointment to scalp daily. Cleanse lacerations with normal saline and apply steri-strips. The orders on 8/30/2020 also documented Neuro-check every 2 hours for 1 day and to transfer to the hospital for altered mental status. The nurses progress note dated 8/30/2020 at 9:27 PM documented Resident #157 was showing increased signs of lethargy and confusion. Resident #157 was sent out for emergency room at 8:20 PM for further evaluation. The Nurses Progress notes dated 8/31/2020 documented that Resident #157 returned from the hospital at 8:50 AM. Resident #157 was noted with 5 staples to the back of the head. The injury was obtained during a peer to peer incident on 8/30/20. The Physician's progress notes dated 8/31/2020 documented Resident #157 was found on the floor by Resident #157's room with two lacerations to the back of the scalp. Resident #157 was transferred to the emergency room after there was a change in mental status. Resident #157's lacerations were approximated with staples. The plan was to monitor the laceration site and monitor temperature. The Behavior care plan for Resident #157 dated 5/20/2020 documented Resident #157 was at risk for distress, disruption to environment, and injury to self/others due to behavioral symptoms which included cursing at others, hitting, pushing, refusal of care and wandering. The goals included that Resident #157 will be free from harm and will not harm others. The interventions included to redirect Resident #157 when going into peer's rooms and redirect other residents from entering Resident #157's room. The CCP was not updated or revised after the resident's return from the hospital on 8/31/2020. The Victimization care plan for Resident #157 dated 5/20/2020 documented Resident #157 is at risk for victimization related to reacting negatively towards peers when redirected. The goals included that Resident #157 will remain free from victimization as evidenced by absence of peer altercation. The interventions included to observe peer interactions and offer redirection as needed and remove peers for safety if resident does not accept redirection. The CCP was not updated or revised after the resident's return from the hospital. The nurses progress note dated 8/31/2020 documented that after lunch, Resident #157 was found in another resident's room (Resident #23) sitting in a chair with blood on their face. Staff assisted Resident #157 out of the room. Resident #157 had multiple small lacerations to the left side of their face near the ear, left check, under left nostril and the nose was bruised. The altercation took place with the same resident as the incident on the previous day. Resident #157's face was cleaned; ice was applied to the nose with good effect. The physician, supervisor, and social worker were made aware. 2) Resident #23 was admitted to the facility with the diagnosis of Dementia with Behavioral Disturbance, Psychosis, and Anxiety Disorder. The Quarterly Minimum Data set (MDS) assessment dated [DATE] documented Resident #23 had a BIMS score of 3, indicating severely impaired cognition. The Behavior care plan for Resident #23 dated 8/18/2020 documented Resident #23 is at risk for distress, disruption to environment, and injury to self/others due to limited insight to safety, territorial behaviors related to Resident #23's room and belongings, pushing, grabbing, pacing, and screaming and cursing at others. The goals included that Resident #23 will be free from harm and will not harm others. Interventions included to redirect peers away from Resident #23, provide a newspaper, offer music and provide familiar caregiver when able. The CCP was not updated/revised after the altercation on 8/30/2020. The Accident and Incident report dated 8/30/2020 documented that at 1:40 PM, CNA #1 saw Resident #23 standing by the entrance of Resident #23's room and observed Resident #157 lying on their back on the floor by Resident #157's room with blood on the floor by Resident #157's head. Resident #23 was standing by the entrance of Resident #23's room, which was adjacent to Resident #157's room. Resident #23 said that Resident #157 grabbed Resident #23's arm and was shaking Resident #23. Resident #23 pushed Resident #157 and Resident #157 fell. Resident #23 repeated and re-enacted the events to make sure that people understood why Resident #23 did what Resident #23 did. A body check revealed 2 lacerations to the top of Resident #157's head measuring 1.5 centimeters (cm) and 1.0 cm. New orders included steri-strips (to the lacerations), bacitracin (topical antibiotic ointment) and a dry clean dressing. Resident # 157 complained of a headache about 1 hour after the incident and was administered Tylenol 650 Milligrams (mg) with good result. Later in the evening, Resident # 157 was noted with increased lethargy and confusion. The resident was sent to the hospital for evaluation of the altered mental status post fall with head injury. The facility summary of findings dated 9/4/2020 (from the 8/30/2020 Accident Incident report) documented that Resident # 157 received 5 staples to his head. The residents' rooms were adjacent to each other and possibly Resident #23's misjudged the location of their room and perceived that Resident #157 was in Resident #23's room. The plan for improvement included a re-evaluation for Resident #157 upon return from the hospital and the care plan was not reviewed and revised. Staff will continue to observe, monitor, and redirect residents while near each other and to anticipate any untold behavior between the two residents. The facility's investigation identified that the incident occurred because both residents had the diagnosis of Dementia; however, the unit is crowded with residents around the nursing station and there was not enough personal space. The facility concluded that there was no reasonable cause to believe any alleged resident abuse, neglect or mistreatment occurred. The Accident and Incident report dated 8/31/2020 documented Resident #157 was sitting in front of the television where a staff member was feeding another resident. The staff member proceeded to place Resident #157 in the hallway across from the dining room to clean up after lunch leaving the hallway unattended. Resident #157 walked past the nurse's station, and no one realized that Resident #157 moved from the seat and probably wandered accidentally in to the peer's room (Resident #23) which was right next to Resident #157's room. Resident (#157) has a history of wandering in other resident rooms. Resident #23 came out of Resident #23's room and asked for someone to get this resident (Resident #157) out of their room. CNA #2 responded, and Resident #157 was found sitting in a chair in Resident #23's room with multiple small lacerations to the left side of the face near the ear, lacerations under the left nostril and a bruised nose. Resident #23 had blood on the right hand. Resident #23 stated that Resident #157 came into Resident #23's room uninvited and when someone wants to fight, you need to hit them first. The facility concluded there was no reasonable cause to believe any alleged resident abuse, neglect or mistreatment occurred. CNA #1 was interviewed on 6/29/2021 at 2:17 PM. CNA #1 stated that on 8/30/2020, CNA #1 was at the nurses station charting and observed Resident #157 wandering in the hallway and they redirected Resident #157 away from Resident #23's room. CNA #1 then continued charting at the nurse's station and then CNA #1 heard a commotion. CNA #1 walked out of the nurse's station to Resident #157's room which was by the station and observed Resident #157 on the floor at Resident #157's doorway, laying on their back with blood on the floor. Resident #23 said Resident #157 was trying to get into Resident #23's room. Resident #23 told CNA #1 that Resident #157 grabbed Resident #23's arm and shook it. Resident #23 then pushed Resident #157 and Resident #157 fell to the floor. CNA #1 stated that Resident #23 can be aggressive and impulsive, so she knows they should be kept separated. CNA #1 stated within moments of the last redirection, Resident #157 still wandered near Resident #23. CNA #1 could not recall the exact time of the events and did not recall if other staff members were around at the time of the incident. CNA #2 was interviewed on 6/29/21 at 2:41 PM. CNA #2 stated that on 8/31/2020, Resident #23 came out to the doorway and asked would you get this person out the room? CNA #2 looked past Resident #23 and saw Resident #157 seated in the room with blood on their face. Resident #23 told CNA #2 that Resident #23 punched Resident #157 on the nose and Resident #23 was observed with blood on their hand. CNA #2 brought Resident #157 out of the room and reported to Charge Nurse #1 what was encountered. CNA #2 stated that CNA #2 generally picks up assignments and monitors everyone on the unit. CNA #2 does not recall if they were assigned to Resident # 157 or Resident #23. CNA #2 stated that Resident #23 has a temper and they know that Resident #157 should be redirected away from Resident #23. Resident #157 had a behavior of habitually returning to Resident #23's room because it used to be Resident #157's room in the past. CNA #2 stated that unless there is a 1:1 assigned to Resident #157, there is no way to do continuous monitoring for Resident #157. CNA #2 was not instructed to increase monitoring for Resident #157 on 8/31/2020. The Director of Nursing Services (DNS) was interviewed on 6/29/2021 at 3:55 PM. The DNS stated that on 8/30/2020, Resident #157 was on the floor and Resident #23 stated Resident #23 pushed Resident #157 and Resident #157 sustained 2 lacerations on the head. Prior to the event, Resident #157 was seen ambulating on the unit. Resident #157 was sent out to the hospital for an evaluation and received 5 staples to the head. The DNS stated that there were no new preventative measures put in the care plan on 8/30/2020 for Resident #157. On 8/31/20, Resident #157 walked into Resident #23's room. The DNS further stated that according to the New York State and Federal definitions of Abuse, both incidents were abuse. The Charge Registered Nurse (RN) was interviewed on 7/1/21 at 1:59 PM. The Charge RN stated that the two residents did not have any altercations prior to 8/30/2020. The Charge Nurse was on the unit on 8/31/20 when Resident #157 returned from the hospital. The Charge RN stated that the plan of care was to observe Resident #157's peer interactions and to offer redirection prior to 8/30/2020. The plan of care also instructed staff to keep other residents away from Resident #157 when Resident #157 does not accept redirection. The interventions in the plan of care did not specify the frequency of monitoring. The Charge RN stated the basic protocol was one-hour visual checks on Resident #157 and Resident #157's monitoring was not increased when the resident returned from the hospital. The Medical Director was interviewed on 7/1/21 at 2:37 PM. The Medical Director reviewed the accident and incident reports for 8/30/20 and 8/31/20. The Medical Director stated that Resident #157 sustained lacerations to the occipital scalp area with staples in place after the 8/30/2020 altercation. The Medical Director stated that Resident #157 incurred injuries and was harmed by Resident #23. The Medical Director expected Resident #157 to be kept in a visual area to keep them away from other residents. Normally when an abuse case occurs, the team determines the frequency of supervision which can be every (Q)15 minutes, Q 30 minutes or 1:1 supervision. In this case, the baseline was 1-hour checks and the frequency of supervision should have been increased. 415.4(b)(1)(i)