**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff, Power of Attorney, and Nurse Practitioner interview, the facility failed to protect a severely cognitively impaired resident (Resident #65) from the right to be free of physical abuse. On 08/29/25 at approximately 10:30 PM, when Nurse Aide (NA) #1 and NA #2 were providing care for Resident #65 who was agitated and combative, NA #2 struck the resident with an open hand on the left side of her face. This action would have caused a reasonable person psychosocial harm such as feelings of anger, fearfulness, humiliation, and helplessness. The deficient practice occurred for 1 of 3 residents reviewed for abuse (Resident #65).Findings included:Resident #65 was readmitted to the facility on [DATE] with diagnoses that included Alzheimer's disease with late onset, dementia with unspecified severity and behavioral and mood disturbances, anxiety and chronic pain.Review of the care plan for Resident #65 revised on 06/05/2025 revealed the following focus areas:Impaired Functional Performance as evidenced by (AEB) requiring staff assistance to complete activities of daily living (ADL) secondary to impaired cognition, decreased mobility, and unsteady gait and balance. Resident #65 refused assistance and resisted care at times. Anticipate resident requiring increased assistance as her disease process progresses. The goals were that Resident #65 would continue to participate in ADL through the next review. Interventions included to always approach in a friendly, non-threatening manner, try to re-direct with refusals; and allow resident to calm down then have another staff member attempt or re-approach in a timely manner if resident is resisting care. Resident #65 has mood and behavior problems with episodes of pacing, rummaging, screaming, being short tempered, being easily annoyed, being verbally and physically abusive towards staff, setting off door alarms and will frequently remove pants secondary to Alzheimer's/dementia with mood and behavioral disturbance. Resident #65 will refuse taking her scheduled medications at times. She gets angry when there is a facility emergency and she's not allowed to assist, such as when another resident falls. The goal was for Resident #65 to continue to participate in decision making regarding her daily routine and not injure herself or others when being abusive by the review date. Interventions included to anticipate and meet the needs of Resident #65, stop and talk with her as passing by (resident enjoys looking at family photos, clipping coupons, flipping through newspapers and books, drinking coffee), encourage visitation from family for socialization and diversion, encourage out of room for meals and activities, attempt to keep a consistent routine, offer snacks or drinks (resident loves coffee) for diversion, intervene as necessary to protect the rights and safety of others, remove from the situation and take to an alternate location as needed, minimize the potential for the resident's disruptive behaviors by offering tasks which divert attention, monitor behavior episodes and attempt to determine underlying causes considering location, time of day, persons involved, and situations and document behavior and potential causes. Review of a quarterly Minimum Data Set (MDS) dated [DATE] documented that Resident #65 had short and long term memory problems and was rarely or never understood. She was aware of the location of her room, staff faces and names; but did not know the current season or that she was in a nursing home. She continuously presented inattention and disorganized thinking. Physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing) occurred on 1 to 3 days. Other behavioral symptoms not directed towards others (such as verbal or vocal symptoms like screaming) occurred on 1 to 3 days. The facility filed an Initial Allegation Report to the State on 08/30/25 at 12:37 AM for an allegation of abuse. The accused employee was NA #2. The facility became aware of the incident on 08/29/2025 at 10:30 PM. The allegation details were that the resident (Resident #65) became combative during care and was hitting and kicking the nurse aides. The resident hit NA #2 in the face and NA #2 swatted back at the resident. NA #2 was suspended pending an investigation, all residents were assessed with no new issues noted. Local law enforcement and DSS were notified on 08/30/25. The facility documented that the resident suffered no physical or mental harm. The facility Investigation Report was filed with the State on 09/08/25. The allegation was not substantiated by the facility because post investigation the Administrator determined that NA #2 did not swat at Resident #65 because there was no injury or mental anguish. The accused individual's employment (NA #2) was terminated related to the allegation on 09/04/25. In a telephone interview with NA #1 on 09/16/25 at 2:27 PM she stated she had asked NA #2 help her with an incontinent round for Resident #65 at approximately 10:30 PM on 08/29/25. She explained that it was the normal baseline behavior for Resident #65 to strike out at staff during incontinence care or showering. She explained that 2 aides were always needed when providing incontinent care to Resident #65. Staff often used chocolate to calm Resident #65 or would leave the room and re-approach Resident #65 later to give her time to calm down. She reported they had already successfully changed the resident's diaper and NA #2 was pulling up the resident's covers on her bed. Resident #65 told NA #2 that she didn't want the blanket and tried to swat NA #2 with her hand. NA #1 heard NA #2 tell Resident #65, If you hit me, I'm gonna hit you back!. NA #1 heard Resident #65 tell NA #2 if she hit her she would report it. NA #2 continued to pull up the covers and NA #1 stated Resident #65 slapped NA #2. NA #1 stated she saw NA #2 slap Resident #65 with an open hand across the left cheek of her face, and it sounded like a loud clap. NA #1 explained she then tried to get herself and NA #2 out of the room as quickly as possible because she knew it was considered abuse to strike a resident. NA #1 noted when they left the room NA #2 was mingling around her and told her, I didn't mean to do it-it was a reflex. NA #1 stated she was afraid to report NA #2 for abuse in NA #2's presence so she texted the nurse working on the Rehabilitation Hall and asked her to call her and Nurse #1 over to the Rehabilitation Hall so that she could tell Nurse #1 what happened, which she did. The Rehabilitation Nurse called the Administrator immediately and Nurse #1 returned to the memory care unit to monitor NA #2. NA #1 stayed on the Rehabilitation Hall because that is where she was originally scheduled to work on third shift and it was time to change shifts. NA #1 reiterated she had reported the abuse as quickly as she could after it happened.In a telephone interview with NA #2 on 09/17/25 at 9:55 AM she stated NA #1 had asked her to help with incontinence care for Resident #65. She noted she knew it was going to be chaotic because earlier in the shift after supper it took 3 nurse aides to put Resident #65 in bed because she was combative. NA #2 noted when she entered the resident's room at the end of the shift, the resident was already screaming, swinging her arms and kicking. She stated she went in the room to complete incontinence care because she was trained to care for residents who had dementia, and this was the resident's normal behavior. NA #2 explained after the incontinence care was done, she bent down to pull up the resident's bed sheet, and the resident slapped her on her face really hard. NA #2 stated she backed up at that time but that she was all tangled up with the Resident #65 who had sat up in bed and had a grip on her. NA #2 noted at that time she was trying to push the resident down in the bed and her hand may have touched the resident's face in the struggle. She stated she was aware there was an allegation that she had slapped the resident but stated she had not. She noted she was also aware that there was an allegation that she told the resident that if the resident hit her she would hit her back and stated she had never said that. NA #2 also explained that law enforcement alleged to her that she had told the resident if the resident smacked her, then she would smack the resident. She stated she had not made either statement to hit or smack the resident. She noted there had been 2 aides on the memory care unit that night instead of 3, but she did not feel that the unit was short staffed. She recalled she had 11 residents on her assignment on 08/29/25 on second shift and explained she was able to complete her assignment during her shift.A telephone interview was conducted with Nurse #1 on 09/16/25 at 9:27 PM. He stated he was the nurse on duty in the memory care unit on 08/29/25 from 7:00 PM until 7:00 AM. He reported NA #1 and NA #2 went to change Resident #65's brief. When they came out of the resident's room, NA #2 told him that Resident #65 had hit her. He stated NA #1 was quiet. He explained he was called by Rehabilitation Hall Nurse who asked him to bring NA #1 to the Rehabilitation Hall. When he arrived at the Rehabilitation Hall with NA #1, NA #1 told him that Resident #65 had swatted at NA #2 while they were in the room providing care and that NA #2 had swatted back at Resident #65 and hit her on the left side of her cheek on her face. The Rehabilitation Hall Nurse tried to call the Director of Nursing but was unsuccessful, so she then called the Administrator to report alleged abuse. Nurse #1 stated the Administrator was present at the facility within 5 minutes. Nurse #1 explained that the Administrator took NA #2 off the memory care unit and told him (Nurse #1) to complete an assessment on Resident #65. Nurse #1 stated he noted Resident #65 had red dots on her left cheek when he assessed her. Nurse #1 explained that he could not determine that the discoloration on the resident's left cheek had been caused by a slap. Nurse #1 stated he completed skin checks on all the other resident's on the memory care unit. Nurse #1 commented that Resident #65 was normally combative during incontinence care, and the nurse aides were to stop care and re-approach later if a combative resident could not be calmed. Nurse #1 stated that NA #2 never told him that she had hit Resident #65 on the face. He reported that NA #2 was removed from the memory care unit by the Administrator on 08/29/25 and had not returned to work. A progress note written by Nurse Practitioner #1 on 09/02/25 at 10:45 AM documented that she assessed Resident #65 who was neurologically at baseline. She noted that she assessed Resident #65 to have multiple skin lesions and age-related changes on both sides of her face with a small area of petechiae on her left cheek. There was no pain, redness, bruising, or edema on her face. Resident #65 had no new complaints or distress noted. An interview was conducted with Resident #65's Power of Attorney (POA) on 09/16/25 at 3:10 PM. She stated she listened to her voice mail on Saturday morning (08/30/25) around 6:30 AM. She reported she called the facility and Nurse #1 told her that Resident #65 had been combative during care and when the resident swatted at a nurse aide the nurse aide hit her back. The POA stated she arrived at the facility that morning around 9:30 AM and took pictures of Resident #65's left side of her face. She stated she did see marks on Resident #65's left cheek. She reported when she was taking the pictures, Resident #65 asked her if someone had hit her. The POA found this unusual because Resident #65 had never said anything like that before. She asked Resident #65 if someone had hit her and the resident replied she did not know. The POA stated she had asked Nurse #1 for a report, and he told her the Administrator would call her. When the Administrator had not called her by noon, she googled what to do and called Adult Protective Services to file a complaint. She recalled the Administrator called her on 08/30/25 and told her he had had interviewed both of the nurse aides involved. He reported to her that he had escorted the accused nurse aide out of the building and suspended her. The POA stated Resident #65 had been at the facility for 6 years and that this was the first time anything like this had happened to her. She noted she had not visited Resident #65 on Friday (08/29/25) but had seen her the day before (Thursday) and the marks on her face were new.An observation of Resident #65 was made on entry (09/15/25) at lunchtime at 12:05 PM and again on 09/16/25 at 12:30 PM. No marks were visible on the left side of Resident #65's face. An attempt was made to interview Resident #65 on 09/17/25 at 3:05 PM, but Resident #65 was not able to understand the conversation. An interview was conducted with Nurse Practitioner #1 on 09/18/25 at 1:33 PM by telephone. She stated when she had assessed Resident #65 on 09/02/25 she had not found any frank marks or bruising on the resident's face. Nurse Practitioner #1 explained although she did observe 3 petechia dots on the resident's left facial cheek, she wouldn't call those marks a bruise. She noted the petechia could have just been due to the aging process and changes in the resident's skin. She stated Resident #65 was at baseline and was not able to tell her if anyone had hit her.An interview was conducted with the Administrator on 09/18/25 at 10:30 AM. He stated that he did not substantiate this allegation of abuse because when he talked to the local law enforcement officer who had responded to the incident, the information the office told him regarding staff interviews varied from the staff interviews that he had conducted himself. The Administrator explained he did not have a copy of the law enforcement report because when he had asked the officer for a copy of the report he was told the report had not been written yet and that the investigation was still open. The Administrator provided a Plan of Correction with an alleged completion date of 09/04/25, but it was not accepted because the plan did not include monitoring of staff to resident interactions or of care being provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff and the Medical Director's interviews, the facility failed to protect a resident's right to be free from physical abuse. On 5/18/24 a severely cognitively impaired resident (Resident #34) was grabbed around the neck using both hands and choked by another cognitively impaired resident (Resident #61) in the dining area of the locked dementia unit. Staff reported Resident #34 was crying and seemed distraught immediately following the incident. A second resident to resident altercation occurred on 5/25/24, 7 days later, when Resident #61 grabbed another cognitively impaired resident (Resident #17) by her neck with one hand and pushed her to the floor. Staff reported Resident #17 yelled out as she was falling down, she seemed scared and frightened during the incident, and after the incident she was upset and distraught and stated that Resident #61 was trying to hurt me. There were no physical injuries during either incident. This occurred with 3 of 3 Residents (Resident #34, #61, #17) reviewed for resident-to-resident abuse. The action inflicted by Resident #61 would have caused a reasonable person psychosocial harm such as feelings of fearfulness and agitation. Findings included. Resident #61 was admitted to the facility 09/19/23 with diagnoses including dementia with anxiety, agitation, mood with behavioral disturbance, and bipolar disorder. A care plan dated 09/28/23 revealed Resident #61 was at risk for injury to self and others due to a neurologic imbalance that could contribute to the development of manic episodes to include impulsivity, reckless behaviors, and aggression, secondary to bipolar disorder. Resident #61 was very possessive of her personal space and could become aggressive towards others. She experienced episodes of paranoia, anxiety, aggression, pacing, exit seeking and sexual behaviors (flirting/kissing). The goal of care was to not injure herself or others when aggressive, she will be redirected by staff with inappropriate behaviors and will participate in unit activities without demonstrating inappropriate behaviors through the review date. Interventions included in part: to administer medications as ordered. Update the physician with escalation in mood and behaviors. Assess and anticipate resident's needs. Attempt to keep resident away from other residents when agitated and aggressive. Provide physical and verbal cues to alleviate anxiety; give positive feedback, assist verbalization of the source of agitation, assist to set goals for more pleasant behavior, encourage seeking out of a staff member when agitated. If the resident becomes agitated: attempt to intervene before agitation escalates; guide away from the source of distress; Engage calmly in conversation; If response is aggressive, staff will walk calmly away, and approach later. Provide a safe environment. Gently redirect other residents out of her personal space as needed. Guide toward socially appropriate behavior. Encourage medication adherence. Provide structured safe activities. Provide Psychiatric consult as indicated. A physicians order dated 10/27/23 for Resident #61 revealed Escitalopram Oxalate (Lexapro) 20 milligrams (mg) daily for generalized anxiety disorder. Resident #61's Medication Administration Record (MAR) revealed a physicians order dated 04/02/24 for Quetiapine Fumarate (Seroquel- an antipsychotic medication) 50 milligrams (mg). Give in the afternoon along with Quetiapine 12.5 mg for dementia with mood disturbance. A physicians order dated 04/12/24 for Resident #61 revealed Escitalopram Oxalate (Lexapro) 10 milligrams (mg) daily for generalized anxiety disorder. The MDS quarterly assessment dated [DATE] revealed Resident #61 was rarely or never understood, with memory problems. She exhibited disorganized thinking and had physical and verbal behaviors directed toward others. She received psychotropic medications. She was independent with ambulation. A physicians order dated 04/26/24 for Resident #61 revealed to increase Escitalopram Oxalate (Lexapro) to 20 milligrams (mg) daily for generalized anxiety disorder. a.) Resident #34 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, and dementia. A care plan dated 02/28/23 revealed Resident #34 had the potential for adverse consequences related to psychotropic medications prescribed for treatment of depression, anxiety, and agitation. Interventions included in part; to administer medications as ordered and monitor for escalating mood and behaviors; and to notify the physician of new or changed symptoms and report unusual behaviors to the nurse, such as agitation, drowsiness, hallucinations, and anxiety. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #34 was severely cognitively impaired. She exhibited verbal behaviors directed toward others. She received psychotropic medications. A behavior note dated 05/18/24 at 7:26 PM documented by Nurse #1 revealed resident (Resident #34) was hit and called names by another resident (Resident #61) . Resident #61 then proceeded to choke the other resident. This nurse intervened and the residents were separated. The Director of Nursing (DON) and family members were notified. During a phone interview on 10/09/24 at 12:44 PM Nurse #1 stated she witnessed the altercation between Resident #61 and Resident #34 on 05/18/24. She was sitting at the nurses station and Resident #34, who had a history of saying things that didn't make sense, she raised her voice and the nurse immediately looked up and saw Resident #34 hit Resident #61 with her arm on her upper leg as she was walking by. She reported that Resident #61 was walking by Resident #34 from the side and grabbed Resident #34 from the side by her neck with both hands wrapped around her neck. This occurred in the dining room in the locked dementia care unit. She stated it happened so fast and she immediately jumped up and ran to where the residents were, and she and another Nurse Aide intervened at the same time and separated the residents. Nurse #1 reported that she saw Resident #61 put both hands around Resident #34's neck but she could not tell the force used by Resident #61 once she grabbed her by the neck. She stated there were no marks or redness on Resident #34's neck at that time and no injury to her neck ever developed. She reported that Resident #34 did not have any shortness of breath or respiratory distress from being grabbed by the neck at that time or at any time following the altercation. She stated Resident #34 started crying and seemed distraught and the Nurse Aide immediately took Resident #34 in her wheelchair to her room. She was still crying but shortly after the incident Resident #34 seemed okay and did not remember what had happened. Nurse #1 stated she immediately redirected Resident #61 who was independent with ambulation and walked her to her private room where she stayed. She stated Resident #61 told her that Resident #34 was picking on her in school and while riding the bus and she had enough of it and stated, I bet she [Resident #34] wouldn't do that again. She stated the altercation occurred in the dining area where the 300 hall and the 400-hall joined. She stated Resident #61 resided on the 300 hall and Resident #34 resided on the 400 hall. She reported that she stayed with Resident #61, and the Nurse Aide stayed with Resident #34 in their rooms until they had both calmed down. She stated she could not recall who the Nurse Aide was that day. She stated as soon as the situation was under control and residents were safe and the situation was deescalated, she then reached out to the Director of Nursing, the Physician, notified the resident's Responsible Party, and notified Psychiatry Services to let them know Resident #61 needed to be seen as soon as possible. She reported both residents rooms were on opposite sides of the unit, and the incident occurred during the afternoon, but she couldn't remember the exact time. She stated Resident #61's room was in direct sight of the nurses station, and she initially stayed in Resident #61's room approximately 30 minutes following the incident. She stated Resident #61 spent a lot of time in her room and stayed in her room for the remainder of her shift. Later in the shift neither resident seemed to remember what happened. She reported signs of agitation had decreased with both residents after the incident. She reported that she was instructed by the Physician to give Resident #34 an as needed medication but could not recall what medication. Nurse #1 stated she had worked in the facility since December 2022, and primarily worked on the locked unit and there had been no previous altercations reported to her regarding the residents. Review of the Medication Administration Record (MAR) dated May 2024 revealed Resident #34 was administered Ativan (anti-anxiety medication) 0.5 milligrams as needed for agitation by Nurse #1 on 05/18/24 at 2:11 PM. During an interview on 10/09/24 at 3:20 PM Nurse Aide #1 stated she worked on 05/18/24 from 3:00 PM until 11:00 PM but she did not witness the incident because she came in later on 2nd shift. She stated she was told Resident #61, who had dementia, had choked Resident #34, who also had dementia. She stated Resident #34 talked a lot and would carry on and could have said something that provoked Resident #61, but she was uncertain if that's what happened since she did not witness the altercation. She stated both residents were acting as usual during the shift, and she did not recall seeing any marks or redness on either resident. She reported she had worked in the facility for 7 months on the locked unit and she had never witnessed Resident #61 or Resident #34 lash out physically to other residents. Attempts were made during the investigation to contact the Nurse Aide #2, #3, and #4 who worked on 05/18/24 from 7:00 AM until 3:00 PM. They were no longer employed and there was no response. Attempts were made to contact Nurse Aide #5 and #6 who worked on 05/18/24 from 3:00 PM until 11:00 PM and there was no response. A physicians note dated 05/20/24 at 10:36 AM documented by the Medical Director revealed Resident #61 was a [AGE] year-old with osteoarthritis (OA) and dementia. She continued to have episodes of agitation. She had an altercation with another resident (Resident #34) over the weekend. Resident #61 was alert and oriented to person only. The assessment included the diagnoses of OA and dementia with agitation. The plan of care for Resident #61 included changing the time of Resident #61's Buspar (antianxiety medication) dosing to noon instead of later in the evening. An interview was conducted on 10/09/24 at 3:30 PM with the Director of Nursing (DON) along with the Administrator. The DON stated she was notified by Nurse #1 on 05/18/24 following the incident between Resident #61 and Resident #34. She stated Nurse #1 told her what happened, and the situation had deescalated, the residents were immediately separated, and there were no injuries. She stated both residents went back to their rooms, and that all residents were safe. She stated Resident #61 had remained in her room following the incident and there was no further contact between the two residents. She stated the residents resided on the locked dementia unit and all residents on the locked unit had constant supervision. She stated both residents had severe dementia, and they had not had any altercations with each other prior to that time. Following the incident, they did a medication review regarding the residents and concluded that Resident #61 had a recent dose reduction of her antidepressant medication. They ended up increasing her back to the initial dose. She stated she instructed Nurse #1 to closely monitor both residents, and to notify the Physician and the Responsible Party. She stated both residents appeared to be at their baseline following the incident. During an interview on 10/10/24 at 12:06 PM the Medical Director stated she was made aware of the incident on 05/18/24 between Resident #61 and Resident #34. She reported that Resident #61 was adjusting to medication changes during that time period. They increased the medication back to the initial dose and she was currently stable on her medications. Resident #34 had no injury from the incident. There had been no further altercations between the residents since that time. She stated both residents had severe dementia and Resident #61 was not considered a threat to other residents. b.) Resident #17 was admitted to the facility on [DATE] with diagnoses including Alzheimer's, dementia with behavioral disturbances, and psychosis. The Minimum Data Set (MDS) quarterly assessment dated [DATE] revealed Resident #17 was severely cognitively impaired. She had no physical behaviors directed toward others but did have verbal behaviors directed toward others. She received psychotropic medications. She used a walker for mobility. A care plan dated 03/15/24 revealed Resident #17 had impaired cognitive function and thought processes secondary to Alzheimer's, Dementia and psychosis. She could be irritable, suspicious of taking medications, short tempered, easily annoyed and physically aggressive. She had episodes of wandering into other residents rooms and taking their personal belongings. Interventions included in part; to administer medications as ordered. Provide consistent care and routines to decrease confusion. Redirect when needed. Cue, reorient and supervise as needed. Evaluate for situational stressors. Review medications and record possible causes of cognitive deficit such as new medications or dosage increases; recent discontinuation, omission or decrease in dose, drug interactions, adverse drug reactions, or drug toxicity. An incident note dated 05/25/24 at 7:52 PM documented by Nurse #2 revealed she heard a crashing noise while she was at the nurses station. She witnessed Resident #17 falling down onto her left side next to another residents chair. A witness stated another resident (Resident #61) grabbed Resident #17 by her neck and pushed her down. Resident #61 stated Resident #17 pushed into her with her walker and hit her in the left eye, so she grabbed her and pushed her down. Resident #17 was unable to state what occurred. The residents were separated for safety with no injuries noted. Neurologic checks were initiated for Resident #17 without abnormal findings. The Physician, the Director of Nursing and the residents' Responsible Party were made aware of the incident. During an interview on 10/09/24 at 2:18 PM Nurse #2 stated she worked fulltime in the locked unit and had worked in the facility since 2022. She stated Resident #17 ambulated with supervision with her rollator and tended to run into things. She didn't witness the incident between Resident #61 and Resident #17 on 05/25/24 but heard the commotion from the nurses station and looked up as Resident #17 was falling down and landed on the floor. Resident #61 said Resident #17 ran into her with her walker. She stated Resident #17 bumped Resident #61 with her rollator and Resident #61 got upset. She reported that she didn't witness Resident #61 putting her hands on Resident #17's neck but a nurse aide (she could not recall which nurse aide) reported that Resident #61 grabbed Resident #17 by the neck and pushed her down. The residents were immediately separated, and she checked on Resident #17. She did a neurologic check, and physical assessment and Resident #17 appeared to be okay and had no marks or redness on her neck, and there was no respiratory distress. Resident #61 was redirected and was walked down to her room. She stated once the situation had deescalated, the residents were redirected, and all residents were safe, she called the Director of Nursing. She also notified the resident's Responsible Party, and Physician and no new physician orders were received. She stated immediately following the altercation Resident #17 was upset and distraught, she yelled out as she was falling down then once they got her up and sitting in a nearby chair, she seemed okay. Resident #17 carried on as usual with no signs of distress. She stated Resident #17 was her usual self and did not remember the incident. She had no indicators of pain that she recalled and her physical assessment including a skin assessment was normal. Nurse #2 stated it happened out of the blue and there had been no arguing or no interaction between the two residents that day and no altercations between them since then. During an interview on 10/09/24 at 3:55 PM Nurse Aide #7 stated she witnessed the altercation on 05/25/24 between Resident #61 and Resident #17. She stated it occurred in the locked unit in the dining area. Resident #17, who had severe dementia, was walking through with her rollator and bumped into Resident #61, who also had dementia. Resident #61 grabbed Resident #17 by the neck with one hand and pushed her to the ground. Resident #17 fell, landed on the floor but she did not hit her head. Resident #17 yelled out as she fell. She stated she immediately went to Resident #17 to make sure she was okay, and at that time Nurse #2 came up and assessed Resident #17. She stated Resident #61 was easily redirected following the incident and went down to her room. She stated she could not tell how strong of a hold Resident #61 had on Resident #17's neck. There was no redness on Resident #17's neck that she saw, and Resident #17 had no difficulty breathing or shortness of breath. She stated the incident happened really fast and the residents were separated. She stated they sat Resident #17 down in a chair close by and she was up moving around as usual soon after. She reported that she routinely worked on the locked unit, and she had not witnessed any change in Resident #17 following the incident and there had been no altercations between the two residents since then. During an interview on 10/10/24 at 11:05 AM Nurse Aide #8 stated she witnessed the altercation between Resident #61 and Resident #17 on 05/25/24. She reported that she was standing in the dining room and Resident #17 was sitting in a chair with her walker in front of her. Resident #61, who ambulated independently, tried to squeeze by her and hit Resident #17's walker. Resident #17 stood up and started yelling at her. Resident #61 grabbed her and caused Resident #17 to fall. She stated she could not say for sure exactly where Resident #61 grabbed Resident #17, but it was somewhere above her shoulder area. The residents were immediately separated. Nurse #2 assessed Resident #17, and they did vital signs on Resident #17 every 15 minutes. She reported there were no injuries that she saw and there was no sign of shortness of breath or difficulty breathing. She indicated that she did not see redness on Resident #17's neck. She stated Resident #61's family came in after the incident and calmed her down. She stated Resident #61 got upset easily but was never aggressive or attacking anyone. She stated Resident #17 had no change in behavior, but she typically got aggressive and resistive to care because she did not understand things but that was her normal behavior. She stated in the moment of the altercation, Resident #17 seemed scared and frightened and Resident #17 stated she was trying to hurt me, but later she did not remember the incident. She stated she routinely worked on the locked unit and there had been no altercations between the two residents since that time. A progress note dated 05/28/24 at 10:22 AM documented by Nurse Practitioner #1 indicated Resident #17 was a [AGE] year-old with dementia with behaviors. She was seen today for follow up from attack by another resident (Resident #61). The nurse this weekend reported she (Resident #17) was choked and pushed to the ground. She denied any pain on assessment and she did not want to be examined fully today and was getting agitated. There was no bruising to her neck. The physical assessment revealed she was in no distress. There were no new skin lesions, or rashes. There was no change in vision, no complaints of headache, and no neurologic changes. She had no anxiety or depressive symptoms. The conjunctiva (thin, clear membrane that covers the inner surface of the eyelid and the white part of the eyeball) was clear with no drainage or erythema (redness). She had no changes from baseline and was up ambulating. The assessment and plan of care revealed weakness, dementia with behaviors, and agitation. There were no medication changes. Resident #17 continued with agitation at times and as needed medications would continue. There was no physical trauma found or reported from assault. A progress note dated 05/29/24 documented by the Psychiatrist revealed a psychiatric evaluation for mood for Resident #61, a [AGE] year-old. The Psychiatrist indicated they were asked to see Resident #61 urgently after an altercation with another resident (Resident #17). When asked about the incident, Resident #61 stated that a little boy hit me, so I sort of swatted back at him, and he told everyone I hit him in the stomach. Sometimes in life you just have to deal with people like that. She denied suicidal ideation or hallucinations and was pleasantly confused. Staff reported that Resident #61 hit another resident (Resident #34) last week, but the other resident provoked and struck her first. This incident occurred as another resident bumped into her with her walker and [Resident #61] reported she hit her [Resident #34]. She [Resident #61] then grabbed her [Resident #34] by the throat and dropped [Resident #34] to the ground. The Primary Care Provider saw Resident #61 since and increased her Seroquel (antipsychotic medication). She has a history of dementia, and bipolar disorder. Her signs and symptoms are moderate, occurring intermittently throughout the week and month. She denied paranoia or delusions, and she was compliant with medications. There were no reported side effects or concerns. The associating and modifying factors include chronic health conditions, loss of mobility and independence, and living in a long-term care/rehabilitation facility. A Physicians note dated 05/30/24 at 12:49 PM documented by the Medical Director indicated Resident #61 had genetic testing and was taken off Lexapro (antidepressant) based on this report. Her behaviors seemed to increase, and she was placed back on Lexapro. She had an incident right before restarting the Lexapro with one resident (Resident #34) and a similar episode with a second resident (Resident #17) on 05/25/24. Resident #61 was on Seroquel (antipsychotic medication) three times a day. Psychiatry Services was asking to change to extended-release dosing. The Medication Administration Record (MAR) was reviewed at length. The Medical Director indicated they would not make any changes at this time and discussed this with her Responsible Party. Resident #61 was noted to only be back on Lexapro for five days and may have needed more time for it to be effective. Resident #61's Buspar (anti-anxiety medication) was continued. A progress note dated 5/30/24 at 3:36 PM documented by Nurse #2 revealed a new order was received for (Resident #61) to change Seroquel (antipsychotic medication) to 150 milligrams extended release daily. The Responsible Party was notified. During an interview on 10/10/24 at 12:06 PM the Medical Director stated she was made aware of both incidents (05/18/24 and 05/25/24) regarding Resident #61. She reported that Resident #61 was adjusting to medication changes during that time period. They made necessary dose adjustments during that time which she tolerated. She was stable on her medications and there had been no further altercations between the residents since that time. She stated both residents had severe dementia and Resident #61 was not considered a threat to other residents. An interview was conducted on 10/09/24 at 3:30 PM with the Director of Nursing (DON) along with the Administrator. The DON stated she was made aware of the altercation between Resident #61 and Resident #17 on 05/25/24. She stated with any resident-to-resident altercation they reviewed the incident, they made sure all residents were safe and then made determinations on the root cause of the altercation. She stated both residents had severe dementia, and, in this case, she felt like the altercation was a reflexive response by Resident #61 versus a willful action regarding both incidents. She stated they determined that Resident #61 had recent psychotropic medication changes during the time of the altercations. Her Lexapro was decreased, and her behavior increased in that short period of time. She stated they notified the Physician and the Psychiatrist, and both evaluated Resident #61 and agreed to increase her Lexapro to the initial dose. She stated her medications were resumed at the original dose and she has had no altercations with any residents since then. She stated that all residents on the locked unit were closely supervised by staff. She indicated Resident #61 was stable on her current medications and was not a threat to other residents. Attempts were made to interview the Psychiatrist who evaluated Resident #61. She was on sick leave and there was no further response.