**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility policy, medical record review, review of the facility investigation, observation, and interviews, the facility failed to prevent abuse for 1 resident, (Resident #2) of 7 residents reviewed for abuse or neglect. The facility's failure to prevent abuse with subsequent injuries of Resident #2 after an assault by Resident #3, resulted in actual Harm of Resident #2. F 600 was cited at a Harm as past non-compliance. The facility is not required to submit additional corrective actions. The findings included: Review of the facility titled, Abuse Policy, revised [DATE], showed .It is the policy of this facility to provide protections .and procedures that prohibit and prevent abuse .Abuse means the willful infliction of injury .resulting physical harm .which can include .certain resident to resident altercations . Medical record review showed Resident #2 was admitted to the facility on [DATE], with diagnoses including Alzheimer's Disease, Dementia with Severe Agitation and Behaviors, Thrombocytopenia (low platelet counts), Generalized Anxiety Disorder, Hypertension, Chronic Obstructive Pulmonary Disease, and End Stage Renal Disease. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], showed Resident #2 had a Brief interview for Mental Status score (BIMS) of 4 which indicated severe cognitive impairment. Resident #2 had hearing and visual impairments, communication deficits, inattention, and disorganized thinking but no history of aggressive behaviors directed towards others. Resident #2 required 1-2 staff assistance with all activities of daily living. Review of the care plan dated [DATE], for Resident #2 showed the interventions for Dementia with Behaviors included non-pharmacologic interventions to address Agitation, Delusions, and Anxiety. Review of the Physician Orders dated [DATE], for Resident #2 showed, .Monitor for side effects associated with Benzodiazepine medications [Xanax/Alprazolam] [antianxiety medication] .new onset or increased severity of .aggressive/impulsive behavior . Monitor for Side Effects associated with antipsychotic Medications .[Seroquel] .new onset or increase in severity of .disorientation, confusion .restlessness .every shift Review of the Medication Administration Record (MAR) dated 1/2023, for Resident #2 showed .Alprazolam 0.25 milligram [mg] tablet, 1 tablet by mouth every 12 hours as needed for anxiety, agitation .every shift .Seroquel Oral Tablet .Give 25 milligram by mouth in the evening for psychosis, agitation and aggression . Review of Physician's orders dated [DATE], for Resident #2 showed to change the Alprazolam 0.25 mg from every 12 hours to every 6 hours as needed (PRN) for Anxiety. Medical record review showed Resident #3 was admitted to the facility on [DATE] with diagnoses including Unspecified Dementia with Behaviors, Generalized Anxiety Disorder, Cardiomegaly (enlarged heart), Stage 2 Chronic Kidney Disease, Major Depressive Disorder, Restlessness and Agitation, and Chronic Obstructive Pulmonary Disease. Review of the quarterly MDS assessment dated [DATE], showed Resident #3 had a BIMS score of 1 which indicated the resident had severe cognitive impairment. The resident had impaired attention, disorganized thinking, delusions, and wandering, but no verbally or physically aggressive behaviors directed towards self or others. Resident #3 required 1 person staff assistance with all activities of daily living. Review of the [DATE]-[DATE] daily nursing notes showed Resident #3 showed no signs of aggression to self or others until [DATE]. Review of the facility investigation dated [DATE] showed Resident #2 and Resident #3 ambulated to the common day/dining area around 6:00 PM. Resident #2 became agitated and began to yell. Resident #3 spoke to Resident #2 who became verbally aggressive towards Resident #3. Resident #3 slapped Resident #2 on the face and grabbed her upper arm in response. Resident #4 who was inside the day area and saw the incident, reported the altercation to nursing staff who immediately interceded and separated the two residents. Resident #3 was taken to her room and placed on 1 to 1 supervision. Resident #2 was taken to her room and assessed by Licensed Practical Nurse (LPN) #1 who documented Resident #2 sustained 2 small skin tears to her upper right arm which were treated with steri- strips (adhesive bandages). Resident #3 was transferred to a local hospital for psychiatric evaluation and returned to the nursing home approximately 4 hours later with no changes in her orders. Resident #3 continued 1 to 1 supervision until [DATE] when the resident was admitted to a geriatric mental health center for acute treatment. Resident #2 received neurological checks for 72 hours with no adverse findings. Resident #2 developed a faint bruise on her lateral right forehead where she had been struck by Resident #3. Review of the Psychiatric Periodic Evaluation for Resident #3 dated [DATE], showed .persisting behaviors .dementia, anxiety, restlessness, agitation, irritability .aggression .distressing psychosis .patient is being cross tapered from .Seroquel to Brexpiprazole [an antipsychotic drug indicated for use in dementia] due to ineffectiveness of Seroquel .staff reporting tolerating this change .but do not report any improvement in patients restlessness, agitation, aggression .patient hit another resident yesterday .continues to have intrusive behaviors .today she is alert and interactive .is calm and pleasant .she is confused, delusional and oriented to person only .cognition remains severely impaired .Most recent GDR [gradual dose reduction] [DATE] cross taper to .Brexpiprazole . Continued review showed .patient needs .secure behavioral unit . Review of the care plan for Resident #3 updated on [DATE], showed .Behavior Problem .Physically abusive, socially inappropriate, verbally abusive, wandering .intervention . address wandering by walking with resident .redirect from inappropriate areas .engage in diversional activity .assess identification of unmet needs .identify events that trigger behaviors . Review of Psychiatric Hospital Records dated [DATE], showed Resident #3 was admitted and was diagnosed with Acute Urinary Tract Infection (UTI) and Unspecified Dementia with Behaviors and Agitation. Resident #3's UTI was treated with oral antibiotics and the resident's behaviors stabilized. Resident #3 was discharged back to the facility for continued long term care on [DATE]. During observations and interviews with Resident #3 which were conducted throughout the survey between [DATE] and [DATE] and included brief interviews at varied times of day. Resident #3 who was confused had no recall of the altercation and showed no signs of agitation or aggression. Resident #3 was observed on [DATE] at 1:06 PM, [DATE] at 5:02 PM and [DATE] at 3:20 PM, with 1 to 1 supervision during assistance with large group activities in which the environment was more stimulating or while in common areas socializing with other residents and staff and the intervention was effective. During an interview on [DATE] at 1:10 PM, LPN #1 (the unit charge nurse) reported she was not on duty at the time of the incident. LPN #1 reported she was updated on the situation by the DON on her return to work. LPN #1 reported she participated in a Quality Assurance review of the incident and Resident #3 had been placed on 1 to 1 supervision until she was transferred to Psychiatric Care. LPN #1 reported Resident #3 was free of verbal or physical aggression towards others. LPN #1 reported Resident #3 was profoundly confused at baseline and had poor safety awareness. LPN #1 stated the facility provided close supervision of the resident. LPN #1 reported the facility revised Resident #3's care plan to always include monitoring of her location and 1 to 1 supervision when in groups or socializing on the unit if she became anxious or agitated. LPN #1 reported thus far increased monitoring of Resident #3 had prevented any recurrent altercations or falls or severe agitation due to overstimulation. During an interview on [DATE] at 1:44 PM, Resident #4 (witness to the altercation between Resident #2 and Resident #3) was alert and oriented to time, place, and circumstances. Resident #4 stated Resident #2 was in the day area and suddenly became agitated and began to yell and repeatedly made Indian sounds (inappropriate ethnic and racist sounds) which caused Resident #3 to become agitated. Resident #3 walked over to Resident #2 and Resident #2 yelled out at Resident #3 which triggered Resident #3 to grab Resident #2's arm and then slapped Resident #2 on the side of the face. Resident #4 stated after Resident #3 slapped Resident #2, Resident #3 stepped away, and Resident #2 sat on a chair and continued to yell incoherently. Resident #4 called for nearby staff to intercede and the two residents were separated. During an interview on [DATE] at 1:52 PM, LPN #2 stated she was not on duty when the incident occurred but was briefed by the DON about the altercation on her return to work the next day. LPN #2 reported Resident #2 was very demented, continuously confused and would often wander the unit looking for lost children, or going to board a train, and required frequent redirection and often called out or yelled randomly. LPN #2 stated Resident #3 had severe cognitive decline, poor impulse control and had intermittent agitation was prone to wandering in the facility and frequently attempted to help other residents. LPN #2 reported several weeks after the altercation Resident #2 expired at the facility of complications of COVID 19 and renal disease. LPN #2 reported Resident #3 had not experienced recurrent resident versus resident altercations since her return from psychiatric care but still required close monitoring when interacting with peers or in group activities or in situations in which the environment was noisy to avoid overstimulation. LPN #2 reported Resident #3 still tried to help other residents and had periods of increased confusion and intermittent agitation, but was care planned for 1 to 1 supervision during those times which had been effective LPN #2 reported Resident #3 was followed by the Psychiatric PA weekly. During interview on [DATE] at 2:02 PM Certified Nurse Aide (CNA #3) reported she regularly cared for Resident #3 and had separated her from Resident #2 during the altercation on [DATE]. CNA #3 reported Resident #3 was a former counselor and believed she was still working at a rehabilitation center frequently. CNA #3 reported since Resident #3 had returned from the Psychiatric Hospital she had not been involved in any resident versus resident incidents. CNA #3 reported staff were trained to monitor Resident #3's whereabouts when on the unit and to provide 1 to 1 as needed during periods of increased confusion or agitation after the Resident returned from the hospital and stated it had been effective. CNA #3 reported staff had incorporated a daily nap after lunch for Resident #3 into her daily routine which appeared to reduce her evening and nighttime confusion and bouts of agitation. During interview on [DATE] at 2:13 PM CNA #4 reported she was working another unit on the day of the incident but was advised of 1 to 1 for Resident #3 the next day when she staffed the 400 wing. CNA #4 reported Resident #3's behaviors had improved since her return from the hospital, but the resident still required close monitoring and redirection at times especially when in the day area or when wandering. CNA #4 reported she had not observed Resident #3 with aggression since the resident's return to the facility. CNA #3 confirmed she had received training related to the incident and was able to discuss interventions in place to prevent agitation or aggression in Resident #3 in response to the incident. During an interview on [DATE] at 2:26 PM, in the conference room, DON and Administrator confirmed the facility investigation determined Resident #3 was the aggressor in the altercation on [DATE]. The Administrator and DON confirmed Resident #3's actions were willful and the facility had failed to prevent abuse of Resident #2. During an interview on [DATE] at 2:00 PM, the Medical Director confirmed the facility Quality Assurance review of the altercation was discussed with him as reported by the DON and Administrator and ongoing QA reviews of the corrective actions implemented in response to the altercation were planned to maintain sustained compliance. The facility submitted an acceptable Plan of Correction on [DATE] which was validated onsite by the surveyor on [DATE]-[DATE]. Non-compliance was noted from [DATE]-[DATE]. The Plan of Correction was summarized as follows: 1. At the time of the incident, the facility immediately separated and performed physical examinations on both residents. Resident #2 suffered 2 small skin tears on her upper right arm which were treated with steri strips. Neurological checks for Resident #2 were implemented and performed. Resident #3 was placed on direct 1 to 1 supervision until transferred to the local hospital for psychiatric evaluation after interview by local law enforcement officers. No other residents were impacted by the incident. 2. The facility Administrator, Director of Nursing, and Medical Director held an ad hoc Quality Assurance Meeting by telephone to discuss the incident once the facility investigation was underway on [DATE]. The Physician ordered Resident #3 transferred by ambulance to a local hospital for psychiatric evaluation. 3. Resident #3 was examined in the local hospital emergency room on the night of [DATE] where it was determined she did not require acute psychiatric care by the emergency room physician. Resident #3 was discharged back to the nursing home with no changes to her regimen ordered. Resident #3 was placed back on direct 1 to 1 supervision pending referral to acute mental health care by the facility. 4. Resident #2 was examined by the Psychiatric Physician Assistant (PA) on the morning of [DATE] and adjustments to her psychotropic regimen were made. Resident #2 had no recall of the incident when examined by the Psychiatric PA. Medication adjustments were implemented to address continued behavioral and psychological symptoms of dementia (BPSD) which pre-existed the incident and were identified as possible triggers for the altercation in the facility investigation. The facility social worker assessed both Resident #2 and Resident #3 on [DATE] and neither resident recalled the altercation. The social worker referred Resident #3 to a geriatric mental health hospital for acute care on the afternoon of [DATE] at the directive of the Psychiatric PA. The mental health hospital agreed to admit Resident #3 on [DATE] when a bed became available. Resident #3 was maintained on direct 1 to 1 supervision without incident until the transfer was executed. The social worker began to seek secure unit placement resources over a multi-county area for Resident #3 with consent of Resident #3's responsible party in the event her behaviors could not be stabilized. 5. Resident #3 was transferred to acute mental health care by the facility van on [DATE] without incident. Resident #3 had no recall of the altercation. Resident #3 was admitted to geriatric mental health for acute care. The facility Administrator and DON held a second Ad Hoc QA meeting to discuss the investigative findings and interventions ongoing. 6. Neurological checks for Resident #2 were completed on [DATE] with no negative findings. Care Plans for both residents previously updated on [DATE] were reviewed by members of the Quality Assurance Team which included the DON, Social Worker and Administrator. The altercation was added to the agenda for follow up by the Quality Assurance Team for February 2024. Brief Staff in-services related to the facility abuse policy and behavioral monitoring for Resident #2 were completed. 7. The facility completed 5 day follow up documentation and transmitted additional findings as requested to the State Agency on the morning of [DATE]. 8. Resident #3 was stabilized and returned to the facility from the mental health hospital on the afternoon of [DATE]. Resident #3's care plan was updated to reflect enhanced behavioral monitoring/ precautions while in common areas outside her room and additional 1 to 1 supervision as needed when changes in behavior occurred. Staff training related to the new interventions were completed the same day by the Director of Nursing. The facility social worker and administrator contacted a total of 5 alternate facilities with secure memory care units, all of whom declined to admit Resident #3 between [DATE] and [DATE]. 9.Resident #3 was examined by the Medical Director on [DATE] and the Psychiatric PA on [DATE] for routine follow up care and no new issues with behaviors or medical co-morbidities were noted. The Psychiatric PA conferred with Resident #3's responsible parties and additional titration of psychotropic medications were implemented along with routine lab monitoring related to new medications put in place by the mental health hospital were completed. Resident #3 remained free of aggressive behaviors and remained in the facility with regular follow up by the mental health service. Resident #3 continues to receive weekly follow up visits by the Psychiatric PA for medication management and behavioral monitoring. The facility has on call access to services with the mental health provider 7 days weekly. During interviews 4 staff which, included LPNs #1 and #2, Certified Nurse Aides CNAs #3 and #4, interviewed were knowledgeable of the incident of [DATE], the new care plan interventions in place to prevent recurrent altercations for Resident #3, as needed line of sight monitoring for the resident when in common areas or in activities with peers, appropriate situations to implement 1 to 1 supervision and all reported her condition had substantially improved since return to the facility from acute care. Abuse interviews with 6 clinical personnel and 3 non-clinical personnel showed all were aware of the facility abuse prohibition policy and reporting requirements. All personnel interviewed could define abuse and neglect as defined in Federal Requirements and confirmed in-service training was provided them after the incident between Resident #2 and Resident #3 as reported by the DON. All interviewed staff were knowledgeable of non-pharmacological interventions related to behaviors. Review of incident logs showed no evidence Resident #3 was involved in additional altercations since [DATE]. No other resident versus resident altercations were noted to have occurred at the facility in the prior 6 months of records reviewed. At the time of the survey, efforts by the facility to obtain secure unit placement for Resident #3 remained ongoing. The facility had expanded the search for secure unit placement for Resident #3, to facilities throughout the region with consent of Resident #3's responsible party.