**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 6. Review of the medical records and facility investigation documentation revealed a resident to resident altercation occurred between Resident #1 and Resident #6 on 4/27/2024. Review of the medical record revealed Resident #1 was admitted to the facility on [DATE] with diagnoses including Dementia, GAD, Chronic Obstructive Pulmonary Disease, and Gout. Review of quarterly MDS assessment dated [DATE], revealed Resident #1 scored a 5 on the BIMS assessment, which indicated severe cognitive impairment and required supervision with transfers and walking. The resident exhibited no negative moods or behaviors. Review of the Nurse's Progress Notes for Resident #1 dated 4/27/2024 at 8:19 PM revealed .Notified by staff that at approximately 6:10 PM [Resident #1] was propelling in wheelchair by room [Resident #6's room] .[Resident #6] who was walking behind his wheelchair then hit him [Resident #1] open handed on the left side of his face .no injuries noted .will continue to monitor . Review of a skin assessment document for Resident #1 dated 4/27/2024, revealed no new skin issues. Review of the Nurse's Progress Notes for Resident #6 dated 4/27/2024 at 8:23 PM, revealed .At approximately 6:10 PM [Resident #6] .was walking outside of him [his] room behind another resident [Resident #1] in a wheelchair .[Resident#6] suddenly hit .[Resident #1] .across the left side of face with an open hand .residents immediately separated .[Resident #6] placed on 1 on 1 observation. Order received .to send out for psych [psychiatric] evaluation and to keep him 1 on 1 if he returns from ER [Emergency Department] .Notifications made to police, APS, Ombudsman, and Resident #6's son . Review of a witness statement dated 4/27/2024, revealed LPN BB documented .per CNA [Resident #6] hit [Resident #1] .open handed and from behind .in the face . Review of a witness statement dated 4/27/2024, revealed .[CNA AA] at the tray cart outside of [Resident #6's room] when I witnessed [Resident #6] hit [Resident #1] with an open hand from behind .I immediately called for help and they were separated . During a telephone interview on 6/5/2024 at 8:16 PM, CNA AA stated she was picking dinner trays up in hall on 4/27/2024 at about 6:00 PM, and Resident #1 was in a wheelchair at the door of Resident #6's room. The CNA stated Resident #6 came up behind Resident #1 and hit him open handed on the left side of the head around the ear and cheek. The CNA called for the nurse to help. LPN BB and another CNA got the residents separated. After residents were separated, Resident #1 was taken to the dining room, and Resident #6 went into his room. The CNA stated both residents were assessed by the nurse, and no injuries were noted. During an interview on 6/6/2024 at 8:45 AM, with the DON, RN E and the Administrator, the Administrator stated he was made aware of a resident-to-resident altercation on 4/27/2024 at 6:10 PM, and he came to the facility. The Administrator stated the residents were separated immediately. Resident #6 was sent for a psychiatric evaluation on that night and returned the next day. The video evidence revealed that Resident #1 had waved as he passed Resident #6's room, and Resident #6 made contact with Resident #1 from behind with an open-handed slap to side of head, and the staff saw it on camera. Video footage was no longer available for review. 7. Review of the medical records and facility investigation documentation revealed a resident to resident altercation occurred between Resident #26 and Resident #24 on 11/25/2022. Review of the medical record revealed Resident #26 was admitted to the facility on [DATE] with diagnoses including Dementia, GAD, Recurrent Depressive Disorders, and Impulse Disorders. Continued review of the medical record revealed Resident #26 expired in the facility on 3/31/2024. Review of a comprehensive care plan for Resident #26 dated 9/13/2022, revealed .Dementia with behaviors, GAD, Depression, and Mood Disorder .Psychosocial Well-Being .Behavior Problem . with appropriate interventions in place. Review of a quarterly MDS assessment dated [DATE], revealed Resident #26 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Resident #26 exhibited no behavioral symptoms during the look back period. Review of LPN T's Nursing Progress Note for Resident #26 dated 11/25/2022 at 5:44 PM, revealed .Res [Resident] was in an altercation with another resident. Other resident [Resident #24] grabbed her [Resident #26] by wrist and was aggressively swinging it. Nurse and CNA's intervened and removed this resident from situation. Nurse checked resident left wrist for injury. No injury noted. Res not reporting any kind of pain. Head to toe skin assessment performed no injuries noted .weekend supervisor made aware of situation .notified .administrator .FNP [Family Nurse Practitioner] . Review of a CNA Skin Care Alert document for Resident #26 dated 11/25/2022, revealed .[no] areas noted . Review of a comprehensive care plan for Resident #26 dated 11/26/2022, revealed the care plan was updated and included interventions for increased monitoring and supervision with psychosocial support as needed. Review of a NP Note for Resident #26 dated 11/28/2022, revealed .involved in an altercation with another resident this visit is for assessment of her overall condition after .Physical Exam .Alert .no acute distress .Assessment & Plan .Patient was involved with altercation where was grabbed by a male resident, there was quick intervention by staff and no apparent injury to patient. She has no recollection of the event during assessment today, she has full range to baseline of all extremities, continues to ambulate, is not experiencing any psychosocial or emotional distress . Review of a PSYCHIATRIC EVALUATION for Resident #26 dated 11/29/2022, revealed .seen today per request .Resident recently involved in resident to resident altercation, another resident had grabbed her by her wrist and was aggressively swinging it. Staff intervened residents were separated. Visited with resident she is alert, oriented x 2 (to person and place), calm and pleasant, asking if she was going home today, states she is waiting on her family to pick her up .Easily redirected. No noted increased anxiety or agitation. No signs or symptoms of depression .Continues to participate in meals in the dining room area. Socializing with other residents appropriately no noted related distress .MENTAL STATUS EXAMINATION .Cooperative .Calm .Alert .Person .Place .DIAGNOSIS, ASSESSMENT AND PLAN .Continue current psychotropic medications per orders .Continue appropriate non-pharmacological interventions to aid in management of mood and behaviors as needed .Monitor for changes in mood or behaviors .Follow-up .As needed . Review of the Every 15 Minute Check List for Resident #26 dated 11/25/2022, revealed the resident was checked every 15 minutes starting on 11/25/2022 at 5:00 PM and ending on 11/28/2022. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia, Muscle Weakness, GAD, Impulse Disorder, and Recurrent Depressive Disorder. Review of a comprehensive care plan for Resident #24 dated 10/5/2022, revealed .Behavioral .diagnoses of Dementia, Depression, Impulsiveness, and anxiety and is experiencing episodes of restlessness, impulsiveness, and verbal aggression. History of physical aggression towards others . with appropriate interventions in place. Review of a quarterly MDS assessment dated [DATE], revealed Resident #24 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. Resident #24 exhibited no behavioral symptoms. Review of the Physician Order Report for Resident #24 dated 11/23/2022 revealed an order for Divalproex (Depakote-medication used to treat seizures and Bipolar Disorder) 125 mg delayed release sprinkles by mouth once daily. Review of LPN T's Nursing Progress Note for Resident #24 dated 11/25/2022 at 5:27 PM, revealed .Res was witnessed per nurse grabbing another resident [Resident #26] by the wrist. Nurse and CNA's intervened. Res grabbed staff [CNA D] by wrist causing a cut to her [CNA D] left wrist. then grabbed her [CNA D] by hair, nurse intervened and removed resident from situation. Contacted weekend supervisor .spoke with resident, resident gave no reason for altercation with other resident or staff. Resident separated from other residents during mealtime. Q [every] 15min [minute] checks initiated . contacted [Administrator] and .Fnp [Family Nurse Practititioner] . Review of the CNA Skin Care Alert form for Resident #24 dated 11/25/2022, revealed the resident had no new skin problems. Review of the Every 15 Minute Check List for Resident #24 dated 11/25/2022, revealed the resident was checked every 15 minutes starting on 11/25/2022 at 5:00 PM and ended on 11/28/2022 at 6:00 PM. Review of a comprehensive care plan for Resident #24 dated 11/26/2022, revealed the care plan was updated to include the resident-to-resident altercation with increased monitoring and supervision of the resident with psychosocial support as needed. Review of a NP Note for Resident #24 dated 11/28/2022, revealed .seen today in review of his condition after a resident to resident involved incident .has dementia, generalized anxiety, impulse disorder .as he was ambulating he reached out to a female resident who was walking by and grabbed her walker pulling it toward him .Apparently the female resident grabbed her walker pulling it back toward her and he reached out to grab her by the wrist the situation de-escalated quickly and he was placed back in his wheelchair for stability .has had progressive decline in his dementia process and was having increased agitation over the last several weeks .started on divalproex [medication used to treat seizures and bipolar disorder] recently and did not show significant change in condition based on his behaviors, this was a low dose .comanaged with psychiatric nurse practitioner .Physical Exam .Alert .no acute distress .Psychiatric: Has orientation to self only .Assessment & Plan .Dementia with behavioral disturbance .Impulsiveness .Agitation .Patient's cognitive processing as well as his reaction to incidents fluctuates throughout the day .He does not respond well to any kind of aggressive or abrupt conversation .will have ongoing comanagement with psychiatric nurse practitioner divalproex has been increased to 250 mg daily .will be monitored for progression of symptoms or condition change . Review of the Physician Order Report for Resident #24 dated 11/1/2022 - 11/30/2022, revealed an order with a start date of 11/28/2022 for Divalproex delayed release sprinkles 250 mg by mouth daily for Unspecified Dementia without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, and Anxiety. Review of the PSYCHIATRIC EVALUATION for Resident #24 dated 11/29/2022, revealed .seen today per request for evaluation of mood and behaviors. Has history of dementia, impulsive behaviors, anxiety can be aggressive at times .recently involved in resident [to] resident altercation, staff report resident had grabbed another resident by the wrist and was aggressively swinging it. Resident has history of impulsive behavior, triggers seems to vary. Staff had reported resident had been ambulating, bumped in to another resident's walker other resident had apparently moved away this upset this resident, staff intervened separating the resident's .alert oriented x1 (to person) makes good eye contact, pleasant in interaction no noted anxiety, restlessness during interview no inappropriate statements during interview. Depakote [Divalproex] sprinkles 125 mg daily initiated last visit due to inappropriate and impulsive behaviors. Depakote sprinkles increased to 250 mg daily on 11/28/2022 . MENTAL STATUS EXAMINIATION .Calm .Alert .Person .DIAGNOSIS, ASSESSMENT AND PLAN .Impulse control disorder .GAD .Unspecified dementia .with other behavioral disturbance .Recommendations .Psychotropic medications reviewed .Continue current psychotropic medications per orders continue to monitor for effectiveness .Continue appropriate nonpharmacological interventions to aid in management of mood and behaviors as needed .Follow-up .As needed . During an observation and interview on 6/5/2024 at 10:53 AM, Resident #24 was observed seated in a repositioning chair in the hallway interacting with other residents. Resident #24 was pleasant during interactions with staff and residents. Resident #24 reported to this surveyor that he had been at the facility for .about 5 months . The resident stated he was treated well in the facility and denied any altercations with other residents. Review of facility investigation documentation revealed a resident-to-resident altercation occurred on 11/25/2022 at 5:20 PM in the Bridge unit (secured gated community) between Residents #24 and #26 and no bodily injury occurred. Resident #24 was the alleged perpetrator and Resident #26 was the alleged victim. Residents #24 and #26 had no prior resident to resident altercations. Witnesses to the altercation included LPN T, CNA D, and CNA J. It was noted .Resident [Resident #24] had escalating behavior and became upset and grabbed female resident [Resident #26] by the left wrist. The two residents were immediately separated by facility staff .Residents were immediately separated and 15 minute checks initiated. NP was notified of incident as well as each residents responsible party .Staff interviews reveal that [Resident #24] pulled at [Resident #26]'s walker and then pulled her wrist .NP visited with patients .Conclusion .It was verified that [Resident #24] did grab [Resident #26'] wrist. The full intent is unknown as [Resident #24's] has a BIMS score of 4/15 and [Resident #26] has a BIMS score of 3/15 . Review of a Witness Statement dated 11/25/2022, revealed .I [CNA D] was in the clean utility room, when I opened the door, I heard [LPN T'] say no [Resident #24], no. He was standing trying to hit anyone in reach. He had grabbed .[Resident #26] by the .wrist. [LPN T] and [CNA J] and I was trying to keep him in his chair and away from other residents. He grabbed me by the right arm and the hair on the back of my head resulting in .me having a skin tear on my right wrist . Review of a Witness Statement dated 11/28/2022, revealed .I [CNA J] was sitting at Bridge nurse desk then I saw [LPN T'] get up and say no so I got up to see and [Resident #24] was standing trying to hit and kick at [LPN T] so I tried to get him to calm down while [LPN T] got his chair then we tried to get him to sit then [CNA D] came to help and he started to try and hit and kick [CNA D]. He [Resident #24] got ahold of her [CNA D] wrist then get [got] the back of her hair and started shaking her head around. we tried to get him to Let go. Finally got him to let go and got him separated from everyone . During an interview on 6/4/2024 at 3:06 PM, CNA D stated she was in the clean utility room of the Bridge unit at the time of the altercation between Residents #24 and #26 and heard Resident #24 yelling .you're not taking my children . CNA D responded to the hallway of the Bridge Unit and observed LPN T and CNA J separating Residents #26 and #24 and trying to get Resident #24 to sit back down in his wheelchair. CNA D assisted CNA J and LPN T to get Resident #24 back into his wheelchair and as the resident sat down he grabbed CNA D by the hair and let go after a few seconds. Resident #24 returned to .being sweet . within 10 minutes of the incident. Resident #26 was taken to the dining room after the altercation and was fine as soon as she got away from Resident #24 and had no change in behaviors after the incident. There had been no previous altercations between the residents. Resident #24 would get agitated and aggressive with staff at times and would calm down quickly with a change of staff or redirection to an activity that he enjoyed. During a telephone interview on 6/4/2024 at 4:33 PM, LPN T stated she recalled the resident-to-resident altercation between Residents #24 and #26. The altercation occurred on the Bridge Unit in the hallway. Resident #26 was walking down the hallway with her walker and Resident #24 was propelling himself in his wheelchair. As Resident #26 passed Resident #24 in the hallway, Resident #24 .grabbed her [Resident #26] wrist .hard .and would not let go . LPN T was unable to recall what Resident #24 said while grabbing Resident #26's wrist. LPN T stated Resident #26 did nothing to provoke the altercation and the interaction was .definitely unwanted . by Resident #26. LPN T, CNA D, and CNA J responded immediately and separated the residents. LPN T stated Resident #26 was not injured. Resident #24 grabbed CNA D's wrists and hair while the staff were separating the residents. Resident #26 went into the dining room after the altercation and had no change in behaviors after the incident. LPN T was unaware of any previous altercations for either resident. Resident #24 was resistant to care at times but was easily redirected. During a telephone interview on 6/5/2024 at 2:48 PM, CNA J stated she had not witnessed Resident #24 grab Resident #26 but did see Resident #24 letting go of Resident #26's wrist when she responded to assist LPN T to separate the residents. CNA J stated she was unable to recall what Resident #24 said about the altercation and recalled that Resident #26 said .he grabbed me . The residents were separated and had no injuries or change in behaviors after the altercation. CNA J was unaware of any previous altercations for either resident and stated Resident #24 was agitated at times and was easily redirected with watching sports or a snack. 8. Review of the medical record and facility investigation documentation revealed a resident to resident altercation occurred between Resident #27 and Resident #24 on 3/1/2023. Review of the medical record revealed Resident #27 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses including Dementia with Other Behavioral Disturbance, GAD, MDD, and Insomnia. Review of the comprehensive care plan for Resident #27 dated 1/9/2019, revealed .Behavioral .Resident has diagnosis of Dementia with behaviors, GAD, and MDD [Major Depressive Disorder] . with appropriate interventions in place. Review of a quarterly MDS assessment dated [DATE], revealed Resident #27 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Resident #27 exhibited no behaviors during the look back period. Review of the Nursing Progress Notes for Resident #27 dated 3/1/2023 at 5:04 PM, revealed .involved with .[Resident #27] : [to] .[Resident #24] altercation .[Resident #27] noted to be the victim. Nursing immediately separated the residents .head to toe assessment completed .reddened area noted to the left cervical area but completely resolved shortly after the incident .took to therapy post the incident and displays no s/s [signs and symptoms] pain, emotional distress, and does not recall the incident at this time. Q [every] 15 min checks initiated .NP and Psych NP notified of incident as well . Review of the CNA Skin Alert form for Resident #27 dated 3/1/2023, revealed the resident had a red mark to the left neck area . Review of the Every 15 Minute Check List for Resident #27 dated 3/1/2023, revealed the resident was checked every 15 minutes starting on 3/1/2023 at 3:00 PM and ending on 3/4/2023 at 3:00 PM. Review of the PSYCHOSOCIAL/BEHAVIOR Care Plan for Resident #27 dated 3/1/2023, revealed the resident had increased monitoring and supervision with psychosocial support provided. Review of a Social Services Progress Note for Resident #27 dated 3/2/2023 at 6:49 AM, revealed .spoke with resident on 03/02/23 [3/2/2023] .Resident could not explain what had happened. No visible injuries. What was reported was that resident was grabbed at the shoulders and forced to put her head down on the table by another resident [Resident #24] .resident states it did not happen . Review of a NP Note for Resident #27 dated 3/3/2023, revealed .seen today for .resident to resident altercation as well as oversight XXX[AGE] years old and she is a resident on the bridge secure unit she has known dementia with behavioral disturbance, anxiety and major depression .Physical Exam .Alert .no acute distress .Patient is pleasant during this interaction .Assessment & Plan . Resident to resident altercation .She was the recipient of altercation during this interaction. There was no injury that occurred . Review of a PSYCHIATRIC EVALUATION for Resident #27 dated 3/8/2023, revealed .Resident recently involved in resident to resident altercation. Resident was allegedly grabbed at the shoulders and forced to put her head down on the table by another resident. Resident has no recall of this happening. No reports of increased anxiety or agitation. No worsening depressive signs or symptoms. No reports of new or worsening mood and behaviors no related distress . During an observation on 6/4/2024 at 3:45 PM, Resident #27 was observed seated in a wheelchair in the dining room working a puzzle. The resident was unable to answer the surveyor's questions, no behaviors were noted. During an observation on 6/5/2024 at 10:26 AM and 3:29 PM, Resident #27 was seated in a wheelchair at a table in the dining room watching TV. The resident was unable to answer any of this surveyor's questions, no behaviors were noted. Review of a quarterly MDS assessment dated [DATE], revealed Resident #24 scored a 4 on the BIMS assessment which indicated the resident had severe cognitive impairment. Resident #24 exhibited .Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) . Review of a Nursing Progress Note for Resident #24 dated 3/1/2023 at 4:52 PM, revealed .Resident noted to have a resident:resident [Resident #24 to Resident #27] altercation. Resident himself was the aggressor. Nursing staff immediately separated residents and completed an assessment. No injury noted to resident. DON notified NP and Psych NP. New medication orders received. Ativan 0.5 mg PO BID [twice daily] PRN [as needed] x [times] 14 days and Increase am [morning] Depakote dose to 375 mg. Q 15 min checks initiated .Resident noted to be calm post the incident and no emotional distress or outburst observed. Nursing to continue to monitor for any physical aggression attempts or behavioral changes . Review of CNA Skin Alert form for Resident #24 dated 3/1/2023, revealed .clear .no areas of concern . Review of the Every 15 Minutes Check List for Resident #24 dated 3/1/2023, revealed every 15 minute checks were performed on Resident #24 starting on 3/1/2023 at 3:00 PM and ending on 3/5/2023 at 5:00 PM. Review of the PSYCHOSOCIAL/BEHAVIOR care plan for Resident #24 dated 3/1/2023, revealed the care plan had been updated to include the altercation with increased supervision and monitoring with psychosocial support as needed. Review of the PSYCHIATRIC EVALUATION for Resident #24 dated 3/1/2023, revealed .being seen today per request for follow-up evaluation inappropriate, impulsive behaviors, aggression, anxiety, agitation. Resident seen today on bridge unit .sitting up in his chair he is calm at present self-propelling throughout the hallways. I received a call from nurse later in the evening patient with increased anxiety, agitation, resident had grabbed another resident by the shoulders and forced to put her head down on the table .as needed Ativan 0.5 mg twice daily was ordered x14 days, Depakote a.m. [morning] dose was increased to 375 mg daily. We will follow-up next visit for patient response to recent psychotropic medication changes for further behaviors MENTAL STATUS EXAMINATION .Calm .Cooperative .Alert .Person .Delusions: Misidentification .Homicidal Ideation: No .DIAGNOSIS, ASSESSMENT AND PLAN .GAD .Impulse control disorder .Unspecified dementia .Pharmacy Orders: Ativan 0.5 mg tablet - Take 1 tablet by mouth twice a day as needed .Recommendations .Psychotropic medications reviewed .Ativan .diagnosis anxiety .Depakote .for mood disorder stabilization, impulsivity .Paxil .for depression and impulsivity .Continue appropriate nonpharmacological interventions to aid in management of mood and behaviors as needed . Review of the Physician Order Report for Resident #24 dated 3/1/2023 - 3/31/2023, revealed the resident's order for Divalproex 250 mg by mouth twice daily ordered on 1/26/2023 was increased to 375 mg daily in the morning and 250 mg daily at bedtime on 3/1/2023. An order for Lorazepam (Ativan) 0.5 mg by mouth twice daily as needed (PRN) for 14 days was also ordered on 3/1/2023. Review of a Social Services Progress Note for Resident #24 dated 3/2/2023, revealed .Resident could not explain what had happened. No visible injuries. What was reported was that resident had grabbed .[Resident #27] .by the shoulders and forced to put her head down on the table .[Resident #24] states it did not happen . Review of a NP note for Resident #24 dated 3/3/2023, revealed .seen today after he was the instigator and [in] a resident to resident altercation .He and a female resident were in the common area of the unit when he appeared on close circuit camera to have been the aggressor .history of intermittent physical aggression or attempts, easily agitates intermittently usually with his perceived provocation .His BIMS score is consistent with severe impairment .Cognitively fluctuates, difficulty with mood with switch changes at times, patient may have an eruption of verbal aggression but within minutes has forgotten about it. He has no recollection of poor behaviors .Physical Exam .Alert .no acute distress .Psychiatric: Cognitively impaired .history of poor judgment .oriented to self, not consistently to time or place, has some delusional thought process .Examples are perceiving others are against him, others in his face and trying to steal from him .Assessment & Plan . Pertaining to this situation patient was .aggressor, he shows no adverse effects or ongoing prolonged distress related to incident .Cognitively patient is showing progression of his dementia . Review of a Social Services Progress Note for Resident #24 dated 3/3/2023 at 3:17 PM, revealed .Resident still does not recall incident. He does not have any injurie [injury] and has not displayed any aggressive .behaviors .alert and pleasant at present . Review of the Physician Order Report for Resident #24 dated 3/1/2023 - 3/31/2023, revealed the following order dated 3/6/2023 for laboratory work including a Complete Blood Count (CBC), Comprehensive Metabolic Panel, Hemoglobin A1c, Lipid Profile, and Thyroid Stimulating Hormone (TSH) . On 3/15/2022 .paroxetine HCl [antidepressant medication] .20 mg .oral .DX: Other recurrent depressive disorders . Review of facility investigation documentation revealed a resident-to-resident altercation occurred on 3/1/2023 at 2:45 PM in the Bridge Unit common area witnessed by CNA Y. The alleged perpetrator was Resident #24. The alleged victim was Resident #27. CNA Y reported that Resident #24 pulled Resident #27's head towards the table by the neck of Resident #27's shirt. Resident #27 had .Redness on the skin in left cervical region, which has resolved by the time this report was submitted . Resident #27 was immediately removed from the area of Resident #24 and Resident #24 remained in sight of staff and every 15 minute checks were initiated. There were no changes to the alleged victim's behavior. Resident #24 was unable to recall the event. It was noted [Resident #24] has had previous behaviors in the past and can be redirected .Conclusion .The allegation was verified as he was seen on camera pulling residents shirt. However intent unable to be determined as both residents have a BIMS score of 3/15 .The residents were immediately separated and 15 minute checks began .Psych NP notified of incident and [Resident #24] medicine has been adjusted. Care plans reviewed and updated to monitor target behaviors . The state agency was notified of the altercation on 3/1/2023 at 4:28 PM. Review of a Witness Statement dated 3/1/2023, revealed .I [CNA Y] .was in room .taking a resident to the restroom. When I hear [Resident #27] yelling so I run out and I see [Resident #24] standing up and have a hold of [Resident #27] by her shirt and had her head on the table .I got [Resident #24] to let go of [Resident #27] and set him back in his chair. And made sure Every one Was ok. And got nurse. resident was immediately separated and [Resident #27] was taken by a staff member to .therapy . During an interview on 6/5/2024 at 10:28 AM, CNA Y stated she recalled the resident to resident altercation between Residents #24 and #27 in the dining room of the Bridge unit. CNA Y exited a resident room that opened directly into the dining room and observed Resident #24 holding onto the neck of Resident #27's shirt pushing Resident #27's head onto the table. Resident #24 was cursing and saying something about somebody taking something from him. Resident #27 did not have anything of Resident #24's. CNA Y immediately separated the resident's and Resident #24 was removed from the area. Resident #27 was unable to give any details about what had happened and Resident #24 said .she took it . There were no injuries and no change in behaviors for either resident. CNA Y was unaware of any previous issues between the residents. CNA Y stated Resident #24 had behaviors that were easily redirected with activities including fidget boards and taking the resident outside. 9. Review of the medical record and facility investigation documentation revealed a resident to resident altercation occurred between Resident #25 and Resident #25 on 4/6/2023. Review of the medical record revealed Resident #25 was admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses including Dementia, GAD, MDD, and Alzheimer's Disease. Continued review of the medical record revealed Resident #25 expired in the facility on 8/2/2023. Review of a comprehensive care plan for Resident #25 dated 1/11/2023, revealed, .dx of dementia, anxiety .depression and mood disorder . with appropriate interventions in place. Review of a quarterly MDS assessment dated [DATE], revealed Resident #25 scored a 3 on the BIMS assessment which indicated the resident had severe cognitive impairment. Resident #25 exhibited no behavioral symptoms during the look back period. Review of the Nursing Progress Notes for Resident #25 dated 4/6/2023 at 6:09 PM, revealed .involved with resident to resident altercation. Another male resident [Resident #24] observed swinging his arm backwards and hitting this resident in right upper arm as staff was attempting to separate residents. Head to toe assessment complete with no injury noted, ROM WNL [within normal limits], no visible marks on resident .Q 15 min checks initiated. DON visited with resident post incident and resident is pleasant, smiling, [TRUNCATED]