**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, it was determined for 1 of 5 sampled residents, that the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive assessment, the comprehensive person-centered care plan, and the resident's preferences. Specifically, a resident with multiple co-morbidities who had a change in condition, was hospitalized after failure to identify the change in condition in a timely manner. The deficient practice for resident 1 was found to have occurred at a harm level. Resident identifier: 1. Findings include: Resident 1 was admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included non-traumatic subdural hemorrhage, encephalopathy, epilepsy, end stage renal disease, hemiplegia and hemiparesis following cerebral infarct, history of falling, attention and concentration deficit following non-traumatic subarachnoid hemorrhage, Alzheimer's disease, dementia, and schizophrenia. Resident 1's medical record was reviewed on 1/3/24. Physician orders included: a. Olanzapine 5 mg tablet. b. Apixaban 2.5 mg tablet c. Aspirin 81 mg tablet d. Donepizil 10 mg tablet e. Divalproex 125 mg tablet f. Monitor for seizure activity every shift. Progress notes were reviewed and revealed the following: a. A provider progress note dated 9/28/23 revealed, admission visit with [resident's name removed] .She has a fall mat next to her bed and her bed is in the lowest position .Review with staff. They report that she has significant dementia and requires significant assistance with standing and pivoting. Per their report she normally can answer questions and usually follows directions .Assessment and Plan .fall precautions . monitor for change in condition .Data .continues with confusion, recurrent falls despite intervention .(P)atient has a baseline level of dementia that will require additional monitoring for an accurate clinical picture. They are also at increased risk for falls, medication side effects and complications related to their baseline level of confusion .Patient is on anticoagulants. These pose a significant risk of increased bleeding. Pros and cons of these medications have been reviewed with patient and they have elected to proceed. Patient is aware of potential of significant bleeding from minor trauma, GI (gastrointestinal) bleeds and closed head injury with associated complications .rec. (recommend) that we stop anticoag given her falls .[Resodent's name removed] appears to have significant impairment. Per report some of this is baseline and some of this is new post her recent decline in illness . She is a huge fall risk and is on anticoagulants, thus increasing her risk. b. A provider progress note dated 9/29/23 revealed, .No reports of illness but she was found on her bottom on the floor, no injury. c. A provider progress note dated 10/2/23 revealed, Recheck with [Resident's name removed]. (S)he has had recurrent falls in house and no related injury. Interventions in place and still falls. Continues with significant confusion and generalized weakness. No new illness, pain. Review her labs, doing well with dialysis. Nurse without concerns. d. An advanced skilled evaluation dated 10/3/23 at 10:21 AM, revealed the following, Neurologic: Resident obeys commands. Resident has weakness (baseline). PERRLA (pupils are round and reactive to light and accommodation): Yes. Mental Status: Resident requires cues. Resident is confused. Oriented to person. Confused: Chronic. Requires cues: Chronic. Level of cognitive impairment: Mild impairment (some confusion). Resident is coherent. Speech is clear. Language barrier: No. Resident makes self understood. Resident understands others .Mood and behaviors: Mood is pleasant, no unwanted behaviors witnessed .Safety: Call light is within reach. Resident is not on seizure precautions .Safety note: High fall risk .Functional: Able to move all extremities. Upper extremity ROM (Range of motion): No impairment. Lower extremity ROM: No impairment. Gait is unsteady. Balance is poor. e. An IDT (interdisciplinary team) progress note dated 10/3/23 at 6:20 PM revealed, Reviewed in risk management meeting. 9/26/23 @2030: CNA (Certified Nursing Assistant) notified nurse that resident was on the floor. FN (Floor Nurse) went into room to assess resident, noted her on the floor sitting on her buttocks. Her brief had stool on it and stool on the floor. Resident alert and talking. Assisted resident to get cleaned up and toilet her, then assisted her back into bed in a safe position and fall mat placed to side of bed. No injuries noted. ROM at baseline. Emergency contact notified. MD (medical doctor) notified. Intervention: Will assist and encourage resident to toilet before bed. f. An IDT progress note dated 10/5/23 at 3:31 PM revealed, Reviewed in risk management meeting. 9/28/23 @0556: Resident was found sitting on floor at nurses station. Resident stated she was trying to go home but didn't know where to go so she sat at the nurse station until someone came to help her. Assessed resident and then redirected resident back to room. No injuries noted. ROM at baseline. VS (vital signs) taken. Assisted resident back to bed. Family notified. MD notified. Intervention: Will evaluated med regimen with provider to ensure resident is supported in sleep regimen. Will offer diversional activity around 0500 to help residents morning routine. Note: It should be noted that there were no nursing progress notes related to resident 1 falling on 9/26/23 or 9/28/23. g. A nursing progress note dated 10/7/23 at 10:41 AM revealed, Pt (patient) was found by CNA sitting on her floor next to her chair. Pt stated she had slid onto the floor, RN (registered nurse) assessed for pain and injury. Pt denied Pain and No evidence of injury noted. Pt was placed on Neuro Checks r/t (related to) unwitnessed fall. Pt education on use of call light and walker for assistance with ambulation. MD and On Call RN notified as well as family. h. An additional nursing progress note dated 10/7/23 at 11:00 AM revealed, No changes in LOC (level of consciousness). No visible injuries. PERRLA (Pupils Equal, Round, Reactive to Light Accommodation). ROM intact. No increase in pain. Pt placed on Neuro checks. Added to alert charting. MD, UM, and Family notified. INTERVENTION: Dycem pad on WC (wheelchair). i. An advanced skilled evaluation dated 10/15/23 revealed the following, .Neurologic: Resident obeys commands. Resident has weakness (baseline). Resident complains of numbness (baseline). PERRLA: Yes .Mental Status : Resident is alert & (and) oriented x3. Oriented to time. Oriented to person. Oriented to place .Level of cognitive impairment: Alert. Resident is coherent. Speech is clear. Language barrier: No. Resident usually makes self understood. Resident usually understands others . Level of cognitive impairment: Alert. Resident is coherent. Speech is clear. Language barrier: No. Resident usually makes self understood. Resident usually understands others. Mood and Behavior : Resident has a flat affect. Flat affect - No recent change in mood. Resident sleeps intermittently. Resident does not wander at night. Resident's psycho-spiritual needs are met. Resident is not currently experiencing unwanted behavior(s). j. A nursing progress note dated 10/16/23 at 5:44 AM revealed, Note Text : Change in condition noticed during AM shift. AM nurse reports that resident not verbally responding to commands from staff or family members. This behavior continued through the night. VS WNL (Within Normal Limits). COVID test negative. Resident now able to follow physical commands, able to squeeze nurses hands and nod in response to commands. Resident now in dialysis. k. A nursing progress note dated 10/16/23 at 1:53 PM revealed, ADON (Assistant Director of Nursing)called residents dialysis center. Resident continued to have stroke like symptoms when she arrived to dialysis- they sent her to [Hospital name removed] ED (Emergency Department) for further work up. Will attempt to call for an update. [NOTE: No additional documentation regarding resident 1 was found in progress notes until readmission on [DATE].] A pre-dialysis form dated 10/16/23 at 4:07 AM revealed that resident 1 was confused and disoriented. The document stated resident 1's baseline was alert and oriented x 2. Comments included, Resident has not been verbally responsive for the past 20 hours. VS WNL COVID negative. A history and physical dated 10/16/23 from the hospital where the resident was sent documented, [AGE] year-old female patient with history of end-stage renal disease, SLE (systemic Lupus erythematosis), relatively recent recurrent subdural hematoma, apparently was doing well until about 24 hours ago when she was noted to have decreased level of consciousness. I spoke with her mother who saw her 2 days ago when she appears to be in her usual state of health, but noticed last evening when she visited with her at her assisted living facility that she was not communicative, and although she was able to eat she was not able to verbalize, and only moaned and screamed when touched. The patient was taken to her dialysis center today according to her schedule but was noted to be altered and brought to the ER (emergency room) for evaluation. In the ER she was found to have left-sided subdural hematoma and admitted for further evaluation and management. Patient herself is not able to answer questions or carry a conversation and only opens her eyes to verbal stimuli-which was reported in the ER note earlier this morning. Additionally, the note stated, Patient appears to be drooling occasionally at the mouth, without obvious facial asymmetry Her right upper extremity is flexed and with increased tone. On 1/3/23 at 10:49 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated if a resident was suspected to have a change in condition, she would do a full head to toe assessment, look at the resident's medications, any as-needed (PRN) medications, look at the last couple of progress notes for trends, and inform the Director of Nursing (DON), Physician (MD), and the resident's family. RN 2 stated she would follow orders or instructions for what to do next. If a resident needed to be sent out, there was an Situation, Background, Assessment, and Recommendation (SBAR) that would be completed, a change of condition form and a transfer form. RN 2 stated she would write a progress note. RN 2 stated there was a binder at the nurse's station with a check list of steps to take for a change in condition. RN 2 stated regarding falls, it would depend on if the fall was witnessed or not witnessed. RN 2 stated she would ask the resident about hitting their head or another body part, obtain vital signs, check the resident's range of motion and level of consciousness. RN 2 stated she would assess for any changes in behavior, look for blood, redness, or swelling, and then notify the MD, DON, and the resident's family. RN 2 stated she would write a progress note and fill out an indecent report, obtain x-rays if ordered, provide fluids, or other interventions as ordered and document them. On 1/3/23 at 10:58 AM, an interview was conducted with RN 3. RN 3 stated that based on the resident's baseline, if he felt there was a change, he would notify the Assistant Director of Nursing (ADON), and notify the MD. RN 3 stated he would document the changes in a progress note. If there was a change in the level of consciousness, RN 3 stated he would make sure the resident was safe, then contact the ADON. RN 3 stated if the ADON was not available, he would contact the next on-call (usually the provider or MD). RN 3 stated he could not think of any other physical paperwork he would need to do. RN 3 stated he would ask the Certified Nursing Assistant (CNAs) to monitor the resident more closely. RN 3 stated he would let someone else know depending on the severity of the situation. RN 3 stated if a resident had a fall, he would make sure the resident was safe, assess them, notify the doctor and the resident's emergency contact, and complete risk management paperwork. RN 3 stated if the fall was unwitnessed he would complete do neurological (neuro) checks. RN 3 stated he would follow the physician recommendations. On 1/3/23 at 11:10 AM, an interview was conducted with the ADON. The ADON stated he was in charge of the skilled nursing side of the facility. The ADON stated if there were skilled nursing issues, the staff would contact him first. The ADON stated the nurse would assess the resident and see what the change in condition was and notify the on-call provider. The ADON stated the nurse would then let the unit managers know, and depending on the severity, follow the protocols in place. The ADON stated protocols might mean sending to the resident to the emergency room (ER), contacting family, or completing forms that nurses fill out if the situation was not urgent. The ADON stated nurses could reach out to the provider through Tiger text. The ADON stated that at night, nursing staff were to bypass the tiger text and call the provider directly, and document that communication. The ADON stated that he and the DON were included in the communications so they could see the chatter about what happened. The ADON stated orders were reviewed every day and discussed in the leadership huddle to ensure follow-through. The ADON stated regarding resident 1, during the night shift she had stroke-like symptoms and the provider was notified. The ADON stated neuro checks were being done. The ADON stated an evaluation had been completed a short time prior and a stroke was ruled out. The ADON stated the provider was notified and resident 1 was going to be sent out and then the provider was informed that she was doing better. The ADON stated the provider told staff that if resident 1 was doing better, to send her to dialysis. The ADON stated while enroute to dialysis, resident 1 had another stroke-like event and the dialysis center sent her to the ED. The ADON stated he was not sure if the issue was metabolic in nature. The ADON stated the dialysis center called the facility to let them know what was happening. The ADON stated he would look to see if he had any additional documentation (neurochecks, communication between the provider and nursing staff, communication between the ADON or DON OR incident reports) about that event and provide the information to the surveyor. The ADON stated that resident 1 came back to the facility after hospitalization, and the 3rd party dialysis center would no longer provide dialysis due to the resident's condition. The ADON stated resident 1 was transferred to another facility where in-house dialysis could be provided. On 1/3/23 at 12:10 PM, an interview was conducted with the DON and the ADON when additional documentation was not received. The DON stated that the communication between the physician/provider and the nurse was only kept in the electronic medical record for 7 days, and then went to the trash. The DON stated that neuro checks were not completed since resident 1 did not hit her head during her unwitnessed falls. The DON stated that both she and the ADON were aware of the incident on 10/16/23 and that resident 1's cognition had improved to the point that she could go to dialysis. The DON stated that the dialysis center did call as they had concerns that the resident was not medically stable when she arrived for dialysis. Note: It should be noted that no additional documentation (neuro checks, physician, provider or administrative staff communication, or incident reports) was provided to the State survey agent. On 1/3/23 at 1:28 PM, an interview was conducted with RN 1. RN 1 stated resident 1 had a stroke prior to being admitted on [DATE] and was not herself and her baseline had changed from prior admissions. RN 1 stated it was hard to tell if she was having physical problems or having behaviors on 10/15/23. RN 1 stated resident 1 was going in and out of being verbal during his shift. RN 1 stated resident 1's mother came to the facility between 5:30 and 6 PM to help resident 1 with dinner, and her mother did not know what to think about resident 1's disposition. RN 1 stated resident 1's was acting strange during her dinner meal on 10/15/23. RN 1 stated resident 1 had become non-verbal, and that was different from her baseline. RN 1 stated later in the interview that he did not remember if resident 1 was verbal during his shift on 10/15/23. RN 1 stated, It was more like a behavior. RN 1 stated he did not know why resident 1 was not verbalizing with staff. RN 1 stated he was pretty sure there was a provider at the facility on the day prior to resident 1's dialysis visit, during his shift. RN 1 stated that he was fairly sure he mentioned resident 1's changes to the provider. RN 1 stated nobody was really concerned about resident 1 being unresponsive . RN 1 stated if what was going on with resident 1 had been something that was out of the ordinary, it would have been documented. RN 1 stated the oncoming nurse went to assess resident 1 after she arrived for her shift. RN 1 stated assessments were always ongoing, some residents got daily assessments and others just as needed. RN 1 stated whatever was going on was evolving. RN 1 stated he was surprised resident 1 had an incident at the dialysis center, and did not see her again until she came back on 10/24/23. RN 1 stated, again, that [physician's name removed] was at the facility on 10/15/23. RN 1 stated that on weekends there was a non-on-call person who could be contacted if there was a concern. RN 1 stated he was told to keep an eye on resident 1, and if something was different, to send her out. RN 1 stated if a resident had to be sent out for a fall, an injury of unknown origin, or change in condition, the nurses would document. On 1/3/23 at 2:59 PM, an interview was conducted with the Administrator (ADM) and the DON. The DON stated she expected staff to include her and the physician in communication about a resident. The DON stated if she was not on call, staff should contact the ADON, and the provider. On the weekend, the DON stated the process was the same. The DON stated the facility had an on-call contracted medical provider. The DON stated the MD did not typically come in on weekends. The DON stated the only standing orders at the facility were for bowel regimens, Tylenol or zofran, and there were standing orders for a change in condition. The DON stated all orders should come from the medical director. The DON stated the process for nurses reporting to the oncoming nurse was a direct handoff. The DON stated the nurse leaving would go through the report sheet on each patient, and it was a verbal handoff, then the nurses completed the narcotic counts. The DON stated behaviors could be a change in condition, but usually vital sign abnormalities would be seen. The DON stated a subdural hematoma presented a lot like a stroke. The DON stated a resident might sleep a lot more, vital signs would be a factor, there would be a drop in blood pressure, unequal hand grip, and pupils might not be reactive. On 1/3/23 at 3:15 PM, an interview was conducted with the transportation driver (TD) who took resident 1 to dialysis. The TD stated he had been transporting resident 1 to and from dialysis for quite some time. The TD stated the routine was that he would arrive at the facility at 4:30 AM, where resident 1 would be waiting at the front door for her ride. The TD stated resident 1 frequently complained about having to be up so early, and he would try to joke around with her to make the best of the situation. The TD stated he would load the resident onto the bus by 4:50 AM, and they would arrive at the dialysis center by about 5:00 AM and would have her in her chair by 5:15 AM. The TD stated on 10/13/23, when he picked up resident 1 for dialysis, she was able to talk to him. The TD stated on 10/16/23 when he picked up resident 1, she was leaning to one side and she was not able to respond to him. The TD stated resident 1 was drooling out of the left side of her mouth. The TD stated the staff member that was waiting at the door with resident 1 was someone he had spoken to before and recognized. The TD stated that he told the staff member that it looked like resident 1 was having a medical issue and asked if he should take her to the emergency room instead of dialysis. The TD stated on previous pick-ups, resident 1 would lift both arms up so he could put the red belt around her, but this particular day, the resident could not move her left arm. The TD asked the staff member what the facility stroke protocol was. The TD stated, I am not a doctor, but I transport people with all kinds of medical issues and I could tell there was something wrong. The TD stated the staff member stated that the resident had been like that for the past 12 hours. The TD stated the staff member stated that he should take the resident to dialysis. The TD stated the staff member at the facility did not appear to be concerned about the issue the resident was having. The TD stated when they arrived at dialysis, he took resident 1's paperwork to the front desk as he always did, and placed it on the counter. The TD told the staff member at the dialysis center that he was concerned about the state of the resident, but was told to bring her to dialysis and was going to leave her there. The TD asked the staff member to assess the resident. The TD stated the staff member began to assess the resident and was unable to get the resident to respond. The TD re-stated he was concerned that the resident was having a medical issue. On 1/3/23 at 3:28 PM, an interview was conducted with Licensed Practical Nurse (LPN) 2. LPN 2 stated she knew resident 1, but the night of 1/15/23 was one of the first times she had cared for the resident 1. LPN 2 stated the resident's baseline was that she was often confused. LPN 2 stated the resident was sometimes spacey but was able to verbally respond to her prior to this day. LPN 2 stated when she got the report from the previous nurse, she was told the resident had not been responsive during the day. LPN 2 stated the previous nurse told her that he had talked to the provider and was told just to monitor the resident. LPN 2 stated she was told to wait for her to go to dialysis. LPN 2 stated that she had worked at a dialysis center before and sometimes residents would become confused prior to having dialysis and she thought that might be what was going on. LPN 2 stated nurses did have report sheets that they kept throughout the shift, but the sheets were destroyed at the end of the shift. LPN 2 stated she did speak with the transport driver when he came to pick up resident 2, and the transport driver mentioned that he knew resident 1 did not like to get up early and might be tired. LPN 2 stated she was concerned for the resident, which was why she wrote the progress note, and noted on the dialysis pre-visit paperwork that the resident had been unresponsive. LPN 2 stated she did not know if resident 1's mother was at the facility during the dinner meal and did not speak with her. LPN 2 stated dialysis may have called the facility after the resident arrived there, but it was not while she was at the facility. LPN 2 stated she arrived at the facility at 6:00 PM and sometimes did not get a report until 7:00 PM because the previous nurse was still doing things. LPN 2 stated the resident was able to take her medications the night of 10/15/23 and on the morning of 10/16/23 without any problem. LPN 2 stated she was worried about the resident, but was told that resident 1 was ok so she did not take any additional action. LPN 2 stated she did not notice any drooling by resident 1. LPN 2 stated the resident was able to grip her hands strongly, and did not have any other noticeable symptoms of a problem. LPN 2 stated that resident 1 frequently was slumped over to one side in her wheelchair, and that was her baseline.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and observation, it was determined the facility did not ensure that each resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. Specifically, for 2 of 31 sampled residents, a resident to resident altercation occurred in which both residents sustained physical injuries. Additionally, one of the residents experienced increased anxiety from her baseline following the altercation. Resident identifiers: 52 and 169. Based on corrective measures taken by the facility, the non-compliance was determined to be past non-compliance. Corrective measures were implemented by 1/8/20. Corrective measures included: Treatment and evaluation of the residents involved in the altercation, identification and review of other residents at risk within the secured unit, documented staff education, audits of behavior monitoring performed by the Quality Assurance and Performance Improvement meeting members, and continued monthly dementia dialogue meetings to assess the efficacy of corrective measures. Findings include: 1. Resident 52 was admitted to the facility on [DATE] with diagnoses which included dementia, major depressive disorder, chronic kidney disease, hypertension, osteoporosis, pain, acute stress reaction, pain, and insomnia. A review of resident 52's medical record was completed on 2/20/20. An incident report, dated 12/17/19, documented the following information related to a resident to resident altercation: . At 0720 (7:20 AM) . [Resident 52] reported another resident wandered into her room. She stated she got up and yelled at him to get out and reported that he hit her in the face. She stated she hit him back and kicked him and he fell. She reported this to the nurse at the nurse's station after the incident. The resident's (sic) were kept separated . [Resident 52] was assessed for injury and bruising was noted on the left side of forehead, bleeding noted at gums . [Resident 52's family member] came to visit and decided to take [resident 52] to the ED (emergency department), leaving at approximately 1255 (12:55 PM). Stop sign was in place on her door at the time of the incident . The Emergency Documentation, dated 12/17/19, from the ED was reviewed and documented that staff found resident 52 being punched in the head by another resident of the dementia unit. The documentation further revealed that resident 52 had some bruising to the right side of her mouth and was very afraid that the man followed her and would find her at the ED. The documentation further revealed that resident 52 was punched several times in the head and once in the mouth hard enough to knock her dentures out . Resident 52 was diagnosed with a facial contusion at the ED, and there was no evidence of an intracranial hemorrhage, stroke, or obvious mass following a computed tomography scan. An ELOPEMENT RISK care plan, dated 9/17/19 and revised 11/19/19, documented that resident 52 was at risk for elopement and wandering due to confusion and dementia. The care plan further documented that resident 52's higher level of cognition than most residents who also reside on the unit put her at risk for resident to resident altercations as others have potential to wander into her space. 2. Resident 169 was admitted to the facility on [DATE] with diagnoses which included Alzheimer's disease, schizophrenia, dementia, hypertension, insomnia, mood disorder, and pain. A review of resident 169's medical record was completed on 2/20/20. Resident 169's medical record documented the following information related to a resident to resident altercation that occurred on 12/17/19: a. A Nursing SBAR (Situation, Background, Assessment, Recommendation) note, dated 12/17/19, documented the following information: . [Resident 169] is being aggressive towards others hit a woman in the face multiple times, the woman hit him back, his ear is bleeding and split requiring sutures that began on 12/17/2019 7:20 AM . being around others agitates him make the symptoms worse . Pressure and dressing on left ear laceration improve the symptoms. These symptoms have occurred before . He has been aggressive in the past never to this extent . Increased confusion . Resident seems unstable, may get worse . increased agitation . b. A Nursing Note, dated 12/17/19, documented the following information: . [Resident 169] was reported by another resident to have wandered into her room. She told him to get out and reported that he hit her in the face. She stated she hit him back and kicked him and he fell. She reported this to the nurse at the nurse's station after the incident. The resident's were kept separated . was assessed for injury, he has a laceration to his Left ear and redness to left his (sic) cheek. Stop sign was in place on the other residents door . new order to send to ED obtained . c. A Nursing Note, dated 12/17/19, documented the following information: . Risk Management Meeting Note: IDT (interdisciplinary team) met and reviewed incident between [resident 169] and another resident as previously noted . Intervention: Removed them from each other and placed [resident 169] on 1:1 (one-on-one monitoring) until EMS (emergency medical services) arrived . Sent to ED for evaluation . d. An incident report, dated 12/17/19, documented the following information: . [Resident 169] was reported by another resident to have wandered into her room. She told him to get out and reported that he hit her in the face and choked her. She stated she hit him back and kicked him and he fell. She reported this to the nurse at the nurse's station after the incident . he has a laceration to his Left ear and redness to left his (sic) cheek . new order to send to ED obtained . A History and Physical report, dated 12/17/19, from the hospital was reviewed and documented that resident 169 went into another resident's room and was involved in an altercation where he was pushed to the floor and sustained a L (left) ear laceration . repaired in ER (emergency room) with topical skin adhesive . A Timeline Res (resident) to Res documented the following information related to altercations between resident 52 and resident 169: a. On 11/16/19; . 1820 (6:20 PM) [resident 169] went into [resident 52]'s bedroom. The female resident was standing in the bathroom and did not like this resident coming in and yelled at him to get out. [Resident 169] picked up a garbage can and tossed it in her direction. It hit the female resident on the R (right) shoulder. The resident was not hurt and this resident was redirected out of the room . Interventions: Stop sign placed to [resident 52]'s door . [resident 52's family member] is looking for placement for [resident 52] elsewhere . [Resident 52's family member] first filed a grievance, but upon following up, she decided she wanted [resident 52] to stay . b. On 12/17/19; . [Resident 169] wandered into [resident 52]'s room. Stop sign was in place. According to staff interview and resident interview the following was stated: She told him to get out. He hit her. He grabbed her neck. She hit him back. He fell. She stepped on his head . She went down to the nurse's station and told the nurse. [Resident 169] has a laceration to his ear and redness to his cheek. She has a bruise on left forehead. She was spitting out blood from being hit in the mouth, but no obvious injury was seen . Interventions: [Resident 169 was sent to ER for psych (psychological) evaluation and [resident 52] was sent to the ER . A Grievance Form, dated 11/18/19 and filed by resident 52's family member, was reviewed and documented the following information related to the resident to resident altercation between resident 52 and resident 169 on 11/16/19: I received a phone message . informing me that a resident of the 400 block threw a trash can at [resident 52] and it hit her on the shoulder . This incident was witnessed . [Resident 52] claims that it was [resident 169] . It was kinda (sic) cute when I was told there are 'shoppers' there, not so cute when it is her room [resident 169] shops at all the time . now [resident 169] is aggressive (sic) toward [resident 52]. I feel we are both being neglectful of [resident 52]'s safety and well being . The investigation, submitted to the State Survey Agency on 12/20/19, related to the resident to resident altercation between resident 52 and resident 169 on 12/17/19 was reviewed. The investigation documented that resident 52 reported to the nurse that resident 169 hit her in the face and she kicked him causing him to fall to the ground. The investigation further documented that resident 169 was unable to provide a description of the incident, and resident 52's account of the incident changed several times. The investigation further documented that resident 52 had bruising above her left eye and resident 169 had an injury to his ear, and both residents were sent to the ER. Ultimately, the investigation documented that abuse was not substantiated due to the residents' cognition and perception of the incident altered by dementia. The facility's FREEDOM FROM ABUSE, NEGLECT, and EXPLOITATION policy, dated November 2017, was reviewed and documented the following information: PURPOSE: To keep residents free from abuse, neglect and corporal punishment of any kind by any person. POLICY: The facility will provide a safe resident environment and protect residents from abuse. The facility will keep residents free from abuse, neglect, misappropriation or resident property, and exploitation. This includes freedom from verbal, mental, sexual or physical abuse, corporal punishment, involuntary seclusion and physical or chemical restraint not required to treat the resident's medical symptoms. This protection extends to abuse by staff, consultants, contractors, volunteers, students and visitors . GUIDELINES: . 5. Resident to resident abuse: a. Cognitive impairment or mental disorder does not preclude a resident from being abusive . b. In determining abuse, willful (deliberate) action (not inadvertent or accidental) will be considered regardless of whether the individual intended to inflict injury or harm . c. Facility will assess the resident and care plan interventions to address resident behaviors that may indicate a risk for abusive, aggressive interactions (e.g. (for example) physical, sexual or verbal aggression; taking, touching or rummaging through another's property; wandering into another's rooms/space) . On 2/19/20 at 10:49 AM, an interview was conducted with Certified Nursing Assistant (CNA) 1. CNA 1 stated if she witnessed a situation involving abuse, she would notify the nurse and Administrator. CNA 1 further stated she was provided with training related to abuse at least 3-4 times per year. On 2/19/20 at 10:59 AM, an interview was conducted with Registered Nurse (RN) 2. RN 2 stated resident to resident altercations were reported to the Administrator and an incident report was completed. RN 2 further stated resident 52 was involved in altercations with other residents on two occasions, but it had been a while. On 2/19/20 at 11:24 AM, an interview was conducted with CNA 2. CNA 2 stated when a resident to resident altercation occurred, efforts were made to determine the cause of the altercation, identify the aggressor, and notify the nurse and Administrator. On 2/19/20 at 11:49 AM, an interview was conducted with Licensed Practical Nurse (LPN) 1. LPN 1 stated resident 52 was involved in resident to resident altercations and on one occasion, she was hit in the head by another resident. LPN 1 further stated following that altercation, emergency services and police officers came to the facility to assess resident 52 and believed resident 52 sustained a small cut. On 2/19/20 at 12:56 PM, an interview was conducted with Unit Manager (UM) 1. UM 1 stated resident 52 was involved in altercations with other residents, and two of the altercations involved resident 169. UM 1 further stated following the second altercation between resident 52 and resident 169, resident 52's family member took her to the hospital and she was prescribed anti-anxiety medication upon her return to the facility. UM 1 further stated an incident report was completed, and the Administrator and management were notified of the altercation. On 2/19/20 at 2:13 PM, an interview was conducted with the Administrator. The Administrator stated he heard ten different stories about what happened between resident 52 and resident 169 on 12/17/20, and resident 52 did not remember the altercation the following day. The Administrator further stated resident 52 experienced behavior changes from her baseline throughout the day following the altercation on 12/17/19, but did not exhibit a change from her baseline after that day. The Administrator further stated there were altercations in the past between resident 52 and resident 169, but the previous altercations did not escalate to the same level as the altercation on 12/17/19. The Administrator further stated it was unclear who the aggressor was in the altercation that occurred on 12/17/19, and both residents involved had cognitive impairments. The Administrator further stated resident 169's wandering was constantly evaluated and a stop sign was put on resident 52's door to prevent resident 169 from entering her room following the altercation on 11/16/19. On 2/20/20 at 7:35 AM, a follow up interview was conducted with UM 1. UM 1 stated resident 52 was prescribed anti-anxiety medication upon her return to the facility from the hospital on [DATE] because she was pretty worked up following the altercation with resident 169. [Note: Resident 52's physician's orders documented an order, started on 12/17/19, for hydrOXYzine HCl (hydrochloride) Tablet Give 25 mg (milligrams) by mouth every 6 hours as needed for Anxiety. This order was discontinued on 12/18/19 and replaced with an order, started on 12/18/19, for hydrOXYzine HCl Tablet Give 25 mg every 6 hours as needed for Anxiety related to ACUTE STRESS REACTION for 14 days. This medication was administered to resident 52 on one occasion following the altercation with resident 169 on 12/17/19. Additionally, a review of resident 52's physician's orders from 11/1/19 through 12/17/19 revealed that resident 52 had not been previously prescribed medication to manage anxiety.] On 2/20/20 at 10:03 AM, an interview was conducted with the Administrator and Director of Nursing (DON). The Administrator stated resident 52's family member increased her anxiety related to the altercation with resident 169 on 12/17/20. The Administrator stated resident 52 would have been fine without hospital intervention, but her family member wanted to take her to the ER. The DON stated resident 52 barely had a bruise that she was aware of, and resident 52 was unable to remember the altercation the following day. The DON further stated resident 169 was sent to the hospital primarily for a psychological evaluation, and resident 169's laceration could have been treated at the facility. The DON further stated the stop signs posted on residents' doors to prevent resident 169 from entering were becoming less effective for resident 169 due to his worsening dementia, and resident 169 maybe became startled when resident 52 yelled at him. On 2/25/20 at 11:02 AM, a follow up interview was conducted with the Administrator. The Administrator stated staff intervened appropriately during the altercation between resident 52 and resident 169 on 12/17/19, interventions were effective for a month following the first altercation between resident 52 and resident 169 on 11/16/19, and there was not anything else staff could have done to prevent the incident on 12/17/19. The Administrator further stated corrective measures were implemented following the altercation, and the facility's compliance date was 1/8/20 in response to the identified concern.