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observed coming down the hallway on his electric wheelchair, yelling, and accusing Resident E to have bashed me in my face.

Resident E exited his room into the hallway and started to argue with Resident D.

Staff members intervened and de-escalated the incident, directing residents to their rooms.During an interview on 9/5/25 at 10:25 a.m., Resident E indicated he made a mistake during the incident and apologized to Resident D. He had misunderstood what Resident D had said and had hit him. He felt the two were fine to be around each other now.

During an interview on 9/5/25 at 11:45 a.m., the Nurse Practitioner (NP) indicated she had seen Resident D on 8/25/25 and observed no swelling, redness or bruising to the left side of his face. He had not mentioned he was fearful or concerned about Resident E or feeling in danger.

She had observed him in the common areas and outside smoking with residents.

She was confident Resident D would have talked to her about any discomfort in being around Resident E.During an interview on 9/5/25 at 10:52 a.m., the Administrator indicated Resident E was protective of other residents and staff. He indicated Resident E had heard Resident D say something inappropriate about someone and had slapped Resident D on the left side of his face. He was on the phone with the nurse when Resident D was at the nurses' station and had requested to call the police. He had instructed the nurse to call the police if that was what Resident D requested.

However, Resident D changed his mind and indicated to the nurse he did not want the police called. He observed Resident D the following day and could not see any redness or swelling to the left side of his face.The Administrator provided the incident investigation information on 9/5/25 at 11:15 a.m., containing a written statement by an LPN 4 and a document signed by the Administrator.The written statement was signed by LPN 5, who had not witnessed or observed the residents on the date of the incident.

The statement indicated she had been notified by other residents that Resident E had made physical contact with Resident D due to Resident D picking and calling other residents names.

Resident E was protecting other residents and became defensive on or about 8/23/25.Another document contained in the investigation file, signed by the Administrator, and dated 8/29/25, included the following:a. 8/25 I (Administrator) spoke with [Resident D] about incident with [Resident E]. [Resident D] didn't know why he was hit by [Resident E].b. 8/25 I spoke with Resident E about incident.

Resident E said he was upset about Resident D talking bad about other residents.c. 8/28 [Resident D] stated he did not say anything wrong about other residentsd. 8/29 [Resident E] informed staff member, LPN 5 that they had apologized and there were no issues between them.

During an interview on 9/5/25 at 2:00 p.m., the Administrator indicated the residents were both cognitively intact and he felt the investigation was as thorough as it needed to be and that the resident's had worked things out. He was unaware that Resident D remained uncomfortable around Resident E. He had not interviewed other residents or staff regarding the incident/behavior.A current facility policy, dated 8/2024, titled, Accidents and Incidents - Investigating and Reporting, provided by the Administrator on 9/5/25 at 2:03 p.m., included the following: Policy Statement All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the administrator.The Administrator indicated on 9/5/25 at 2:28 p.m., the policy provided was the only policy regarding resident-to-resident or resident-to-staff incidents.

The facility follows the Indiana Department of Health guidelines.This citation relates to Incident 2600099.3.1-28(d)

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