**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to follow hospital orders for a fluid restriction after a resident (R1) was hospitalized for low sodium and failed to complete additional laboratory work for a resident's (R1) low sodium levels for one out of three residents reviewed for improper nursing care in a total sample of three. This failure resulted in R1 suffering a syncopal episode twice within four days and needing to be hospitalized each episode for low sodium and bradycardia. Findings Include: R1 is a [AGE] year old with the following diagnosis: epilepsy, type 2 diabetes, schizoaffective disorder, bradycardia, and syncope/collapse.R1 no longer resides in the facility. A Nursing note dated 5/ 31/ 25 document R1 was found lying on the floor in R1's room. The fall was unwitnessed. Vital signs were within normal limits except the heart rate. The heart rate was 49 (normal heart rate is 60-100 beats per minute). R1 was not able to stand. The doctor was called and ordered to send R1 to the hospital. A call was made later to the hospital to check on R1's status. R1 was admitted with a diagnosis of low sodium. A Nursing note dated 6/2/25 documents R1 returned from the hospital with the discharge diagnosis of low sodium. R1's heart rate upon admission was 68. R1 was able to ambulate with a steady gait. The physician was made aware of R1's return and the medication that was given during the hospital including insulin. No new orders were received.The Hospital Records dated 6/2/25 document R1 was admitted with a diagnosis of low sodium. R1 was ordered a regular diet with a fluid restriction of 800 mL. Sodium levels were 124 on presentation to the emergency room and raised to 131 the next morning after receiving IV fluids overnight. This is consistent to volume depletion which is likely a component of SIDAH (Syndrome of Inappropriate Antidiuretic Hormone Secretion) due to psych medications.Per the National Library of Medicine, an article titled, Clinical management of SIADH, dated 04/2012 documents, Hyponatremia is the most frequent electrolyte disorder and the syndrome of inappropriate antidiuretic hormone secretion (SIADH). SIADH should be treated to cure symptoms. Therapeutic modalities include nonspecific measures and means (fluid restriction, hypertonic saline, urea, demeclocycline), with fluid restriction and hypertonic saline commonly used. (https://pmc.ncbi.nlm.nih.gov/articles/PMC3474650/)A Laboratory note dated 6/13/25 documents the sodium level was 134. All lab levels were reviewed by the physician and no new orders were received. The Laboratory Report dated 6/13/25 documents a sodium level of 134 mEq/L. The reference range for a normal level is 138-147 mEq/L. No other laboratory levels were tested again after this. A Transfer to Hospital note dated 6/25/25 documents R1 was observed having a near syncopal episode in the dining room. R1 was taken back to R1's room and assessed. R1's pulse was 58. The physician ordered to send R1 to the hospital. A Nursing note dated 6/25/ 25 at 8:37 PM documents arrived back to the facility. Vital signs are within normal limits. Diagnosis from the hospital was low sodium and slow heart rate. R1's discharge instructions include wearing a cardiac monitor for seven days continuously then returning it back to the hospital. The physician was called several times and the nurse was not able to get a hold of the physician for any new orders. This will be endorsed to the next shift. A Nursing note dated 6/26/25 documents the physician ordered an electrolyte panel for R1 to follow up on the hyponatremia diagnosis. A Nursing note dated 6/29/25 documents R1 fell in the dining room. Vital signs were within normal limits except heart rate was 38. R1 was picked up off the floor and assisted to a private room to be monitored. The physician was notified in order to send R1 to the hospital. The pulse was rechecked while waiting for the ambulance and R1 was still bradycardic. R1 was admitted to the hospital with a diagnosis of syncope and bradycardia. R1 was admitted for monitoring. There is no documentation that the psychiatrist or primary physician adjusted any medications to address the low sodium levels or that a fluid restriction was ordered.Vital signs from 5/31/25-6/29/25 were reviewed. A heart rate of 46 beats per minute was documented on 5/31/25 and a heart rate of 30 on 6/29/25. Vitals signs are not documented each shift every day per the care plan intervention. The Physician Order Summary was reviewed. There is no order for a fluid restriction, a cardiac monitor for one week, or a medication adjustment in the psychiatric medication. R1 has an order for carbamazepine 100mg three tablets twice a day and one 200mg tablet once a day, phenytoin 100mg two capsules three times a day, invega sustenna 11mg injection once a month, seroquel 300 mg two tablets twice a day, and metformin 500mg tablet once a day. All these medication especially when used in combination can cause SIADH. None of these medications have had dosages lowered within the last six months. On 7/18/25 at 12:37PM, V1 (Nurse) stated V1 received notification that the labs were abnormal so V1 notified the physician. V1 reported the facility uses the reference numbers in the laboratory report to tell if a laboratory level is low, high, or normal. V1 stated all abnormal lab levels must be reported to the physician by a phone call and faxing the numbers over to the physician. V1 stated if no new orders are given by the physician that it must be documented. V1 reported the physician was looking for hyponatremia in this lab draw, and it was a previous issue R1 kept having. V1 stated no new orders were put in for this lab level per the physician's request. V1 reported R1 had a near syncopal episode on 6/25/25 where R1 was dizzy when R1 tried to stand. V1 stated R1 was sent to the hospital by the physician and came back with a cardiac monitor. V1 reported R1 fell again on 6/29/25 after having another syncopal episode. V1 reported R1 did have a low heart rate in the 30s at the time of this fall. V1 stated hospital paperwork is reviewed by the nurses and a medication review as well as any other changes in orders have to be reviewed with the physician when the resident is readmitted . V1 reported all new orders have to be reviewed with the physician so any changes can be made to the current orders at the facility. V1 stated a nurse documents in the computer system that a physician was notified of any new orders or changes from current orders after returning from the hospital. V1 reported if it is not documented, it means it didn't happen. V1 stated a fluid restriction needs to be documented in the computer system as well as an order be put in. V1 was not able to show the surveyor in the computer system where the fluid restriction documentation for R1 was. V1 denied being aware that R1 was on a fluid restriction. On 7/18/25 at 1:07PM, V2 (CNA) stated staff was monitoring R1 due to recent episodes dizziness and falls. V2 denied R1 having a fluid restriction while R1 was at the facility. V2 reported if a resident is on a fluid restriction then it is charted in the computer system.On 7/18/25 at 1:38PM, V3 (ADON/Restorative Nurse) stated it is the admitting nurse's responsibility to review the hospital paperwork and inform the physician of any changes. V3 reported the DON should also be made aware of any changes to the plan of care. V3 stated r1 was having low heart rate and low sodium but was unaware of what was causing it. V3 reported the nurses have to document any conversation with a doctor to let the oncoming staff what is going on with the resident. V3 stated if a resident is on a fluid restriction, staff have to monitor them and document the amount of fluids. V3 reported the CNAs will document in the computer under the meals tab which allow staff to watch how much the resident is drinking. V3 was not sure not if R1 was supposed to be on a fluid restriction. V3 stated if a resident was on a fluid restriction from the hospital then it needs to be continue at the facility. V3 reported the doctor will be called for an order, the dietitian will come to evaluate the resident, and the dietary department will be notified.On 7/18/24 at 2:34PM, V4 (Former Nurse) stated V4 took care of R1 the day of the first fall on 5/31/25. V4 reported R1 was too weak to stand and R1's pulse being low at the time of the fall. V4 stated that R1 was diagnosed with low heart rate and low sodium while at the hospital, but was unaware of the cause. V4 reported when a resident is readmitted from the hospital, orders must be reviewed, and the physician must be called to carry out any new orders. V4 confirmed a fluid restriction must be ordered so everyone knows that a fluid restriction is in place for that resident. V4 stated a fliud restriction must be documented in the computer system so continuing shifts know how much fluid a resident is having throughout the day. V4 denied ever seeing an order for a fliud restriction. V4 reported a physician must be notified of any new orders from the hospital or any changes while the resident was in the hospital so the doctor is aware of the plan of care. V4 denied remembering a fluid restriction was ordered after R1 returned from the first hospitalization. On 7/18/25 at 2:45PM, V5 (Nurse) stated V5 readmitted R1 back to the facility after the second admission to the hospital. V5 confirmed R1 was diagnosed at the hospital with low heart rate and low sodium levels. V5 reported the physician (V7) was called to get orders after R1 arrived, but the physician did not return a call, so this task was endorsed to the next nurse. V5 reported an administrator or DON should notified if the nurses cannot get in contact with the physician. V5 admitted that V5 was busy and probably forgot to notify the administrator or DON that V5 could not get in contact with the physician for any new orders. V5 denied R1 ever being on a fluid restriction. V5 was unaware why R1 would need a fluid restriction. V5 denied being aware that the last sodium level drawn was trending low. On 7/18/25 at 3:13PM, V6 (DON) stated R1 was admitted to the hospital after a fall due to a syncopal episode where R1 was diagnosed with bradycardia as well as low sodium. V6 reported after a resident is readmitted from the hospital, the physician must be notified of their return and makes the physician aware of any new orders from the hospital. V6 stated the nurse must document this conversation and if any orders have changed. V6 reported the nurse is responsible for letting the physician know of any diet change orders. V6 stated R1 did have a redraw of labs to check the sodium level. V6 stated V6 knows the sodium level was low but close within normal range so no additional orders were put in. V6 denied the sodium level was monitored again or any additional orders put in place until R1 went to the hospital on 6/25/25. On 7/18/25 at 7:00PM, V7 (Primary Physician) stated R1 is a diabetic and also takes psych medication and this combination can cause low sodium. V7 reported it is caused by a disturbance in electrolytes due to the hormones being imbalanced. V7 stated a blood test was completed about one week later after the first hospitalization and the sodium level was normal. V7 stated the sodium level was only one point out of normal range at 134. V7 reported V7 did not feel like it needed to be checked again because it was near normal. V7 stated V7 was aware that R1 went out to the hospital a second time for bradycardia and low sodium and was readmitted to the facility with a cardiac monitor. V7 stated V7 told the admitting nurse to continue all treatments from the hospital after each readmission. V7 reported V7 cannot adjust the psychiatric medications so the nurses were informed to get in contact with psych to adjust R1's medication to help with low sodium levels. V7 was unaware why a fluid restriction was done and was unable to explain how a fluid restriction would increase a sodium level. V7 said, Whatever maneuver they used in the hospital to get normal sodium is what they did. V7 stated it is the nurse's responsibility to speak with the psych physician about changing medication. V7 reported V7 was not aware of a third admission for bradycardia and low sodium. On 7/22/25 at 10:26AM, V8 (Psych Nurse Practitioner) stated V8 saw R1 in May and June of this year. V8 reported R1 was not having any new delusions or behaviors so no medication adjustments were needed. V8 stated V8 did not know about R1's low sodium. V8 confirmed psych meds can cause low sodium from SIADH. V8 denied being aware that R1 was ever treated for that condition while at the hospital. V8 stated that low sodium is a medical condition and the medical doctor (V7) would've handled that. V8 reported the medical doctor would've handled this because the medical doctor has access to the laboratory levels. V8 stated low sodium levels can cause generalized weakness and if the sodium gets low enough, it can cause a person to have seizures. V8 reported that condition is usually managed with a fluid restriction before adjusting any medications because adjusting the medications can have a negative effect on behaviors. V8 stated if V8 were told about the low sodium, then it would have been documented in the progress notes in June. The surveyor asked if V8 was aware about the low sodium, what changes to the medication would V8 have made? V8 reported that V8 would have had to have a discussion with the medical physician before making any changes to any medications. On 7/22/25 at 11:14AM, V6 stated if the primary physician and psych physician need to discuss a resident's plan of care then they will communicate with each other. V6 stated that V7 is a medical doctor so V6 was under the impression that V7 was managing the low sodium level. V6 denied V7 ever asking the facility to get psych involved for R1's medication adjustments. V7 denied being aware why a fluid restriction wasn't re-ordered after R1 was readmitted . V6 reported if the facility does not agree with the doctor's orders or feel a resident needs additional orders than another physician can be contacted that sees that resident. V6 denied any other physicians being contacted for R1's low sodium level. The Fall Report dated 5/31/25 documents R1 was found lying on the floor in R1's room. Vital signs were within normal limits except heart rate was low at 49. R1 reported hitting R1's head. R1 was not able to stand on R1's own. An order was received to send R1 to the hospital. There are no predisposing environmental or physiological factors that caused the fall. The Fall Report dated 6/29/25 documents R1 fell in the dining room. R21 reported R1's legs gave out while R1 was going to the bathroom. The physician ordered R1 go to the hospital. R1 was bradycardic. There are no predisposing environmental or physiological factors except change in condition that caused the fall. The Care Plan dated 6/3/25 documents R1 is at risk for falls after sustaining a fall on 5/31/25. An intervention includes to endure R2 drinks water throughout the day. The Care Plan dated 6/26/25 documents R1 present with decreased cardiac output related to a diagnosis of bradycardia as evidenced by near fainting episodes. An intervention includes that R1 will wear a cardiac monitor as ordered by the physician and vital signs will be documented every shift. The Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status score as a 12 (Moderate cognitive impairment). There were no hospital records available from the hospitalization on 6/25/25 or 6/29/25.Intake and output or fluid restriction documentation was requested during this survey but none was provided. The policy titled, admission Process, dated 03/2021 documents, .2. When a resident arrives at the facility.utilize accompanying hospital records for detailed information. The policy titled, Change in Condition, dated 03/2021 documents, Guideline: To keep the physician or extender, who is in charge of medical care, responsible party, responsible for health care decisions, informed of the resident's medical condition so they may direct the plan of care as needed. Standard: Notification of the physician, legal representative, or responsible party, should occur when there is a change in the resident's condition. Change in condition is defined as (notify parties immediately in the event of death): an incident or accident that involved the resident which results in injury and requires physician intervention; a change in the resident's physical, mental or psychosocial status; a need to alter treatment; and/ or a decision to transfer or discharge the resident from the facility. The policy titled, Physician Orders - Verbal and Fax, dated 03/2021 documents, .Procedure: 1. Verbal Orders: Verbal orders are those given to the nurse by the physician or extender in person or by telephone, however are not written in the medical record. Follow this process: a) Write the orders verbally given by the prescriber in the medical record.d) The prescriber should sign the according order according two state guidelines. e) Follow through with the orders as required. If the orders are unable to be followed the provider should be made aware and then additional orders received.3. Outside Appointment Orders:.b) If the resident returns with orders from the consulting physician, the orders must be verified with the attending physician before they can be carried out.d) If the attending position is not in agreement with the orders, the consulting physician must be notified by the nurse. e) It is the responsibility of the physicians to come to agreement on which orders are to be followed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to protect a resident's right to be free from physical abuse (R2) from another resident with known history of aggressive behavior (R3) for one (R2) of five residents reviewed for abuse in a sample of eight. This failure resulted in R2 being physically assaulted and emergently transferred to the hospital for evaluation of facial trauma. Findings include: R1 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Schizoaffective Disorder, Bipolar Type; Malignant Neoplasm Of Skin; Morbid (Severe) Obesity Due To Excess Calories; Age-Related Nuclear Cataract, Bilateral; Hypermetropia, Bilateral; Presbyopia; Major Depressive Disorder, Recurrent, Severe With Psychotic Symptoms; Schizophrenia; And Chronic Viral Hepatitis C. According to R1's MDS (Minimum Data Set) assessment dated [DATE] under section C, R1 has BIMS (Brief Interview of Mental Status) score of 14 indicating, indicating intact cognition. R2 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but not limited to Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms; Other Polyosteoarthritis; Polyp of Colon; Unspecified Hemorrhoids; Unspecified Abdominal Pain; Hypertensive Heart Disease Without Heart Failure; and Other Hyperlipidemia. According to R2's MDS (Minimum Data Set) assessment dated [DATE] under section C, R2 has BIMS (Brief Interview of Mental Status) score of 15 indicating, indicating intact cognition. R2's abuse care plan dated 09/10/2024 reads in part, (R2) is at risk for abuse/neglect based on comprehensive assessment as evidenced by: (R2) has a diagnosis of mental illness. (R2) is not able to make her needs known. Interventions: Assure (R2) that she is in safe and secure environment with caring professionals. Explain psychosocial adjustment is often facilitated by developing a trusting relationship with another person and verbalizing thoughts, needs and feeling. R2's anxiety care plan dated 09/12/2024 reads in part, (R2) has exhibited or has history of anxious behavior such as: Evidenced by Apprehension in response to severe and persistent mental illness. Excessive and persistent daily worry about life circumstances. Concentration difficulty such as losing a train of thought. Persistent and unreasonable fear of a specific object or situation. Interventions: Assist in identifying actual life situations. R3 is a [AGE] year-old female admitted to the facility on [DATE] with diagnosis including but limited to Schizoaffective Disorder, Bipolar Type; Major Depressive Disorder, Recurrent, Severe with Psychotic Symptoms; Hypertensive Heart Disease Without Heart Failure; Morbid (Severe) Obesity Due To Excess Calories; Chronic Obstructive Pulmonary Disease, Unspecified; Suicidal Ideations; and Insomnia, Unspecified. According to R3's MDS (Minimum Data Set) assessment dated [DATE] under section C, R3 has BIMS (Brief Interview of Mental Status) score of 15 indicating, indicating intact cognition. According to R3's MDS (Minimum Data Set) assessment dated [DATE] section E shows R3 has been demonstrating potential indications of psychosis such as hallucinations and delusions, and daily occurrence of threatening and screaming at others. R3's aggression care plan dated 06/26/2024 reads in part, (R3) has a history of aggressive, inappropriate, attention seeking behavior due to Severe mental illness. (R3) becoming physical inappropriate and verbal aggressive with peer. (R3) becoming verbally aggressive with staff when redirected. Interventions: Intervene when any inappropriate behavior is observed. Communicate assertively that (R3) must exercise control over impulses and behavior (Social skills training). R3's delusional statements care plan dated 3/16/2028 reads in part, (R3) has shown evidence of making delusional statements related to diagnosis of severe mental illness. Interventions: Assess ability to maintain reality orientation. Provide reality orientation as needed. Per record review, R2 was discharged from the facility on 01/10/2025 and is not available for observations or interview during this investigation. Per record review, R3 was hospitalized for behavioral evaluation on 12/22/2024 and later discharged the facility and is not available for observations or interview during this investigation. On 03/20/2025 at 1:41 PM V8 (Certified Nurse Assistant) said, I worked 7:00 AM - 3:00 PM on 12/22/2024. R3 was walking and talking to herself, like usual. I was monitoring A wing which is right across from B wing. R3 got to the end of B wing and that's where R2 was. Out of nowhere, R3 grabbed R2 from behind, put her in a choke hold and started punching her head and then face. R2 did not say anything to R3 before R3 attacked her. I was standing maybe 5 feet away from them. There was no other staff there. I was trying to pull R3 off R2, but I couldn't. I started to yell, Help! Help! Help!. After about 5 minutes, V9 (Certified Nurse Assistant) and R4 came up and we were able to pull R3 off R2. R2 was beat up pretty bad. I didn't see any blood and R2 didn't lose consciousness, but it was pretty extreme. After more staff showed up, I had to step away, the incident upset me. R3 attacked R1 a few months prior to December 2024. R1 had a concussion because of the attack. There was nothing special we had to do for R3 as far as monitoring. PRSAs (Psychiatric Rehabilitation Service Aids) is supposed monitor R3, that's what they're there for. R3 was acting like always that day, I didn't see any signs that she might attack someone. On 03/20/2025 at 02:34 PM V11 (Psychiatric Rehabilitation Service Coordinator) said, I worked as a PRSA (Psychiatric Rehabilitation Service Aids) on 12/22/2024. PRSAs are considered security in the facility. I saw the incident between R2 and R3 but didn't see the escalation of it. Code orange was called shortly after lunch. I responded to the code and saw R2 yelling, Get off me! while R3 was pounding on her. Other staff and I separated R2 and R3, and R3 was escorted to the social service office. I think, R2 suffered concussion after the incident. I've never seen R3 to have a behavioral outburst like that, but I heard that she's aggressive. There was nothing special related to R3's monitoring, all I was told was not to come too close to R3 because she might have aggressive behaviors. It was like walking on eggshells around R3. On 03/21/2025 at 10:29 AM V12 (Psychiatric Rehabilitation Service Director) said, I wasn't here at the time of the incident (12/22/2024) because it happened on a Sunday, and I don't work on Sundays. When I came on 12/23/2024, R2 came to talk to me and told me that R3 was talking to herself and thought R2 was talking to R3 and then R3 attacked R2. R2 was in the facility for only 3 months (admitted [DATE]) whereas R3 had been a long-term resident in the facility, admitted in 2018 at the time of the incident. R3 was hospitalized for behavioral evaluation multiple times while in the facility. Surveyor asked about R3's previous physical attack on R3's roommate, V12 (PRSD) said, It might have happened, I don't remember. R3's behavior was always deceitful, she didn't really have escalating behaviors, so it was hard to tell when R3's aggression might escalate. You would ask R3 if everything is ok, and R3 would respond, Yes, everything is fine. Some of the interventions to prevent R3's behavioral escalation were group therapy, 1:1 tele-health program with psychiatrist, and day program. If R3 refused any of the interventions, it was a good indication that she might escalate her aggressive behaviors. On 03/21/2025 at 12:06 PM V14 (Family Nurse Practitioner) said, R3 had delusions at the baseline. R3 was taking psychotropic medications. R3 was often hiding her symptoms or downplayed them, you could tell she's responding to an internal stimulus but when asked, R3 would deny. R3's medications could manage her behaviors unless R3 refused them. R3 didn't refuse her medications often but it happened on occasion, and that's when she would act out. We don't put in an order for behavioral monitoring, the nurses should document in progress notes if any behavioral changes occur. With R3, it was hard to predict behavioral outbursts because she was downplaying her stimuli. R3's more frequent monitoring would be recommended. Staff should definitely place someone like R3 on 1:1 observation if they saw any concerning behaviors. Before a resident with mental illness hits someone, they usually show signs such as pacing and talking to self. Staff should request PRN (as needed) medications from us as well to help manage the symptoms. On 03/21/2025 at 12:20 PM R1 said, In June (2024), R3 punched me in my eye. I didn't do nothing. R3 came up to me while I was sleeping, around 3:00 AM and just hit me. We were roommates at the time. R3 was aggressive. They didn't do anything about it. On 03/21/2025 at 12:28 PM V9 (Certified Nurse Assistant) said, On 12/22/2024, I was in the dining room, on resident's 1:1 monitoring. I heard code orange, so I responded to the code and broke up R2 and R3. I was under the impression V8 (CNA) was getting attacked. R3 always walked up and down the hallway, it was the norm for her. If anything, R3 was talking to herself a little more than usual that day. I don't really know what triggered R3 that day. After the two residents were separated, I walked away and went back to monitoring. On 03/21/2025 at 12:38 PM V6 (Registered Nurse) said, I worked on 12/22/2024. R3 was really quiet, except for when she would have an outburst in her room. R3 usually was yelling and cursing in her room. I don't remember R3 talking excessively or pacing on the day of the incident. The only thing that I remember that day, was seeing R2 sitting at the nursing station and R3 in the social service office. I was told what had just happened. Generally speaking, we document residents' behaviors in progress notes. We document when resident displays abnormal behavior, but it also depends on the nurse. Some nurses document both, abnormal and normal residents' behaviors. R3 was generally compliant with taking her medications and she took her psychotropic medication on the day of the incident (12/22/2025). On 03/21/2025 at 1:09 PM V1 (Administrator/Abuse Prevention Coordinator) said, On 12/22/2024, staff called me and told me that there was an incident, that R3 hit R2. I asked if there was a CNA in a monitoring spot at the time of the incident, I was told that V8 (CNA) was there. I assured that both residents are safe, nobody is hurt, and all staff is monitoring their areas. I asked for V8 (CNA) to talk to me then. V8 (CNA) told me that R2 was walking and R3 came up to her, said something out loud, hit R2 from behind, and pushed R2 to the floor. V8 (CNA) was trying to intervene, and other staff responded to code orange and came to help. The following day (12/23/2024), I interviewed V8 (CNA) and R2. I did speak to few more staff, but they all stated that they came after the escalation. There were no residents who witnessed the incident. I did not have a chance to talk to R3 because she was hospitalized for behavioral evaluation at that time. R2 was hospitalized for medical evaluation and returned to the facility after a few hours. R2 called the police while she was getting assessed by the nurses before facility staff had a chance to do so. R2 came to me after she returned from the hospital and said she wanted to go home for holidays, and she said that she doesn't know why R3 attacked her. R2 said she felt safe in the facility because R3 was not there. The conclusion of the internal investigation was that R2 was hit by R3 as a result of R3 exhibiting symptoms of her mental illness. R3's Medication Administration Record for December 2024 does not show any requests for PRN psychotropic medications for behavioral management. Absent are any progress notes or behavioral assessments to show R3's escalating behaviors that led to an altercation on 12/22/2024. R1's progress note dated 06/26/2024 reads in part, Writer was informed by social service that (R1) was punched on her face by her roommate. Upon assessment (R1) stated that she was on the toilet when roommate walked up to her and punched her on her face, leaving her with left cheekbone swelling. Ice was applied. (R1) room was changed, and MD ordered that resident go to the ER for medical evaluation of her face. R3's progress note dated 06/26/2024 reads in part, This writer was informed that (R3) punched her roommate on the face, and left roommate's face swollen. (R3) stated that roommate was verbally aggressive towards her, and she proceeded to call her names, she ask her to stop but she didn't and she punched her on the face. At this time (R3) was separated from her roommate, roommate is assigned to a new room and her swelling is treated with ice. We will continue to monitor and document. R2's progress note dated 12/22/2024 reads in part, Writer was informed of the altercation between (R2) and (R3). Situation was immediately deescalated, head to toe assessment done. Skin discoloration and a scratch noted to the right side of the face. Vitals are (Blood Pressure) 128/86, (Temperature) 98.3, (Pulse) 82, (oxygen level) 98% on room air. (R2) denied pain. Police called. (Physician) notified. (R2) transferred to (local hospital) via EMS (emergency medical service) for medical evaluation. R3's progress note dated 12/22/2024 reads in part, (R3) was reported for initiating an altercation with another resident. Removed the receiver (R2) of the altercation from the initiator (R3) of the altercation. Writer assessed the initiator (R3) of the altercation for any injuries or cognitive changes. Resident that initiated the altercation (R3) VS's (vital signs) were (Blood Pressure) 156/97, (Respiratory Rate) 18, (Temperature) 97.5 (Oxygen level) 98%, (Pulse) 92. (R3's) eyes were round and equal, normal chest rise, skin intact and warm & dry. No bruising, lacerations, scratches or abrasions. (R3) is verbally responsive. Psychiatric physician was called. Initially, writer was ordered to send the resident to (local hospital). (Local hospital) rejected intake of the initiator (R3) because facility capacity was full. (R3) taken to (another local hospital) via (transport) ambulance. R2's hospital record dated 12/22/2024 reads in part, (R2) presenting for evaluation of physical assault. (R2) report that she was walking down the hallway at (the facility) and got assaulted by another resident. (R2) reports of the resident slammed her face to the ground. (R2) is complaining of pain to the right side of the face and her jaw. Physical exam: (R2) appears anxious but non-toxic; multiple bruises noted to the right side of the face, tenderness to palpation to the right maxilla. Police report requested on 03/20/2025, unable to obtain it during course of the survey. The facility Abuse policy dated 03/2022 reads in part, The facility affirms the right of our consumers to be free from verbal, physical, sexual, mental abuse, neglect, exploitation, misappropriation of property, involuntary seclusion, or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of consumers. In order to do so, the facility has attempted to establish a consumer sensitive a consumer secure environment. The purpose of this policy is to assure that the facility is doing all that is within its control to prevent occurrences of abuse, neglect, exploitation, misappropriation of property and mistreatment of consumers. This will be done by establishing an environment that promotes consumer sensitivity, consumer security, and prevention of mistreatment; identifying occurrences and patterns of potential mistreatment.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to identify a resident (R1) as a high fall risk after new onset shuffling of gait and failed to put interventions on the care plan in regards to the shuffling. This affected one of three residents (R1) reviewed for fall prevention interventions. This failure resulted in R1 getting up unassisted and falling causing a laceration to the forehead that needed repair at the hospital with three to four stitches. Findings include: R1 is a [AGE] year old with the following diagnosis: dementia, schizophrenia, and epilepsy. A Nursing note dated 8/16/24 at 6 AM documents the CNA reported to the nurse that R1 fell in R1's room. R1 stated that R1 lost R1's balance while trying to use the bathroom. R1 had a small laceration to the right forehead. The wound was cleaned and R1 was sent to the hospital via 911. An admission Summary note dated 8/16/24 documents R1 returned from the hospital with 3 to 4 stitches noted and facial bruising. The Hospital After Visit Summary Record dated 8/16/24 documents R1 was seen in the emergency room for a fall from the bed and was diagnosed with a head injury. There was a cut on the forehead. R1 had stitches/tape to repair the laceration. On 11/14/24 at 12:30PM, R1 was sitting in the dining room waiting for the lunch meal. R1 did remember falling but was unable to state the date. R1 was able to report the fall happened at night. R1 stated R1 fell while getting up from bed but was not able to remember why R1 was getting out of bed. R1 reported R1 did have an injury to the head that required stitches. There was a scar about one inch long above R1's right eye brow. R1 confirmed this was from the fall. R1 was not able to remember what happened after that fall except that R1 went to the hospital. R1 stated that R1 walks fine and denied needing any help. R1 reported R1 now uses a wheelchair to get around the facility. R1 then stood up and walked over to the wheelchair. R1 has a shuffled gait. R1's mental status was checked and R1 was alert and oriented times two. R1 stated that date and location correctly but was not able to name the current president. On 11/14/24 at 1:15PM, V2 (Restorative Aide) stated R1 has been in restorative programs for about one year along side with getting therapy on and off. V2 reported R1 moves very slow and has a shuffled gait so R1 is a high fall risk. V2 stated the shuffling is a new development within the past four or five months and that is why therapy has been working with R1. V2 reported R1 walked with a normal gait before the shuffling began. V2 stated the DON is responsible for putting in interventions in the care plan for fall safety and educating staff on the interventions. V2 stated therapy worked with R1 before the falls but V2 denied being aware of any other interventions put in place before the fall on 8/16/24. On 11/14/24 at 1:52PM, V3 (Nurse) stated R1 fell on the overnight shift, but was unable to remember a time. V3 reported checking on R1 around midnight and then one more time before the fall occurred, but could not remember the timeframe of when R1 was last check to the time R1 was found on the ground. V3 stated R1 was sleeping on both occasions during rounds before the fall. V3 reported the CNA (V4) told V3 that R1 fell. V3 stated R1 told V3 that R1 was getting out of bed while trying to use the bathroom. V3 stated this was not a witnessed fall. V3 reported R1 had a cut to the forehead and was sent out to the hospital. V3 stated at the time of the fall R1 could get up and walk around alone, but does have an unsteady gait. V3 was unsure if R1 is a high fall risk and could not state why R1 would be a high fall risk. V3 was unaware of R1 shuffling R1's feet when walking. On 11/14/24 at 2:08PM, V4 (CNA) stated V4 was doing hourly checks and saw R1 on the floor and immediately went to tell the nurse. V4 reported R1 did have some bruises and a cut on the face and was sent to the hospital. V4 stated R1 was found on the ground around 3 or 4 AM. V4 reported checking on R1 around 11 PM and then one more time before R1 was found on the floor but was not able to give an exact timeframe. V4 stated R1 was a high fall risk at the time of the fall because does not walk normal and is not steady. V4 reported R1 is only supervision with assistance and does everything with without much help. V4 was unaware of any interventions put into place before the fall occurred due to the shuffling gate. On 11/14/24 at 2:23PM, V5 (Director of Therapy) stated R1 was picked up on 6/28/24 for physical therapy. V5 reported R1 was referred because R1 presented with decreased standing balance and safety with ambulation. V5 reported R1 was at high risk for falls at the time R1 was admitted to therapy. V5 stated R1 also had occasional shuffling, and therapy worked with R1 so R1 could improve walking patterns and posture as well as increase lower extremity muscle strength. V5 stated R1 was discharged from therapy on 8/15/24 because R1 met R1's goals to the best of R1's ability and was referred to restorative. V5 reported restorative completes their own assessment to see what programs are appropriate. V5 stated R1 was picked up again on therapy on 8/22/24 for the same reasons that R1 was picked up in June. V5 stated R1 is a contact guard assist while, indicating someone should be physically touching R1, but, they are not doing any work. V5 reported staff hold R1 walking in case there is a loss of balance. V5 stated the therapy department is always in communication with staff at the facility to let them know what level the resident is at or what they need. V5 reported upon discharge the facility staff are made aware of any safety concerns with the residents. On 11/14/24 at 2:56PM, V6 (DON) stated the CNA told V6 that R1 was found on the floor while doing rounds. V6 reported interviewing R1 and R1 told V6 that R1 was trying to go to the bathroom. V6 stated R1 is supervision with limited assist for some things. V6 was unable to specify what R1 needed more assistance with. V6 defined limited assist as needing more help and supervision means someone only needs to be watching. V6 reported after the fall on 8/16/24, staff educated R1 to call for assistance before getting up. V6 stated R1 was working with therapy around the time of this fall. V6 reported the fall was caused by R1's shuffling gait. V6 stated this shuffling has been occurring for about four or five months and is the reason R1 was referred to physical therapy. V6 reported putting in an intervention of physical therapy and notifying the physician about the shuffling. V6 stated any new interventions are put on the care plan and staff will be told verbally. V6 reported R1 was not a high fall risk at the time of the fall. V6 stated some risk factors to be considered a high fall risk would be previous falls, taking medication that can increase risk for falls, or any type of change that would affect ambulation. V6 denied putting in any other interventions because R1 continued to ambulate at the same level. On 11/14/24 at 3:09PM, V1 (Administrator) stated nursing completed the investigation for the falls. V1 reported R1 had a fall while getting up to the bathroom unassisted. V1 stated if there is any kind of changing condition, V1 would expect the staff to investigate and find out the reason why there is a change as well as put in interventions to prevent any falls. On 11/15/24 at 10:26AM, V7 (Primary Physician) stated V7 vaguely remembered R1 had a fall and had some type of injury to the head requiring R1 be sent out to the hospital. V7 reported R1 does not walk normally and has some type of knee problem or leg problem but was unable to elaborate any further. V7 stated being aware there was a change in R1's gait, and R1 was referred to physical therapy but denied R1 needing any other fall interventions. V7 reported R1 was a fall risk, but not a high fall risk. When asked what makes a resident a high fall risk, V7 stated problems with walking or an abnormal gait can make someone a high fall risk. V7 reported the gait issue is why R1 was referred to therapy, but no other interventions were needed to prevent falls. The Physical Therapy Evaluation dated 6/28/24 documents R1 was referred to therapy due to new onset shuffle in walking and decrease in lower extremity strength. The Fall Scale dated 7/5/24 documents a total score of 15, indicating R1 is at low risk for falls. Anything higher than a 24 indicates a resident is at high-risk for falls. It is documented incorrectly that R1 has a normal gate. The shuffling of the gait was noted by staff sometime before R1 was referred to therapy on 6/28/24. There is no documentation in the nursing notes as to when the shuffling began. The Physical Therapy Treatment note dated 8/5/24 documents R1 completed a session of physical therapy and is able to perform all functional tasks, however, R1 requires constant cuing for proper foot clearance during ambulation to avoid shuffling gait and increasing risk for falls. The Physical Therapy Treatment note dated 8/9/24 documents R1 completed a session of physical therapy and tolerated treatments well with improved strength noted. R1 remains with shuffling gate during ambulation tasks. The Follow Up Fall note dated 8/16/24 documents R1 experienced a fall and is able to ambulate independently without an assistive device. There is no documentation in this note that R1 has a shuffled gait. The Fall Report dated 8/16/24 documents the CNA reported to the nurse that R1 fell in R1's room. R1 stated that R1 lost R1's balance while trying to use the bathroom. R1 has a small laceration on the right forehead. R1 was transferred to the hospital. No predisposing environmental or physiological factors are checked as contributing to the fall. The Post Fall Observation dated 8/16/24 documents R1 fell on R1's room but this was not a witnessed fall. R1 reported trying to use the bathroom and slid to the floor. R1 was previously lying in bed prior to the fall. It is documented that R1 is able to ambulate independently without an assistive device. R1 continued therapy after the fall on 8/16/24 and continued to show the shuffled gait was an issue when ambulating. The Occupational Therapy Treatment note dated 8/22/24 documents R1 is in the fall prevention group. R1 presents with shuffled walk and was instructed to pick up feet and take bigger steps with 100% carryover. R1 was observed with crossing feet and shuffling small steps when turning. R1 required consistent cues to ensure R1 was not crossing feet and taking bigger steps while turning in the bathroom. The Final Investigation Fall Report dated 8/23/24 documents R1 sustained a small cut to the right forehead as a result of losing R1's balance and falling while walking to the bathroom. The incident was unwitnessed. The floor was checked and noted to be dry. R1 was wearing shoes at the time of the incident. Upon return from the hospital, R1 was placed on increase monitoring for safety. R1 was also counseled to seek assistance from staff as needed. The Care Plan was reviewed and there is no documentation of R1 having a shuffling gait or a care plan and/or interventions addressing safety for the change in gait. The Care Plan dated 8/29/24 documents R1 is at risk for falls due to having a fall on 8/16/24. The only intervention documented on this care plan is to educate R1 on using caution when ambulating and paying attention to surroundings. The Minimum Data Set (MDS) Section GG dated 7/5/24 documents R1 needs supervision or touching assistance with all ADLs, bed mobility, transfers, and walking. The policy titled, Fall Program, dated 04/2020 documents, All residents will be evaluated for falls. The following is the schedule for these evaluations: on admission/readmission, quarterly after admission, change in condition, and after a fall. Upon completion of the fall evaluation, if a resident is identified at risk for falls, the following may occur: a care plan is developed or updated, new fall interventions are reviewed with the resident and/or responsible and applicable staff, and education regarding the resident's risk of falls or interventions to prevent falls is provided.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a lab draw for an antiseizure medication was completed as ordered for two residents (R1, R2) out of three reviewed for physician orders in a total sample of five. This failure resulted in R2 suffering a seizure and being sent to the hospital where the antiseizure medication level was low. Findings Include: R2 is a [AGE] year old with the following diagnosis: idiopathic epilepsy and paranoid schizophrenia. On 3/13/24 at 12:00PM, R2 was unable to remember when R2 went to the hospital last, but reported it was due to having a seizure while at the facility. R2 stated R2 was born with seizures and R2 has to take medications to control them. R2 was not aware of any missed blood draws. R2 does not remember the last time R2's blood was drawn at the facility. R2 was unaware if any seizure medication levels were low. On 3/14/24 at 11:29AM, V10 (Nurse) was not able to remember a date but stated one day R2 was not responding and staring off while sitting in the dining room. V10 reported 911 was called for R2 having a seizure longer than one minute. V10 denied being aware of any missed laboratory work for R2. V10 was not aware the last time R2 had laboratory work completed for Dilantin levels. V10 stated a physician will put in an order for what date the laboratory work should be completed and then a requisition should be sent over to the outside laboratory company so they know what to draw when they come to the facility. V10 reported the outside laboratory company comes to the facility every Wednesday and Friday and collects from the residents that are on the collection list. V10 stated if the physician ordered the laboratory work then the order must be followed. On 3/14/24 at V11 (Primary Physician) stated the Dilantin level is usually drawn every three months. V11 reported Dilantin is a very sensitive medication that must be tested to see if it is within normal limits. V11 stated the laboratory works must be completed so they know how to treat the seizures. V11 stated V11 had over 50 residents in the facility and was unable to report when R2's Dilantin level should have been drawn. V11 reported it is the responsibility of the nurse to keep track of orders in the system and complete them. V11 stated if the Dilantin level was tested as ordered and low then V11 would have treated the abnormal value. The Physician Order Summary documents an order for Dilantin (anti-seizure medication) laboratory blood work on 10/20/23 and 1/20/24. Both of these orders were placed on 10/19/23. The Laboratory Report dated 10/20/23 documents the Dilantin level was 14.8 ug/mL (normal is 10.0-20.0 ug/mL). There is no Dilantin level laboratory work documented after this date. A Daily note dated 1/21/24 documents the nurse observed R2 with seizure activity this morning. R2 was unresponsive in the day room in a wheelchair. R2 was assisted to the floor and placed on the left side. R2 had seizure activity for about five minutes. 911 was called and R2 was transported to the hospital. The Hospital Discharge summary dated [DATE] documents the reason for visit was a seizure reevaluation and the diagnosis was seizure. The Dilantin level was measured while in the hospital and is documented as 2.6 ug/mL. This level is low. R2 was given an injection of Dilantin and sent back to the facility. The Care Plan dated 8/23/23 documents R2 has seizures/an epilepsy disorder and is it risk for complications. An intervention for this care plan is documented to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. R1 is a [AGE] year old with the following diagnosis: schizophrenia disorder, bipolar disease, and epilepsy with seizures. On 3/13/24 at 11:46AM, R1 reported R1 takes an antiseizure medication (Dilantin) to manage the seizures. R1 reported at the hospital R1's blood was taken and the Dilantin level was low but R1 did not know what the level was. R1 stated the hospital gave Dilantin via IV and sent R1 back to the facility. R1 was unaware how frequently the Dilantin levels need to be tested. R1 does not remember when R1 was last tested before being at the hospital. On 3/13/24 at 12:35PM, V5 (Nurse) stated V5 was not aware how often a Dilantin level should be checked. V5 reported all the orders the nurses need to follow are in the POS (Physician Order Summary) and will tell you what labs need to be drawn when. V5 stated the facility uses an outside laboratory company and a requisition must be sent to the company so the resident will have the lab draw completed. V5 reported this medication level must be checked to make sure it is therapeutic. V5 stated a resident could have a seizure if the medication is not within range. On 3/13/24 at 12:52PM, V2 (Interim DON) stated R1's antiseizure medication levels are monitored through laboratory work ordered by the physician. V2 reported Dilantin levels are measured every three months. V2 stated R1 had Dilantin levels drawn in 10/2023 and other labs were ordered but did not have a result for 01/2024. V2 reported V2 nurses are responsible for checking and carrying out all the orders in the system. V2 denied being aware why these labs were not collected. On 3/13/24 at 1:35PM, V7 (Nurse) stated all orders must be completed as the physician order requires. V7 denied being aware of any missing laboratory works for R1. V7 stated the importance of checking the laboratory work is to see what is going on with a resident. On 3/13/24 at 1:49PM, V8 (Nurse) stated R1 is on Dilantin for seizures. V8 reported the level of this medication must be checked to make sure it is not too high or too low. V8 stated nurses must check the order sheet every day to ensure no new orders were placed on any residents. V8 denied being aware of any missed laboratory work for R1. V8 stated if any laboratory work is missed on the date it is to be collected then the physician should be notified. On 3/13/24 at 4:37PM, V9 (Primary Physician) stated R1 has a history of seizures and takes Dilantin. V9 reported that medication level needs to be collected every three to six months depending on what the previous levels were at. V9 stated the levels for this medication must be checked so make sure they are within a therapeutic range to prevent any seizures from occurring. V9 reported if there are no results for the lab that was ordered in 01/2024 then that means it was not completed. V9 denied being aware that R1's Dilantin levels were low while R1 was in the hospital. The Physician Order Summary documents an order for laboratory work to be collected on 10/20/23 and 1/20/24. Both of these orders were placed on 10/19/23. A Physician note dated 10/20/23 documents R1 was assessed on this day by the physician. A blood test was ordered for a Dilantin level on this day. The Laboratory Report dated 10/20/23 documents R1 had a Dilantin level drawn on this day and it is documented at 7.8 ug/mL which is considered low (normal is 10-20 ug/mL). There is no documentation the facility provided to the surveyor during this survey that any lab work was drawn on 1/20/24 as ordered. A Nursing note dated 3/9/24 documents an ambulance was called per request of R1's family. The ambulance attendants arrived to the facility around 9:45 AM to transfer R1 to the hospital. R1 denied any complaints of pain and had no signs or symptoms of distress upon transfer. The Hospital Records dated 3/9/24 documents R1 present of the emergency department for evaluation of possible seizure. R1 had a Dilantin level drawn while at the hospital. The Dilantin level was 8.1 ug/mL which is considered low. R1 was given Dilantin via an injection to bring the level to normal and sent back to the facility. The Care Plan date 5/15/23 documents R1 has a seizure disorder related to disease process and is at risk for complications. In intervention documents to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated. The policy, titled, Laboratory and Diagnostic Testing, dated 04/2020 documents, Guideline: To accurately report and monitor laboratory and diagnostic testing. Standard: Laboratory and diagnostic testing are performed according to the order; Testing is based upon the resident condition and/or to monitor therapeutic blood levels for medication management. Oversight in coordination is completed by the Director of Nursing or designee .Procedure: 1. The nurse receives the order for laboratory or diagnostic testing, and; c) Completes requisitions according to the date the test is to be completed. Laboratory requisitions are filed in designated accordion folder . 2. Laboratory and diagnostic results are received and reviewed by the licensed nurse. 3. The nurse receiving the laboratory or diagnostic results a) The nurse documents in the medical record communication with the physician and/or extender regarding results.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provided a resident (R1) with proper footwear to prevent or reduce the risk of a fall incident. This affected one of three residents (R1) reviewed for fall prevention interventions. This failure resulted in R1 falling in the hallway and sustaining a fracture to the right arm. Findings Include: R1 is a [AGE] year old with the following diagnosis: paranoid schizophrenia, alcohol abuse, and fracture of shaft of right humerus. On 8/9/23 11:53AM, R1 was interviewed. When asked why R1's arm was in a sling R1 stated R1 fell to the floor and broke R1's arm. R1 endorsed being sent to the hospital after that. R1 was not able to give any other details what happened after the fall. R1 then endorsed that 2 other staff were present but was not able to give any names. R1 endorsed staff gave R1 a pair of shoes without any laces when R1 returned to the facility. On 8/9/23 at 12:39PM, V2 (Nurse) stated that V3 (CNA) and V4 (Manager on Duty/Director of Housekeeping) said R1 fell down because R1's shoe laces were untied. After R1 tripped, the facility got R1 new shoes and always make sure they are now tied. The facility makes sure R1 has the appropriate footwear when R1 is up and walking. V3 endorsed that R1 doesn't wants to tie the shoes so R1 just leaves them undone. On 8/9/23 at 12:47PM, V3 stated V3 was on the D wing doing rounds and was near the end of the hallway. V3 heard a whine and turned around. R1 was on the floor when V3 turned around. When V3 walked over to R1, R1's shoe laces were untied and V3 just assumed that R1 fell over the shoe laces. V3 doesn't think R1 can tie the shoes alone. R1 walks around with the shoe laces undone a lot. V3 reported staff tells R1 to tie them or ask R1 to tie them and R1 just keeps walking. On 8/9/23 at 12:57PM, V4 stated the fall was after lunch and V4 was doing rounds on the D wing. V4 endorsed being was in the middle of the hall and R1 at the doorway when you come down the hall. V4 stated it happened so fast but all of the sudden I just saw R1 go down. V4 reported another V3 and V4 walked up to R1 to see what happened and R1 was on the floor on R1's right side. V4 endorsed R1 had red gym shoes on and both of them were untied. V4 stated R1 must have tripped and fell over R1's shoes that time. V4 stated R1 always has them untied though. V4 reported R1 gets the shakes sometimes so V4 doesn't think R1 can tie them without assistance. V4 endorsed V1 asked V4 to get him a pair of shoes out of storage without any laces. The facility had some in there so I know R1 was given shoes without laces in them since R1 has a hard time tying them. On 8/9/23 at 3:09PM, V1 (Administrator) stated V1 got a call on the weekend saying that a fall occurred with R1. V1 then spoke with the nurse and was sending R1 to the hospital because R1 was having pain in the right arm. V1 endorsed staff told V1 that R1 stepped on R1's shoelace and fell. R1 had x-rays taken at the hospital that noted a fracture. V1 stated for this fall, the facility got R1 shoes that did not have any laces. V1 endorsed R1 can tie them, but it requires extra time and queuing. Sometimes R1 would tell staff that R1 does not want the shoes tied. Staff would tie them when they noticed they were undone. V1 stated R1 didn't have any issues regarding falls and R1's shoes being untied before this fall. On 8/9/23 at 3:33PM, V6 (MDS Coordinator/Fall Team) stated this fall was related to R1 tripping on R1's shoes because the shoelaces weren't done. After the fall, the facility got R1 shoes without shoestrings. V6 endorsed staff try to encourage R1 to wear the shoes without laces. V6 reported R1 also had a fall in February that was due to poor coordination where he tripped. V6 stated staff gives the same amount of monitoring to everyone in the facility because no one is considered a high fall risk. V6 endorsed staff do basic interventions for everyone that hasn't had a fall like watching their gait to make sure residents are steady and making sure they have on appropriate footwear. Having appropriate footwear on can reduce your chance of falling. Like in this case, if R1 had R1's shoelaces tied, maybe R1 would not have fallen. A Nursing note dated 6/10/23 at 2:57 PM documents the manager on duty (V4) came to the nurse's station and reported R1 fell on the right side. The nurse (V2) assessed R1 and noted slight swelling in the right hand and arm. R1 complained of pain to the upper right shoulder. An x-ray was ordered to the right arm STAT. A Nursing noted at 6/11/23 documents R1 returned back to the facility after the hospital visit with a fracture to the right lower humerus. R1 is currently wearing a sling immobilizer with slight swelling. R1 is ordered to follow up with a general orthopedic physician. The Fall Report dated 6/10/23 documents R1 fell onto the right side. R1 reported pain when being assessed with slight swelling noted to the right hand. The physician was called and ordered x-rays to the right arm. It is incorrectly documented that there are no predisposing situation factors. Improper footwear should have been documented as a pre-disposing situation factor to this fall. The Hospital Records were requested but were not received in time. The Final Investigation Report dated 6/10/23 documents R1 was in the hall attempting to get in line for smoke break when R1 stepped on R1's shoelace and tripped and fell to the floor. As a result of the fall, R1 sustained a fracture to the right lower humerus. R1 reported that R1 fell while walking in the hall towards the patio for smoking. The fall was witnessed by staff. Staff reported that R1 was walking towards the patio while in line and R1 was wearing shoes with shoelaces untied at the time of the fall. R1 was sent to the hospital for medical evaluation and return with a splint to the right hand in a sling. R1 had follow up orthopedic appointments scheduled. R1's shoes have been replaced with slip on style without tie up laces. The Care Plan dated 4/6/23 documents R1 is at risk for falls related to psychoactive drug use and other underlying medical conditions. On 4/13/23, R1 slid to the ground while in the dining room, but had no injuries. Interventions were placed after this fall. There is no intervention addressing R1 ambulating with shoes untied. The Care Plan dated 6/26/23 documents R 1 sustained a fall on 6/10/23 with an injury. An intervention placed on this date documents that R1 will wear appropriate footwear and shoes will be tied when ambulating.

Based on interviews and record reviews, the facility failed to follow its abuse policy to prevent a resident-to-resident physical assault. This affected 2 of 3 residents (R2, R3) reviewed for physical abuse. This failure resulted in R2 being assaulted by R3. R3 hit R2 in the face multiple times causing R2 to sustain facial lacerations and facial fractures. Findings include: On 4/13/23 at 3:50pm, V7 CNA (certified nurse aide) stated that V7 worked on 4/6/23 from 3:00pm to 11:30pm. V7 stated that R2 will occasionally curse at staff or peers if R2 does not like what the person is saying to R2. V7 denied R2 involved in any resident-to-resident physical altercations previously. V7 stated that R2 uses a cane and can ambulate with some difficulty. V7 stated that R2 usually goes between R2's room and dining room. V7 stated that R3 was being very vocal on 4/6/23. On 4/14/23 at 7:41am, V10 (nurse) stated that V10 worked 11:00pm 4/6 to 7:30am 4/7. V10 stated that V10 did not witness the event involving R2 and R3. V10 stated that V10 was at the nurses' station getting ready to pass medications. V10 stated that R2 was moving around a lot that night in his wheelchair. V10 stated that the last time she saw R2 was at 2:30am. V10 stated that the CNA during rounds, saw what happened and came and got her. V10 stated that she went to room immediately with the CNA. V10 stated that V10 observed R2 sitting on R2's bed with blood on face, cuts to left eyebrow and below left eye. V10 stated that R3 was standing not far from R2's bed; appearance was threatening. V10 stated that R3 was next to R2's bed, directly facing the door, and smiling with fists clenched at sides of his body. V10 stated that it was difficult to get into room to assess R2's injuries. V10 stated that V10 called EMS (emergency medical services) 911 requesting police and ambulance services. V10 stated that police came and took control of the situation. V10 stated that the police officers had to barricade R3 against the wall with R3's bed so paramedics could get to R2. V10 stated that V10 asked R2 what happened, R2 responded 'he did it' pointing at R3. When V10 asked R3 what happened, R3 just smiled. V10 stated that the paramedics took R2, and the police officers took R3 out of the building at the same time. On 4/14/23 at 8:10am, V11 CNA stated that she worked on D wing on 4/6/23 from 11:00pm to 7:30am. V11 stated that R2 was awake all night, self-propelling in wheelchair from R2's room to dining room. V11 stated that V11 did hourly rounding on all residents in D wing. V11 stated that R3 was in bed awake all night. V11 stated that V11 was assigned three residents to assist with their showers. V11 stated that she got these residents starting at 4:30am. At that time, R2 was coming from dining room to his room. V11 stated that after showers were completed, V11 rounded on residents; between 5:30am and 6:00am. V11 stated that before she did rounds at 6:00am, V11 informed V12 CNA on adjacent wing she was going to the bathroom. V11 stated that V12 found R2 bleeding during that time. V11 stated that V11 heard overhead page for code white and ran to R2 and R3's room. V11 stated that R3 appeared mean, and no staff could get into room to assist R2. V11 stated that when the police arrived, they had to barricade R3 against wall using R3's bed in order to get to R2. On 4/14/23 at 8:20am, V12 CNA stated that V12 worked on the E wing, which is adjacent to D wing on 4/6/23. V12 stated that on night of 4/6, R2 didn't sleep. V12 stated that R3 remained in R3's room all night. V12 stated that V12 observed R2 bleeding during code white. V12 stated that V12 rounded on all residents on D and E wing at 6:00am. R2: Review of R2's medical record notes R2 was admitted to this facility on 9/9/2022 with diagnoses including schizoaffective disorder-bipolar type, major depressive disorder, borderline personality disorder, and schizophrenia. Review of R2's risk for abuse screening, dated 4/13/23, notes R2 is at risk for abuse as evidenced by mental illness diagnoses and requiring extensive assistance with ADLs (activities of daily living). Review of R2's BIMS (brief interview of mental status) score, dated 3/2/23, notes R2's score is 14 out of 15. R2 is able to make needs known. Review of R2's hospital medical record, dated 4/7/23, notes R2 presented to the emergency room with complaints of headache after an assault. R3 assaulted R2. R2 was being punched with R3's fists. R2 is normally alert and oriented x 4 at baseline but currently disoriented. Complaining of diffuse headache. Assessment noted multiple lacerations to face with associated swelling and bruising. Nose swollen and bruised. Eyes with conjunctival bleeding. Left eyebrow laceration is 9cm (centimeters) and was sutured. Right eyebrow laceration is 4cm and was sutured. Left cheek laceration is 1cm and was sutured. CT (computed tomography) of R2's head and face noted displaced fractures of the left orbital floor, left lateral orbital wall and left lamina papyracea (medial orbital wall) with extraconal soft tissue gas and bleeding in the inferior left orbit. Associated bleeding is also seen in the left maxillary sinus. Mildly displaced bilateral nasal bone fractures are seen. R2 was admitted to the hospital for further evaluation. R3: Review of R3's medical record notes R3 was admitted to this facility on 3/14/23 with diagnoses including schizoaffective disorder-bipolar type, schizophrenia, psychosis, and alcohol abuse. R3 was hospitalized 3/21-4/3 for psychiatric evaluation. Review of R3's medical record notes: On 3/15/23, R3 walked around facility during most of the shift. R3 had to be redirected repeatedly. On 3/21/23, R3 displayed behaviors of yelling/ screaming, hallucinations, delusions, verbally threatening, responding to internal stimuli, and rejection of care. Interventions attempted: R3 was re-directed, assisted to office, and removed from situation. R3's behaviors continued and rejected redirection. R3 then attempted to kill himself - tied a linen around his neck with a knot standing behind the door thereby attempting to commit suicide. On assessment, R3 states that he is fine and wasn't planning on harming himself. R3 was placed on 1:1 until he was transported to the hospital for psychiatrist evaluation. EMS (emergency medical services) reported R3 became highly suicidal during transport and needed to be re-routed to the closest hospital due to R3's acuity. On 4/4, nurse noted R3 needs to be continuously redirected before R3 follows directions. On 4/7 at 6:15am, V10 (nurse) was called by the CNA into R2's room while passing medication. Nurse noted R3 standing very close to R2 holding the room curtain and pacing. V10 asked R3 what happened, no verbal response. R2 was noted bleeding from the face; no initial explanation was received from either R2 or R3. Review of this facility's abuse policy, dated 04/2020, notes this facility affirms the right of our residents to be free from physical abuse. Physical abuse is the infliction of injury on a resident that occurs other than by accidental means and that requires medical attention.