Riverside Health Care Center, Inc.

room.

The investigation indicated there had been a verbal altercation earlier that day, 12/7/25 when Resident #1 saw Resident #2 on his/her unit speaking with a staff member.

The hospital Discharge summary dated [DATE] identified Resident #1 was admitted to the hospital on [DATE] with diagnoses of open fracture of the nasal bone, hematoma of the nasal septum, periorbital hematoma, and open fracture of the ethmoid bone (a square bone at the root of the nose).

Interview with Resident #1 on 12/30/25 at 10:50 AM indicated he/she saw Resident #2 on the unit talking to an aide after lunch on 12/7/25 and did not want Resident #2 on the unit. Resident #1 indicated he/she left the unit, went downstairs to the front lobby area, and when downstairs, Resident #2 appeared, came up in his/her chair and tangled it up with mine. Resident #1 indicated he/she lifted his/her arm up to protect him/herself when Resident #2 approached and then was punched by Resident #2 to the left side of the face multiple times.

Interview and review of the Facility Reported Incident report with Director of Nursing (DON) on 12/30/25 at 11:02 AM identified a verbal altercation between Resident #1 and Resident #2 occurred on 12/7/25 on the fourth floor and then led to physical contact in the front lobby area, Resident #2 punched Resident #1 in the face on 12/7/25 around 1:20 PM.

The DON identified following the incident, Resident #2 no longer resided at the facility.

Review of facility Abuse policy dated January 2023 identified abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish and directed that each resident has the right to be free from abuse and will not be subjected to abuse by anyone, including other residents.

The facility identified the deficient practice and developed an immediate plan of correction for past noncompliance. DON/Designee will complete a 100% audit of residents with documented aggression independent with their mobility to ensure current care plan interventions are present, appropriate and individualized with behavioral monitoring in place.Nursing, aides, social services, recreation, and management were education on:Resident-to-resident altercation preventionAbuse reporting timelinesBehavioral health recognition and required documentationAlcohol use policy and recognizing signs and symptoms of impairmentIdentifying triggers and early escalation signsSupervision expectations for high-risk residentsHow and when to update the care planWhen to request a provider or Behavioral Health consultThe DON/designee will complete audits weekly for four weeks then monthly for two monthsNew incidents of aggression will be audited for timely reporting, investigation completion, throughout care plan review and implementation of appropriate interventionsFindings will be reported to QAPI monthly.Completion date December 21, 2025.

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