**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to protect the residents' right to be free from physical abuse by another resident for 1 (#1) of 3(#1, #2, #3) sampled residents reviewed for abuse. This deficient practice resulted in an actual harm for resident #1 (who was cognitively impaired) when on 10/10/2023 at 7:30 a.m. resident #2 physically abused resident #1. Resident #2 (who was cognitively impaired) hit resident #1 in the face because resident #1 was in his bed. Resident #1 was sent to the hospital diagnosed with a nose bleed and a broken nose. Findings: Review of the facility's current Abuse Prevention Program policy revealed the following: As part of the resident's abuse prevention, the administration will: 1. Protect our resident's from abuse by anyone including, but not limited to: facility staff, other residents, consultants, volunteers, and staff from other agencies, family members, legal representatives, friends, visitors or any other individual. Review of the facility's Abuse and Neglect Protocol Definitions revealed the following: 1. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Instances of abuse of all residents, irrespective of any mental or physical condition cause physical harm, pain or mental anguish. 4. Willful is used in the definition of abuse, means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Review of resident #1's medical record revealed an admit date of 06/01/2023 with a diagnosis of but not limited to anxiety disorder, bipolar disorder, unspecified dementia with behavioral disturbances, insomnia and depression. Review of resident #1's MDS (Minimum Data Set) dated 08/25/2023 revealed a BIMS (Brief Mental Status Interview) score of 00 indicating severely impaired cognition. Review of resident #1's Comprehensive Care Plan dated 10/02/2023 revealed: Potential for injury related to dementia, at risk for being abused, wanders, and enters others rooms: monitor resident socialization behavior and document, observe for changes in mental status and document, and report any negative finding to the physician. Review of the facility's incident report dated 10/10/2023 7:30 a.m. revealed S4 LPN (Licensed Practical Nurse) was called to the dementia unit and upon arriving to resident #1's room found resident #1 lying in resident #2's bed, holding his nose. Resident #1's nose was bleeding. S4 LPN asked resident #1 what happened and resident #1 stated, He hit me in my nose. S4 LPN instructed resident #1 to remain in the room. Review of resident #1's Incident/Accident Nurses Notes revealed the following: 10/10/2023 7:30 a.m. S4 LPN was called to the dementia unit by S3 CNA, upon arriving to resident #1's room, S4 LPN saw resident #1 lying in another resident's bed holding his nose. Resident #1's nose was bleeding. S4 LPN asked resident #1 what happened and resident #1 stated, He hit me in my nose. S4 LPN told resident #1 to remain in the room. 10/10/2023 8:00 a.m. Physician notified, received order to send resident #1 to the emergency room for evaluation and treatment. 10/10/2023 12:30 p.m. X-ray revealed resident #1 had a broken nose. Resident #1 had no recollection of what had happened. Review of resident 1's x-ray report dated 10/10/2023 at 9:12 a.m. revealed the following results: Findings: Fracture of the left nodes of bone with 1 millimeter medial displacement and medial angulation. Right lateral nasal septal deviation. Degenerative changes cervical spine Soft tissues: Soft tissue swelling in the nares. Frontal scalp soft tissue swelling. Sign increased attenuation nasal septum anterior inferiority. Impression: Fracture of the right and left nasal bones with associated soft tissue swelling. Thickening of nasal septum correlate for nasal septal hematoma. Review of resident #1's CT (Computerized Tomography) of brain done on 10/10/2023 revealed the following: Impression: Nasal bone fractures Review of resident #2's medical record revealed an admit date of 04/12/2023 with a diagnosis of but not limited to attention concentration deficit, major depressive disorder, unspecified dementia and Parkinson's disease. Review of resident #2's MDS dated [DATE] revealed a BIMS score of 00 indicating severely impaired cognition. Review of resident #2's Comprehensive Care Plan dated 08/25/2023 revealed; Violence, Risk for related to Psychosis, Depression approaches included: allow for quality time to communicate ,provide reality orientation during waking hours, remove objects from the immediate environment that could be used to harm self or others, provide close supervision and watch for early signs of agitation or increasing anxiety and report, psychiatric evaluation per doctor's order, provide medications as ordered and monitor effectiveness of prescribed medication used in controlling aggressive behavior and assisting to remain calm, monitor for side effects of antipsychotic medication and record. Combative Behavior approaches included: 1:1 supervision for 14 days, approach resident warmly and positively, Provide consistency with direct care providers on all shift, allow resident opportunity to make choices and participate in cares. Do not argue with resident, elicit family input for best approach to resident, social service to evaluate and visit with resident, praise resident for demonstrating desired behavior, monitor and documents resident behaviors, administer behavior medications as ordered by physicians, review drug regime at least monthly and evaluate for dosage reduction and document findings. Review of the facility's incident report dated 10/10/2023 7:30 a.m. revealed S4 LPN was called to the dementia unit and upon arriving saw resident #2 sitting with blood on his right hand. S3 CNA informed S4 LPN of resident #2 standing over resident #1 with his fists balled up and blood on his right hand. S4 LPN asked resident #2 if he had hit another resident and resident #2 stated, he deserved it. S4 LPN then asked resident #2 why did the other resident deserve it and resident #2 stated, he was in my bed and I want him out of my home. Review of resident #2's Incident/Accident Nurses Notes revealed: 10/10/2023 7:30 a.m. S4 LPN was called to the dementia unit. Resident #2 was found sitting in the dementia unit dining area with blood on his right hand. S3 CNA informed S4 LPN of resident #2 standing over resident #1 with his fists balled up and blood on his right hand. S4 LPN asked resident #2 if he had hit another resident and resident #2 stated,He deserved it. S4 LPN then asked resident #2 why did the other resident deserve it and resident #2 stated, he was in my bed and I want him out of my home. During an interview on 10/30/2023 at 3:30 p.m. S3 CNA stated, I was in the hallway and I heard some noise in resident #1's room and when I went to open to door, resident #2 hit me in the face. I told resident #2 to come out of the room and resident #2 went down to the dayroom and another CNA sat with him. When I went into resident #1's room I saw resident #1 sitting on the bed holding his head with blood on his face. I told the S4 LPN and she came and assessed resident #1. Resident #1 was sent to the hospital. Resident #2 was put on one on one supervision until they sent resident #2 to the behavioral hospital. During an interview on 10/30/2023 at 1:40 p.m. S4 LPN reported resident #1 lived on the dementia unit and was resident #2's roommate. S4 LPN stated, I was told resident #2 had hit resident #1 by S3 CNA. I went down and got resident #2 to go to the dayroom to be monitored one on one. When I assessed resident #1, I noticed him holding his nose with blood dripping from it. Resident #1 told me in reference to resident #2, He hit me in my nose. Resident #1 was sent out to the hospital. Resident #1 returned to the facility the same day with a diagnosis of a broken nose. During an interview on 10/31/2023 at 8:00 a.m. S2 DON (Director of Nurses) reported S4 LPN called and told me resident #2 had hit resident #1 by S3 CNA. S2 DON confirmed resident #1's nose was broken as a result of resident #2 hitting resident #1. During an interview on 11/01/2023 at 10:00 a.m. S1 Administrator confirmed resident #1 was hit by resident #2. S1 Administrator further confirmed resident #1's nose was broken as a result of the altercation.