**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, interviews, review of facility policy, and review of a facility self-reported incident (SRI) investigation, the facility failed to ensure Resident #7 was free from staff to resident physical abuse. This affected one resident (#7) of three residents reviewed for abuse. The facility census was 38. Actual harm occurred on 09/09/24 when Resident #7 was physically abused by a State Tested Nursing Assistant (STNA) during care resulting in large areas of bruising to both of the resident's arms. Bruising to the left upper arm measured 4.5 centimeters (cm) in length by 3.0 cm width and was described as purple to dark red in color. Bruising to the right upper arm measured 15.0 cm in length by 6.0 cm with and was described as deep purple and dark red with intact skin. A facility SRI dated 09/09/24 indicated Resident #7 reported pain as a result of in incident, however the type or level of pain was not described. An interview with Resident #7 by the Director of Nursing (DON) on 09/09/24 about the nature of his injuries revealed the resident reported the STNA had been rough with him. An interview with Resident #7's daughter revealed this bruising was not the first time Resident #7 had sustained bruising from staff as a result of rough care. In addition to the actual physical harm/pain caused to the resident, by using the reasonable person concept, Resident #7 would have experienced psychosocial harm as a result of the physical abuse since there was an expectation the resident would not be harmed by staff providing his care. Findings include: Review of the medical record for Resident #7 revealed an admission date of 07/27/24 with diagnoses including hypertensive heart disease without heart failure, asthma with status asthmaticus, dementia with agitation, depression, type two diabetes mellitus, pulmonary fibrosis, left eye cataract, dizziness, and insomnia. Review of the care plan dated 07/29/24 revealed Resident #7 had a self-care deficit related to multiple medical conditions. The care plan was updated on 09/09/24 to reflect Resident #7 had bilateral arm bruising with an added intervention to monitor the bilateral arm bruising and report any other type of skin abnormality. Further review of Resident #7's care plan revealed an update dated 09/13/24 which noted Resident #7 demonstrated anxiety and resistance with transfers. Interventions included breaking tasks into manageable subtasks, providing cuing and prompting as needed, allowing for frequent rest periods, and monitoring for signs of fatigue, frustration, being overwhelmed, or intolerance to care. Review of the admission Minimum Data Set (MDS) 3.0 assessment completed on 08/02/24 revealed Resident #7 had intact cognition. Resident #7 was always continent of urine but required substantial assistance for toileting hygiene, bathing, personal hygiene, chair to bed transfers, and toilet transfers. The MDS did not indicate the use of anticoagulants. Review of a nurse's note dated 09/09/24 timed at 3:15 P.M. revealed Certified Nurse Practitioner (CNP) #300 and the resident's family were notified Resident #7 sustained bruises to both of his arms. Review of the Skin and Wound Assessment dated 09/09/24 revealed in-house acquired bruising to Resident #7's left upper arm measuring 4.5 centimeters (cm) by 3.0 cm by 0.0 cm, described as purple to dark red in color with no pain. Review of a second Skin and Wound Assessment completed on 09/09/24 revealed in-house acquired bruising to Resident #7's right upper arm measuring 15.0 cm by 6.0 cm by 0.0 cm, described as deep purple and dark red with intact skin and no pain. Review of the progress notes dated 09/10/24 timed at 10:47 A.M., authored by CNP #300, revealed an assessment of bilateral arm contusions with additional similar discolorations over the antecubital region of both arms. At the time of this assessment, Resident #7 was noted to have full range of motion of both arms and no indicators of pain. Review of the nursing progress note dated 09/10/24 timed at 1:50 P.M. revealed an x-ray was taken of the right humerus with no acute osseous abnormality noted. Review of a facility SRI submitted to the Ohio Department of Health (ODH) Enhanced Information Dissemination & Collection (EIDC) on-line system on 09/09/24 revealed Hospice Nurse #329 reported to the facility Administrator that Resident #7 sustained bruising on his right upper arm after the assigned STNA from the prior night shift was too rough with him. The SRI initial report revealed Resident #7 did report pain and the Nurse Manager reported Resident #7 sustained bruising on both the right and left upper arms. Resident #7 was interviewed by the DON on 09/09/24 about the nature of his injuries and reported the STNA had been rough with him. Review of the findings for the incident investigation competed on 09/13/24 revealed the facility did not substantiate abuse had occurred due to the nurse on duty at the time, Licensed Practical Nurse (LPN) #323, reported the alleged perpetrator, STNA #332, was not rough with Resident #7 when she requested STNA #332 to stay with him while he was in the bathroom. Review of LPN #323's undated witness statement revealed no indication she was present at the time of Resident #7's injuries but did indicate STNA #332 was witnessed entering Resident #7's room later that shift. Review of a witness statements from Hospice Nurse #329 dated 09/09/24 (untimed), STNA #333 (undated and untimed), and STNA #334 dated 09/09/24 timed 11:19 A.M. revealed none had witnessed the cause of Resident #7's bilateral arm bruises. Review of the witness statement from STNA #332 forwarded from the staffing agency to the facility on [DATE] at 3:47 P.M. revealed no knowledge of abuse and no confirmation she provided care to Resident #7 on the night shift scheduled from 11:00 P.M. on 09/08/24 to 09/09/24 at 7:00 A.M. Interview on 09/24/24 at 10:07 A.M. with Resident #7 confirmed he remembered a couple of girls being too rough with him and hurting his arms, but he could not recall any additional details. During the interview, Resident #7 used hand gestures to demonstrate his arms being grabbed. Observation at that time revealed a medium purplish to yellow healing bruise on his right forearm, a yellow healing bruise to his right upper arm, and a faint yellowish bruise to his left upper arm. Interview on 09/24/24 at 10:10 A.M. with the daughter of Resident #7 (Daughter #1) confirmed the resident had sustained bruises to both of his arms on 09/09/24 and a few weeks prior. She further stated the previous DON was informed of the first incident and the STNAs involved were not allowed back in the facility and the family was shocked when the resident was injured again in the same manner. Interview on 09/24/24 at 11:28 A.M. with the power of attorney (POA) for Resident #7's healthcare (Daughter #2) confirmed Resident #7 sustained bruises on his arms on two separate occasions by staff handling him too roughly during night shifts. The POA further revealed both incidents were first assessed and reported by the Hospice nurses and the previous DON was involved in investigating and terminating facility privileges to the perpetrators after the first incident, which she was unable to confirm the date of. Daughter #2 further indicated the current DON had informed the family the staff responsible for Resident #7's injuries reported on 09/09/24 were not allowed back to the facility. The POA had no knowledge of who the named alleged perpetrators were for either incident. Telephone interview on 09/24/24 with Hospice Nursing Supervisor #327 at 11:39 A.M. confirmed Resident #7 sustained two separate negative events leading to bruising of his arms, one reported by Hospice Nurse #329 on 09/09/24 and one reported by Hospice Nurse #328 on 08/28/24. Telephone interview on 09/24/24 at 12:47 P.M. with Hospice Nurse #328 confirmed she visited Resident #7 on 08/28/24 for a (hospice) recertification visit and noted bruises on his arms in various stages, some new around both upper arms. Hospice Nurse #328 further stated Resident #7 reported an STNA, described as a short, heavy-set black lady, threw him onto the bed like he was a rag doll (Hospice Nurse #328 said those were his exact words). Hospice Nurse #328 stated she was informed by the previous DON the girl Resident #7 reported was agency staff and was placed on the do not return list as a result of the incident. Hospice Nurse #328 was unaware of any additional follow-up. Interview on 09/24/24 at 4:05 P.M. with STNA #325 confirmed Resident #7 informed her he had been handled too roughly and was injured by another staff member. During the interview, STNA #325 confirmed she reported it to the nurse who informed her the facility was aware and involved staff would not be allowed to return to the facility. Telephone interview on 09/24/24 at 5:32 P.M. with LPN #323 revealed she was the only nurse on duty on the night shift beginning 09/08/24 until 09/09/24 and that STNA #332 from a staffing agency was the STNA assigned to the hall where Resident #7 resided. LPN #323 further confirmed she was not present in Resident #7's room for any chair, bed, or toilet transfers but had found Resident #7 on the toilet by himself and instructed STNA #332 to stay with Resident #7 and not leave him unattended while in the bathroom because he was a fall risk. LPN #323 stated there was no bruising to Resident #7's arms when she left him with STNA #332, and she had not seen his arms or been present during any other care by STNA #332 after that encounter. The next night, LPN #323 noticed the bruising on Resident #7's right arm and stated it looked suspicious of a fracture. According to LPN #323, Resident #7 stated the aide from the previous night had to show him who was the boss, so she threw him near the couch in the room. LPN #323 revealed she immediately reported this information to the DON via telephone and was informed the facility was aware and investigating and the aide involved would not be allowed back in the facility. LPN #323 confirmed an x-ray was ordered. The x-ray showed there was no fracture. Telephone interview on 09/25/24 at 7:06 A.M. with STNA #309 confirmed knowledge of bilateral arm bruises on Resident #7, stating there was no reason for that sort of bruising if he was handled properly, as he described large bright red bruises on both arms, including from the forearm all the way to his upper arm. During the interview, STNA #309 revealed Resident #7 informed STNA #309 the night aides were too rough with him during a previous incident as well and gave no indicators that would cause facility staff not to believe Resident #7. STNA #309 further stated when the conversation with Resident #7 was reported to the previous DON, the STNA was informed the facility was aware and that two female STNAs were not allowed back to work in the facility as a result of the incidents. STNA #309 denied receiving any in-service or training related to abuse after the reported injuries sustained by Resident #7. Telephone interview on 09/25/24 at 8:56 A.M. with STNA #306 confirmed she had knowledge Resident #7 had bright red bruises on both arms. During the interview, STNA #306 was unable to recall the date she first noted bilateral arm bruising, but stated she reported the bruises to the nurse on duty who informed her the incident was under investigation. STNA #306 stated when Resident #7 was asked about the origin of the bruises, he responded that the aide from the previous night had to show me who's boss. Interview on 09/25/24 at 10:35 A.M. with Hospice Nurse #329 confirmed that on 09/09/24 she noted large bright red bruises on both of Resident #7's arms. She further confirmed Resident #7 would occasionally get small, scattered marks on his skin, but stated this was different, they looked like two hand grasps and were new skin concern areas. During the interview, Hospice Nurse #329 confirmed Resident #7 had occasional short-term memory issues, but was alert and oriented to person, place, time, and situation and could see no reason to doubt his recall of events. Hospice Nurse #329 also stated that the facility seemed to believe Resident #7 right away. She also confirmed that when she reported the incident to her supervisor, she was informed that Hospice Nurse #328 had reported an incident of bruising that occurred previously after being handled too rough by facility staff. Interview on 09/25/24 at 1:31 P.M. with STNA #326 confirmed awareness that Resident #7 sustained bruises on his arms somewhere around the end of August 2024 or the beginning of September 2024 then heard there was a second similar incident not long after. STNA #326 was not certain of the date(s) of injury. During the interview, STNA #326 stated some of the other aides may not have the patience required for Resident #7's night-time confusion and this was reported to the previous DON. STNA #326 was not aware of the outcome after reporting to the previous DON. Interview with the current DON on 09/25/24 between 2:30 P.M. and 2:50 P.M. confirmed she placed two agency STNAs (STNAs #332 and #334) on the do not return list because she felt they were both being dishonest and could not confirm with 100 percent certainty which one of them may have been providing care to Resident #7 the night he sustained bilateral arm bruising and accused staff of being too rough with him. During the interview, the DON confirmed she had no reason not to believe Resident #7's report of how he sustained the bruises, but added he did have a tendency to display some confusion and agitation in the late afternoon or evenings and thought the injuries could possibly have been incidentally caused during a difficult transfer. The DON also confirmed after learning on 09/24/24 that the Hospice staff, Resident #7, and Resident #7's two daughters reported there was a previous incident involving staff causing bruises by handling too roughly, she went to the room and spoke with the daughter who was Resident #7's POA for care. Resident #7's POA confirmed there was an incident in August 2024 where Hospice Nurse #328 reported bilateral arm bruising Resident #7 told her happened when the aide was too rough with him. According to the DON, the POA stated this was reported to the previous DON who immediately placed that staff member on the facility's do not return list, though she did not know who the alleged perpetrator was determined to be. Interview on 09/25/24 at 3:00 P.M. with the Administrator confirmed there had been no thorough/comprehensive investigation completed regarding the bruises reported by the Hospice Nurse to the previous DON on 08/28/24 and that he was waiting for Hospice to provide additional information at which time he planned to move forward with an investigation. He reported this was all new information to him and was awaiting additional information before moving forward. Review of the policy titled Abuse, Neglect, Exploitation & Misappropriation of Resident Property dated 11/28/16 revealed the facility was to take steps to identify and prevent resident harm, including injury caused by rough handling during resident care. The definition of abuse included the willful infliction of injury, unreasonable confinement, intimidation, or punishment resulting in physical harm, pain or mental anguish. Mistreatment was defined as inappropriate treatment or exploitation of resident. The policy indicated willful meant the individual must have acted deliberately, not that the individual must have attended to inflict injury or harm. This deficiency represents non-compliance investigated under Complaint Number OH00157332.