**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility Self-Reported Incidents (SRI), review of the facility investigation, review of facility policy and procedure, resident interview, and staff interview, the facility failed to ensure Resident #100 was free from resident to resident physical abuse. Actual harm occurred on 02/03/25 when Resident #57, who had a history of resident altercations and impaired cognition, pushed Resident #100 causing a fall and a right femur fracture. This affected one (Resident #100) of six residents reviewed for abuse. The facility census was 98. Findings include: a. Review of a facility submitted SRI dated 02/03/25 for physical abuse revealed Resident #57 pushed Resident #100 to the ground when Resident #100 wandered into Resident #57's room. Both residents were assessed for injuries. Resident #100 was left immobilized on the floor due to an obvious range of motion deficit to the right hip. Nine-one-one (911) was called for Resident #100's pain and range of motion deficit. Neurological checks were initiated but did not continue due to the transfer to the hospital. The medical provider and families were notified of the incident. Resident #57 was assessed for physical injuries with none noted. Resident #57 was placed on 15-minute checks until he retired for sleep at 11:00 P.M. the same day. The facility unsubstantiated abuse and marked that the evidence indicated abuse, neglect, or misappropriation did not occur. Review of the medical record for Resident #100 revealed an admission date of 12/29/21. Resident #100's diagnoses included Alzheimer's disease with late onset, vascular dementia, osteoarthritis, and major depressive disorder. The resident was discharged to the hospital on [DATE] and did not return to the facility. Review of the physician's order initiated 04/28/24 for Resident #100, revealed the resident had orders for Zoloft and Trazodone, and an order to monitor for side effects for antidepressants and report to physician: sedation, drowsiness, dry mouth, blurred vision, urinary retention, tachycardia, muscle, tremor, agitation, headache, skin rash, photo sensitivity, and excess weight gain every shift. Review of quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #100 had severe cognitive impairment. Resident #100 was independent for all mobility such as transferring and walking 150 feet. Review of the care plan dated 12/20/24 revealed Resident #100 had the potential for mobility limitations with expected fluctuations with chronic medical conditions. Interventions included providing hands on assistance to steady him daily, as needed, when exhibiting weakness or resistance and to monitor his safety with the use of his assistive device. The care plan also identified Resident #100 had a tendency to misperceive information. Interventions included for the chair that he typically sits in, in the common area, to be labeled to reflect that the chair belonged to him and staff would also redirect him away from the [NAME] Pod if observed ambulating in that area, as this is where Resident #57's room was located. Review of a nursing progress note dated 02/03/25 at 11:21 P.M. revealed that Resident #100 stated that another resident [Resident #57] pushed him, and he had a fall. The note also revealed that Resident #100 was in a lot of pain and he received as needed Norco 5-325 milligrams (mg) for pain. The resident was taken to the hospital for further evaluation. Review of a nursing progress note dated 02/03/25 at 3:55 P.M. revealed Resident #100 received a fall risk assessment. The assessment indicated the resident had an unwitnessed fall that occurred in the common area and the resident was injured. The assessment note revealed another resident pushed Resident #100 and he fell. The assessment note also revealed Resident #100 had verbal complaints and facial expressions of pain. The pain was sharp and aching in the right hip and was worse with movement. Daily as needed pain medication, Norco, was administered. Review of the Incident Report dated 02/03/25 for Resident #100, revealed Resident #100 was found lying on his back on the [NAME] Pod near Resident #57's room. Resident #100 stated that a man pushed him, and he fell. Resident #100 was in a lot of pain and was given as needed Norco 5-325 mg for pain. The incident was unwitnessed. Resident #100's vital signs were taken, he was given as needed medication for pain, and neurologic checks were initiated. Resident #100 was immobilized due to an obvious range of motion deficit to his right hip. There were no obvious outward signs of skin impairment. The resident was taken to the hospital and the injury observed at the time of the incident was determined to be a fracture of the right hip. The report also stated Resident #100 was ambulating without assistance and was very territorial about particular chairs on the unit and he sought out the whereabouts of the male resident he was accusing of pushing him down, to tell him not to take his chair. Review of the Neurological Evaluation Flowsheet dated 02/03/25 for Resident #100 revealed neurologic (neuro) checks were completed at 3:30 P.M. and 3:45 P.M. Resident #100 was in the hospital for any further neuro checks. Review of the Fall Risk Evaluation dated 02/03/25 at 3:55 P.M. for Resident #100 revealed he had one to two falls in the past three months, had intermittent confusion, was ambulatory, had adequate vision, and did not have a change in condition in the last 14 days. Review of the Post Fall Evaluation dated 02/03/25 at 3:56 P.M. for Resident #100 revealed an unwitnessed fall with an injury occurred and the resident was sent to the hospital. The Certified Nurse Practitioner (CNP) #250 was notified on 02/03/25 that there was a resident to resident fall where another resident pushed Resident #100 and he fell. The evaluation noted that Resident #100 had severe right hip pain. Review of the Hospital Transfer Form dated 02/03/25 revealed Resident #100 ambulated independently, and he was alert and disoriented, but could follow simple instructions. Review of hospital records for Resident #100 revealed he had an X-ray on 02/03/25 that showed an acute obliquely oriented intertrochanteric fracture of the proximal right femur. Resident #100 received surgery on 02/04/25 for his right intertrochanteric hip fracture with osteopenia. b. Review of the medical record for Resident #57 revealed an admission date of 01/22/25. Resident #57's diagnoses included dementia, depression, cognitive communication deficit, and conversion disorder with seizures or convulsions. Review of the care plan for Resident #57 dated 01/22/25 revealed he was resistive to care related to dementia, he wandered about the facility, and he had the potential to become agitated if his routine or patterns of behavior were disrupted. The plan noted that Resident #57 liked to rearrange furniture in the common area, he had a history of aggression toward male residents that wandered into his room, and he was rigid with his room. Interventions included psychiatric services to evaluate and treat, provide consistency in care to promote comfort with activities of daily living (ADLs), and to maintain consistency in timing of ADLs, caregivers and routine as much as possible. Review of admission Minimum Data Set (MDS) 3.0 assessment dated [DATE] for Resident #57 revealed he had severe cognitive impairment. Resident #57 was independent for all mobility such as transferring and walking 150 feet. Review of the nursing progress note dated 02/03/25 at 12:00 A.M. for Resident #57 detailed his History and Physical which revealed Resident #57 transferred from another skilled nursing facility on 01/22/25. The note also revealed there were no previous facility records to review. Review of the nursing progress note dated 02/03/25 at 3:30 P.M. for Resident #57 revealed the resident stated he made contact with another resident. Resident #57 was assessed with no injury noted and his skin was intact. The Director of Nursing (DON), CNP #250, and the residents family member were notified. Fifteen-minute checks were initiated. Review of the incident report dated 02/03/25 at 3:30 P.M. for Resident #57 revealed Resident #57 stated I pushed that man who wandered in my room, out of the room, because I don't want anyone in my room. An assessment of Resident #57 was completed with his skin intact and no injury noted. Resident #57 received 15-minute checks through 11:00 P.M. to ensure he made no further reactive movements toward other residents. Predisposing physiological factors included Resident #57 was confused and had impaired memory. Predisposing situation factors included Resident #57 was a wanderer and he was ambulating without assistance. Resident #57 had a pattern of coming out of his room to straighten chairs and rearrange some of the chairs in the common area. Interventions included 15-minute checks through 11:00 P.M. on 02/03/25 and the activities director was to assist the resident to find activities to distract him from his patterned behavior of moving chairs around in the common area. Review of the 15-minute check log sheet dated 02/03/25 for Resident #57 revealed sign offs every 15 -minutes from 3:30 P.M. to 11:00 P.M. were completed. Review of the written staff statement dated 02/03/25 by Licensed Practical Nurse (LPN) #111 revealed she did not witness the incident, but walked into her shift and noticed Resident #100 was lying on the floor and in pain. LPN #111 gave the resident as needed pain medicine. Review of the written staff statement dated 02/03/25 by Certified Nursing Aide (CNA) #112 revealed she heard a noise and saw Resident #100 laying down and observed Resident #57 standing in front of his room looking angry. Review of the written staff statement dated 02/03/25 by Registered Nurse (RN) #14 revealed she was sitting at the nurses station and heard a scream from the common area. She saw Resident #100 on the floor on his left side. RN #14 and staff assessed Resident #100. They tried getting Resident #100 off the floor, but he was in too much pain to move around. RN #14 called 911. Review of the written interview statement dated 02/03/25 by Resident #57 revealed Resident #57 initially denied knowledge of any interaction with Resident #100. Resident #57 then stated he pushed Resident #100 out of his room because he walked in. Resident #57 stated he didn't want strangers in his room. Review of the nursing progress note dated 02/04/25 at 1:52 P.M. for Resident #57 revealed he had an altercation with another male resident who he indicated, wandered into his room. Resident #57 had some rigid behaviors involving repositioning chairs. The note indicated that activities staff would be working with him to find one on one activities to distract him. Resident #57 stated, I feel sorry the guy got a fracture. Review of physician's orders dated 02/11/25 for Resident #57 revealed the resident was to be seen by psychiatric services to evaluate and treat. An interview on 02/21/25 at 11:37 A.M. with Resident #57 revealed he had not been a part of or witnessed resident abuse. Resident #57 also revealed he had not been involved in a resident to resident altercation. An interview on 02/21/25 at 12:08 P.M. with LPN #6 confirmed Resident #100 fractured his hip during a resident to resident altercation. An interview on 02/21/25 at 12:25 P.M. with RN #23 revealed he was not at the facility for the altercation, but if two residents had an altercation it would be considered resident to resident abuse. An interview on 02/21/25 at 6:17 P.M. with the DON revealed Resident #57 had ridged behaviors of moving chairs around and Resident #100 had a chair that he [Resident #100] liked. Resident #57 moved the chair and Resident #100 went into Resident #57's room and Resident #57 pushed Resident #100 resulting in a fall. The DON stated she thought Resident #100 intimidated Resident #57, but that no one knew why Resident #100 went into #57's room. The DON confirmed that Resident #100 was injured from the shove, with a right hip fracture. The DON stated it wasn't resident to resident abuse, because the residents didn't know what they were doing based on their BIMS scores. The DON revealed they were both reacting on impulse, she didn't think they were plotting to hurt each other. An interview on 02/21/25 at 6:31 P.M. with the Administrator revealed Resident #100 liked to have his table and chair a certain way and Resident #57 liked to move chairs around the tables. Resident #100 entered Resident #57's room and Resident #57 didn't want Resident #100 in his room, so he pushed him. Resident #100 fell and was sent out [to the hospital] subsequently. The Administrator revealed she received an update after Resident #100 was sent out and he was going to have surgery. The Administrator confirmed Resident #100 had a right hip fracture when he was injured from the shove and fall. The Administrator did not claim the situation was abuse, because it was a resident to resident altercation with no intention to cause harm. The Administrator revealed the nature of the facility was dementia and they did not have an intent to harm. An interview on 02/24/25 at 12:11 P.M. with the Administrator revealed residents did not have intent and they were reacting. The Administrator also revealed nobody could be held liable for abuse of somebody else at the facility and law enforcement had told her this in the past. The Administrator explained that the residents had to have a dementia status to be at the facility and she couldn't think of a time she had ever substantiated two residents abusing each other. Review of the facility policy titled, Abuse, Mistreatment, Neglect, Exploitation, and Misappropriation of Resident Property, dated October 2023, revealed residents had the right to be free from abuse, neglect, exploitation, and misappropriation of resident property. The facility policy defined abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. If another resident was accused or suspected of abuse, the policy also stated the facility would ensure other residents were protected as determined by the circumstances, which may include but were not limited to, increased supervision of the alleged perpetrator and/or other residents, room or staffing changes, and immediate transfer or discharge, if indicated. This deficiency represents non-compliance investigated under Master Complaint Number OH00162994 and Complaint Number OH00162478.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a facility submitted Self-Reported Incident (SRI), hospital record review, interviews with staff, review of incident reports, and facility policy review, the facility failed to ensure care was delivered, as assessed and care planned for, utilizing the appropriate number of staff assistance during the provision of care for Resident #10. This resulted in actual harm when Resident #10 was provided care by one facility Certified Nursing Assistant (CNA) #100, who repositioned and provided incontinence care on 03/27/25 at approximately 10:00 A.M. and when Resident #10 was provided a bed bath and hair care on 03/27/25 at approximately 2:45 P.M. by one Hospice Aide #115 resulting in a comminuted femur fracture, a fracture where the bone breaks into three of more pieces often the result of major impact injury. Resident #10 was noted to have bruising to the right leg by the hospice aide (#115) on 03/27/25 when the aide was providing care alone to the resident. Resident #10 had bruising and deformity of the leg noted and was sent to the hospital for further evaluation and diagnosed with a comminuted femur fracture that required surgical intervention. This affected one (#10) of three residents (#10, #18, and #34) reviewed for injury of unknown origin. Findings Include: Review of the medical record for Resident #10 revealed an admission date of 01/24/25. Diagnoses included dementia, atherosclerotic heart disease, Type II Diabetes Mellitus and anxiety. She was receiving hospice services. Review of the Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #10 was severely cognitively impaired with a Brief Interview of Mental Status (BIMS) score of 99 and required extensive assistance of two staff members for activities of daily living (ADL). Review of Hospice Interdisciplinary Group (IDG) Comprehensive Assessment and Plan of Care for benefit period 01/17/25 to 03/27/25 revealed terminal diagnosis of frontotemporal neurocognitive disorder. Resident #10 can become very emotional, can be combative and aggressive verbally and physically. She refuses medications and personal care. She is prone to visual and auditory hallucinations. Review of the Resident #10's plan of care, dated 02/06/25, revealed she has an ADL Self-Care Performance Deficit and requires total dependence of two persons for peri care, bathing, bed mobility, personal hygiene, dressing, eating and transferring. Given Resident #10's needs and behaviors, care is to be given by two people (prefers hospice as the second caregiver). The need for two staff to provide care to Resident #10 was verified in an interview with the Director of Nursing (DON) on 04/09/25 at 10:30 A.M. Review of Resident #10's weekly wound assessments completed on 03/16/25, 03/19/25, 03/20/25, 03/23/25 and 03/26/25 revealed no concerns. Review of a Hospice Visit Note dated 03/25/25 revealed Hospice Registered Nurse (RN) #125 visited during lunch and helped her aid give her a bath, and she had no skin concerns. Review of the Weekly Skin Assessment completed on 03/27/25, after the bruising was identified by the hospice staff, revealed right knee (front) bruising light green in color, length 8.0 centimeters (cm), by 2.0 cm, no depth or stage. Review of Resident #10's nurses' progress notes from 03/25/25 to 04/09/25 revealed that on 03/27/25 Hospice Licensed Practical Nurse (LPN) #114 told facility LPN #105 that Hospice Aide #115 had notified her about a bruise on Resident #10's right knee area. Hospice LPN #114 and LPN #105 assessed Resident #10 and noted the bruise to right knee. The bruise was not previously noticed by LPN #105 on 03/24/25 when she assessed Resident #10's skin. Hospice LPN #114 notified family members and LPN #105 notified Certified Nurse Practitioner (CNP) #120. Review of the incident report dated 03/27/25, revealed Hospice Nurse/LPN #114 notified nurse that her Hospice Aide #115 noted resident with bruise near knee area. Facility Nurse LPN #105 went to assess the resident, and she had discoloration and swelling to her right knee area, also noted obvious V shaped deformity to her right femur shaft. This resident is often combative with care, but was not combative with the facility CNA #100 that did her peri care on 3/27/25 at 10:00 A.M. LPN #105 did not see bruising on knee the morning prior to Hospice Aide 115's visit. Resident #10 was interviewed and asked how the injury occurred. She kept repeating the name of Hospice Aide #115 that worked with her that day. She stated over and over She washed my hair. I did not want my hair washed. Review of the facility SRI dated 03/27/25 revealed statements were obtained from LPNs #105, #115, CNA #100 and CNA #115. Statement from facility CNA #100 revealed she changed Resident #10 in the morning and did not help the hospice aide in the afternoon with her care. Hospice Aide #115 confirmed she washed Resident #10's hair and was giving her a bed bath alone. She washed Resident #10's front of body then when she rolled the resident to her back side she saw yellow bruising on her right leg. She immediately reported it to Hospice LPN #114. Statement written by Hospice LPN #114 revealed Hospice Aide #115 reported Resident #10 had bruising, and she immediately assessed Resident #10's right leg at bedside. There was a yellow swollen area above the front right knee, and the yellow wrapped around to the back of the knee. Resident #10 requested for her to stop touching the area. She immediately reported her findings to LPN #105. Together LPN #114 and LPN #105 assessed Resident #10 and confirmed there was bruising. Review of the Hospice Visit Note dated 03/27/25 at 10:30 A.M. revealed LPN #128 was able to get Resident #10's vital signs, listen to her abdomen, and lungs and noted no concerns with visit. Review of the Hospice Client Coordination Note Report dated 03/27/25 revealed CNA #115 notified this nurse that Resident #10 had a large yellow area with swelling on leg. This nurse went to Resident #10's room. This nurse noted Resident #10 had yellow discoloration wrapping around right knee. Resident #10 had purple areas of discoloration at the back of knee. No pain noted, no warmth noted. This nurse informed facility LPN #105. This nurse and facility LPN #105 went to Resident #10's room and more area was exposed. This nurse and facility nurse noted swelling, deformity to lateral thigh and discoloration. Physician notified of findings, new order for two view x-rays of right thigh and knee. Attempted to contact Power of Attorney (POA). No answer, a message was left. The DON was notified of findings and orders. POA returned the call. POA indecisive if Resident #10 should be sent to emergency room (ER). After more conversation with the facility nurse, DON and this nurse, the POA decided to have Resident #10 sent to ER. This nurse worked in collaboration with facility nurse and the DON to transfer the resident to the hospital. Per review of Resident #10's nurses' progress notes dated 03/27/25, the medical provider for Hospice ordered a portable x-ray at the facility of the right knee/femur. Per family request Resident #10 was sent to the local emergency room for further evaluation of the right lower extremity rather than wait for the portable x-ray. At the emergency room Resident #10 was diagnosed with a right femur fracture and admitted . Surgery was performed on 03/28/25. Per review of Resident #10's Hospital Emergency Department Report dated 03/27/25 at 5:15 P.M., there is extensive subcutaneous edema throughout the right lower extremity. Clinical impression Femur Fracture. Review of the Radiographic CT Angiogram (03/27/25) of Resident #10 revealed Comminuted right distal femur fracture with 2 large fragments laterally and anterior to the distal fracture fragment. There are several additional smaller fragments. There is extensive subcutaneous edema throughout the right lower extremity. Review of the Operative Report dated 03/28/25 at 12:48 P.M. by the orthopedic surgeon revealed pre-operative diagnosis was closed right highly comminuted femoral shaft fracture. Procedure performed Retrograde Intramedullary nailing fixation of the right femur. Post-Review Operative Diagnoses Closed displaced comminuted fracture of shaft of right femur. Review of the Brief Post Operative Note by the orthopedic surgeon on 03/28/25 at 1:54 P.M. revealed operative findings: highly comminuted distal femoral shaft fracture. Severe osteopenia. Very limited hip and knee range of motion, unable to be externally rotated to access lateral hips. Review of the Trauma Service Progress Note dated 03/30/25 at 1:52 P.M. revealed injuries/active problems Right femur fracture non weight bearing (NWB) Right lower extremity (RLE) ice, pain management, frequent neurovascular checks, pathological fracture of right femur due to a combination of osteopenia and possible trauma that alone would not have caused the fracture. An interview on 04/07/25 at 10:30 A.M. with the DON confirmed facility CNA #100 performed per-care for Resident #10 alone and Hospice Aide #115 also performed ADL care alone on Resident #10 on 03/27/25. Interview on 04/07/25 at 11:55 A.M. with LPN #102 confirmed she was with LPN #105 to assess the bruising on Resident #10's right leg when it was reported by the hospice nurse. She confirmed Resident #10 was a two-person assist with ADLs. Interview on 04/07/25 at 12:03 P.M. and on 04/09/25 with facility CNA #100 confirmed Resident #10 is a two-person assist for ADLs. Because the resident was not combative on 03/27/25 she stated she provided Resident #10's peri-care in the A.M. by herself without help from another staff. She explained that on 03/27/25, she went into the room and explained to Resident #10 what she was going to do. Because she was not combative, she continued providing care alone. Resident #10 had a white bed pillow under her right knee. She moved the resident to the left, changed the under pads on the bed, then she moved her on to the right side and continued. She rolled the resident to lay on her back and applied a brief. She elevated the head of the bed and covered her and gave her a glass of water. She confirmed later in the day that the hospice aide asked her to assist with care for Resident #10's ADLs, and she stated she was unavailable to assist the hospice aide until she finished giving care to other residents on her assignment. Interviews on 04/10/25 from 7:25 A.M. to 7:40 A.M. with RN #108, CNAs #103 and #106 confirmed Resident #10 was a two-person assist before she had her knee surgery. Interview on 04/11/25 at 10:45 A.M. with Registered Nurse #300, the nurse of the Medical Physician of Orthopedic Surgery #200 clarified Resident #10's condition of osteopenia would be a contributing factor coupled with a trauma sustained by Resident #10 that resulted in a comminuted fracture requiring Resident #10 to have a retrograde intramedullary nailing fixation of the right femur procedure completed on 03/28/25. Hospice Aide #115 was unable to be reached for an interview during the survey. Review of the Facility's Incident Report from 02/07/25 to 04/07/25 revealed Resident #10 had a bruise on her finger on 03/04/25 at 07:28 A.M. and listed the new bruise discovered on 03/27/25. Review of the facility policy titled Activities of Daily Living (ADLs) Supporting, dated 08/2022 revealed appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance.