Gramercy Court

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to protect the resident's right to be free from physical abuse by another resident for one of four sampled resident (Resident 1), when Resident 2 pushed Resident 1 which caused a fall to the floor.

This failure resulted in an injury to Resident 1's left leg.Findings:Resident 1 was admitted to the facility in mid-2025 with diagnosis which included anxiety disorder, dementia, history of falls, and a mental health condition where a person has hallucinations, delusions and mood swings.During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 6/16/25, the MDS showed a Brief Interview for Mental Status (BIMS, a cognitive screening tool) score of 14/15 which indicated intact cognition.Resident 2 was admitted to the facility in late 2024 with diagnosis which included anxiety disorder, intellectual disabilities, and a mental health condition where a person has hallucinations, delusions and mood swings.During a review of Resident 2's MDS dated [DATE], the MDS showed a BIMS score of 12/15 which indicated moderate cognitive impairment.During a review of Resident 1's Progress Note (PN) Type: Change in Condition, dated 8/31/25 at 7:25 p.m. the PN indicated, At approximately 1:15 PM [Resident 1] was observed walking in the hallway.[Resident 2] who was seated suddenly stood up without warning and pushed the (sic) [Resident 1], [Resident 1] fell onto her left side.she [Resident 1] was noted to have limited mobility in the left leg and hip.received result of the x-ray: conclusion Intertrochanteric fracture varus deformity [break in the upper part of the femur near the hip].During an interview on 9/17/25 at 9:57 a.m. with Resident 2 in her bedroom, Resident 2 confirmed she had pushed Resident 1, Yes, I just pushed her.I got tired of hearing her voice, so I just pushed her and told her to be quiet.

During an interview on 9/17/25 at 10:08 a.m. with Licensed Nurse (LN 1), LN 1 stated he was following behind Resident 1 as she walked past Resident 2, Resident 2 stood up and pushed Resident 1 with both hands. Resident 1 fell on the ground landing on her left hip/leg and could not move her left foot.

LN 1 stated when the facility received the x-ray results for Resident 1, she was transferred to the hospital for a left hip fracture.

During an interview on 9/17/25 at 12:38 p.m. with the Director of Nursing (DON), the DON confirmed Resident 2 pushed Resident 1 which caused her to fall to the floor and resulted in a left hip fracture.

The DON stated all residents have the right to be free from abuse.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect, Exploitation and Misappropriation- Program, dated 4/21, the P&P indicated, Residents have the right to be free from abuse.This includes but is not limited to.physical abuse.Protect resident from abuse.by anyone including but not necessarily limited to.other residents.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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