Based on medical record review, staff interview, review of incident and facility documentation, and policy and procedure review, the facility failed to ensure residents were free from physical abuse by other residents for 1 of 9 sample residents reviewed. This failure resulted in actual harm to resident #1. The findings were: The facility had implemented corrective action prior to the survey and was determined to be in substantial compliance as of 9/27/24. 1. Review of the 10/6/24 admission MDS assessment showed resident #1 (victim) had a BIMS of 3, which indicated severely impaired cognitive skills, and had diagnoses of non-Alzheimer's dementia and pelvic fractures. Further review showed the resident had limited ability to make concrete requests and exhibited verbal behavioral symptoms toward others. 2. Review of the 7/22/24 admission MDS assessment showed resident #2 (perpetrator) had a BIMS score of 4, which indicated severely impaired cognitive skills. Further review of the resident's medical record revealed a diagnosis of unspecified dementia, severe, with other behavioral disturbance. Further review showed the resident exhibited physical behavioral symptoms directed toward others, and rejection of care had occurred 1 to 3 days of the 7-day look-back period. The following concerns were identified related to a resident-to-resident interaction between resident #1 and resident #2: a. Review of an incident report showed on 9/24/24 at 8:35 PM resident #1 and resident #2 had been visiting in the dining room of the memory care unit after dinner with another resident. They were assisted to their rooms by the CNA #2. For an unknown reason, resident #2 later entered resident #1's room and left the room telling staff that s/he had pushed resident #1 down. CNA #1 entered the room and found resident #1 on the floor of his/her room with a laceration to the scalp. Resident #1 was provided first aid by the Nurse #2 and was sent to the emergency room for evaluation. Resident #1 was diagnosed with a probable pelvic fracture. b. Review of the history and physical from the hospital dated 9/25/24 showed resident #1 was admitted to the hospital with a severe pelvic fracture and exacerbation of his/her severe bone on bone degenerative joint disease of the right hip. c. Interview with the DON on 10/24/24 at 11 AM revealed resident #2 had a gradual dose reduction of his/her antipsychotic medication prior to the incident on 9/24/24, and following the incident the resident's medication was increased back to prior dosage. Further, the resident was moved out of the memory care unit, and had 1-to-1 supervision for 3 weeks before placement in a new facility closer to family. d. Interview with CNA #1 on 10/24/24 at 1:21 PM revealed the incident happened out of nowhere. The CNA reported three residents were sitting at a table and talking to each other when she went to assist another resident to get ready for bed. The CNA then heard a door slam and after she walked into the hall she saw resident #2 had walked out of resident #1's room. The CNA went to resident #1's room and found resident #1 on the floor. The CNA revealed resident #1 was shocked and adamant s/he needed to get off the floor. The CNA placed a pillow under the resident's head and saw the blood from resident #1's head hitting the floor. e. Interview with CNA #3 on 10/24/24 at 2:23 PM revealed there were 3 residents sitting at a table in the dining room and they were getting along great. The CNA guided residents #1 and #2 to their rooms to get ready for bed. While he assisted another resident, the CNA heard a high pitched scream, and after going to the hall to see where the scream came from, the CNA saw resident #2 standing outside resident #1's room, and resident #2 stated s/he won't be doing that again. The CNA redirected resident #2 back to his/her room and got Nurse #2 to assess resident #1. 3. The facility implemented the following corrective action by 9/27/24: a. Resident #1 was provided immediate first aid in-house to the laceration on his/her head and was sent to the emergency room for further evaluation and treatment. b. Resident #2 received 1-to-1 monitoring by staff and labs were ordered to rule out any acute issues. c. The facility reported the incident to the State Survey Agency and the Police Department on 9/24/24. d. Care plans were updated for both residents. e. The DON/Designee reviewed the last 30 days of incidents/accidents to determine any pattern or trends. f. The DON/Designee reeducated all staff who work with residents on abuse and behavior management to decrease the risk of aggression towards other residents. g. Weekly audits were started to review incident/accident documentation and ensure re-education with staff members present during incidents was performed. Audits to be done weekly then monthly and discussed in the QAPI meetings. 4. Review of the facility's policy, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, showed .Residents have the right to be free from abuse .1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including but not necessarily limited to: . b. other residents .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital medical record review, resident representative interview, and staff interview the facility failed to identify and assess for change of condition in accordance with professional standards of practice for 1 of 7 residents (#4) reviewed for possible change of condition assessments. This failure resulted in harm to resident #4, whose signs and symptoms of pneumonia, UTI, heart failure and/or heart attack went unaddressed until family intervention. The findings were: Review of the 12/6/22 admission MDS assessment for resident #4 showed resident had a BIMS score of 14 out of 15, which indicated intact cognitive ability. Further assessment review showed resident had a medically complex condition which included anemia, coronary artery disease, renal failure, diabetes mellitus, non-Alzheimer's dementia, history of myocardial infarction, and unspecified pain. Review of the care plan with a revision date of 12/14/22 showed the resident to have a risk for alteration in cardiovascular status and vital signs related to hypertension, history of MI, and atherosclerotic heart disease. Review of the care plan interventions dated 12/14/22 showed facility staff should monitor and document signs and symptoms of malignant hypertension which included headache, visual problems, confusion, disorientation, lethargy, nausea, vomiting, irritability, seizure activity and difficulty breathing. Further review showed interventions to provide anti-hypertension medications as ordered, and report tachycardia (increased heart rate) and unexplained shortness of breath. The following concerns were identified: 1. Review of the resident's February 2023 MAR showed the resident received the medications losartan potassium 100 mg by mouth one time a day related to essential hypertension and metoprolol succinate extended release 50 mg by mouth one time a day related to essential hypertension. Each of these medications had a start date of 11/30/22. No end date was indicated. 2. Review of the resident's March 2023 MAR showed the medications losartan potassium 100 mg and metoprolol succinate extended release were no longer listed on the MAR and were not administered during the month of March. 3. Review of nursing progress notes for the resident showed the first entry for the month of April 2023 occurred on 4/15/23 at 3:02 AM. The note showed Resident reported increased pain in neck and shoulder, scheduled Tylenol administered with noted improvement. Around midnight resident reported same pain. VS [vital signs] BP 141/80, P [pulse] 90, R [respirations] 20 .PRN [as needed] Ibuprofen administered with noted pain improvement . 4. Review of the progress note dated 4/15/23 at 11:59 AM showed Resident's daughter here and concerned about [resident's] breathing, stating [s/he] may have pneumonia. Upon exam found LCTA [lungs clear to auscultation] X 4 [times 4] . [Resident's name] was exhibiting signs of anxiety and c/o upper neck pain .Tylenol given in AM med dose .After 15 minutes, anxiety ceased and resident was relaxing in lounge chair. Then roommate [name] called daughter and expressed [the resident] need a chest x-ray. Daughter arrived again and resident was transported, by facility van, to hospital for x-ray. Review of the progress note dated 4/15/23 at 7:23 PM showed Nurse report from ER nurse [nurse's name]. Resident has slight pneumonia and UTI. 5. Interview with the resident's daughter on 5/2/23 at 11:40 AM revealed the family did not know the resident was not receiving his/her anti-hypertension medications, but they did note the resident developed new symptoms of mood swings, loss of appetite, fatigue, restlessness and edema. 6. Review of the resident's medical record showed a weight of 154.3 pounds was recorded on 4/3/23, and a weight of 170.2 pounds was recorded on 4/28/23, an increase of 15.9 pounds. 7. Review of the 4/24/23 at 9:29 AM eINTERACT SBAR Summary for Providers showed Situation: The Change of Condition/s reported on this CIC [change in condition] evaluation are/were: Edema (new or worsening), Shortness of breath .Pulse: P 101 . 8. Review of the progress note dated 4/24/23 at 9:48 AM showed Daughter notified nurse this am that herself and siblings had decided that they would like [the resident] seen in the ER [emergency room] for evaluation of the increased edema, SOB [shortness of breath] and overall decline. I offered to contact clinic if need be to address issue. Family requests that [s/he] be seen in ER at this time. ER contacted and notified of condition change and need for evaluation .Resident transported via facility van . 9. Review of the 4/24/23 at 1:15 PM hospital history and physical showed Patient is a [AGE] year-old nursing home resident with known coronary artery disease (status post stenting), congestive heart failure, stage III chronic kidney disease, and mild dementia .At [his/her] nursing home they have been noticing increasing lower extremity edema and decreasing exercise tolerance including difficulty with transfers. Patient is also having some mild shortness of breath .Patient was seen and evaluated in the emergency department secondary to acute exacerbation of congestive heart failure along with concerningly elevated troponin to 1184 with a proBNP of over 32,000 [laboratory results indicative of heart damage] .[the patient's cardiologist] opined that [s/he] likely has ischemic heart disease causing and aggravated by fluid overload .Assessment/Plan: 1. Acute on chronic congestive heart failure .Patient with acute CHF and NSTEMI [a type of myocardial infarction/heart attack] .2. Acute non-ST segment elevation myocardial infarction .3. Chronic kidney disease . 10. Interview with the DON on 5/4/23 at 2:15 PM revealed the facility failed to identify the resident's anti-hypertension medications had been dropped off of the MAR, and should have recognized the medications were not being administered, stating, If we had recognized that was happening we might have prevented [the resident's] decline. 11. Review of the Centers for Disease Control and Prevention's (CDC) Women and Heart Disease found at https://www.cdc.gov/heartdisease/women.htm and accessed on 5/5/23 showed symptoms of heart disease in women include pain in the neck, jaw, or throat, and When to Call 9-1-1 .In some women, the first signs and symptoms of heart disease can be: Heart attack: Chest pain or discomfort, upper back or neck pain, indigestion, heartburn, nausea or vomiting, extreme fatigue, dizziness, and shortness of breath .Shortness of breath, sudden fatigue, or swelling of the feet, ankles, legs, or abdomen .