Every finding on record at Arizona State Veteran Home-Phx

Based on clinical record review, State Agency (SA) complaint/incident tracking system, resident and staff interviews, and policy review, the facility failed to implement written policies and procedures to prevent, report, and investigate an allegation of sexual abuse for one of three sampled residents (#67). The census was 95. The deficient practice could result in corrective actions not being taken and residents being further abused.Findings include:Resident #67 was admitted to the facility on [DATE], with a diagnosis of hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, testicular hypofunction, depression, hypothyroidism, anemia, hypertension, and age-related osteoporosis.A quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview for Mental Status (BIMS) assessment score of 14, which indicated intact cognition. A request was made on July 28, 2026, at 12:45 p.m. for the incident report/facility investigation, which revealed two undated staff statements. One of the signed statements was handwritten by a certified nursing assistant (CNA/Staff#2), who overheard a CNA saying that a resident had pictures of a staff member, and that they were laughing about it, but that he thought it was enough to report to the administrator. The second signed statement was typed by the administrator, Staff #25, and revealed that the CNA, Staff #2, reported that he heard a rumor that Resident #67 had inappropriate pictures on his phone of another CNA, Staff #32. The statement further revealed that upon hearing that information, the administrator spoke to Resident #67 to see if he had any pictures on his phone, to which the resident reported that Adult Protective Services (APS) was there the week before to ask him the same questions, and denied that he had the photos. The statement further revealed that the facility knew APS was out to see him the week before, but they did not know why they were out to see him. A request was made on July 28, 2026, at 12:45 p.m. for the incident timeline, and the administrator signed that the allegation was reported to the NHA, nursing home administrator, on 6/30/2025. An interview was conducted on July 28, 2026, at 9:22 a.m. with the Registered Nurse Supervisor (RN Supervisor/Staff#22), who stated that the timeframe for reporting an allegation of abuse was within 2 hours to the administrator, police, and the ombudsman if it was reported to her or if she witnessed it. The RN supervisor stated that an allegation of a staff member sending or selling inappropriate photos to a resident would absolutely be considered sexual abuse. The RN supervisor also stated that she heard someone say that a resident had explicit material on his laptop of a staff member, and that she identified the resident as Resident #67. The RN supervisor stated that it was investigated by the state and reported within the last month. The RN supervisor stated that Adult Protective Services (APS) also investigated the incident and that she learned about it when the resident approached her and asked the nurse if she heard what happened. The nurse stated that the resident reported to her that APS went to see him, asked about pictures on his computer or if he had inappropriate pictures of a staff member, and that the resident told them he didn't. An interview was conducted on July 28, 2026, at 9:49 a.m. with Resident #67, who stated that he had not received any photos from staff members and that another state agency had come in to speak with him about the same matter a few weeks prior.An interview was conducted on July 28, 2026, at 10:13 a.m. with a registry CNA (CNA/Staff#47), who stated that the timeframe for reporting an allegation of abuse was 2 hours. The CNA stated that an allegation of a staff member sending or selling an inappropriate photo of themselves to a resident would be sexual abuse, and that she had heard a rumor by another CNA, Staff #85, that another CNA, Staff #32, was fired from the building for showing a resident pictures of herself, but did not know if the CNA was nude or in a bikini in the photos. The CNA, Staff #47, also stated that she did not know if the rumor about the inappropriate photos was reported, but that Staff #85 made it sound like facility administration knew about it.An interview was conducted on July 28, 2026, at 10:24 a.m. with a registry CNA (CNA/Staff#85), who stated that the timeframe for reporting an allegation of abuse was immediately, and that an allegation of a staff member sending or selling inappropriate photos of themselves to a resident would be sexual abuse. The CNA stated that she had not heard of that happening at the facility, but that there was a rumor regarding another CNA upstairs, but that she did not want to spread rumors. The CNA further stated that the director of nursing (DON/Staff #8) and administrator (Administrator/Staff #25) could provide an answer about the inappropriate photos better than she could. The CNA stated that the allegation was made about a former CNA, Staff #32, she did not know which resident was involved, she did not know the timeframe for the allegation, and she did not believe that the allegation happened.An interview was conducted on July 28, 2026, at 10:39 a.m. with a former CNA (former CNA/Staff#32), who stated that the timeframe for reporting an allegation of abuse was 2 hours to her supervisor, and that sexual abuse was defined as inappropriate behaviors, communications, or boundaries with a resident. The CNA also stated that an allegation of staff sending or selling inappropriate photos of themselves to residents would be sexual abuse. The CNA stated that she had not sent any photos of herself to a resident. A follow-up interview was conducted on July 28, 2026, at 10:51 a.m. with the former CNA, Staff #32, who stated that she recalled more information about the allegation, and that her agency called her on June 22, 2026, asking if she had sent pictures of herself to a resident for compensation, and the CNA told them no and immediately reported the information to the administrator, Staff #25, who told her that the agency did not inform her before calling the Staff #32. The CNA stated that after she spoke to the administrator, no one ever contacted her again about the allegation, and she knew nothing else. The CNA further stated that she was terminated by the facility on June 30, 2026, because of the sexual abuse rumors, employee complaints, and APS complaints regarding her care for residents.An interview was conducted on July 28, 2026, at 11:08 a.m. with the director of nursing, Staff #8, who stated that the timeframe for reporting an allegation of abuse was 2 hours, and that administration or floor staff had to report to the Arizona Department of Health Services (AZDHS), police, APS, the ombudsman, the provider, and the administrator within that timeframe. The DON stated that sexual abuse was defined as any unwanted physical, mental, or emotional contact that was unwanted by another party, and that an allegation of a staff member sending or selling inappropriate photos of themselves to a resident would be sexual abuse if it was unwanted, and then corrected herself and stated that an allegation of that nature would be inappropriate, but it would be a fine line if it would be considered sexual abuse. The DON corrected herself again and stated that if that allegation of inappropriate photos being sent or sold to residents occurred in the facility, it would be considered sexual abuse. The DON stated that the facility did have an allegation of a CNA, Staff #32, sending inappropriate photos of herself to a resident, and that APS had come out before they were alerted to it. The DON also stated that the facility did not report the allegation to anyone, because when the facility investigated the allegation and questioned the resident, he denied having photos of the staff member on his device. The DON stated that they became aware of the allegation a couple of weeks after APS came out, which was the same day that they terminated the accused CNA, Staff #32, which was 3-4 weeks ago; however, the DON later stated that the CNA was not immediately terminated, and that she continued working for 2 weeks after they found out. The DON stated that they decided to terminate the CNA for bullying, sending nude photos to another staff member, and choking another CNA. The DON stated that they were told somehow that the CNA, Staff #32, had been accused of sending a resident inappropriate pictures, but she did not recall how it was brought up or who said it. The DON stated that the purpose of reporting an allegation of abuse was to make the state aware, notify the authorities, and to have the allegation investigated, but that they failed to report the allegation of abuse. The DON stated that it would be the facility's expectation to have reported the allegation, and that the risk of failing to report, investigate, and implement their abuse policy for an allegation of abuse would be multiple citations, additional abuse occurrences, ongoing abuse to the resident, and mental, emotional, and physical impacts to the resident such as withdrawal. The DON also stated that they did have a full investigation of the incident that was documented with statements, but that they did not report it because they did not see it as an allegation of abuse due to the resident denying having the photos. An interview was conducted on July 28, 2026, at 11:30 a.m. with the administrator, Staff #25, who stated that the timeframe for reporting an allegation of abuse was 2 hours, but ideally, immediately, to AZDHS, APS, the police, the ombudsman, the physician, and the case manager if applicable. The administrator stated that sexual abuse was defined as unwanted advances, including touching and verbal. The administrator stated that all allegations of sexual abuse would be reportable, and that an allegation of a staff member sending or selling inappropriate pictures of themselves being reportable would depend on what the photos were of. The administrator stated that an allegation of a staff member sending pictures of their breasts would be inappropriate, but she would need to do a small investigation to see if the allegation was founded, and if it was, she would report it. The administrator further stated that she would do the small investigation before their 2-hour reporting window was up, and that in the instance that we would be discussing, she asked the individual, Resident #67, if he had pictures of a staff member on his phone, and he denied having pictures. The administrator stated that a staff member told her through the grapevine that the resident had pictures on his phone that were inappropriate, and stated that they did not report the allegation to anyone. The administrator stated that they did not speak with any other residents or staff members about the alleged incident and that their policy was to interview all of the people involved if the allegation was reportable, but in this case, there was nothing to report and she did not know who she was going to interview. The administrator stated that the purpose of reporting an allegation of abuse to the applicable state agencies was to allow more time for them to investigate, because 2 hours was not a lot of time to investigate. The administrator stated that the facility's expectation for investigating an allegation of abuse would be to interview the resident, gather statements from staff members involved, write up a final investigation, and submit the investigation to AZDHS and the ombudsman. The administrator also stated that the facility's expectation for reporting any allegation of abuse would be immediately, or within 2 hours. The administrator stated that the risk of failing to report, investigate, and implement their policy for an allegation of abuse would be possibly putting other residents in danger. Review of a policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2026, revealed that the facility had an abuse prevention program that consisted of developing and implementing policies and protocols to prevent and identify abuse or mistreatment of residents. The policy also revealed that the facility would identify and investigate all possible incidents of abuse, and report any allegations within timeframes required by federal requirements. The policy also revealed that the facility would protect residents from any further harm during investigations. Review of a policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated April 2026, revealed that all reports of resident abuse would be reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The policy further revealed that findings of all investigations would be documented and reported. The policy also revealed that if resident abuse was suspected, the suspicion had to be reported immediately to the administrator and to other officials, according to state law. The policy also revealed that the administrator or the individual making the allegation would immediately report his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, the resident's representative, adult protective services (where state law provides jurisdiction in long-term care), law enforcement officials, the resident's attending physician, and the facility medical director. The policy revealed that immediately was defined as within 2 hours of an allegation involving abuse, and that verbal or written notices to agencies would be submitted via special carrier, fax, e-mail, or by telephone. The policy further revealed that notices would include the resident's name, the resident's room number, the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.), the date and time the alleged incident occurred, the name(s) of all persons involved in the alleged incident, and what immediate action was taken by the facility. Continue review of a policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated April 2026, revealed that all allegations would be thoroughly investigated, and that any employee who was accused of resident abuse would be placed on leave with no resident contact until the investigation was completed. The policy also revealed that, at a minimum, the individual conducting the investigation would need to review the documentation and evidence, review the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident, observe the alleged victim, including his or her interactions with staff and other residents, interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident (as medically appropriate) or the resident's representative, interview the resident's attending physician as needed to determine the resident's condition, interviews staff members (on all shifts) who had contact with the resident during the period of the alleged incident, interview the resident's roommate, family members, and visitors, interview other residents to whom the accused employee provides care or services, review all events leading up to the alleged incident, and document the investigation completely and thoroughly. The policy further revealed that each interview would need to be conducted separately and in a private location, and that the purpose and confidentiality of the interview would be explained thoroughly to each person involved in the interview process. The policy revealed that witness statements would be obtained in writing, signed and dated, and that the witness was permitted to write his/her statement, or the investigator would obtain a statement. The policy also revealed that the investigator would notify the ombudsman that an abuse investigation was being conducted, and the ombudsman would be invited to participate in the review process. The policy revealed that any allegations of abuse were filed in the accused employee's personnel record along with any statement by the employee disputing the allegation, if the employee chose to make one.

Based on clinical record review, State Agency (SA) complaint/incident tracking system, resident and staff interviews, and policy review, the facility failed to report an allegation of sexual abuse within the required timeframe for one of three sampled residents (#67). The census was 95. The deficient practice could result in corrective actions not being taken and residents being further abused.Findings include:Resident #67 was admitted to the facility on [DATE], with diagnoses of hemiplegia, hemiparesis, testicular hypofunction, and depression.A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The assessment also documented that the resident was negative for indicators of psychosis and behavioral symptoms.The SA complaint/incident tracking system revealed that another state agency submitted a report on July 24, 2026, alleging sexual abuse and exploitation of a vulnerable adult identified as resident #67. The complaint alleged that a staff member was sending the resident explicit content in exchange for money.A request was made on July 28, 2026, at 12:45 p.m. for the incident report/facility investigation, which revealed two undated staff statements. One of the signed statements was handwritten by a certified nursing assistant (CNA/Staff#2), who overheard a CNA saying that a resident had pictures of a staff member, and that they were laughing about it, but that he thought it was enough to report to the administrator. The second signed statement was typed by the administrator, Staff #25, and revealed that the CNA, Staff #2, reported that he heard a rumor that Resident #67 had inappropriate pictures on his phone of another CNA, Staff #32. The statement further revealed that upon hearing that information, the administrator spoke to Resident #67 to see if he had any pictures on his phone, to which the resident reported that Adult Protective Services (APS) was there the week before to ask him the same questions, and denied that he had the photos. The statement further revealed that the facility knew APS was out to see him the week before, but they did not know why they were out to see him. A request was made on July 28, 2026, at 12:45 p.m. for the incident timeline, and the administrator signed that the allegation was reported to the NHA, nursing home administrator, on 6/30/2025. Further review of the SA complaint/incident tracking system on July 28, 2026, revealed no evidence that the facility had reported the allegation to the SA. An interview was conducted on July 28, 2026, at 9:22 a.m. with the Registered Nurse Supervisor (RN Supervisor/Staff #22), who stated that an allegation of abuse has to be reported within 2 hours to the administrator, police, and the ombudsman. Per the RN supervisor, an allegation of a staff member sending or selling inappropriate photos to a resident would absolutely be sexual abuse. The RN supervisor also stated that she heard someone say that Resident #67 had explicit material on his laptop of a staff member, but she could not recall who had told her or what date she found out. According to the RN supervisor, it was investigated by the state and reported within the last month, so she did not report it. The RN supervisor said that Resident #67 informed her that another state agency also investigated the incident. The nurse stated that the resident informed her that the other state agency inquired about pictures on his computer or if he had inappropriate pictures of a staff member, and that the resident indicated that he had none in his possession. The RN supervisor stated that her conversation with the resident about his encounter with the other state agency occurred at the beginning of July 2026. An interview was conducted on July 28, 2026, at 9:49 a.m. with Resident #67. The resident denied having any photos from staff members. Per the resident, another state agency had come in to speak with him about the same matter a few weeks prior.During an interview with a registry CNA (Staff #47) conducted on July 28, 2026, at 10:13 a.m., Staff #47 stated that an allegation of abuse had to be reported within 2 hours. The CNA said that an allegation of a staff member sending or selling an inappropriate photo to a resident would be sexual abuse. Additionally, the CNA indicated she heard a rumor from Staff #85 (CNA) that Staff #32 was fired for showing a resident pictures of herself. However, she was unsure if the photos were nude or bikini shots. Staff #47 noted that she did not know if the rumor about the inappropriate photos was reported. Staff #47 commented that Staff #85 made it sound like the facility administration knew about it.An interview was conducted on July 28, 2026, at 10:24 a.m. with a registry CNA (Staff #85), who stated that an allegation of abuse had to be reported immediately. Per Staff #85, an allegation of a staff member sending or selling inappropriate photos to a resident would be sexual abuse. The CNA denied having knowledge of such incidents occurring at the facility., However, she acknowledged hearing about another CNA upstairs but was unsure if it was true. The CNA further stated that the director of nursing (DON/Staff #8) and administrator (Administrator/Staff #25) could provide an answer about the inappropriate photos better than she could. The CNA stated that the allegation was made about a former CNA, Staff #32., However, she is unaware which resident was involved. Additionally, she did not know the timeframe for the allegation, and did not believe that the allegation happened.An interview was conducted on July 28, 2026, at 10:39 a.m. with a former CNA (Staff#32/alleged perpetrator). Staff #32 stated that an allegation of abuse had to be reported within 2 hours to the supervisor, and that sexual abuse was defined as inappropriate behaviors, communications, or boundaries with a resident. The CNA said that an allegation of staff sending or selling inappropriate photos of themselves to residents would be sexual abuse. The CNA denied sending any photos of herself to a resident. A follow-up interview with Staff #32 was conducted on July 28, 2026, at 10:51 a.m. Staff #32 stated that her agency called her on June 22, 2026, and questioned whether she sent pictures of herself to a resident for compensation. Staff #32 denied the allegation and immediately reported the information to the administrator (Staff #25). The administrator told her that the agency did not inform her before calling Staff #32. After her conversation with the administrator, no one ever contacted her again about the allegation, and she knew nothing else. Staff #32 admitted that she was terminated by the facility on June 30, 2026, because of the sexual abuse rumors, employee complaints, and state agency complaints regarding her care for residents.An interview was conducted on July 28, 2026, at 11:08 a.m. with the director of nursing (DON/Staff #8). Per the DON, an allegation of abuse had to be reported within 2 hours. Additionally, the administration or floor staff had to report the allegation to outside organizations such as the SA police, the ombudsman, the provider, and the administrator within that timeframe. The DON stated that sexual abuse was defined as any unwanted physical, mental, or emotional contact that was unwanted by another party. The DON said that an allegation of a staff member sending or selling inappropriate photos to a resident would be sexual abuse if it was unwanted, and then clarified that an allegation of that nature would be inappropriate, but it would be a fine line if it would be considered sexual abuse. The DON then stated that if that allegation of inappropriate photos being sent or sold to residents occurred in the facility, it would be considered sexual abuse. The DON admitted that there was an allegation of Staff #32 sending inappropriate photos of herself to a resident, and that another state agency had come out before they were alerted to it. The DON also admitted that the facility did not report the allegation to anyone, because when the facility investigated the allegation and questioned the resident, he denied having photos of the staff member on his device. The DON stated that they became aware of the allegation a couple of weeks after the other state agency visited, which was the same day that they terminated the accused CNA, Staff #32. The DON said this was approximately 3-4 weeks ago. However, the DON later acknowledged that the CNA was not immediately terminated, and that she continued working for 2 weeks after they found out. The DON said they terminated the CNA for bullying, sending nude photos to another staff member, and choking another CNA. The DON said they were told somehow that Staff #32 was accused of sending a resident inappropriate pictures, but do not recall how it was brought up or who said it. The DON stated that the purpose of reporting an allegation of abuse was to make the state aware, notify the authorities, and to have the allegation investigated., The DON admitted that they failed to report the allegation of abuse, and that they did not follow their abuse policy, which would have been to report the allegation within 2 hours. The DON said it was the facility's expectation to have reported the allegation, and that the risk of failing to report, investigate, and implement their abuse policy for an allegation of abuse would be multiple citations, additional abuse occurrences, ongoing abuse to the resident, and mental, emotional, and physical impacts to the resident such as withdrawal. The DON also stated that they did have a full investigation of the incident that was documented with statements, but that they did not report it because they did not see it as an allegation of abuse because the resident denied having the photos. An interview was conducted on July 28, 2026, at 11:30 a.m. with the administrator (Staff #25), who stated that an allegation of abuse had to be reported within 2 hours, but ideally, immediately, to the state agencies, the police, the ombudsman, the physician, and the case manager if applicable. The administrator stated that sexual abuse was defined as unwanted advances, including touching and verbal. The administrator stated that all allegations of sexual abuse would be reportable. Additionally, an allegation of a staff member sending or selling inappropriate pictures of themselves would be reportable depending on the photos' content. The administrator said that an allegation of a staff member sending pictures of their breasts would be inappropriate, but she would need to do a small investigation to see if the allegation was founded, and if it was, she would report it. The administrator further stated that she would do the small investigation before their 2-hour reporting window was up, and that in the instance that we would be discussing, she asked Resident #67 if he had pictures of a staff member on his phone, and he denied having pictures. The administrator stated that a staff member told her through the grapevine that the resident had pictures on his phone that were inappropriate, and she admitted that they did not report the allegation to anyone. The administrator also admitted that they did not speak with any other residents or staff members about the alleged incident and that their policy was to interview all of the people involved if the allegation was reportable, including the resident and staff members. However, in this case, there was nothing to report and she did not know who she was going to interview. The administrator stated that the purpose of reporting an allegation of abuse to the applicable state agencies was to allow more time for them to investigate, because 2 hours was not a lot of time to investigate. The administrator stated that the facility's expectation for investigating an allegation of abuse would be to interview the resident, gather statements from staff members involved, write up a final investigation, and submit the investigation to the SA and the ombudsman. The administrator also stated that the facility's expectation for reporting any allegation of abuse would be immediately, or within 2 hours. The administrator stated that the risk of failing to report, investigate, and implement their policy for an allegation of abuse would be possibly putting other residents in danger. The facility policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2026, revealed that residents have the right to be free from abuse and exploitation. Per their policy, it is the facility's objective to protect residents from abuse and exploitation. Additionally, the policy directed the facility to develop and implement policies and protocols to prevent and identify abuse and exploitation of residents. The policy also noted that the facility would identify and investigate all possible incidents of abuse, and report any allegations within timeframes required by federal requirements. Per the policy, the facility would protect residents from any further harm during investigations. The policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated April 2026, indicated that all reports of resident abuse and exploitation would be reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Additionally, findings of all investigations would be documented and reported. Per the policy, if resident abuse was suspected, the suspicion had to be reported immediately to the administrator and to other officials, according to state law. Immediately was defined as within two hours of an allegation involving abuse. The policy directed the administrator or the individual making the allegation to immediately report his or her suspicion to the following persons or agencies: the state licensing/certification agency responsible for surveying/licensing the facility, the local/state ombudsman, the resident's representative, where state law provides jurisdiction in long-term care, law enforcement officials, the resident's attending physician, and the facility medical director. Furthermore, verbal or written notices to agencies would be submitted via special carrier, fax, e-mail, or by telephone. The policy further revealed that notices would include the resident's name, the resident's room number, the type of abuse that is alleged (i.e., verbal, physical, sexual, neglect, etc.), the date and time the alleged incident occurred, the name(s) of all persons involved in the alleged incident, and what immediate action was taken by the facility. Per the policy, any employee who was accused of resident abuse would be placed on leave with no resident contact until the investigation was completed. The policy noted that the individual conducting the investigation would need to review the documentation and evidence, review the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident, observe the alleged victim, including his or her interactions with staff and other residents, interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident (as medically appropriate) or the resident's representative, interviews staff members (on all shifts) who had contact with the resident during the period of the alleged incident, interview the resident's roommate, family members, and visitors, interview other residents to whom the accused employee provides care or services, review all events leading up to the alleged incident, and document the investigation completely and thoroughly. Per the policy, witness statements would be obtained in writing, signed and dated, and the witness was permitted to write his/her statement, or the investigator would obtain a statement. The policy also revealed that the investigator would notify the ombudsman that an abuse investigation was being conducted, and the ombudsman would be invited to participate in the review process. The policy revealed that any allegations of abuse were filed in the accused employee's personnel record along with any statement by the employee disputing the allegation, if the employee chose to make one.

Based on clinical record review, State Agency (SA) complaint/incident tracking system, resident and staff interviews, and policy review, the facility failed to thoroughly investigate an allegation of sexual abuse for one of three sampled residents (#67). The census was 95. The deficient practice could result in corrective actions not being taken and residents being further abused.Findings include:Resident #67 was admitted to the facility on [DATE], with diagnoses of hemiplegia, hemiparesis, testicular hypofunction, and depression.A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated intact cognition. The assessment also documented that the resident was negative for indicators of psychosis and behavioral symptoms.The SA complaint/incident tracking system revealed that another state agency submitted a report on July 24, 2026, alleging sexual abuse and exploitation of a vulnerable adult identified as resident #67. The complaint alleged that a staff member was sending the resident explicit content in exchange for money.A request was made on July 28, 2026, at 12:45 p.m. for the incident report/facility investigation, which revealed two undated staff statements. One of the signed statements was handwritten by a certified nursing assistant (CNA/Staff#2), who overheard a CNA saying that a resident had pictures of a staff member, and that they were laughing about it, but that he thought it was enough to report to the administrator. The second signed statement was typed by the administrator, Staff #25, and revealed that the CNA, Staff #2, reported that he heard a rumor that Resident #67 had inappropriate pictures on his phone of another CNA, Staff #32. The statement further revealed that upon hearing that information, the administrator spoke to Resident #67 to see if he had any pictures on his phone, to which the resident reported that Adult Protective Services (APS) was there the week before to ask him the same questions, and denied that he had the photos. The statement further revealed that the facility knew APS was out to see him the week before, but they did not know why they were out to see him. There were no additional investigative documentation provided for review during the survey.An interview was conducted on July 28, 2026, at 9:22 a.m. with the Registered Nurse Supervisor (RN Supervisor/Staff #22), who stated that she heard someone say that Resident #67 had explicit material on his laptop of a staff member, but she could not recall who had told her or what date she found out. According to the RN supervisor, it was investigated by the state and reported within the last month. The RN supervisor said that Resident #67 informed her that another state agency also investigated the incident. The nurse stated that the resident informed her that the other state agency inquired about pictures on his computer or if he had inappropriate pictures of a staff member, and that the resident indicated that he had none in his possession. The RN supervisor stated that her conversation with the resident about his encounter with the other state agency occurred at the beginning of July 2026. An interview was conducted on July 28, 2026, at 9:49 a.m. with Resident #67. The resident denied having any photos from staff members. Per the resident, another state agency had come in to speak with him about the same matter a few weeks prior.During an interview with a registry CNA (Staff #47) conducted on July 28, 2026, at 10:13 a.m., Staff #47 stated that she heard a rumor from Staff #85 (CNA) that Staff #32 was fired for showing a resident pictures of herself. However, she was unsure if the photos were nude or bikini shots. Staff #47 noted that she did not know if the rumor about the inappropriate photos was reported or investigated. Staff #47 commented that Staff #85 made it sound like the facility administration knew about it.An interview was conducted on July 28, 2026, at 10:24 a.m. with a registry CNA (Staff #85), who denied having knowledge of such incidents occurring at the facility; however, she acknowledged hearing something similar about another CNA upstairs but was unsure if it was true. The CNA further stated that the director of nursing (DON/Staff #8) and administrator (Administrator/Staff #25) could provide an answer about the inappropriate photos better than she could. The CNA stated that the allegation was made about a former CNA, Staff #32. However, she was unaware which resident was involved. Additionally, she did not know the timeframe for the allegation, and did not believe that the allegation happened.An interview was conducted on July 28, 2026, at 10:39 a.m. with a former CNA (Staff#32/alleged perpetrator), who stated that sexual abuse was defined as inappropriate behaviors, communications, or boundaries with a resident. The CNA said that an allegation of staff sending or selling inappropriate photos of themselves to residents would be sexual abuse. The CNA denied sending any photos of herself to a resident. A follow-up interview with Staff #32 was conducted on July 28, 2026, at 10:51 a.m. Staff #32 stated that her agency called her on June 22, 2026, and questioned whether she sent pictures of herself to a resident for compensation. Staff #32 stated that she denied the allegation and immediately reported the information to the administrator (Staff #25). The administrator told her that the agency did not inform her before calling Staff #32. Staff #32 stated that after her conversation with the administrator, no one ever contacted her again about the allegation, and she knew nothing else. Staff #32 admitted that she was terminated by the facility on June 30, 2026, because of the sexual abuse rumors, employee complaints, and state agency complaints regarding her care for residents.An interview was conducted on July 28, 2026, at 11:08 a.m. with the director of nursing (DON/Staff #8), who stated that an allegation of a staff member sending or selling inappropriate photos to a resident would be sexual abuse if it was unwanted, and then clarified that an allegation of that nature would be inappropriate, but it would be a fine line if it would be considered sexual abuse. The DON then stated that if that allegation of inappropriate photos being sent or sold to residents occurred in the facility, it would be considered sexual abuse. The DON admitted that there was an allegation of Staff #32 sending inappropriate photos of herself to a resident, and that another state agency had come out before they were alerted to it. The DON also admitted that the facility did not report the allegation to anyone, because when the facility investigated the allegation and questioned the resident, he denied having photos of the staff member on his device. The DON stated that they became aware of the allegation a couple of weeks after the other state agency visited, which was the same day that they terminated the accused CNA, Staff #32. The DON said this was approximately 3-4 weeks ago. However, the DON later acknowledged that the CNA was not immediately terminated, and that she continued working for 2 weeks after they found out. The DON said they terminated the CNA for bullying, sending nude photos to another staff member, and choking another CNA. The DON stated that they were told somehow that Staff #32 was accused of sending a resident inappropriate pictures, but did not recall how it was brought up or who said it. The DON stated that the purpose of reporting an allegation of abuse was to make the state aware, notify the authorities, and to have the allegation investigated. The DON said it was the facility's expectation to have investigated the allegation, and that the risk of failing to investigate an allegation of abuse would be multiple citations, additional abuse occurrences, ongoing abuse to the resident, and mental, emotional, and physical impacts to the resident such as withdrawal. The DON also stated that they did have a full investigation of the incident that was documented with statements, but that they did not report it because they did not see it as an allegation of abuse because the resident denied having the photos; however, there was no evidence provided by the facility to show that a full investigation had been conducted per the facility policy. An interview was conducted on July 28, 2026, at 11:30 a.m. with the administrator (Staff #25), who stated that sexual abuse was defined as unwanted advances, including touching and verbal. The administrator stated that all allegations of sexual abuse would be reportable. Additionally, an allegation of a staff member sending or selling inappropriate pictures of themselves would be reportable depending on the photos' content. The administrator said that an allegation of a staff member sending pictures of their breasts would be inappropriate, but she would need to do a small investigation to see if the allegation was founded, and if it was, she would report it. The administrator further stated that she would do the small investigation before their 2-hour reporting window was up, and that in the instance that we would be discussing, she asked Resident #67 if he had pictures of a staff member on his phone, and he denied having pictures. The administrator stated that a staff member told her through the grapevine that the resident had pictures on his phone that were inappropriate, and she admitted that they did not speak with any other residents or staff members about the alleged incident and that their policy was to interview all of the people involved if the allegation was reportable, including the resident and staff members. The Administrator stated that in this case, there was nothing to report and she did not know who she was going to interview. The Administrator stated that the purpose of reporting an allegation of abuse to the applicable state agencies was to allow more time for them to investigate, because 2 hours was not a lot of time to investigate. The administrator stated that the facility's expectation for investigating an allegation of abuse would be to interview the resident, gather statements from staff members involved, write up a final investigation, and submit the investigation to the SA and the ombudsman. The administrator stated that the risk of failing to investigate an allegation of abuse would be possibly putting other residents in danger. Review of a policy titled, Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated April 2026, revealed that the facility had an abuse prevention program that consisted of developing and implementing policies and protocols to prevent and identify abuse or mistreatment of residents. The policy also revealed that the facility would identify and investigate all possible incidents of abuse. The policy also revealed that the facility would protect residents from any further harm during investigations. Review of a policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated April 2026, revealed that all allegations would be thoroughly investigated, and that any employee who was accused of resident abuse would be placed on leave with no resident contact until the investigation was completed. The policy also revealed that, at a minimum, the individual conducting the investigation would need to review the documentation and evidence, review the resident's medical record to determine the resident's physical and cognitive status at the time of the incident and since the incident, observe the alleged victim, including his or her interactions with staff and other residents, interview the person(s) reporting the incident, interview any witnesses to the incident, interview the resident (as medically appropriate) or the resident's representative, interview the resident's attending physician as needed to determine the resident's condition, interviews staff members (on all shifts) who had contact with the resident during the period of the alleged incident, interview the resident's roommate, family members, and visitors, interview other residents to whom the accused employee provides care or services, review all events leading up to the alleged incident, and document the investigation completely and thoroughly. The policy further revealed that each interview would need to be conducted separately and in a private location, and that the purpose and confidentiality of the interview would be explained thoroughly to each person involved in the interview process. The policy revealed that witness statements would be obtained in writing, signed and dated, and that the witness was permitted to write his/her statement, or the investigator would obtain a statement. The policy also revealed that the investigator would notify the ombudsman that an abuse investigation was being conducted, and the ombudsman would be invited to participate in the review process. The policy revealed that any allegations of abuse were filed in the accused employee's personnel record along with any statement by the employee disputing the allegation, if the employee chose to make one.

Based on clinical record reviews, staff interviews, facility documentation, policy and procedures, the facility failed to ensure adequate supervision to prevent elopement for one resident (#1) out of 3 sampled residents. The deficient practice could result in avoidable accidents.Findings include:Resident # 1 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, hypertensive heart disease, and post-traumatic stress disorder. Records revealed a prior history of elopement as evidenced by a facility investigation report dated December 21, 2022 which revealed that Resident # 1 had eloped from the facility on December 16, 2022. The investigation further revealed that Resident # 1 was found not to be in his room during medication pass, and was later located approximately 11 miles from facility heading to his home to be with his wife who was sick. Review of the care plan revealed no evidence of a problem/goal related to the elopement that occurred on December 16, 2022.A physician order dated June 4, 2023 revealed that staff were to document if the resident exhibited any wandering behaviors or behavior of leaving the facility. Further review of the order revealed that it was discontinued on February 18, 2026. A behavioral symptoms care plan initiated on January 9, 2024 revealed that Resident #1 demonstrated unsafe travel outside the facility without responsible party or proper authorization. Interventions included to assess, record, report to Medical Doctor risk factors for potential elopement, if resident is seen wandering in potentially unsafe area of situation, redirect to safer area, leave safe and reassess. An annual Minimum Data Set (MDS) assessment dated [DATE] revealed that the wander-guard was utilized daily. However, the was no evidence in the care plan that the wander-guard had been placed, or interventions regarding the wander-guard.A physician's order dated December 9, 2025 revealed that the facility may place wander-guard on Resident #1.A progress note dated February 14, 2026 revealed that while the resident's spouse was picking up the resident for a home visit and had requested that the wander-guard be removed permanently. The note relayed that the Nurse Practitioner determined that the resident was safe to have the wander-guard removed. Further review of the resident's care plan related to behavioral symptoms, revealed no evidence that the care plan was updated that the wander-guard had been removed on February 14, 2026.Further review of the physician's order for the wander-gaurd, revealed that the wander-guard was discontinued on February 18, 2026.A progress note dated March 5, 2026 revealed that at about 1:14 p.m. the receptionist notified staff that Resident # 1 was by the park entrance across the parking lot. The progress note documented noted that the receptionist had eyes on the Resident the entire time. The note revealed that Resident # 1 was sitting by the entrance talking with other residents who congregate there, and that the resident was redirected back into the facility.A progress note dated March 8, 2026 revealed that the spouse was visiting Resident #1 and requested that her husband have an independent travel pass to the park entrance, to allow the resident to interact with peers.A Quarterly MDS assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS assessment revealed that Resident #1 could operate a motorized wheelchair independently 50 and 150 feet with two turns, and also revealed that elopement alarms were not used. A progress note dated March 12, 2026 revealed that the physician was in to see Resident # 1 and informed the resident that the travel pass was not approved but could be revaluated in one month. The progress note also revealed that the physician approved visits to the park with spouse or accompanied by staff, and that Recreation Therapy was notified to schedule park walks. Review of the progress notes revealed that Resident #1 went on 6 walks with recreational therapy between March 13, 2026 through April 6, 2025.A behavioral symptoms care plan long-term goal edited on March 13, 2026, revealed that the resident will remain safe within facility unless accompanied by staff, other authorized persons through review date of June 25, 2026. The care plan revealed no evidence that the wander-guard had been removed on February 14, 2026.A progress note dated April 18, 2026 revealed that a Nurse Practitioner (NP) spoke with the Resident's wife regarding the independent pass for the resident to go to the park entrance and no further. The note revealed that the NP and the resident's spouse discussed with the resident that he could go to the park entrance only and not travel further or the independent pass would be taken away. The progress note documented that the resident acknowledged understanding and new order was received for independent travel. Despite the change in orders, there was no evidence that the care plan was updated to reflect the new orders.An Observation Detail List report dated April 18, 2026, revealed that the resident had been approved for an independent travel pass, and was okay to go across the park with peers.A progress note dated May 1, 2026 at 11:54 AM, revealed that at approximately 9:45 a.m. during the morning Interdisciplinary (IDT) Meeting, a code pink was announced on the speaker regarding Resident # 1. The progress note revealed that the writer and another nurse got in their cars to search for Resident # 1, and that calls were made to the resident's and spouse's phones. The progress note relayed that the resident's spouse called the facility back telling the facility that the resident was at their home approximately 24 miles from the facility. Further review of the clinical record revealed no evidence that the resident had been accompanied to the park by staff or other authorized persons, or supervised per the behavioral symptoms care plan, edited on March 13, 2026.A progress note dated May 1, 2026, at 11:57 a.m., revealed that a Registered Nurse (RN) left the facility at approximately 10:20 a.m. to drive around and search for the resident.A progress note dated May 1, 2026 at 12:33 p.m., revealed that a code pink had been initiated, and a LPN and Infection Control Nurse, immediately left the facility in search of the resident, attempting to contact him on his cell phone, as well as his spouse. The note indicated that the surrounding area and nearby business were checked, but the resident was not found. The note relayed that when the LPN and Infection Control Nurse returned to the facility, the resident's spouse contacted the facility and reported she believed that the resident was at her home, but had not visually confirmed his presence. The note included that the spouse later reported that she confirmed the resident was with her, and he refused to return to the facility.A Resident Tracking form dated May 1, 2025 revealed that Resident # 1 was signed out of the building at 8:10 a.m. with the destination listed as the portico, the seating area immediately outside the front doors of the facility. The resident tracking form also revealed the return time as 1:04 p.m. with the comment Code Pink Cancelled. A progress note dated May 1, 2026 at 1:15 p.m. revealed the resident was returned to the facility, by his spouse, in stable condition. The progress note documented that the resident declined assessment and that the doctor was notified. The note documented that a wander-guard order was initiated was applied to the back of the resident's wheelchair. An Event Report, dated May 1, 2026, revealed that the resident left the facility unattended at approximately 8:15 a.m., and was found at his home at 11:01 a.m. The report indicated that the resident had exhibited elopement behaviors in the past, and that the wander-guard was removed on February 14, 2026, per the resident's preference and provider order, but the resident had not exhibited wandering behaviors since. The report indicated that a wander-guard was immediately applied, and the resident may not leave the premises without escort, including park entrance.A Facility Reported Incident (FRI) dated May 5, 2026, revealed that Resident #1 was reported missing from the facility. The report indicated that staff attempted to locate the resident in the facility and outlaying areas, including the park entrance, but the resident was not located. The report relayed that the camera system was checked and the cameras indicated that the resident was not picked up in the facility paring lot. The report revealed that the allegation of elopement was not verified due to the resident's cognitive status. The report included a written statement dated May 1, 2026 from the Social Worker Supervisor (Staff # 78), which revealed that Staff # 78 saw Resident # 1 at about 8:15 a.m. between the parking lot entrance of the facility and the intersection of a major cross street. The statement revealed that Resident # 1 was heading south towards a major intersection while the Social Worker Supervisor was heading north toward the facility parking lot. The statement did not indicate if the Social Worker Supervisor tried to stop the resident and help the resident to get to a safe place per the care plan, or notified anyone about the resident when he arrived at the facility. The care plan focus related to behavioral symptoms, was edited on May 1, 2026 with updated interventions that included applying a wander-guard to reduce risk of elopement, and to check device for proper functioning.An interview was conducted with the spouse of Resident # 1 on May 5, 2026 at 10:48 a.m., who stated that the facility had notified her sometime between 10:30 a.m. and 11:00 a.m. that Resident # 1 was missing. The spouse stated that she got in her car to drive towards the facility, she realized she could track his phone, and that she was able to track his phone to their house about 24 miles from the facility. The resident's spouse also stated that when she arrived at her home the resident was there waiting for her. The spouse further stated that Resident #1 may have mixed up the days of the week, that she usually comes on saturday, and the Resident thought May 1, 2026 was a saturday and not a friday, so he got worried about her and went home. The spouse stated at first Resident # 1 did not want to go back to the facility but she was able to convince him and they drove back. The spouse stated the resident did not appear injured and was proud of himself for being able to travel home. The spouse stated that a couple weeks ago they had pushed for the wander-guard to be removed and for an independent pass to the park entrance to see friends.An interview was conducted on May 5, 2025 at 12:09 p.m. with the Recreational Therapist (Staff #49), who stated that when residents want to get an independent pass the Recreational Therapy team will work with residents 1:1 taking them for walks through the park. Once the IDT team and doctor feel confident that the resident will be safe for an independent pass, they get a flag to place on their wheelchairs which alert staff driving in the neighborhood if they see a resident with a red flag, that they have an independent pass. The Recreational Therapist stated that they worked with Resident # 1 and watched how the resident maneuvered the wheelchair through the park. The Recreational Therapist also stated that the resident did great with his wheelchair, and that the resident only got hung up off the sidewalk once but was able to maneuver back onto the sidewalk. The Recreational Therapist further stated that with each walk he would stay back and let the resident be more independent, and that he felt confident that the resident could handle the small trip to and from the park entrance. The Recreational Therapist stated that Resident # 1 did not get a flag since he was not allowed past the park entrance at that time and would not be in the neighborhood. An interview was conducted with Receptionist (Staff #59) on May 5, 2026 at 12:34 p.m., who stated that anytime someone leaves the facility they sign the log book and document the time they left. The receptionist stated that Resident # 1 usually stayed out in the front of the building or by the entrance to the park to talk with the other residents. The receptionist stated that on May 1, 2026 at 8:10 a.m. Resident # 1 was in hurry to sign out not saying anything and he wheeled out to the front portico where she last saw him. The receptionist further stated that when she was getting ready to go on break at 9:15 a.m. she went out front to the portico to put eyes on the residents and that is when she noticed that Resident # 1 was not in the portico or the entrance to the park. The receptionist stated that she called the nurses station to verify that the resident had not returned and staff denied that the resident was upstairs. She stated she called a Code Pink indicating to staff there is a missing resident. The receptionist stated that during a Code Pink staff come to the front desk and get a copy of the resident's picture and are assigned an area in the neighborhood to look. The receptionist stated that she was alerted by management that the resident's spouse found him at their home and was bringing the resident back to the facility. An interview was conducted on May 5, 2025 with Social Services Director (Staff # 78), who stated that he was familiar with Resident # 1's history with elopements in the past and he stated that he was aware of the discussions during the morning meetings about allowing the resident to go across the parking lot to be with the other residents who sit and congregate while they smoke. The Social Services Director stated that on May 1, 2025 he was driving toward the facility parking lot around 8:15 a.m. and noticed Resident #1 driving his electric wheelchair south. The Social Services Director stated that he did not see a flag on the Resident's wheelchair and did not make the connection that he was eloping at that time. The Social Services Director further stated he was familiar with Resident # 1's care plan, and acknowledged that it is the social services team's responsibility to update/monitor some of the interventions. The Social Services Director reviewed the care planned interventions for Resident # 1 related to wandering behaviors, and stated that the interventions included that if the resident was seen wandering in a potentially unsafe area or situation, staff are to redirect to safer area, and reassess. The Social Services Director stated that he was aware of the intervention and that the social services team were part of the disciplines listed as responsible for the intervention. The Social Services Director stated that he should have stopped and helped Resident # 1 or told staff when he got into the facility. The Social Services Director stated the concern for not assisting the resident or notifying staff could have resulted in the resident getting hurt by the heat or by a car. An interview was conducted on May 5, 2025 at 1:34 p.m. with Administrator (Staff #83) who stated that independent travel is utilized when a resident wants to go out of the facility into the neighborhood and it is determined that the resident is capable and will be safe during the travel. The Administrator stated that Resident #1 had been approved for independent travel but just to the park entrance and no further. The Administrator also stated that limiting independent travel to one location is impossible to enforce without staff following the resident to that particular location. The Administrator further stated that going forward the facility will only do full independent travel and not partial travel to specific locations. The Administrator stated that her concerns about the incident included that Resident # 1 got a limited independent pass, no one watched him while he was outside for over an hour, and when staff saw Resident # 1 without a flag leaving the facility, the resident was not stopped or taken to safety, and staff were not notified. The Administrator stated that this could have led to serious injury to Resident # 1.A policy and procedure titled Emergency Procedure missing resident, revised 2018, revealed that Resident's at risk for wandering and or elopement will be monitored, and staff will take necessary precautions to ensure their safety. A policy titled Care Plans, Comprehensive Person-Centered, Revised 2024, revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.

Based on interviews, clinical record review, review of facility documentation, and review of facility policy and procedure, the facility failed to protect the rights of one (#67) of five sampled residents to be free from abuse by another resident (#61). The deficient practice could result in further abuse of residents and appropriate action not taken.Findings include:-Resident #67 was admitted to the facility on [DATE], with diagnoses of senile degeneration of the brain, dementia with other behavioral disturbance and severe anxiety, unspecified mood affective disorder, adjustment disorder, and insomnia.A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed that the resident had memory problem both for short-term and long-term memory. Additionally, the assessment indicated that the resident had some difficulty in new situations pertaining to cognitive skills for daily decision making. Further review of the MDS revealed that resident #67 had exhibited no verbal or physical behavioral symptoms directed towards others during the assessment period. A cognition/dementia care plan initiated on April 7, 2025, revealed that resident #67 had a history of disturbance in thought process and was unable to follow both verbal and visual cues. Interventions included alerting the medical provider regarding changes in cognition with the goal of maintaining his functional independence as much as possible. An RN (Registered Nurse) progress note dated November 23, 2025 documented that a Certified Nursing Assistant (CNA) reported that a resident approached resident #67 from behind, placed his hands on resident #67's head, and moved resident #67's head side to side. Per the note resident #67 had a habit of counting out loud and the counting had aggravated the other resident. Residents were separated by the CNA and no injuries were noted to either resident. An RN note dated November 24, 2025, documented an Alert Charting and indicated Vet accosted. The note revealed that resident #67 was observed in his room, dining hall and common areas without issue. Per the note the resident was not approached by other residents and appeared to be in no distress. A Social Services progress note dated November 25, 2025 documented that resident 67's son was informed that the resident would be moved to a room upstairs for his safety, by the end of the week. Review of the Resident Census documented a room change in which resident #67 was moved from unit C1 to unit C2 on November 26, 2025.A Nursing progress note dated November 26, 2025 stated that the resident was moved to room C261.-Resident #61 was initially admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses of Alzheimer's disease, dementia with unspecified severity and other behavioral disturbance, psychotic disorder with delusions due to known physiological condition, psychotic disorder with delusions due to known physiological condition, adjustment disorder with mixed disturbance of emotions and conduct, and insomnia.A review of the quarterly Minimum Data Set (MDS) assessment for resident #61 dated November 13, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. A late entry NP (Nurse Practitioner) note regarding a psychiatric reevaluation dated November 15, 2025, documented that resident #61 was assessed to have displayed relative stability on current treatment plan. Per the assessment the resident's functional impairment and behaviors were consistent with dementia progression. The reevaluation included medication review. According to the reevaluation no medication changes were recommended and the resident progress will be monitored and the indication and efficacy of current treatment regiment will be reevaluated. Additionally, the reevaluation included a plan for resident to be encouraged to socialize with other residents for improved quality of life. A behavioral care plan revised November 17, revealed that resident #61 had a history of socially inappropriate and disruptive behavioral symptoms toward other residents and required continuous supervision. Interventions included assessing whether the behavior endangers resident #61 and other residents. When behaviors occur provide redirection to divert resident from the peer that may be causing the frustration or behavior. The goal of the focus was for resident #61 not to harm self or others. An RN (Registered Nurse) progress note dated November 23, 2025 documented that a Certified Nursing Assistant (CNA) reported that a resident was sitting in his wheelchair in a common area of the facility when resident #61 approached the resident from behind, placed his hands on either side of the other resident's head and moved it from side to side. The progress note indicated that the other resident had a habit of counting out loud and the counting had aggravated resident #61. Residents were separated by the CNA and no injuries were noted to either resident.A Nursing progress note dated November 25, 2025 documented that resident #61 was returning from being weighed by a CNA when he overheard another resident counting out loud. Resident #61 stated I am tired of listening to him count all of the time. He's a lunatic. Resident #61 was redirected and reminded to speak about peers with empathy. The resident was accompanied to his room. A behavioral care plan initiated on November 26, 2025 revealed that the resident had socially inappropriate/disruptive behavioral symptoms as evidenced by the resident placing hands on another veteran on November 23. Review of the facility's Follow-Up Report dated November 26, 2025 revealed that the facility verified the resident to resident altercation. An interview was conducted on December 9, 2025, at 11:41 a.m. with CNA (staff #108). Staff #108 stated that resident #67 was frequently loud and would count out loud. This behavior disturbed other residents at times. She stated that on the day of the altercation between resident #67 and resident #61, she was the only staff member to witness the event. She revealed that on November 23, 2025, at around 1:00 p.m she had heard resident #67 counting out loud while seated in the common area outside the dining room. She was closing the dining room doors when she witnessed resident #61 come up behind resident #67 and grabbed resident #67 with both hands over resident's #67's ears. Staff #108 stated that she called out to resident #61 to stop and quickly walked about 20 steps over to separate the residents. She then directed resident #61 to go to his room and resident #61 stated that he could still hear the other resident count from his room and that the counting was driving him crazy. Resident #61 immediately went to his room and closed the door. Staff #108 stated that resident #67 was unable to defend himself, but neither resident appeared to be injured. Staff #108 then reported the incident to her supervisor, Registered Nurse (RN/staff #38).A telephonic interview was conducted on December 9, 2025, at 12:32 p.m. with Registered Nurse (RN/staff #38). Staff #38 stated that she was notified by staff #108 that a resident-to-resident altercation had occurred. Both residents had already been separated when she arrived. She assessed both residents and documented the incident in their clinical record. Staff #38 stated that no physical injuries were noted to either resident, therefore, no formal skin assessment was required. The incident was reported to the administrator. An interview was conducted on December 9, 2025, at 12:45 p.m. with the facility Administrator (staff #77). Staff #77 stated that as the abuse coordinator, she was notified of the resident-to-resident altercation on November 23, 2025, by staff #38. Staff #77 stated that the altercation between resident #67 and resident #61 is considered physical abuse and failed to meet her expectations for the facility. She further stated that physical abuse could result in physical or psychological harm to residents. Review of facility policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated January 2025, revealed that residents have the right to be free from abuse. Further, the facility will establish and maintain a culture of compassion and caring for all residents and particularly those with behavioral, cognitive or emotional problem.

Based on facility documentation, staff interviews, and policy review, the facility failed to ensure that the required staffing information and Certification and Survey Provider Enhanced Reporting (CASPER) Payroll-Based Journal (PBJ) data was submitted to CMS (Centers for Medicare & Medicaid Services) for one quarter. The deficient practice could result in residents receiving inadequate care due to a potential lack of staffing. Findings include: A review of the [NAME] PBJ Staffing Data Report that was run on May 21, 2025 revealed that the facility was triggered for failure to submit data for the quarter for the following: Fiscal year, quarter four (July 1 - September 30) 2024 Interview was attempted with the staffing coordinator on May 30, 2025 at 10:37AM, but she could not be reached for interview. Interview was conducted with the Assistant Director of Nursing (ADON/Staff #22) on May 30, 2025 at 12:02PM, who stated that the previous staffing coordinator used to be very involved with submitting PBJ data. The ADON explained that this staff member was no longer employed, but that the new staffing coordinator would likely be the person responsible for submitting PBJ data. The ADON stated that she did not know much about PBJ staffing data, but the Regional Compliance Director of Nursing would know more. Interview was conducted on May 30, 2025 at 12:22PM with the Regional Compliance Director of Nursing (Staff #200), who stated that the staffing coordinator was responsible for submitting PBJ data for the facility. She stated that she did not believe that the facility had a staffing coordinator at this time. Staff #200 stated that the facility's prior Administrator and Director of Nursing were aware that staffing data was not submitted for quarter four of 2024, though she was not aware of why. Staff #200 identified the risks of not submitting staffing data to CMS to be that the facility could face a penalty, and that the facility's star rating would be affected.

Based on documentation, resident and staff interviews, and facility policy and procedures, the facility failed to ensure that the medical record, including recorded weights, was complete and accurate for two residents (#59). The deficient practice could lead to interdisciplinary team members not being aware of the resident's status and could lead to a gap in care. Findings include: Resident #59 was admitted to the facility on [DATE] with diagnoses that included cirrhosis of the liver, major depressive disorder, and enterocolitis due to clostridium difficile. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, indicating intact cognition. The MDS also indicated that the resident had not experienced any weight gain or loss. Review of the documented weights for Resident #59 revealed the following: 05/27/2025 17:31 - 236.8 lbs 05/22/2025 14:13 - 156.4 lbs 04/04/2025 01:20 - 258.2 lbs 03/23/2025 18:22 - 241 lbs Review of the care plan revealed a problem focus, initiated March 22, 2025, which indicated that Resident #59 was at risk for dehydration related to receiving daily diuretic medication. Interventions in place included to monitor weights as ordered, to give a diet as ordered, and to notify the physician of any abnormal findings. Review of physician orders revealed an order, dated April 3, 2025, which instructed staff to obtain weights monthly, which should be obtained by the third day of the month. Review of the progress notes revealed no evidence of staff acknowledging the low weight recorded on May 22, 2025 or any potential weight loss. Interview was conducted on May 27, 2025 at 09:35AM with Resident #59, who stated that he felt that he had lost weight. The resident stated that he had been having almost daily vomiting and had noticed that he had lost weight. Interview was conducted on May 28, 2025 at 10:25AM with a Diet Technician (Staff #196) who stated that Certified Nursing Assistants often obtain the resident's weights, and the obtained weights are reviewed by nurses, herself, and the dietician. The Diet Technician stated that if the obtained weights seemed inaccurate, staff would obtain a re-weight. When asked to review Resident #59's documented weights, the Diet Technician stated that she did not yet see the weight recorded on May 22, 2025 but stated that this was inaccurate documentation. The Diet Technician stated that she was familiar with Resident #59, and stated that he did not appear to have had a significant weight loss. She also stated that in an instance where a weight is noted to be much different than the others is obtained, a re-weight should be obtained, and the Diet Technician stated that this was done in this case. Interview was conducted on May 29, 2025 at 11:21AM with a Certified Nursing Assistant (CNA/Staff #195), who stated that both the CNAs and the RNAs (Restorative Nursing Assistants) obtain resident weights. The CNA stated that if staff obtain a weight that seemed very different from other weights, the staff should reweigh them. She also stated that when obtaining weights, the nurses would compare the weights obtained to previous weights. The CNA stated that she felt that a lot of the staff did not know the proper way to obtain weights, including the RNAs. The CNA explained that the facility did not offer much training on obtaining weights, and she stated that this is a training that the staff need, as the weights could affect a resident's medications. The CNA stated that a lot of the staff do not know that residents need to be weighed the same way each time to get an accurate weight. The CNA also stated that staff conducting hoyer weights often weigh the resident in the hoyer sling and then subtract a certain amount of weight for the sling, stating that, they take the weight and subtract five pounds for the sling. The CNA voiced concerns at this, stating that residents should be weighed with the sling, and this weight should be recorded without subtracting anything. The CNA voiced great concern about the inconsistencies in methods used by staff to obtain weights on residents. Interview was conducted on May 29, 2025 at 12:17PM with a Nurse Supervisor (Staff #29), who stated that weights are often obtained by CNAs. She explained that the person who obtained a weight should chart the weight or refer it to the nurse or supervisor. She stated that the nurse or supervisor then reviews the weights. She stated that if she noticed a change, she would assess the resident and notify the provider and dietician if a weight change was noticed. The Nurse Supervisor also stated that if a weight seemed inaccurate, she would expect a re-weigh to be done, though she could not state the timeframe in which this should be completed. The Nurse Supervisor stated that if a weight was found to be inaccurate, the weight should not be removed from the Electronic Health Record, but a note should be made explaining that the weight was deemed inaccurate documentation. Interview was conducted on May 29, 2025 at 2:33PM with Resident #59's Attending Physician (Staff #198) who was unable to recall if he had seen or been notified of Resident #59's low recorded weight on May 22, 2025. The Physician stated that upon reviewing the weights, the low weight was likely a typo, as he did not believe that the resident experienced such a drastic weight change. The Physician acknowledged that an incorrect weight reading could potentially affect a resident's care, especially depending on their disease process. The physician stated that certain residents, such as those with heart failure, need to have their weights monitored very closely. Interview was conducted on May 30, 2025 at 1:00PM with the Restorative Nursing Assistant (RNA/Staff #194) who had documented Resident #59's weight on May 22, 2025. She stated that whoever obtained the weight should document it in the Electronic Health Record (EHR) and report it to the nurse. If the nurse noticed that the weight appeared very different from other weights, they would ask the RNA or CNA to repeat the weight. When asked about the weight of 156.4 pounds recorded by the RNA on May 22, 2025, the RNA stated that she did not see this lower number. She explained that the CNA had obtained the weight that day and given it to her to document. The RNA could not recall which CNA had obtained this weight, and the RNA was unsure if this was reported to the nurse. Observation was conducted on May 30, 2025 at 1:15PM of a weight being obtained via Hoyer lift by the RNA (Staff #194) and a CNA who assisted. During the observation, the staff first zeroed the Hoyer scale and attached a Hoyer sling. The staff obtained the weight of the sling. The RNA stated the weight of the sling was 1.8 pounds. The staff then zeroed the scale again, placed a sling under the resident, and attached the sling to the Hoyer. The staff then raised the resident in the sling via the Hoyer lift, and announced the displayed weight as 129.8 pounds. When asked what would be the weight recorded in the record, the RNA replied that she would record the weight as 129.8 pounds, and that she would not subtract the weight of the sling before documenting the weight. Interview was conducted on May 30, 2025 at 2:06PM with the Director of Nursing (DON/Staff #24) and the Assistant Director of Nursing (ADON/Staff #22). In this interview, the DON stated that weights should be obtained per the facility policy. The DON and ADON agreed that when weighing a resident with a Hoyer lift, the resident should either be transferred for a chair weight, or if the Hoyer lift had a scale, the weight of the sling should be known and should be removed from the total weight. When asked what staff should do if they obtain a weight that is abnormal for a resident, the DON stated that a reweight should be obtained and documented per policy and the provider and family would be notified. Upon reviewing Resident #59's weight reading from May 22, 2025, the DON and ADON stated that they thought the reading was an error, as the other readings were consistent within a few pounds. The DON and ADON could not identify any charting where this weight was addressed or confirmed to be inaccurate. Review of the facility policy titled, Weighing and Measuring the Resident (dated October 2021) revealed that significant weight loss/weight gain should be reported to the nurse supervisor. This policy also contained procedures for obtaining residents weights via a standing scale, a platform scale, and by using a mechanical lift to move a resident into a chair scale. Review of this policy revealed no evidence of a policy or procedure in place for staff to obtain or record resident weights using a Hoyer lift with a scale.

Based on facility documentation, staff interviews, and policy review, the facility failed to ensure one resident's (#32) Preadmission Screening and Resident Review (PASARR) was completed accurately and was referred to state designated authorities for evaluation and determination. The deficient practice could result in residents not receiving specialized services needed. Findings include: Resident #32 was admitted to the facility on [DATE] with diagnoses that included diffuse traumatic brain injury, bipolar disorder, and major depressive disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. The MDS also revealed that Resident #32 had diagnoses of anxiety disorder, depression, and bipolar disorder. Review of physician orders revealed the following orders: Depakote Sprinkles (divalproex) capsule, delayed [NAME] sprinkle; 125 milligram; oral Twice A Day 07:30, 19:00 04/23/2025 hydroxyzine pamoate capsule; 25 milligram; oral 1 Time Per Day - PRN 04/23/2025 trazodone tablet; 50 milligram; oral At Bedtime 21:00 04/23/2025 Review of the Pre-admission Screening and Resident Review (PASARR) Level One Screening, dated May 5, 2025, revealed that the resident's mental health diagnoses were not all reflected. The PASARR level I confirmed that the resident was not exempt from the evaluation as per documented 'No' for the resident not qualifying for 30 day convalescent care as well as not having dementia as primary diagnosis. The PASARR reflected that the resident had a serious mental illness diagnosis of psychotic/delusional disorder. The PASARR also reflected that the resident had the mental disorders of anxiety disorder and bipolar disorder. However, the PASARR did not document the resident's diagnosis of Major Depressive Disorder. The PASARR further indicated that a referral for level two evaluation was not necessary. Review of the care plan revealed a problem focus, initiated on May 27, 2025 that indicated that Resident #32 was receiving antidepressant medication related to his diagnosis of major depressive disorder. Additionally, another problem focus, initiated on May 27, 2025 indicated that Resident #32 was receiving mood stabilizer medication related to his diagnosis of anxiety disorder. Interview was conducted on May 30, 2025 at 9:44AM with a Medical Social Worker (Staff #84), who stated that any mental health related diagnoses should be reflected on a PASARR assessment. The Social Worker stated that the purpose of a PASARR assessment would be to help with accountability and to ensure that placement at the facility would be appropriate and able to meet the needs of the residents. When reviewing the PASARR completed for Resident #32, the Social Worker agreed that the form did not reflect Resident #32's mental health diagnoses accurately. He acknowledged that the resident's major depressive disorder diagnosis was not included; and that, the level one screening should be redone. Interview was conducted on May 30, 2025 at 2:06PM with the Director of Nursing (DON/Staff #24) and the Assistant Director of Nursing (ADON/Staff #22). In this interview, the DON stated that she would expect a completed PASARR to reflect mental health diagnoses such as major depressive disorder. When discussing Resident #32's PASARR, the DON agreed that major depressive disorder was not reflected on the PASARR, and stated that she would expect corrective action to make the PASARR accurate. Review of the facility policy titled, Behavioral Assessment, Intervention and Monitoring (dated October 2021), indicated that nursing staff and the attending physician, as part of the initial assessment, identify individuals with a history of impaired cognition, altered behavior, substance use disorder, or mental disorder. The policy indicated that all residents would receive a level one PASARR prior to admission, and if the level one screen indicated that the individual may meet the criteria for a mental disorder, intellectual disability, or related condition, he or she would be referred to the state PASARR representative for the Level two (evaluation and determination) screening process.

Based on clinical record reviews, interviews, and facility policy, the facility failed to ensure that pharmacy recommendations for one resident (#14) were reviewed and addressed by the attending physician. The deficient practice could result in medication irregularities that go unnoticed or are not acted upon. Findings include: Resident #14 was admitted to the facility on [DATE] with diagnoses that included dementia with agitation, adjustment disorder, anxiety disorder, depression, and schizophrenia. Review of the care plan revealed a problem focus, initiated November 25, 2022, which indicated that the resident received antidepressant medication related to his diagnosis of depression. The goal for this problem was that the resident's medication would be effective during his stay and until the next review. Interventions included carrying out the medication management regimen as prescribed. Review of the physician orders revealed the following active medication order: Mirtazapine tablet; 15 mg; amt: 15 mg; oral Special Instructions: Dx: Depression aeb poor appetite At Bedtime 21:00 11/28/2023 Open Ended Review of the Medication Regimen Review (MRR) dated March 31, 2025 revealed recommendations made by the consultant pharmacist conducting the review (Staff #199), which included a recommendation to discontinue the resident's mirtazapine as the patient's weight on March 4, 2025 was 191.6 and his BMI was 25.28. The pharmacist also recommended consideration of an alternative agent for depression that would not stimulate appetite, and the pharmacist recommended Sertraline 25mg by mouth daily. The MRR indicated that a note was written to the physician. Review of the MRR revealed no evidence that the physician had signed the MRR, or if the physician had agreed or disagreed with this recommendation. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] indicated that the resident was receiving antidepressants, opioids, and antipsychotic medication on a routine basis. Review of the progress notes revealed no evidence found that the attending physician had reviewed or acknowledged the pharmacist's medication recommendations from March 31, 2025. A progress note dated April 23, 2025, which was created on May 7, 2025, from the Psychiatric Nurse Practitioner (Staff #197) detailed that she had conducted a psychiatric reevaluation on Resident #14. The note indicated that the resident was last seen March 19, 2025, and no medications changes were made at that time or in the interim. The note included a plan, which detailed no medication changes, as the benefits outweighed the risks for prescribed psychotropic medications. The NP's note revealed no evidence that the pharmacist's March recommendations were seen and considered by either the attending physician or herself. Interview was conducted on May 29, 2025 at 8:15AM with the Consultant Pharmacist (Staff #199), who stated that non-emergent recommendations from the MRR are given to the Director of Nursing, who then takes it to the attending physician. He stated that if he makes recommendations, the physician should sign the MRR after reviewing. Interview was conducted on May 30, 2025 at 9:18AM with Resident #14's Attending Physician (Staff #198), who stated that he normally receives the pharmacist's recommendations in writing, and the forms are placed in his binder at the facility. He stated that he typically reviews any pharmacy recommendations every one or two weeks. The physician stated that he responds to the recommendations by marking whether he agreed or disagreed with the recommendation on the paper form, which is then sent to medical records to be uploaded. When asked if the physician had seen the pharmacy recommendation regarding mirtazapine on March 31, 2025, the physician stated that he was unsure if this had been addressed and that he would have to review the resident's chart to find out. The physician stated that it was also possible that the recommendation may have been sent to the Psychiatric Mental Health Nurse Practitioner (NP/Staff #197) instead. Interview was attempted via telephone on May 30, 2025 at 10:25AM with the Psychiatric Mental Health Nurse Practitioner (NP/Staff #197), but she could not be reached for interview. Interview was conducted on May 30, 2025 at 2:06PM with the Director of Nursing (DON/Staff #24) and the Assistant Director of Nursing (ADON/Staff #22). In this interview, the DON stated that pharmacy recommendations from the MRR are printed out and placed into the provider's folder for review. She explained that from this point, the provider either agrees or disagrees with the recommendation. If the provider agreed with the recommendations, the nurses would enter the orders. If the order required consents, the staff would obtain the consents, and then send them to medical records. The DON explained that the provider would respond to pharmacy recommendations directly on the paper form, marking agree or disagree, and then this form would be uploaded into the resident's Electronic Health Record. Upon reviewing Resident #14's uploaded documents and clinical records, the DON and ADON agreed that the pharmacist had given a recommendation, and they could not locate that the MRR recommendation had been responded to. Review of the facility policy titled, Medication Regimen Reviews (May 2019), revealed that within twenty-four hours of the MRR, the consultant pharmacist should provide a written report to the attending physicians for each resident identified as having a non-life-threatening medication irregularity, which would include the identified irregularity and the pharmacist's recommendation. The policy indicated that the attending physician should document in the medical record that the irregularity had been reviewed and what (if any) action was taken to address it. The policy also revealed that copies of medication regimen review reports, including physician responses, should be maintained as part of the permanent medical record.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that the abuse policy was adhered to following an incident involving an injury of unknown origin for one of three sampled residents (#3). The deficient practice could result in abuse policies not being followed, which could result in residents being harmed. Findings include: Resident #3 was admitted on [DATE] with diagnoses that included type 2 diabetes, fecal impaction, hypotension, streptococcus group B, post-traumatic stress disorder, depression, adjustment disorder, pneumonia, hyperlipidemia, and hypoglycemia. An Annual Minimum Data Set (MDS) assessment initiated on May 8, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of the facility investigation for an injury of unknown origin dated May 6, 2025 revealed that staff made a report to AZDHS at 6:25 a.m. on May 7, 2025 following Resident #3 complaining of left hand pinky finger pain. The investigation revealed that the pinky finger was red, swollen, and painful, and an x-ray was completed to reveal a nondisplaced fracture. The investigation further revealed that an interview was conducted with the resident who was unaware of how the injury occurred, and the resident did not believe he had a recent fall. The facility investigation was unsubstantiated due to the x-ray report showing mild osteopenia, mild osteoarthritis, and bony mineralization being mildly decreased. However, the facility investigation revealed no evidence of further interviews conducted with staff, family, visitors, other departments, or other residents. A progress note dated May 7, 2025 at 6:56 a.m. revealed that staff identified and reported an allegation of neglect, abuse, misappropriation of property, and exploitation to the Arizona Department of Health Services (AZDHS), Adult Protective Services (APS), Ombudsman, police department, Assistant Director of Nursing (ADON/Staff#63), and the Administrator (Admin/Staff#101). An interview was conducted on May 15, 2025 at 12:07 p.m. with a Registered Nurse, (RN/Staff#42) who stated that she did not know how the resident sustained the injury to his finger, but if she had discovered it, her process would be to document and report the event before beginning to interview and take statements from the people involved as per the facility policy. The RN stated that she would always document who she talked to and she would call the doctor, responsible party, charge nurse, administrator, ombudsman, and police, if applicable. An interview was conducted on May 15, 2025 at 12:15 p.m. with a Certified Nursing Assistant, (CNA/Staff#70) who stated that if she identified an injury of unknown origin, she would report it right away to the nurse and get a documented interview with the resident to see what happened as per the facility policy. An interview was conducted on May 15, 2025 at 12:45 p.m. with the Interim Director of Nursing, (DON/Staff#30) who stated that if an injury of unknown origin were reported to the facility, they would need to interview residents, visitors, and all staff working on the floor according to the facility policy for abuse investigations. The DON stated that the incident report would contain all of the interviews in the form of handwritten statements that were signed by the person interviewed. The DON stated that the risk of not thoroughly investigating injuries of unknown origin would be a negative outcome to the resident. An interview was conducted on May 15, 2025 at 12:55 p.m. with the ADON, Staff #63, who stated that if an injury of unknown origin were reported to the facility, they would complete an investigation which would involve interviews with staff, residents, other departments, hospital staff (if applicable), or visitors. The ADON stated that the interviews for the investigation would need to be handwritten statements with the date, time, and signature of the person who was interviewed. The ADON further stated that they needed to interview as many people as it would take to get to the bottom of an allegation starting with the resident and all staff on the unit for all of the different shifts as per the facility policy. The ADON stated that the risk of not thoroughly investigating injuries of unknown origin would be potential continued abuse or residents doing something to jeopardize their safety. An interview was conducted on May 15, 2025 at 1:03 p.m. with the Administrator, Staff #101, who stated that if an injury of unknown origin were reported to the facility, they would need to complete an investigation which would involve interviews with the resident and staff members on the floor, and interviews would be documented on the interview or witness forms to become a part of the investigation documentation. The Administrator further stated that the investigation of the injury for Resident #3 was different because she, was not led down the path to interview. The administrator stated they were required to interview during an investigation, and that the risk of not thoroughly investigating could be that they would not fully know what happened to a resident, and residents could be exposed to a risk from a staff member or outside person. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, revealed that all allegations of resident abuse, including injury of unknown origin, were reported to local, state, and federal agencies and thoroughly investigated by facility management. This policy also indicated that the individual conducting the investigation as a minimum should interview: the person reporting the incident; any witnesses to the incident; the resident or representative; staff members who had contact with the resident during the period of the alleged incident; the resident's roommate, family members, and visitors. The policy indicated that the investigation should be documented completely and thoroughly, and any witness statements should be obtained in writing, signed, and dated.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an incident involving a reported injury of unknown origin was thoroughly investigated for one of three sampled residents (#3). The deficient practice could result in injuries of unknown origin occurring without being appropriately investigated or identified in order to implement measures to protect residents. Findings include: Resident #3 was admitted on [DATE] with diagnoses that included type 2 diabetes, fecal impaction, hypotension, streptococcus group B, post-traumatic stress disorder, depression, adjustment disorder, pneumonia, hyperlipidemia, and hypoglycemia. An Annual Minimum Data Set (MDS) assessment initiated on May 8, 2025, revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of the facility investigation for an injury of unknown origin dated May 6, 2025 revealed that staff made a report to AZDHS at 6:25 a.m. on May 7, 2025 following Resident #3 complaining of left hand pinky finger pain. The investigation revealed that the pinky finger was red, swollen, and painful, and an x-ray was completed to reveal a nondisplaced fracture. The investigation further revealed that an interview was conducted with the resident who was unaware of how the injury occurred, and the resident did not believe he had a recent fall. The facility investigation was unsubstantiated due to the x-ray report showing mild osteopenia, mild osteoarthritis, and bony mineralization being mildly decreased. The facility investigation revealed no evidence of further interviews conducted with staff, family, visitors, other departments, or other residents. A progress note dated May 7, 2025 at 6:56 a.m. revealed that staff identified and reported an allegation of neglect, abuse, misappropriation of property, and exploitation to the Arizona Department of Health Services (AZDHS), Adult Protective Services (APS), Ombudsman, police department, Assistant Director of Nursing (ADON/Staff#63), and the Administrator (Admin/Staff#101). An interview was conducted on May 15, 2025 at 11:55 a.m. with Resident #3 who stated that he did not know where or how the injury to his pinky occurred. The resident further stated that he noticed it was hurting when he woke up and an x-ray revealed it was broken. An interview was conducted on May 15, 2025 at 12:07 p.m. with a Registered Nurse, (RN/Staff#42) who stated that she did not know how the resident sustained the injury to his finger, but if she had discovered it, her process would be to document and report the event before beginning to interview and take statements from the people involved. The RN stated that she would always document who she talked to and she would call the doctor, responsible party, charge nurse, administrator, ombudsman, and police, if applicable. An interview was conducted on May 15, 2025 at 12:15 p.m. with a Certified Nursing Assistant, (CNA/Staff#70) who stated that if she identified an injury of unknown origin, she would report it right away to the nurse and get a documented interview with the resident to see what happened. An interview was conducted on May 15, 2025 at 12:45 p.m. with the Interim Director of Nursing, (DON/Staff#30) who stated that if an injury of unknown origin were reported to the facility, they would need to interview residents, visitors, and all staff working on the floor. The DON stated that the incident report would contain all of the interviews in the form of handwritten statements that were signed by the person interviewed. The DON stated that the risk of not thoroughly investigating injuries of unknown origin would be a negative outcome to the resident. An interview was conducted on May 15, 2025 at 12:55 p.m. with the ADON, Staff #63, who stated that if an injury of unknown origin were reported to the facility, they would complete an investigation which would involve interviews with staff, residents, other departments, hospital staff (if applicable), or visitors. The ADON stated that the interviews for the investigation would need to be handwritten statements with the date, time, and signature of the person who was interviewed. The ADON further stated that they needed to interview as many people as it would take to get to the bottom of an allegation starting with the resident and all staff on the unit for all of the different shifts. The ADON stated that the risk of not thoroughly investigating injuries of unknown origin would be potential continued abuse or residents doing something to jeopardize their safety. An interview was conducted on May 15, 2025 at 1:03 p.m. with the Administrator, Staff #101, who stated that if an injury of unknown origin were reported to the facility, they would need to complete an investigation which would involve interviews with the resident and staff members on the floor, and interviews would be documented on the interview or witness forms to become a part of the investigation documentation. The Administrator further stated that the investigation of the injury for Resident #3 was different because she, was not led down the path to interview, and the resident denied having a problem with staff, which meant there was no reason to interview. The administrator stated they were required to interview during an investigation, and that the risk of not thoroughly investigating could be that they would not fully know what happened to a resident, and residents could be exposed to a risk from a staff member or outside person. Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated September 2022, revealed that all allegations of resident abuse, including injury of unknown origin, were reported to local, state, and federal agencies and thoroughly investigated by facility management. This policy also indicated that the individual conducting the investigation as a minimum should interview: the person reporting the incident; any witnesses to the incident; the resident or representative; staff members who had contact with the resident during the period of the alleged incident; the resident's roommate, family members, and visitors. The policy indicated that the investigation should be documented completely and thoroughly, and any witness statements should be obtained in writing, signed, and dated.

Based on clinical record reviews, staff, resident and family interviews, and policies and procedures, the facility failed to ensure that allegations of abuse, neglect, and/or misappropriation of resident property were thoroughly investigated for residents (#3, #10, #11, #20, #30, #54 #63, #129, #146, #98, #14). The deficient practice could result in violations towards residents without being identified or without appropriate steps being taken to protect residents. Findings include: -Resident #63 was admitted to the facility on [DATE] with diagnoses that included neurocognitive disorder with Lewy bodies, cognitive communication deficit, and dementia. Review of the care plan revealed a problem focus, initiated November 15, 2019, that indicated that the resident was alert and oriented x2-3 and was able to make needs known. This problem also indicated that the resident had a diagnosis of dementia with behavioral disturbance, and the resident's BIMS score may fluctuate. Review of the Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 4, which indicated severe cognitive impairment. Review of the progress notes revealed that on December 20, 2022, the resident was noted with increased behaviors and aggression toward staff. There was no evidence found in the progress notes that the Resident #20 made any abuse allegations toward staff on December 20, 2022. Review of the facility investigative report revealed that on December 20, 2022, Resident #63 was overhead on the phone alleging that a male Certified Nursing Assistant (CNA) threw him down the hall. The facility investigation indicated that following the event, Resident #63 was interviewed and his story changed multiple times. There was no evidence of interviews with Resident #63 in the facility investigation . Attached to the facility investigation were two interviews, one of which was from a Licensed Practical Nurse (LPN/Staff #98), which revealed that Resident #63's family had called to talk to him on the phone. The statement revealed that during the conversation, Resident #63 alleged that a man dragged him out and beat him up. The statement revealed that the LPN asked if this occurred on this date, and Resident #63 confirmed that it did. The LPN at this time notified the ADON and the resident's family. The LPN revealed that the family stated that she would take the allegation with a grain of salt, as the resident had a history of making such allegations at home. The investigation did not indicate who was the male CNA working the shift, or any evidence that this staff member was interviewed for a statement. An additional attached statement was from an LPN (Staff #100), who indicated that she did not see anything, but overheard Resident #63 calling a male staff member profanities multiple times. The statement gave the first name of a male staff member. Based off of this information and review of the staff assignments from December 20, 2022, it was revealed that this male staff member was likely Staff #103. Further review of the facility investigative report revealed that video footage was reviewed with no incidents being observed for Resident #63. The investigation also indicated that ten residents and ten staff were interviewed with no findings. There was no evidence found that any residents were interviewed, and the only two staff statements found were from the LPNs. There was no statement found from the alleged perpetrator. The facility investigative report also indicated that the resident's care plan would be edited to include that the resident should be a two-person approach. Review of Resident #63's care plan for December 2022 revealed no evidence that the resident was supposed to be a two-person approach. Further review of the care plan revealed that a two-person approach was initiated later as an intervention on January 4, 2025. Review of the charted observations revealed no evidence that a skin assessment was completed on December 20, 2022, following the abuse allegation. Interview was conducted on April 23, 2025 at 3:10PM with a CNA (Staff #103), who confirmed he was familiar with Resident #63, and stated that the resident was really confused and verbally aggressive. The CNA confirmed that he was aware that Resident #63 had made an allegation against him a couple of years ago. The CNA stated that Resident #63 had alleged that he had beat him up and thrown him down the hall. The CNA stated that he did not do these things, and that he had never witnessed any staff be abusive towards residents. The CNA stated that the resident had been upset with him that night, as the CNA had placed him at the nurses' station because the resident was attempting to ambulate and almost falling. The CNA recalled that Resident #63 was upset about this and stated that he would report the CNA. -Resident #20 was admitted to the facility on [DATE] with diagnoses that included fibromyalgia and major depressive disorder. Review of the MDS dated [DATE] revealed a BIMS score of 12, which indicated resident was moderately cognitively impaired. Review of Resident #20's care plan initiated on February 16, 2022, revealed that the resident had socially inappropriate behavioral symptoms, evidenced by false accusations toward staff. Interventions included using a 2 person assist for all personal care, and reporting and investigating allegations per facility protocol. A review of the facility reportable investigation revealed that on September 21, 2022, Resident #20 alleged abuse against a male staff member who had worked with her on either September 18, 2022 or September 19, 2022. The resident described that the staff member was an African American male Certified Nursing Assistant (CNA) with a thick accent and was approximately five foot and eleven inches tall. Staff identified three potential staff who had fit the description. Upon being shown images of the males CNAs working these nights, Resident #20 failed to identify any of the staff as the perpetrator. Further review of the facility investigation revealed a statement from the Interim Director of Nursing (DON), dated September 23, 2022, which revealed that the administrator on DON had spoken to Resident #20 about her allegation. In this interaction, the resident stated that she had received ADL care from a male CNA who was very physical and caused her pain. She gave the same description of the alleged perpetrator. The statement then detailed that two of the three staff that fit the description were placed on administrative leave, while the third staff member was brought to the resident, who stated that he was not the alleged perpetrator. Further review of the facility investigation revealed a statement from a Registered Nurse (RN/Staff #109), dated September 22, 2022, which revealed that this RN had completed a skin assessment on Resident #20 was completed with no new skin concerns noted. There were no other statements or interviews with other staff, including any of the potential perpetrators, included in the facility investigation. The facility investigation included an identification badge for one of the staff members that had matched Resident #20's description. No statement from this staff member was included in the investigation. Additionally, the investigation did not reveal the identities of the two other staff members who had fit the description or statements from these staff. -Resident #11 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease without dyskinesia, anxiety disorder, and atrial fibrillation. Review of the MDS dated [DATE] revealed a BIMS score of 14, which indicated that the resident was cognitively intact. Review of the resident's inventory sheet, dated December 3, 2024, revealed that the resident had brought multiple items into the facility, including: seven blouses, five pants, three shorts, three socks and two compression socks, two t-shirts, and four rings. The inventory sheet did not provide details of the appearance of these items. Review of the nursing progress notes revealed a nursing note dated December 7, 2024, which revealed that Resident #11 had reported that he was missing clothes, including 2 shirts and compression stockings. The resident was noted to be upset with the laundry attendant, refusing to allow the laundry staff to take any more of his clothing. Further review of the progress notes revealed a note dated December 10, 2024, which revealed that social services spoke with Resident #11 regarding his missing items. The resident again reported the same details of the missing clothing and also reported missing two rings. The note revealed that staff planned to speak with the director of housekeeping about the missing clothing, and staff planned to check the resident's lockbox for the missing rings. Review of the facility investigative report revealed that following Resident #11 reporting the rings and clothing missing, the facility notified Resident #11's family, who suggested that the rings may be in the resident's locked lockbox. The report revealed that the lockbox was checked but no rings were located. This report also revealed that the resident stated he was missing his clothing after housekeeping took the clothing for labeling. Review of the investigative report revealed no evidence that housekeeping staff were interviewed about this allegation, or that the laundry facilities were searched for the missing items. The facility investigative report also revealed no evidence that any staff or other residents were interviewed for this investigation. Interview was conducted on April 17, 2025 at 12:13PM with a Registered Nurse (RN/Staff #12), who explained that items are inventoried on admission. She stated that staff would document what items and how many of each item the resident comes in with. She also stated that she would describe the items on the inventory sheet, such as describing what types of stones are on rings. The RN also stated that this inventory sheet was supposed to be updated if new items are brought in, but family does not always tell staff what new items are brought. The RN reported that the process for missing items would be to first get a history in an attempt to find where the items were last seen. She reported that staff then searches for the items with permission. The RN stated that the missing items are always reported to the administrator and the POA, and an event occurrence is filed. She further explained that the POA, family, or visitors are asked if they took the item when visiting. The RN stated that if the item is still not located, social services takes over from this point. She was unsure if the facility replaces missing items. Interview was conducted on April 17, 2025 at 2:48PM with the Social Services Director (Staff #9), who stated that items brought into the facility should be written on the resident's inventory sheet, as long as the family notifies the staff that they have brought in the items. She also stated that clothing is taken by housekeeping for labeling and is brought back to the resident. The Social Services Director stated that if an item is reported missing by a resident, staff will begin searching for the item, and staff attempt to ask the resident where it was last seen. She stated that staff will ask the resident if they are missing the item or if they suspect it was stolen. If the resident suspects theft, then staff are expected to report this to appropriate agencies. From this point, a five-day investigation is completed. She also stated that a complete investigation is conducted, even if the occurrence is not deemed to be a reportable event. Interview was conducted on April 23, 2025 at 10:42AM with Resident #11, who recalled that he had some clothing go missing around the time he admitted to the facility in December 2024. The resident recalled that laundry had taken some of his clothing off of his shelf to put his name in them, but laundry never returned them. The resident reported that he filed a grievance against the housekeeping department in response to the taken items, and police came to the facility. The resident denied that the items were ever returned or replaced by the facility, and he is unsure what ever came of the situation. The resident reported that his wife brought replacement clothes for him. Interview was conducted on April 23, 2025 at 10:49AM with a Medical Social Worker (Staff #47), who stated that if a resident reported stolen or missing items, he would attempt to look in the rooms, and if it is not found, he is mandated to report it within forty-eight hours. From there, he gives the filled-out grievance form to the administrator or administrative assistant. When asked what types of items required a reportable to be submitted, the social worker replied that items with monetary value or cash are required to be reported, and it was rare to report other missing items to outside agencies. When asked about Resident #11's missing items in December 2024, the social worker recalled that the resident had reported a few missing rings and some missing clothing, including two special shirts. When asked if staff were able to determine when the items were last seen, the social worker referenced his progress note from December 10, 2024. Upon reviewing this note, he could not determine details on when the items were last seen, but stated that the process for when a resident admits to the facility is for items to be taken for inventory and then to housekeeping for name tags to be placed onto the items. The social worker stated that he believed that one or two of the missing rings had been found, and he could not state what the outcome of the clothing was. The social worker stated that Resident #11 had told him to not worry about the clothing. The social worker explained that the clothing items did not have much monetary value, and the resident said to not worry about it, so he did not pursue these items much. The social worker acknowledged that while these items may not have had much monetary value, he could not say if the resident's clothing had sentimental value or if the resident would have been upset about the lost clothing. He stated that he would have to ask the resident to determine the outcome of the investigation. A follow-up interview was conducted on April 24, 2025 at 08:30AM with the Social Services Director (Staff #9). When asked how the facility determines that staff are not responsible for missing items, the Social Services Director stated that the resident is interviewed with open-ended questions. She stated that if the resident reports that they believed someone stole the items, it is brought to the administrator. She reported that video cameras should be reviewed and staff should be interviewed. She stated that sometimes other residents on the hall will be interviewed to see if they have had similar concerns. -Resident #30 was admitted originally on March 22, 2012 and readmitted on [DATE] with diagnoses that included malignant neoplasm of rectum, quadriplegia c5-c7 and ptsd. Review of the MDS dated [DATE], revealed a BIMS score of 15, which indicated that the resident was cognitively intact. Review of a progress note dated February 13, 2023 at 14:29 indicated that the resident alleged that two Certified Nursing assistants approached him the prior weekend and asked for his money since he could not have it in his possession. The note further revealed that the resident stated it was $100 that was taken and that a grievance statement was filed and taken to the Director of Nursing (DON). A review of the facility reportable investigation dated February 16, 2023 revealed no resident or staff interviews. There was no interview conducted with the alleged victim or perpetrator either. There were no conclusive remarks regarding the residents' allegations either. -Resident #3 was admitted to the facility on [DATE] with diagnoses that included osteoarthritis and heart failure. Review of the MDS dated [DATE] revealed a BIMS score of 14, which indicated that the resident was cognitively intact. Review of the progress notes revealed that on November 28, 2023, Resident #3's family member reported to staff that Resident #3's jewelry was missing. At this time, Resident #3 was in the hospital. Further review of the progress notes revealed that on December 4, 2023, social services received a grievance form from Resident #3's family member, which mentioned a bunch of money. The social services note revealed that the Social Worker (Staff #91) spoke to Resident #3's family member. The family denied knowing how much money was missing, and staff informed the family that Resident #3 had recently put money into the bank service at the facility. The family also discussed and provided details on the missing jewelry, which included two gold necklaces (one with a crucifix), three gold rings, and a gold chain. The note indicated that the writer had submitted a report about this situation. Further review of the progress notes revealed that on December 5, 2023, the social worker (Staff #91) attempted to call Resident #3's family member but was unable to reach him. A progress note dated December 6, 2023 revealed that a social worker (Staff #91) spoke with Resident #3's family member again. This note indicated that staff had investigated the report of missing jewelry, and staff had discovered that Resident #3 wore his jewelry to the hospital. The note did not specify how staff were able to discover this information. All grievances and investigations for Resident #3 in 2023 were requested to the facility on April 16, 2025 at 9:30AM. Among the documents provided, there was no evidence of any grievances or investigations for November or December 2023. Grievances and investigations for Resident #3 for November and December 2023 were again requested to the facility on April 16, 2025 at 2:24PM. The facility's administrator responded with a statement that said that the facility was unable to find any records that matched this request. An additional request was made on April 21, 2025 at 10:09AM for investigations relating to Resident #3 for November-December 2023, and the facility was again unable to provide these records. Interview was conducted on April 23, 2025 at 10:49AM with a Medical Social Worker (Staff #47), who stated that he could not recall how long grievances are logged or maintained for. He stated that he would make sure to keep grievances that are still relevant. Interview was conducted on April 24, 2025 at 9:19AM with a Medical Social Worker (Staff #91), who confirmed that she was familiar with Resident #3. The social worker reviewed her progress notes in Resident #3's chart. She confirmed that she had been in communication with Resident #3's family about missing jewelry and money. Upon review of her notes, the social worker recalled that she was able to determine that Resident #3 wore his jewelry to the hospital. The social worker stated that the resident normally did not take off his rings. When asked how the social worker was able to make the determination that the resident wore his jewelry to the hospital, the social worker attempted to locate the grievance mentioned in her progress notes. After a brief search in her cabinets, the social worker stated that she sometimes keeps a copy of grievances and she would search for the grievance. The social worker could not recall how long grievances were kept for. Interview was conducted on April 24, 2025 at 11:15AM with the Administrator (Staff #97), who confirmed that he was the abuse officer. The Administrator also explained that once an allegation of abuse or misappropriation is received, staff report it to him. From this point, the administrator determines who conducts the investigation based on what the allegation was. The administrator described that during the investigation, the investigator should speak to the people involved. He also stated that if the allegation involved staff-to-resident abuse, the staff suspected would be placed on administrative leave during the investigation. He elaborated that any witnesses would be interviewed, and any staff who were sent home on administrative leave would also be interviewed. The administrator also stated that the investigator would also ask other residents on the hall about the staff in question, and would ask if the residents felt safe or if they had been harmed. When asked if the facility maintains record of any investigations conducted, the administrator stated that the facility kept the past one or two years of investigations in file cabinets in the office, and would keep records from 2022 to 2023 in a storage room near the office. He explained that medical records staff would evaluate how long the records needed to be kept and if any could be disposed of, though the administrator was unaware of the length of time the records had to be kept. The administrator stated that to his knowledge, the investigations provided to the surveyor team were the completed investigations. He also stated that the risks of not conducting a complete investigation into allegations would be that the allegation may be true and it would not be able to be verified if not fully investigated, which could result in residents being injured or stolen from. -Resident #54 was admitted to the facility on [DATE], with a diagnosis of major depressive disorder, Hemiplegia, and hemiparesis following cerebral infarction affecting the left non-dominant side. Review of the BIMS assessment dated [DATE], reveals a BIMS score of 15, which indicated that the resident was cognitively intact. Review of the resident's progress notes dated May 08, 2024. revealed that at approximately 11:53 AM, the assigned nurse informed TW that she was told by CNA that the veteran was bleeding from the bottom. Noted a moderate amount of blood on the floor. Noted shearing approximately 3cm x 3cm shearing with small bleeding noted. Blanchable redness on the back. The veteran stated he had redness to his buttocks, but it was not open. Vet stated injury happened when she was pulling the sling from under me and pulling the shorts off. CNA said the veteran told him he had something on his bottom, she saw blood where the veteran was sitting, and notified the nurse. Further review of the resident's progress notes dated May 08, 2024, at 3:33 PM, A telephone order was received from the resident's primary physician to clean left buttock skin shearing with Normal Saline, pat dry, apply bacitracin, and a dry dressing three times a day. Review of the facility investigation dated April 25, 2024, revealed that there were no resident interviews conducted, nor were skin assessments attached. Further review revealed that there was no thorough investigation conducted. Grievances and investigations for Resident #54 for May 2024 were requested by the facility on April 16, 2025, at 2:24PM. The facility's administrator responded with a statement that said the facility was unable to find any records that matched this request. An interview was conducted on April 22, 2025, at 10:00 AM, with the resident #54, who reported that the CNA was a bit rough when pulling the Hoyer sling cloth out from his bottom, and it caused an open wound that was bleeding significantly. The resident clarified that the staff did not cause the injury intentionally. He mentioned that incidents can happen, and he was unaware that informing the nurse would result in someone getting in trouble. He also stated that he has a good relationship with the staff. An interview was conducted on April 22, 2025, at 2:51 PM, with the Certified Nursing Assistant (staff#104), who stated that when she provided a shower to the resident that day, she remembered that there was another Certified Nursing Assistant who was helping her. She stated that it wasn't a Hoyer sling that the resident was seated on; the resident was wearing shorts, and she noticed that his shorts were a little loose on him when she pulled his shorts. An interview was conducted on April 22, 2025, at 1:45 PM, with the interim DON (staff#102), who stated that whoever is in charge of the resident, whether the LPN or RN, should report the incident to the abuse coordinator. An investigation will be conducted, and the staff will be separated from the resident. The incident will be reported to a third-party agency, including the police, POA, and the ombudsman. Staff are typically suspended if there is staff-to-resident abuse, and HR will be involved. Abuse training is provided to the staff annually and as needed. She stated that she wasn't the DON when the staff-to-resident incident occurred.-Resident #129 was admitted [DATE] with diagnoses that included end stage renal disease, major depressive disorder, PTSD, polyosteoarthritis, hyperlipidemia, hypertension and atherosclerotic heart disease of native coronary arteries. Review of the Minimum Data Set (MDS) dated [DATE], revealed the resident was assessed for mental status due to the inability to complete the Brief Interview for Mental Status assessment. Review of the resident ' s progress notes dated April 24, 2024 at12:28 p.m., revealed the transportation company ' s representative called the facility and reported that during transportation to a medical appointment the resident was involved in a vehicular accident. The note further states that the resident was dropped off at dialysis and that the nurse notified the resident ' s Power of Attorney (POA) of the accident. Another progress note dated April 24, 2024 at 23:04 p.m., revealed that the resident was brought back to the facility by POA with no concerns and that neurological checks were started. Review of the facility investigation dated April 26, 2024, revealed that there were no staff or resident interviews conducted. Further review revealed that there was no evidence of skin assessments being done. Further review revealed that there was no evidence of a conclusive ending to the investigation. -Resident #146 was admitted on [DATE] with diagnoses that included glaucoma, PVD, pneumothorax, obstructive and reflux uropathy, pressure ulcer, insomnia, constipation and chronic pain. Review of the MDS dated [DATE], revealed a BIMS summary score of 15 which indicated that the resident was cognitively intact. Review of the resident ' s progress notes dated August 16, 2022 11:03 a.m., revealed the transportation company ' s staff member reported that the resident had hit his head while getting into the van. The progress note further revealed that an assessment was performed and the resident denied any type of pain. Review of the facility investigation dated August 22, 2022, revealed that there were no resident interviews conducted. Further review revealed that there was no evidence of a conclusive ending to the investigation. -Resident #14 was admitted on [DATE] with diagnoses that included macular degeneration, diabetes, speech disturbances, muscle spasm, xerosis cutis, neoplasm of right choroid, presence of intraocular lens, periostitis of right orbit, astigmatism and presbyopia. Review of the MDS dated [DATE], revealed a BIMS summary score of 15 which indicated that the resident was cognitively intact. Review of the resident ' s progress notes dated July 7, 2022 at 11:24 a.m., revealed the transportation company ' s staff member reported that the resident lost control while wheeling himself down a sidewalk and ended up tipping his wheelchair over and causing injury. The progress note further revealed that the resident was transported to the hospital via ambulance. Further review of the resident ' s progress notes dated July 8, 2022 at 14:18 p.m., revealed the resident was transported back to the facility and measurements regarding the resident ' s injury were notated. Review of the facility investigation dated July 14, 2022, revealed that there were no resident interviews conducted nor were skin assessments attached. Further review revealed that there was no evidence of a conclusive ending to the investigation. -Resident #98 was admitted on [DATE] and readmitted on [DATE] with diagnoses that included permanent atrial fibrillation, pressure ulcer, hematuria, cellulitis, sepsis. Review of the MDS dated [DATE], revealed a BIMS summary score of 14 indicating minimal cognitive impairment. Review of the resident ' s progress notes dated July 7, 2022, revealed that the transportation company ' s representative called to report an incident that occurred on July 6, 2022 about the resident hitting his head and a skin tear to his right arm. Further review of the resident ' s progress notes dated July 7, 2022 at 14:38 p.m., revealed the resident relayed information regarding the incident that occurred the day prior to nurses at the nursing station. The note revealed a bump to the resident's head and the skin tear to the right arm. Review of the facility investigation dated July 14, 2022, revealed that there were no resident interviews conducted nor were skin assessments attached. Further review revealed that there was no evidence of a conclusive ending to the investigation. An interview was conducted on April 24, 2025 at 10:11 a.m., with a Medical Social Worker (Staff #91), who stated that the process of a reportable incident is for the administrator to overview it and deem it appropriate to report. Staff #91 then stated that the investigation will be given to the appropriate department (i.e. nursing, social services or adminstration). The medical social worker then stated that the investigation includes victim and perpetrator interviews in additon to other resident and staff interviews on a sampled scale. Interview was conducted on April 24, 2025 at 11:15AM with the Administrator (Staff #97), who confirmed that he was the abuse officer. The Administrator also explained that once an allegation of abuse or misappropriation is received, staff report it to him. From this point, the administrator determines who conducts the investigation based on what the allegation was. The administrator described that during the investigation, the investigator should speak to the people involved. He also stated that if the allegation involved staff-to-resident abuse, the staff suspected would be placed on administrative leave during the investigation. He elaborated that any witnesses would be interviewed.The administrator also stated that the investigator would also ask other residents on the hall about the staff in question, and would ask if the residents felt safe or if they had been harmed. When asked if the facility maintains record of any investigations conducted, the administrator stated that the facility kept the past one or two years of investigations in file cabinets in the office, and would keep records from 2022 to 2023 in a storage room near the office. He explained that medical records staff would evaluate how long the records needed to be kept and if any could be disposed of, though the administrator was unaware of the length of time the records had to be kept. The administrator stated that to his knowledge, the investigations provided to the surveyor team were the completed investigations. He also stated that the risks of not conducting a complete investigation into allegations would be that the allegation may be true and it would not be able to be verified if not fully investigated, which could result in residents being affected or injured. Review of the facility policy titled, Grievances/Complaints, Filing, dated April 2017, revealed that upon receipt of a grievance and/or complaint, the grievance officer will review and investigate the allegations and submit a written report of such findings to the administrator within five working days of receiving the grievance and/or complaint. This policy also revealed that the results of all grievances files, investigated and reported will be maintained on[TRUNCATED]

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure resident #49 was free from elopement. The deficient practice could result in further incidents of elopement or physical injury. Findings include: Resident #49 was admitted on [DATE] with diagnosis included Hemiplegia, Vascular dementia, psychotic disturbance, mood disturbance, anxiety, and major depressive order. A wandering assessment done October 01, 2022 revealed that resident is physically able to leave the building on their own and no behaviors exhibited for wandering. A care plan dated October 19, 2022 had focus area for Cognitive loss/Dementia. Goal: Veteran will attend activities are focused on memory. Veteran will work on communicating verbally or non-Verbally regarding his memory. Approach: notify Medical Doctor of any changes in cognition/condition, staff will provide emotional support as needed, Social worker conduct assessments as needed to observe for any changes in cognition. A wandering Risk assessment conducted on October 01, 2022 revealed that the resident was not at elopement risk and did not exhibit any wandering behaviors. It also revealed preventative measure were to have identification band on resident. A progress note dated December 16, 2022, revealed that resident was not found during medication pass; and that, security was called at 10:15AM-10:30AM and alert code pink was called. Vet had left the facility premises and was found by his wife at 70ave and [NAME]. Upon return, wheelchair was placed on manual and he refused to be removed from his wheelchair. A review of event report of elopement dated December 16, 2022, revealed that resident exhibited behaviors of elopement and attempted to leave in past but was unsuccessful. Evaluation notes: event reviewed, wander guard placed, and resident has been evaluated for need for secured unit along with pictures posted in appropriate places in the unit. A progress note dated December 17, 2022, still refused to give up his wheelchair, he denied any pain, was educated of safety reasons and still refused, wander guards placed to prevent episode wandering during the shift and was on continuous monitoring. A facility investigation report dated December 21, 2022, revealed that resident had eloped from the facility and was found by his wife on 70 th ave and [NAME]. The reason why resident elope because he wanted to take care of his sick wife who was just released from hospital. Resident was not elopement risk prior to the incident. After the incident the resident ' s electric wheelchair was placed on Manual mode and wander guard was placed on his chair. Wandering Assessment report dated January 05, 2023 revealed that resident is able to leave the building by their own, wandering alarm is used to daily, resident is not disorientated to place, elopement success in the past. Interventions measures are placed such has activities and door alarm band applied. Preventative measures include clothing labeled with identification and door alarm band applied e.g wander guard. A care plan dated January 24, 2023, had focus area of behavioral symptoms of wandering, pacing or roaming related to the diagnosis of unspecified symptoms and signs cognitive functions and awareness. Goal: The resident will remain safely engaged in activity-focused care, a meaningful intervention, or social interaction without trying to elope from the facility (by the next 90-day review). Approach: assess for potential elopement/unauthorized departure risk. Make rounds/rooms check per facility protocol to minize change of unauthorized leave, use positive language, and provide simple, clear direction to help resident know what is expected. A quarterly admission Minimum Data Set (MDS) assessment dated [DATE], revealed no Brief Interview for Mental Status (BIMS) Assessment score. A quarterly wandering assessment dated [DATE] revealed that resident is able to physically leave the building their own, wandering behaviors not exhibited and not risk of getting to dangerous place. Alarm and wander elopement guards are placed daily, is not disoriented to place, able to make its own decisions, resident has elopement success in the past. Has changes in medication Prozac dosage decreased from 60 milligram (mg) to 40 mg. Resident had CVA and depression, resident not present elopement risk. Preventative measure clothing labels with identification and identification band on resident. Review of the progress note dated September 15, 2023, revealed that resident was not found while doing med pass, he left the facility without a pass and was found by director of rehab on 7 th street and Palm lane in his electric wheelchair. Veteran stated that he was going to Chase Bank. When waiting on Van Veteran kept attempting to leave and was educated and instructed on travel policy and that it could be considered as elopement. When Veteran and Director of Rehab decided to start head back to the facility resident demonstrated impaired safety awareness in his electric wheelchair running into fire hydrants, getting stuck on a curb, crossing the cross walk at unsafe times and was following instructions for safety. Veteran was returned to facility with Director of Rehab via Van. A wandering assessment dated [DATE] revealed that resident left the building without pass, the resident is physically able to leave the building on their own, has electric wheelchair/scooter, wandering behavior is exhibited, preventative measures are door alarm band applied-e-g. wander guard and identification band on resident. Interventions measures taken were physician/nurse practitioner/ Physician assistant. Resident had Depression and Post-Traumatic Stress Disorder. A care plan dated September 15, 2023 had focus area movement behavior of wandering. Interventions included apply wander guard to vet ' s electric wheelchair to notify staff if veteran leaves and take note of the most likely times of day for wandering. Plan the activities of the patient during that time. A facility investigation report dated September 18, 2023, which revealed that code pink was called at 11:30PM when resident was not found in the building and the writer went in the car to find the resident and he was found at 12:08pm. Resident was asses after returned to the facility. Interventions were put in place such as guard place on resident, wife was contacted for permission, and asked if this was appropriate setting for the resident stay at the facility. An interview was conducted on April 18, 2025 at 2:40PM with Certified Nurse Assistant (CNA/staff #84), who stated she considers elopement when resident tries to leave the facility without notifying anyone. She stated that the facility process for elopement is to check the resident all over the facility and call security, check the facility as well. She stated some preventative measures for resident who are risk of elopement would be to have bracelet on the resident which triggers the alarm if they try to leave the facility. She stated some of the risk of resident eloping would be the resident getting hurt, car might hit them, and they will not know where they are going. An interview was conducted on April 18, 2025 at 2:46PM with Certified Nurse Assistant (CNA/staff #101), who stated that elopement is when resident leaves facility, runs away, or resident does not know where they at. He stated that facility process for elopement is to call the police and notify the family. CNA stated some interventions for resident who are at elopement risk that have wander guards on them and have one-on-one staff. He stated that if resident tries to leave that the alarms go off and they have pagers to know if someone has eloped. An interview was conducted on April 18, 2025 at 2:52PM with Licensed Practical Nurse (LPN/staff #80), who stated elopement is anybody goes of the ground or parking lot area of the facility. She stated that independent traveler is able to go out of the facility by themselves, but only if they are evaluated by the doctor and has doctors note. The independent travel is care planned. She stated that anyone who is not independent traveler would be signed off by someone. She stated that if someone leaves the premseses and can ' t find them, they would call code pink which sets off everyone to look for the resident, nursing supervisor notified, outside agency are notified, the police is called, and continue to search. LPN mentioned that resident #49 is not independent traveler and has wander guard placed. She stated that he has elopement history because he ran and left the premises of the building without anyone signing him off. She stated some risk pose to him leaving the facility without someone signing him off would be emotional change, risk of fall, confusion, misdirection because he is unable to communicate with public and he is evasive. She stated that his electric chair would go low on battery and he could injure himself. An interview was conducted on April 21, 2025 at 8:45AM with Licensed Practical Nurse (LPN/staff #100), who stated that resident #49 has eloped from the facility in his electric wheelchair because he wanted to go home. She stated that security guard alerted them when he left the premises. He was found on the 7 th street which would be considered as elopement. She stated that the wife comes quite often to see him. An interview was conducted on April 21, 2025 at 8:58AM with the Social Service Director (staff #103), who stated that elopement is when someone leaves the facility without signing out with the responsible party and when residents do not have approval of independent traveler. She stated that who ever is independent travel they are approved by the doctor. The security guard had list of independent traveler list and they need to sign out when they leave the building. Anyone who is independent traveler they are care planned for it. Social Service Director stated that if resident is elopement risk they are placed on wander guards, if they are try to leave the building it will beep and staff member will be aware to search the resident. Staff stated that she is familiar with resident #49 and confirmed that he eloped multiple times. She stated that he eloped in December 2022, and September 2023 where rehab director found him. She stated he has not been approved for independent traveling. She stated some risks for him eloping would be his electric wheelchair can breakdown, could have fall, not figuring out where he is, not able to communicate due to dysphagia. An interview was conducted on April 21, 2024 at 2:56 PM with interim Director of nursing (DON/ Staff #102), who stated that elopement is defined as when someone left the facility without notifying anybody. She stated that they do assessment for resident to see if resident is elopement risk. If they are elopement risk they put wander guard. She stated that if someone elopes they would start the elopement process. She stated that she does not know exactly what the elopement process is. Then later she looked up the policy stated that the elopement process is to identify where the resident is at, look at the camera, to search the facility, and look in the front of the park. If not found call the police and notify administrator. She stated some risk of resident eloping would be getting injured, something can happen to them, and they can get lost in the park and fall. An interview was conducted on May 1, 2025 at 2:52PM with Licensed Practical Nurse (LPN/staff #60), who stated that elopement is escape, resident leaving against medical advice, want to go out, and want to go somewhere; and that, an independent traveler are able to go out and sign out themselves and who are not independent travelers can still go out, but someone has go out with them such as family member or staff member. She stated that it should be care planned if they can or not go out by themselves and all the resident are assessed upon admission by nursing supervisor if they are at risk of elopement by asking series of question like -- do they want to go home?, if they are ok here?, or they want to go somewhere else?. They also ask family members if they have any history of elopement or wandering if the resident are not cognitively intact. She stated that if resident is at risk for eloping then they place them on wander guard. If resident tries to leave the unit the alarm will go off or if they try to leave. She stated that the staff members make sure they check up on these patients and know where they at. She stated that resident #49 is on wander guards and wife comes often and take him off home for one day pass. LPN also stated that the resident has eloped and has history of wandering. They make sure he is safe by checking often. She stated resident has eloped from the facility, but does not remember when he was last eloped. Review of the policy titled Emergency Procedure-Missing Resident (revised August 2018) revealed that residents at risk for wandering and/or elopement will be monitored and staff will take necessary precautions to ensure their safety.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to provide adequate supervision which resulted in the elopement of one resident (#22). The deficient practice could result in residents being physically and/or psychosocially harmed. Findings include: Resident #22 was admitted to the facility on [DATE] with diagnoses that included Parkinson's disease without dyskinesia, unspecified dementia, and a cognitive communication deficit. Review of the brief interview for mental status (BIMS) dated January 10, 2025 revealed, that the resident is rarely understood; and that, the interview could not be completed. The care plan dated February 16, 2025 revealed that the resident demonstrated unsafe travel outside the facility without a responsible party or proper authorization. An elopement dated February 16, 2025. Interventions included to apply Wander-guard to reduce risk of elopement and hourly checks. Review of the order summary revealed an order: -March 22, 2024, the resident may go out on pass with a responsible party with medications. -February 16, 2025, nursing to check Wanderguard is in place every shift: 6:00 a.m to 18:00 p.m. and 10:00 p.m. to 6:00 a.m. -February 16, 2025, alert charting - elopement episode every shift: 6:00 a.m to 18:00 p.m. and 10:00 p.m. to 6:00 a.m. The Independent Travel-Admission form dated January 3, 2025 revealed that resident #22 is able to make self understood, understands others with clear comprehension, and is not interested in independent travel because the resident goes out with family only. A progress note dated February 16, 2025 revealed that the Social Services Manager (staff #6) has seen the resident at the cross roads propelling himself to the gas station to buy a mocha coffee. Staff #6 noted the resident and assisted the resident back into the facility. A head to toe assessment was completed by a supervisor. The resident stated that he wanted to buy a mocha coffee at the gas station. The resident eloped from the facility. The resident was last observed by staff at 1:30 p.m. Per the security guard, he signed out of the facility at 1:30 p.m. and then the resident was assisted back into the facility by staff #6 at 1:40 p.m. An interview was conducted on February 18, 2025 at 3:08 p.m. with the Social Services Manager (staff #6), who stated that resident #22 can't go out except with family per the physician order. Staff #6 stated that she was in her car and saw the resident was in his wheelchair approximately fifty feet away from a traffic intersection. She went after the resident and asked him what he was doing and resident stated that his wife was supposed to be here and she usually gets his mocha drink, so he was going to get it himself. Staff #6 stated that the resident's wife was not supposed to visit the resident on this day, and that, she assisted the resident with returning to the facility and got him the drink. She stated that it is the guard's responsibility to monitor the residents on the front patio and had access to the video cameras to monitor the residents, but stated that he didn't know how to work them; but that, he also stated that he didn't know that the resident was not allowed to leave the facility by himself. Staff #6 stated that the resident was at risk of not making it across the busy intersection on the green light. An interview was conducted on February 19, 2025 at 12:57 p.m. with the Director of Nursing (DON/staff #1), who stated the doctor determines if a resident is able to go out independently, which is done on a quarterly basis. The facility does the assessment and the doctor signs it. DON stated that it is his expectation that the receptionist and the guard refer to the independent travel book to verify is a resident can go out independently. He stated that the security guard is supposed to watch the video cameras to monitor the residents on the front patio area. He stated that resident #22 was at risk because he was in a manual wheelchair; and that, he is not sure that the resident would have been able to find his way back to the facility. The facility policy, Emergency Procedure - Missing Resident states that resident elopement resulting in a missing resident is considered a facility emergency. Residents at risk for wandering and/or elopement will be monitored, and staff will take necessary precautions to ensure their safety.

Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident (#79) was free from a significant medication error. The deficient practice resulted in the resident experiencing a Fentanyl overdose, requiring treatment at the hospital's Intensive Care Unit (ICU). Findings include: Resident #79 was admitted to the facility on [DATE] with diagnoses including acute on chronic right heart failure, urinary tract infection, and Parkinson's disease. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, indicating intact cognition. Review of physician orders revealed the following prescribed medication: Fentanyl - Schedule II patch 72 hour; 50 micrograms per hour; amount: 50 micrograms; transdermal Special Instructions: One patch to upper arm Every 72 Hours 12:00 Start Date: January 11, 2025 Review of the care plan revealed a problem focus initiated on January 18, 2025 that the resident was at risk for adverse reaction related to medication error, with approaches in place including making sure the old medication patch is removed before placing a new patch and to have another nurse assess if the patch is not found, and to notify the provider and nurse manager of any medication errors. Review of the careplan as of January 17, 2025 revealed no evidence that a problem focus was in place to monitor the resident's Fentanyl usage or that the resident was at risk for adverse reactions related to his Fentanyl usage, prior to January 18, 2025. Review of the Medication Administration Record for January 2025 revealed an order to administer one Fentanyl 50 microgram patch to the upper arm every 72 hours. Review of the MAR for this order revealed that a patch was applied to the resident's right chest on January 11, 2025, and that the previous patch that was on the left chest was removed. On January 14, 2025, the patch on the right chest was removed, and a new patch was placed onto the left chest. Lastly, on January 17, 2025, the nurse charted that they could not locate the previous patch, and a new patch was applied to the right upper shoulder. Review of the nursing progress notes revealed that on January 18, 2025 at 04:49AM, the resident was resting in bed with his eyes closed. Further review revealed that on January 18, 2025 at 09:59 AM the resident did not receive his morning medications because the resident was still asleep, and the nurse supervisor was made aware. The nursing note dated January 18, 2025 at 03:03PM revealed that the nurse supervisor had checked on the resident after the Certified Nursing Assistant (CNA) had notified her that the resident had slept through breakfast. The floor nurse also reported that the resident had not taken his morning medications yet. Later, at 1:45PM, the CNA again notified the nurse supervisor that the resident had not woken up, and had now slept through lunch. The nurse supervisor then assessed the resident, finding that the resident was in bed, lethargic, difficult to arouse, and with altered mental status. The resident was mouth breathing and had dry lips. The resident's vital signs were as follows: Blood pressure 78/48, pulse 76, respirations 16, O2 Saturation 84% on 2L nasal cannula, blood glucose 123. The nurse supervisor then contacted the physician, who ordered to send the resident out to the hospital. Review of the nursing progress note on January 18, 2025 at 4:01PM revealed that the nurse supervisor spoke with a nurse from the hospital emergency department, who stated that the resident was found with two Fentanyl patches on him. The nursing progress note on January 18, 2025 at 5:13PM revealed that the hospital had decided to admit the resident, with diagnoses of Fentanyl overdose, hypoxia, and acute kidney injury. The nursing progress note on January 20, 2025 at 5:26AM revealed patient is currently hospitalized , on Narcan drip but will taper off this morning, and transfer out of ICU. Interview was attempted with Resident #79, but the resident was unable to be reached since he was still admitted to the hospital. Interview was conducted on January 22, 2025 at 2:04PM with Resident #79's representative, who confirmed that Resident #79 was recently sent to the emergency room for a Fentanyl overdose. She stated that the facility nurse had explained that she had found the resident unresponsive and sent him out to the hospital, where they found two Fentanyl patches on him. The representative stated this was the only time she knew about any issues with his medications, and that the facility explained to her that the correct facility procedure is to remove the old patch before applying another patch. Interview was conducted on January 22, 2025 at 1:02PM with a Registered Nurse (RN/Staff#17), who explained that the facility process allows one nurse to administer a Fentanyl patch. He explained that the nurse should notate the location of where the previous patch was removed from and where the new patch was applied. He also stated that two nurses are required to be present when disposing of Fentanyl patches. Interview was conducted on January 22, 2025 at 1:18PM with another RN (Staff #8), who explained the process to apply Fentanyl patches was to place the Fentanyl patch onto the resident, place Tegaderm on top, and to date and initial the dressing. She also stated that two nurses were required to apply and to waste Fentanyl patches. Interview was conducted on January 22, 2025 at 2:24PM with the Assistant Director of Nursing (ADON/Staff #12), who stated that it is the expectation of nurses to notify their supervisor if they do not find the old Fentanyl patch on a resident when changing Fentanyl patches. She elaborated that at that time, the nurse and the supervisor should both complete a full-body check of the resident to confirm the patch is really missing, and if it is, they should notify the physician. ADON explained that on January 17, 2025, the agency nurse assigned to care for resident #79 did not find the old Fentanyl patch on the resident and applied a new patch to the resident's right shoulder. She stated that the nurse did not notify the supervisor or the physician that she could not find the old patch. The ADON stated that the nightshift nurse on January 17, 2025 had found an extra Fentanyl patch on the resident's back, in addition to the patch on the resident's front side. ADON explained that the nurse removed the patch from the resident's back, as she could not read the date on the patch, but the nurse did not report this to anyone. The ADON further explained that the resident was difficult to arouse the morning of January 18, 2025, but the nurse thought this was his normal sleep pattern. When the resident did not wake for lunch, the supervisor then assessed resident #79 and sent him out to the emergency department, where he was diagnosed with a fentanyl overdose. When asked why the resident's fentanyl patches had been placed in locations other than the area specified in the orders, the ADON confirmed that the facility nurses had not been following the provider's orders for placement of the Fentanyl patch. Review of facility policy titled, Administering Medications, revealed that medications are to be administered in a safe and timely manner, and as prescribed.

Based on clinical record reviews, staff and resident interviews, facility documentation, and policy and procedures, the facility failed to ensure residents (#3 and #4) were free from abuse. The deficient practice could lead to further resident to resident abuse. Findings include: -Regarding Resident #3 Resident #3 was admitted to the facility on [DATE] with diagnoses including Neurocognitive disorder with Lewy bodies, encephalopathy, and post-traumatic stress disorder. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicated intact cognition. Review of the careplan revealed, initiated on July 19, 2023, a problem that indicated that the resident had socially inappropriate and disruptive behavioral symptoms. This entry addressed that the resident is occasionally aggressive towards staff. The entry was revised on January 4, 2025 to include that the resident had shown sexually inappropriate behaviors; and that, the resident had a peer to peer physical altercation. An approach was added on January 4, 2025 to provide a two staff approach with care. Another approach was initiated on January 5, 2025 that indicated that the resident's room was moved. -Regarding Resident #4 Resident #4 was admitted to the facility on [DATE] with diagnoses including major depressive disorder, mild cognitive impairment of uncertain or unknown etiology, and dementia. Review of the Quarterly Minimum Data Set (MDS) dated [DATE] revealed a BIMS score of 08, which indicated moderate cognitive impairment. Review of the careplan revealed that the resident had socially inappropriate and disruptive behavioral symptoms, as evidenced by a physical altercation with a peer on January 4, 2025. Review of the nursing progress notes for Resident #3 and Resident #4 revealed that on January 4, 2025, at approximately 5:30PM, the two residents were observed sitting next to each other, when they both raised their fists to each other. The CNA (Certified Nursing Assistant) on the unit then intervened, separating the residents. When questioned, both residents confirmed they had hit each other, but both residents claimed that the other had struck first. The initial contact was unwitnessed by staff. An interview was conducted on January 14, 2025 at 11:14AM with a CNA (Staff #15) who stated that Resident #3 normally has sundowning behaviors, but prior to the altercation, with Resident #4, he was showing behaviors at different times of day than normal. She stated that the resident was speaking loudly to some of the residents, so she had to move him away from the other residents. The CNA stated that she did not witness the altercation with Resident #4, but Resident #3 had claimed that Resident #4 hit him. She claimed that no one witnessed the altercation, but confirmed that cameras may have caught the incident. The CNA stated that Resident #3 was upset all day following the altercation, but both residents did not recall the incident the next day. An interview was conducted on January 14, 2025 at 11:24AM with another CNA (Staff #24) who had witnessed the altercation between Resident #3 and Resident #4. She claimed that she did not see the residents hit each other, but had seen both residents sat by each other in their wheelchairs with their fists raised up towards each other. She had immediately separated the residents, and Resident #3 kept saying that Resident #4 had hit him. The CNA explained that Resident #3 can be aggressive, and tends to sundown toward the night time. He can sometimes initiate fights with other veterans and has increased behaviors at night time. She claimed that Resident #4 had never shown any aggressive behaviors prior to this altercation. She claimed that the two residents have never had prior issues together, and often sat together for meals. An interview was conducted on January 14, 2025 at 11:50PM with a Registered Nurse (RN/Staff #22) who stated that she did not see the altercation, but the CNA had seen the residents with fists up and had separated them. The RN stated that no one saw any contact being made and that there was no yelling prior to seeing the residents with raised fists. She stated that after separating the residents, Resident #3 claimed Resident #4 had hit him. Resident #4 confirmed that he had hit Resident #3, but only because he claims he was hit first. The RN explained that skin assessments were done and no marks or bruising was found. She also stated that Resident #3 stated he wanted to file a complaint. The RN stated that she believed that Resident #3 had a history of inciting others. She also explained that following the altercation, both residents' careplans were updated, their rooms were separated, and that they are being monitored closely. An interview was conducted on January 14, 2025 at 12:23PM with the Assistant Director of Nursing (ADON/Staff #7), who idenfitied verbal threats, physical touching, and stealing to be examples of abuse. She explained that the altercation between Resident #3 and Resident #4 occurred on January 4, 2025 around 5:30PM by the fish tank near the nursing station. She explained that the CNA had noticed the two residents with their arms up and had separated them. The ADON stated that Resident #3 claimed Resident #4 hit him, and Resident #4 confirmed he had hit him because Resident #3 had hit him first. She explained that both residents have severe dementia. She also stated that Resident #3 sometimes had behaviors, describing him as hard to re-direct, fixated, and sometimes will kick and hit, normally towards staff. She also stated that Resident #4 had not previously shown any behaviors. The ADON explained that following the incident, the two residents rooms were moved further apart, their dining room tables were moved, urine cultures were obtained, which showed that both residents had urinary tract infections (UTIs), and Resident #3's antipsychotic medication was increased. The camera footage from the altercation between Resident #3 and Resident #4 was reviewed on January 14, 2025 at 12:45PM with the Executive Director (ED/Staff #44). The ED stated that the footage was from January 4, 2025 at approximately 5:30PM. The camera captured the floor space by the nursing station, and the camera was positioned over the large fish tank near the wall. The ED was able to identify the two visible residents as Resident #3 and Resident #4. In the footage, it was observed that Resident #3 was in his wheelchair, near the center of the room. Resident #4 sat in his wheelchair in front of the fish tank. In the footage, Resident #3 appears to slowly roll his wheelchair backward to near where Resident #4 was seated, almost into him. Resident #3 continued to roll his wheelchair, moving it to where his chair was positioned almost beside Resident #4's wheelchair, on the left side. At that point, it can be seen that both residents raise their arms suddenly, forearm to forearm. The two residents' arms can be seen pushing against eachother, swaying under the struggle. It could not be determined what caused the two residents to suddenly raise their arms to eachother. The CNA could be seen shortly after rushing over and removing the residents away from each other. Interview was conducted on January 14, 2025 at approximately 12:48PM with the ED (Staff #44), who explained the camera footage in his perspective. The ED explained that upon watching the footage, it can be seen that Resident #3 was backing up his wheelchair, and was backing into Resident #4. He stated that it appeared that the residents were talking to eachother. As Resident #3 was backing up the wheelchair, the ED explained that Resident #3 was backing up further to talk to Resident #4. The ED stated that Resident #4 becomes out of sight at this point. He then explained that he saw what he described as hand-fighting, indicating no solid punches were thrown. He stated that it appeared that Resident #3 raised his arms, attempted to hit Resident #4, who then grabbed Resident #3's hand. He stated that the residents were hand-fighting when the CNA separated the residents. Review of the facility policy titled, Abuse, Neglect, Exploitation and Misappropiration Prevention Program, indicated that residents have the right to be free from abuse, including freedom from verbal, mental, sexual or physical abuse.

Based on review of the clinical record, staff interviews, facility documentation, policy and procedure, the facility failed to ensure the care plan was implemented related for fall prevention for one resident's (#2). The deficient practice could result in residents sustaining falls with injuries that may be preventable. Findings include: Resident #2 was admitted on [DATE] with diagnoses of multiple sclerosis, mood disorder due to known physiological condition with depressive features, adjustment disorder, unspecified, weakness. A review of the quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview Of Mental Status) score of 13 indicating resident's cognition was intact. The assessment also included that the resident required extensive assistance of 2 for bed mobility and transfers. Further review of the MDS revealed resident had lower extremity impairment on both sides. Review of the progress notes dated September 9, 2023 revealed resident was found on the floor close to his bed and his head facing the door. Resident stated I was trying to turn to my right side and slide to the floor. Per the progress note the resident complained of pain to his right hip. Resident was sent to the hospital a CT revealed a non-displaced fracture of the right posterior acetabulum and no surgical interventions required. Review of the facility reportable event record dated September 28, 2023 revealed the fall risk care plan had been updated to include new interventions that included; maintain bed in low position while in bed, place floor mat on right side of bed while in bed-remove when out of bed, provide 1/4 side rail on right side of bed to facilitate bed mobility, turning and positioning, position call light above resident's right shoulder, anticipate needs. The comprehensive care plan last reviewed/revised on October 25, 2024 included that the resident was at risk for falls related to altered mobility, diagnosis of multiple sclerosis. The care plan that the resident had following incidents of fall: - 02/18/23 resident had a witnessed fall due to slide out of w/c (Wheelchair) - 05/08/23 resident had a witnessed fall. - 09/23/2023 resident had a unwitnessed fall with injury, resident slide out of bed while repositioning self- - non-displaced fracture of the right posterior acetabulum-no surgical intervention-readmission s/p hospitalization on [DATE]: no fracture identified. - 09/29/23 resident had an unwitnessed fall while traveling independently. - 03/17/24 resident had an unwitnessed fall from bed with no injuries. - 10/28/2024 resident had an unwitnessed fall while out on Independent Travel pass-abrasions to right elbow and right knee and small laceration to right inner thigh. An observation was conducted on December 9, 2024 at 1:38 P.M of resident #2 while in bed. Resident was observed in bed with bed in the high position. Floor mat was observed leaning against the wall near the resident's bed. An interview was conducted with resident #2 on December 9, 2024 at 1:38 p.m. Resident #2 stated he had been placed in bed with the Hoyer lift and staff had left the bed in the high position. The resident stated he did not change the position of the bed. An interview was conducted on December 9, 2024 at 1:40 p.m. with a CNA (Certified Nursing Assistant/ staff #28) and CNA (staff # 14) who stated they had placed resident #2 in bed, but were unaware that the bed position should be lowered, then stated the resident must have changed his bed position. An interview was conducted on December 9, 2024 at 1:42 p.m. with another CNA (staff #9) who stated she is the assigned CNA for resident #2. She stated CNA's #28 and #14 had placed resident #2 in bed for her and should have placed the resident's bed in the low position and floor mat on the floor due to the resident being a fall risk. CNA# 9 then placed the resident #2's bed in the low position and placed the floor mat on the right side of the resident's bed and ensured the residents call light was within reach. CNA#9 stated the risks of not following the care plan is that the resident could get hurt and sent to the hospital if he were to hit his head. An interview was conducted on December 9, 2024 at 1:46 p.m. with a registered nurse supervisor (RN/staff #3) who stated resident #2 is identified as a fall risk and preventive measures are in place which include an electric wheel chair for indoor use only with a seat belt, floor mat when in bed, call light in place on right side due to left sided weakness, 1/4 side rail, proper footwear , properly positioned while in wheelchair, low position for bed and a don't fall, Call sign in his room. Staff #3 stated the CNA's have access to the resident's plan of care on the matrix, census sheet received during report, huddles, and the expectation is that they are to always ask staff, their peers, supervisor if they are unsure of the resident's POC (plan of care). Staff #3 stated the risks are any injury to the resident or a re-current fall. An interview was conducted on December 9, 2024 at 2:15 p.m. with the DON (Director of Nursing/Staff #5) who stated that there was a POC task for low bed and floor mats for resident #2 due to high risk for falls. The DON said that the risk of not placing the bed in low position and the floor mat is a potential injury if the resident should fall. The facility policy titled Care Plans-Baseline with a revision date of May 2024 revealed that the baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The facility policy titled Falls and Fall Risk, managing states based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and try to minimize the complications from falling.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure an order for blood pressure medication was administered within the prescribed parameters for Resident # 7. The deficient practice could result in undesirable medication-induced harm. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses that included generalized body pain, osteoarthritis, and essential (primary hypertension). The care plan dated November 15, 2023 revealed that the resident requires pain monitoring and management related to a diagnoses of chronic pain; and that, is at risk for complications related to diagnosis of hypertension. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 12 indicating the resident was cognitively intact. Review of the order summary revealed: -March 27, 2024 Amlodipine 2.5 mg tablet oral every 12 hours for hypertension. Hold if systolic blood pressure (SBP) less than 110 or diastolic blood pressure (DBP) less than 70. Review of the medication administration record dated September 2024 revealed: -March 27, 2024, Amlodipine 2.5 mg tablet every 12 hours for hypertension, hold if systolic blood pressure (SBP) less than 110 or diastolic blood pressure (DBP) less than 70 was administered on: -September 2, 2024 with a BP of 132/68 -September 11, 2024 with a BP of 136/67 -September 12, 2024 with a BP of 126/55 -September 17, 2024 with a BP of 136/67 Review of the medication administration record dated October 2024 revealed: -March 27, 2024, Amlodipine 2.5 mg tablet every 12 hours for hypertension, hold if systolic blood pressure (SBP) less than 110 or diastolic blood pressure (DBP) less than 70 was administered on: -October 1, 2024 with a blood pressure (BP) reading of 127/68 -October 6, 2024 with a BP of 164/68 -October 7, 2024 with a BP of 121/67 -October 10, 2024 with a BP of 115/69 -October 12, 2024 with a BP of 132/68 An interview was conducted on October 30, 2024 at 11:07 a.m. with a licensed practical nurse (LPN/staff #48), who reviewed the resident's order for Amlodipine 2.5 mg tablet every 12 hours for hypertension, hold if systolic blood pressure (SBP) less than 110 or diastolic blood pressure (DBP) less than 70. She stated that there is a risk of the resident's BP dropping, dizziness, or the resident could pass out if the medication is given outside of parameters. She reviewed the MAR dated October 2024 and stated that the Amlodipine was administered outside of parameters. An interview was conducted on October 31, 2024 with the Assistant Director of Nursing (ADON/staff #2), who stated stated that if BP medications is given outside of parameters, staff may call the physician and there is risk of not effectively monitoring the resident's BP and could cause it to go too low. The facility policy, Medication Orders state that the purpose of this procedure is to establish uniform guidelines in the receiving and recording of medication orders. When recording PRN medication orders, specify the type, route, dosage, frequency, strength, and the reason for administration. The facility policy, Administering Medications states that medications are administered in accordance with prescriber orders, including any required time frame.

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that adequate supervision was provided to prevent resident (#55) to resident (#12) abuse. The deficient practice could result in residents harming each other physically and emotionally. Findings include: Resident #12 was admitted on [DATE] to the facility on with diagnoses that included major depressive disorder, mood disorder due to known physiological condition with depressive features, and an adjustment disorder. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 8 indicating a moderate cognitive impairment. A care plan dated November 21, 2022 revealed that the resident is receiving a mood stabilizer medication for a diagnosis of adjustment disorder with mixed anxiety and depressed mood disorder, depression, major depressive disorder, delirium, anxiety disorder, and other signs and symptoms involving cognitive functions following cerebral infarction. Interventions included to monitor for mood or behavior changes that improve or worsen and notify the medical practitioner. A progress note dated September 5, 2024 by a recreational therapist revealed that she walked into the dining room to see two residents next to each other shouting. The therapist separated the residents and asked them what had happened and both residents said, he hit me. A progress note dated September 5, 2024 that the nurse was called into the dining room by the recreational therapist due to an altercation between two veterans. The therapist stated that she stepped out of the dining room and when she returned she saw two residents arguing and shouting, shut up, he hit me. The therapist stated that resident #55 was behind resident #12 and she separated them. Resident #55 stated that resident #12 wouldn't shut up. Resident #12 stated that resident #55 had hit him. Resident #12 was assessed and had no redness on either arm. The care plan dated September 5, 2024 that the resident has socially inappropriate/disruptive behavioral symptoms as evidenced by an altercation with another resident. Interventions included to allow distance in seating other residents around the resident and place the resident in a specially designed therapeutic unit. -Resident #55 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included a psychotic disorder with delusions, adjustment disorder with mixed disturbance of emotions and conduct, and unspecified dementia without behavioral disturbance, mood disturbance, and anxiety. A care plan dated October 27, 2020 revealed that the resident has a history of socially inappropriate/disruptive behavioral symptoms toward other residents, wandering, and need for continuous supervision. The resident has a diagnoses of Alzheimer's disease, adjustment disorder, dementia, psychotic disorder as evidenced by: -March 5, 2019, the resident grabbed another resident by the back of the hooded jacket and pulled. -June 24, 2019, the resident had a verbal altercation with another resident. -September 1, 2021, during the review period, the resident had a verbal altercation with another resident. The resident has a history of disruptive behaviors. -December 18, 2023, the resident pulled another resident in his wheelchair away from the table because the other resident was banging on the table and making noise. -September 5, 2024, the resident had an altercation with another resident. Interventions included to assess whether the behavior endangers the resident and/or others. When behaviors occur, provide redirection to divert the resident from the object/peer/staff that may be causing the frustration/behavior. The care plan dated June 11, 2024 revealed that the resident is receiving psychotropic medication related to diagnosis of psychotic disorder with delusions caused by a known physiological condition. Interventions included to monitor/record occurrence of target behavior symptoms: pacing, wandering, disrobing, inappropriate response to verbal communication, violence/aggression towards staff/others, and document as per facility protocol. The minimum data set (MDS) dated [DATE] included a brief interview for mental status score of 5 indicating the resident had a severe cognitive impairment. The physician's note dated August 6, 2024 revealed that resident #55 was seen for his 60-day regulatory visit. The resident was noted to have increased aggression over the last 6 weeks. An interview was conducted on September 23, 2024 at 3:51 p.m. with the Administrator (staff #1), who stated that resident #55 grabbed resident #12 by the forearm and was telling him to stop yelling. He stated that resident #12 pulled away and did not have any injuries. He stated that he did not substantiate abuse because this was a one-time thing. An interview was conducted on September 23, 2024 at 4:46 p.m. with the Therapeutic Program Director/Recreational Therapist II (staff #64), who stated that she was walking a resident into the dining room for dinner around 4:30 p.m. and heard yelling as soon as she entered the room. She stated that both residents (#12 and #55) were yelling, He hit me. Let me at him and she separated them. She stated that resident #12 was in his wheelchair and was facing the table and resident #55 was in his wheelchair behind resident #12 and was facing towards resident #12. She stated that there is supposed to be staff monitoring the dining room during meal time and had to find staff to help. When she returned to the dining room, there was a CNA present and there was a nurse following behind her. An interview was conducted on September 23, 2024 at 5:10 p.m. with the Director of Nursing (DON/staff #3), who stated that there is supposed to be a staff in the dining room supervising the residents, especially, on the unit where resident #12 and #55 reside because the residents have dementia and behaviors. He stated that the unit used to be a closed unit, but was opened to create more space. He stated that he reviewed the tape and could see resident #55 grab resident #12's left arm, but there was no sound, so he doesn't know if the residents said anything. He stated that he did not see staff in the dining room when he reviewed the tape, but there was not a full view of the room. The facility policy, Safety and Supervision of Residents states that the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices.

Based on clinical record review, staff interviews, and review of facility policies and procedure, the facility failed to ensure skin pathologies and/or injuries for three residents (#9, #14, #25) were documented accurately. The deficient practice may result in suboptimal care to the residents due to pertinent clinical information being unavailable. Findings include: -Resident #9 was admitted into the facility on [DATE] with diagnoses of unspecified dementia, type 2 diabetes mellitus with hyperglycemia, and adjustment disorder with mixed anxiety and depressed mood. The annual minimum data set (MDS) assessment dated [DATE] revealed a brief interview for mental status (BIMS) score of 2, which indicated the resident was severe cognitive impairment. The showers sheets for May 13, 16 and 20, 2024 revealed no skin issues identified. An interview was conducted on May 22, 2024 at 12:35 p.m. with a registered nurse (RN/staff #18) who stated that the skin lesion on the right arm of resident #9 appeared to be a spontaneous ecchymoses measuring approximately 5 x 7 centimeters and may be related to the use of blood thinner medication. The RN stated that the lesion had been evaluated by the medical provider when it was first noted. An interview was conducted on May 22, 2024 at 12:35 p.m. with primary medical doctor (MD/staff #14) who stated that the skin lesion on the right arm of resident #9 would be at least 7-10 days old; and that, it had already been a few days old when he learned about it. The MD stated that he hoped he would be notified immediately when it was first noticed by staff; and that, if he were notified early, he would have marked it to see if it was growing. The MD further stated that the skin lesion was not raised or raising which was good; and, he was speculating it was not from medication as it would have been smaller. The MD said that knowing resident #9, it would likely be from accidental hit. -Resident # 14 was admitted into the facility on [DATE] with diagnoses of neurocognitive disorder with Lewy bodies, long term use of antibiotics, and unspecified dementia. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 6, which indicated the resident had severe cognitive impairment. The clinical record revealed no documentation that the resident had any skin issues or lesions. An observation conducted on May 22, 2024 at 4:32 p.m. who was standing nearby had a skin lesion on her left arm. -Resident # 25 was admitted on [DATE] with diagnoses of Parkinson's disease without dyskinesia, history of falling, and hypotension. The MDS assessment dated [DATE] revealed a BIMS score of 14, which indicated the resident was cognitively intact. The clinical record revealed no documentation that the resident had any skin issues or lesions. An interview was conducted on May 24, 2024 at 10:55 AM with Interim Director of Nursing (Staff # 10) who stated, after reviewing shower sheets and visually observing Resident # 25: - May 21, 2024 revealed no new issues on the shower sheet, however I don't know if staff were educated because I can definitely see it is a problem, she clearly has a black eye and it is not documented. - May 10, 2024 nothing documented on shower sheets. - May 7, 2024 nothing documented on shower sheets. In an interview with Interim Director of Nursing (interim DON/staff #10) conducted on May 24, 2024 at 10:55 a.m., the interim DON stated that after reviewing shower sheets and visually observing resident #9, that the resident clearly had a bruise and it should have been documented. However, there was no documentation in the clinical record including the shower sheets of the bruise. The interim DON also stated that the clinical record for resident #14 also revealed that the staff were not documenting anything that was old. The interim DON also said that together with the assistant DON was in the process of educating staff; and that, it was important to know about the old things. Further, the interim DON stated that not documenting skin issues was something that the facility needed to fix. The interim DON further stated that the facility expectations were not met that these skin findings were not documented and definitely should be documented after reviewing shower sheet documentation and visually assessing each of the Residents (# 9, 14, 25). He stated that his expectation was that staff document any new bruising and skin tears because facility staff do plan to fix those shower sheets. Further, the interim DON stated that sometimes residents have skin lesions that were accidental; however, if the resident was not alert and oriented and was non-verbal, there was no way staff would know how the resident had the skin issue or lesion. Review of the facility's policy on Charting and Documentation with revision date of August 2021 revealed that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care: -Documentation in the medical record may be electronic, manual, or a combination. -Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate.

Based on observations, clinical record review, staff and resident interviews and review of facility policy, the facility failed to ensure adequate supervision was provided to prevent one resident (#84) from committing suicide. The deficient practice resulted in injury and hospitalization of the resident; and, increased risk of death by suicide. Findings include: Resident #84 was admitted on [DATE] with diagnoses of suicidal ideations, recent history of major depressive disorder, generalized anxiety disorder with racing thoughts, and pain. Review of a progress note from a prior facility dated [DATE] included that the resident had a history of chronic pain, suicidal intention and weakness; and, was transferred to that facility for continued care. It also included that resident had a follow-up with his neurologist due to the persistent pain and cerebrovascular accident history. Per the documentation, the resident was sent to a mental health facility after being seen in the emergency room (ER) due to suicidal ideation statement because of his frustration with his medical condition. The baseline care plan dated [DATE] revealed the resident had admitting diagnoses of major depressive disorder, single episode, severe without psychotic features and had generalized anxiety disorder with racing thoughts. The Level 1 PASRR (Pre-Admission Screening and Resident Review) dated [DATE] included that the resident had serious mental illness (major depression) and mental illness (anxiety). It also included that the resident had suicidal ideations. Per the documentation, there was no necessary referral for any Level II for resident #84. The BIMS (Brief Interview for Mental Status) dated [DATE] revealed a score of 15 indicating the resident had intact cognition. A care plan dated [DATE] included that the resident had signs and symptoms of depression; and had diagnoses of major depressive disorder, suicidal ideation, and generalized anxiety disorder. Approaches included to observe the resident for any signs and symptoms of emotional distress related to or not related to mental illness and to consult with psychiatrist as needed. A psychiatric provider note dated [DATE] revealed that the resident had a documented history of suicidal ideations which were related to poor coping with medical challenges. The documentation included that the resident displayed seemingly stable adjustment despite situational stressors and medical challenges with treatment. The documentation also included that the resident displayed signs and symptoms of mood disorder which appeared to have preceded baseline medical challenges; and, will rule out possibility of neurocognitive challenges precipitating mood related symptoms and challenges. Plan was to start Lithium (antipsychotic) ER (extended release) 300 mg (milligram) orally at hour of sleep for mood disorder and mild neurocognitive disorder as evidenced by restlessness, mood fluctuations, and history of suicidal thoughts. A consent form dated [DATE] included that the resident had refused to take Lithium. A progress note dated [DATE] revealed that the facility will defer further evaluation and management of neurological disorder to attending and Interdisciplinary Team (IDT) for further evaluation and treatment recommendations. Despite documentation that the resident had history of suicidal ideation and refusal to take medication to address his mood disorder, there was no evidence found in the clinical record that the IDT evaluated the resident, made recommendations or new interventions were implemented for suicide prevention. A progress note dated [DATE] included the resident reported that his whole left side was numb, was waiting for an MRI (magnetic resonance imaging) and podiatry; and that, he has yet to see anyone. Per the documentation, the resident had been hyper focused on this C,d+[DATE] fracture and his blood pressure, gets very agitated, paces his room when he was trying to describe his situation, and tried to tell his whole life story when being asked the current tissue at hand. An event report dated [DATE] revealed the resident requested for an Ibuprofen (analgesic) because his neck hurts and had a bit of numbness; and that he had this problem for years. Per the documentation, the resident appeared to be anxious, restless and was walking to the bathroom and back to bed. The documentation included that a sitter was sitting outside the resident's room; and that, the resident was being monitor every 15 minutes. Per the documentation, that at 2:08 a.m., the call light was placed and the resident appeared to be anxious and was holding his neck, complaining of pain, requested for and was given tramadol (opioid). According to the documentation, the resident appeared to be in an episode of flight of ideas and racing thoughts; and at 3:15 a.m. the resident got up from bed and told staff that he wanted to go to hospital because the pain was getting worse and medication was not effective. Per the documentation, the resident felt numbness and burning on the whole left side of body, had pain scale of ,d+[DATE]; and that, the resident reported his whole neck and arm were swelling and if continued his heart will stop. Further, the documentation included that the nurse supervisor and the physician were notified; and, resident #84 was transferred to ER for complaints of neck pain. An event report dated [DATE] revealed that the resident reported that his left side was getting progressively numb than before and was extremely worse. Per the documentation, the resident initially denied pain; and, the vital signs included BP (blood pressure) of ,d+[DATE], and pulse rate at 106-irregular. It also included that the resident appeared anxious and walking to the bathroom and sitting down to eat makes the numbness worse. According to the documentation, the resident was getting irritable because of the numbness, was redirected to be calm, and was given Ativan (antianxiety) which helped him stay calm for 2 days. Further, the report included that the resident reported pain to left shoulder and left side of the back and felt tight; and, the resident said that he was at the ED (emergency department) and the ED did not address his numbness. The documentation included that the resident asked the nurse if he should go to the ED; and the resident was redirected that the physician was notified. Further, the report included that an order to offer as needed tramadol and tizanidine (muscle relaxant) and to encourage resident to drink water. The progress note dated [DATE] included that the resident was on alert charting due to increasing numbness to the left side. Per the documentation, the resident stated that he had a pinched nerve between C2 and C3 and this explained his numbness. A progress note dated [DATE] revealed the resident was on alert charting due to increased complaints of left sided weakness and tightness. Per the documentation, the resident continued to verbalize complaints at some assessments and denied complaints at others. Further, the documentation included that the resident had fast speech, flight of ideas, and trembling hands; and that, the resident stated that he was unable to move his neck while pacing at bedside. Despite documentation that the resident's suicidal ideations were related to poor coping with medical challenges; and that, the resident complained of increased numbness, There was no evidence found in the clinical record that supervision was increased for resident #84. A progress note dated [DATE] included that security alerted an LPN (licensed practical nurse) and a RN (registered nurse) who were entering the building that a resident was laying on the floor face down in prone position. Per the documentation the nurses were unable to find a pulse or respirations, code blue and 911 was called 911 was called and cardiopulmonary respiration (CPR) was initiated. Another progress note dated [DATE] revealed the resident was transported to a hospital. In another progress note dated [DATE] included that the primary care physician advised the resident to not return to the facility because the resident required a higher acuity level of care, was noncompliant and refused medications and care. The progress note dated [DATE] included that the resident had a lot of fracture on the left hip, arms, ribs and legs. Per the documentation, the resident blood transfusion and was scheduled for surgery. The facility incident/accident packet signed by the Director of Nursing (DON) and the Administrator on [DATE] included that the date/time of the unwitnessed fall was [DATE] at 6:00 p.m. Per the documentation, the resident was found unresponsive to touch or name; and that, security heard a loud sound as if something was hitting the ground. It also included that the resident was found on the floor, unconscious with no pulse or respiration and code blue was called. The documentation also included that it was unknown what the activity was at the time of the occurrence or what the resident was attempting to do. According to the documentation, the resident had a red bruise on the left side of the face and had bleeding on the left leg which appeared to be shortened. Further, the documentation included that the resident was last medicated with tramadol on [DATE]; and, the resident was screaming for pain when transferred to the stretcher by the local fire department. Immediate intervention included the resident was transferred to ED. Continued review of the facility incident/accident packet included a written statement dated [DATE] from a CNA (certified nurse assistant). The documentation included that the CNA last saw the resident on [DATE] at 4:30 p.m. The CNA wrote that the resident complained of pain and this was reported to the nurse who instructed to take the resident's vital signs. Per the documentation, after taking the resident's vital signs, the CNA reported the result to the nurse and the CNA proceeded to the dining room, passed meal tray and assisted another resident with meals. It also included that later the CNA heard the nurse calling for the supervisor and the CNA heard the announcement of code blue. Further review of the facility incident/accident packet revealed a written statement dated [DATE] from the security officer (SO) who wrote that the SO was at the front desk on [DATE] at approximately 4:00 p.m. when the SO heard a loud sound as if something hitting the ground floor and saw a maroon hat laying on the ground. Per the documentation, the SO then got up from the seat and looked down the hall towards the elevator and saw the resident lying face down on the ground floor. The SO also wrote that the resident was still breathing but was moaning and did not respond when the SO asked if resident was ok. The documentation also included that the SO informed the two female staff who were coming in the door that the resident was down laying on the floor. The facility was not able to provide documentation of staff training on identifying suicide risks or identifying or recognizing signs and symptoms of impending suicide. An interview conducted on [DATE] at 11:10 a.m. with an alert and oriented resident (#2) who knew resident #84. The resident (#2) stated that when he heard someone took the [NAME] the first name that came to his mind was resident #84. The resident (#2) said that resident #84 was always in a lot of pain; and, that was all he would talk about. An interview conducted on [DATE] at 11:15 a.m. with another alert and oriented resident (#70) who stated that knew resident #84 as a friend; and that, resident #84 had emotional problems. The resident (#70) said that he could not understand how resident #84 was allowed to be at the facility; and that, resident #84 had come from a more mentally focused facility and needed intensive psychiatric care. Further, the resident (#70) said that since day 1 of admission, resident #84 was talking about going to heaven. A review of the two video footages of the incident was conducted with the Administrator on [DATE] at 1:10 p.m. The administrator played the first video which showed that resident was falling onto the lobby floor, a security guard coming over to check and nurses coming in the front door and beginning cardiopulmonary resuscitation. The administrator then played the second video and revealed that the same resident was on the second level looking over at something off screen, got up, climbed on a chair next to the rail, stepped over the rail, and then jumped downstairs. The Administrator stated that these videos were of resident #84 and it was pretty clear in the videos that resident #84 jumped on purpose. Further, the administrator stated that the facility did not have any other videos of this incident. In an interview was conducted with a CNA (staff #58) on [DATE] at 1:48 p.m., the CNA stated that she provided care to resident #84 the Friday ([DATE]) before the resident jumped. The CNA said that resident #84 seemed fine on Friday, was laughing and was telling her that he did not need his walker. She said that she never heard resident #84 say anything about suicide. The CNA said that a week before the incident the resident was at the hospital and the nurse was asking the hospital to get a psychiatric evaluation done before the resident comes back at the facility. The CNA also stated that the resident was normally in his room, complained of pain a lot and a bunch of things that were wrong with him. Further, the CNA said that the facility does not have residents with suicidal issues; and that, the facility does not have a suicide ward. She said that if a resident tells her that resident wanted to commit suicide, she will inform the nurse; and, both the nurses and CNAs will document on behaviors in the clinical record. An interview was conducted on [DATE] at 3:19 p.m. with another CNA (staff #94) who said that the facility does not admit suicidal residents and there were no residents with suicidal risk at the facility. Further, the CNA said that if a resident reports suicidal ideation the facility will send the resident to the hospital next door. Regarding resident #84, the CNA stated that the resident stayed in his room most of the time. In an interview with another CNA (staff #51) conducted on [DATE] at 3:26 p.m., the CNA stated that resident #84 stayed by himself a lot, was always asking for pain meds, liked to talk mostly about himself/what he had been through, his pain and how he got a stroke. She said that resident #84 did not talk about suicide, that when he talked to her it was all about pain medication and his progress with his pain. The CNA stated that she had not taken care of anyone who was suicidal and she did not know the history of the residents. Further, the CNA stated that she did not have any training on suicidal signs; however, that if anyone had suicidal ideations that she would report this to the nurse. An interview was conducted on [DATE] at 11:28 a.m. with a registered nurse (RN/staff #108) who stated that on the day of the incident, resident #84 was doing good; and that, the resident usually would be in his room with the door closed. The RN said that on the day of the incident, the resident was hanging out in the doorway, had his door open and was in a good mood; and that, she last saw the resident at 5:14 p.m. (approximately 45 minutes before the incident) when he asked if he could get blood pressure medications and Tylenol (analgesic). The RN said that she went to the bathroom and saw one of the nurses get the supervisor (staff #144) by name; and, the RN followed them out, got down the stairs and saw resident #84 on the floor. The RN said that she jumped in and started doing CPR. Further, the RN said that she never heard the resident verbalize hurting himself; and that, the resident would just talk about the pain or numbness. Further, the resident would deny any mental health issues, and did not want any chemical help. An interview was conducted with Social Services Director (SSD/staff #54) on [DATE] at 12:12 p.m. The SSD stated that resident #84 refused counseling and she kept trying to talk the resident into counseling. The SSD said that the resident had been seen by the psychiatric nurse practitioner (NP). The SSD said that resident #84 went once to the hospital for anxiety and the facility wanted a psychiatric evaluation to be completed while at the hospital; however, the social worker at the hospital released him. She said that resident #84 was refusing psychiatric medication at the facility and had not been at the facility long enough to start seeing a psychiatrist. The SSD further stated that the facility was not for bipolar or schizophrenia residents, does not make it a habit to admit suicidal residents. and cannot monitor these residents. In an interview with a nursing supervisor (staff #144) conducted on [DATE] at 1:59 p.m., the nurse supervisor said that the assigned nurses do the behavior charting. Regarding resident #84, the nurse supervisor said that she had met the resident; and, the resident talked really fast and will talk about his medical condition and all the problems that had happened to him in the past. She said that it was noted in the clinical record that the resident had suicidal issues; but, the resident had always denied it and had refused to take the prescribed Lithium because he said that he was fine. An interview was conducted with the Administrator and the DON on [DATE] at 4:34 p.m. The Administrator said that the criteria for not admitting a person at the facility would include the following: the facility staff could not handle the resident needs, such as tracheostomies, mechanical ventilation, or significant behaviors. He said that if the resident had a history of suicidal issues the facility would assess how long it has been and if the resident was actively having suicidal ideation, the facility will not admit the resident because the resident would need a higher level of care. The Administrator said that the signs of suicidal ideation included the resident being more depressed, or could be hearing voices, or the resident could be happy and relieved. Regarding resident #84, the administrator said that resident #84 was socializing with everyone and went to a salsa event the day before attempting suicide. The DON said that typical signs of suicidal ideation would be writing a note, saying goodbye. A policy titled Safety and Supervision of Residents, revised ,d+[DATE], revealed that the facility strives to make the environment as free from accident hazards as possible. This document included Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes; QAPI reviews of safety and incident/accident data; and a facility-wide commitment to safety at all levels of the organization.

Based on clinical record review, staff and resident interviews, review of facility policy, and the rules of the State Board of Nursing, the facility failed to ensure appropriate care and services related to indwelling catheter care was provided to two residents (#20 and #1). The deficient practice could result in residents not receiving necessary treatment and infection or the catheter having to be replaced sooner. Findings include: -Resident #1 was admitted on [DATE] with diagnoses of history of urinary tract infections, urogenital implant, neuromuscular dysfunction of bladder and benign prostatic hyperplasia with lower urinary tract symptoms. A physician order dated May 20, 2020 included to replace the foley catheter as needed for dislodgement or obstruction; and, to irrigate foley catheter with 50 ml of normal saline as needed for leaking or plugging. The physician order dated October 7, 2020 included for foley catheter to be replaced monthly on the 7th of each month. The clinical record revealed a Brief Interview for Mental Status (BIMS) score dated July 6, 2021 was 13 indicating resident had intact cognition. A physician order dated July 9, 2021 included for the resident to return to urologist on August 5, 2021 at 1:45 p.m. The treatment administration records (TAR) for July 2021 included that the foley was documented as changed at urology clinic on July 8, 2021 and replaced by nursing on July 18, 2021. A nursing note on July 18, 2021 included that the foley was changed and flushed without difficulty. A progress note dated August 7, 2021 revealed that the foley catheter was unable to be changed due to the resident stated it had just been changed. The progress note dated August 20, 2021 included that the urologist progress note from the August 5, 2021 appointment was received; and that when a new foley catheter was placed, the balloon was filled with 10 ml of sterile water. It also included that there was no urine returned after insertion, so the resident's bladder was irrigated with 300 ml and then the drainage bag was attached. Further, the documentation included that the resident was instructed to return to the clinic in 4 weeks to have the foley catheter replaced. A late entry progress note dated August 20, 2023 revealed that the note was for August 18, 2021. The documentation included that a RN (registered nurse/staff #155) was requested by staff to see that resident for an issue with an indwelling catheter. Per the documentation, The RN found the licensed practical nurse (LPN/staff #154) at bedside holding a washcloth over the resident's penis and there was blood in the foley catheter bag and tubing. It also included that the LPN explained that he was attempting to replace the resident's foley catheter because it was blocked; then the resident began bleeding. Further, the documentation included that the resident began to have respiratory changes and his oxygen saturation decreased below 90%; and that, 911 was called. Per the documentation, the resident was transported to the hospital emergency roiagnom on [DATE] at 2:30 p.m. The physician order dated August 25, 2021 for foley catheter to be replaced at the urology clinic. Another late entry progress note dated August 21, 2021 revealed that the entry was for August 18, 2021. Per the documentation, the certified nurse assistant (CNA) notified the nurse (LPN/staff #154) that the resident's foley catheter was not draining; and that, the LPN attempted to flush the catheter with 75 ml of normal saline without success. It included that at 1:45 p.m., the LPN removed the old foley and noted it to be full of sedimentation; and, the LPN then prepped the resident for insertion of a new foley catheter. According to the documentation, the new foley catheter was inserted into the urethra and up into the bladder and urine began flowing out of the catheter so the LPN pinched the foley to stop the flow of urine, attached the drainage bag and then inflated the balloon of the catheter with 10 ml of sterile water. It included that at this time urine stopped flowing and blood began to come out of the foley and into the bag; and, the LPN then pushed the emergency button, removed the 10 ml of sterile water from the balloon of the foley and removed the foley catheter. After removal of the foley catheter, the resident's penis continued to bleed so he applied a washcloth and pressure to the area to try to control the bleeding; and, then the RN (staff #155) arrived and attempted to get the resident's vital signs. Per the documentation, a blood pressure was unable to be obtained, the oxygen saturation was in the 60% and the resident's breathing was very shallow. It also included that oxygen was applied via a non-rebreather mask at 15 liters per minute; and the resident continued bleeding from his penis so the LPN continued to apply pressure. Further, the documentation included that the assistant director of nursing called 911 and when emergency personnel arrived the LPN secured a diaper and 4x4 gauze pads to the resident's penis. Review of hospital records revealed the emergency room revealed that the resident presented to the emergency department for traumatic foley insertion by nursing staff resulting in frank blood coming from the urethral meatus; and that, the resident arrived without a foley. Per the documentation, imaging results showed a hematoma forming near the meatus; and, admitting diagnoses included traumatic penile hematoma and urinary tract infection. It also included that the resident was also hypotensive which did not improve after receiving four (4) liters of intravenous fluids and one (1) unit of blood transfused. Further, it included that a new foley catheter was placed in the emergency room ; and that, the resident was admitted to the intensive care unit (ICU) for severe sepsis with septic shock after lab results showed a while blood cell count of 1.7 and acute kidney injury. During an interview with the administrator (Staff #1) conducted on November 2, 2023 at 3:00 p.m., the administrator stated that the RN (staff #155) and LPN (staff #154) no longer work at the facility and the facility did not have their contact information. An interview was conducted on November 2, 2023 at 2:24 p.m., with the Director of Nursing (DON/staff #76) who stated that she had only worked there a couple of months and did not have any knowledge of the event from 2021. Review of the facility policy Indwelling (Foley) Catheter Insertion, Male Resident revealed the steps of inserting a foley catheter to include once the catheter is inserted until urine flows to inflate the catheter balloon by using the prefilled syringe and then to connect the drainage bag to the catheter. -Resident #20 was admitted on [DATE] with diagnoses of other retention of urine, cystostomy status, urethritis, calculus in bladder and calculus of kidney. A physician order dated May 6, 2022, included to flush suprapubic catheter with 50 ml (milliliters) of normal saline daily to help prevent catheter clogging. A physician order dated May 7, 2022 included for suprapubic catheter care every day and to cleanse the site with normal saline, pat dry, and apply split gauze. The orders for flushing and suprapubic catheter care was transcribed onto the treatment administration record (TAR) for August 2023. Despite the order for suprapubic catheter care, review of the clinical record revealed that catheter care and flushes were not completed on August 4, 2022 and August 8, 2022. During an interview conducted with nurse #71 on November 2, 2023 at 1:09 p.m., the nurse stated that normally one nurse was staffed for each hall and another nurse was scheduled to work at the desk. Nurse #71 stated there were always two nurses on each hall except last year; and that, there was a time when she was the only nurse. She also stated that acceptable reasons for not completing catheter care and flush would be if the patient refused or if the nurse had difficulty completing the task. The nurse also stated that the risk of not completing catheter care and flush would be infection, urinary tract infection, or sepsis. In an interview conducted with licensed practical nurse (LPN/staff #2) on November 2, 2023 at 12:44 p.m., the LPN stated that usually there are five (5) nurses scheduled on each unit. The LPN stated the only reason for not completing physicians' orders would be if the patient refused; and that, not completing catheter care and flushes could result in a clogged catheter, urinary tract infection, or catheter needing to be changed sooner. Further, the LPN stated that if she was unable to complete scheduled orders, she would notify her supervisor for assistance to complete the tasks or orders or would pass it on to the night shift. An interview was conducted on November 2, 2023 at 2:24 p.m. with the Director of Nursing (DON/staff #76) who stated that the facility was able to fill all of their nursing positions with the use of agency and per diem staff. The DON stated there are usually two nurses scheduled on each hall with an additional nurse scheduled at the desk on each unit; and that, if a nurse called in, the DON would call the agency or per diem staff or pull a nurse from another unit. The DON stated the expectation was that if an order was not completed, the nurse was to report this to the oncoming shift to pick up where the previous shift had left off, to prioritize patient care tasks and to utilize the Assistant Director of Nursing or nursing supervisor on the floor for assistance. The DON stated that the only acceptable reason for not completing an order would if the patient was in the hospital. The Rules of the State Board of Nursing stated that in participating in the nursing process and implementing client care across the lifespan, a nurse shall implement aspects of a client's care consistent with the scope of practice in a timely and accurate manner including following nurse and physician orders and seeking clarification of orders when needed. A review of the facility policy on Catheter Care, Urinary dated August 2022, revealed that maintaining unobstructed urine flow could include catheter irrigation being ordered in residents at risk for obstruction.

Based on clinical record review, facility documentation, staff interviews and review of policy and procedures, the facility failed to ensure one resident (#110) was free from abuse/neglect. Findings include: Resident #110 was admitted to the facility on [DATE], and discharged on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed that from February 2017 through May of 2017, resident #110 had multiple episodes of urinating and defecating in public places. The documentation included that resident #110 refused to use the bathroom at times and often refused to be cleaned up. At times, when staff attempted to provide care to resident #110 he would become very agitated and combative. Review of a behavioral care plan revealed the resident had behavioral symptoms of hitting, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes and screaming. The care plan included that the resident had been observed on multiple occasions urinating in common areas or in the threshold of other resident's rooms. The resident has also been observed voiding and having bowel movements in places other than the bathroom, including the dining room. A care plan goal included the resident would not harm himself or others, secondary to socially inappropriate and/or disruptive behavior. Interventions included the following: -When resident becomes physically abusive, STOP and try task later. Do not force to do task. -Respect the resident's right to refuse any and all medical treatment and document refusals. -Offer one step verbal directions for tasks. Allow for extra time to process the information. -Maintain a calm, slow, understandable approach with the resident. -Maintain a calm environment. -Avoid power struggles with resident. -Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). Review of a quarterly Minimum Data Set assessment dated [DATE], revealed the resident had a Basic Interview for Mental Status score of 0, which indicated the resident had severe cognitive impairment. A nurse's note dated May 21, 2017 at 9:45 p.m., documented the resident continues to have difficulty allowing staff to provide personal and toileting care and had refused to have peri care provided on the previous two shifts. The note included the resident was wet with urine, and had feces on his buttocks and genital area. The resident was taken to his bathroom and peri care was provided and his brief and clothes were changed. The note further included that the resident was very aggressive and was hitting staff, and was kicking and hurting himself and that his behavior's have gradually gotten worse. According to a facility's investigation, the resident had defecated in his pants on the morning of May 23, 2017. A licensed practical nurse (LPN/staff #270) and two certified nursing assistants (CNA/staff #78 and staff #269) gave resident #110 a shower in his room. During the shower, the resident became very combative and was yelling and punching staff, and was flailing his arms. Per the report, staff #78 and staff #269 held the resident's hands down on the shower chair arms, while staff #270 cleaned the resident and completed the shower. As a result, the resident sustained [REDACTED]. The report included that staff #78 felt that the shower was performed at the insistence of the nurse and was done without consent of the resident. The investigative report further included a statement from staff #78. The statement included that the resident had been forcefully showered against his will. The nurse (staff #270) had been very aggressive in giving him a shower. Per the statement, the resident was screaming so loud even the other residents heard him. He was shaken up on his shower chair that day while having showered. He was being held down by his hands by 2 CNAs, while the nurse was scrubbing him good. The report also included a statement from staff #269. He reported that he, CNA (#78) and the nurse (staff #270) assisted in getting the resident ready for a shower. He reported that the other two staff were helping with the shower, and that the nurse told him they could take it from here, so he stepped away and let them finish the shower. He reported that after the resident calmed down, he helped get him dressed. Further review of the investigative report revealed a statement from staff #270. She reported that the resident had dried feces on his buttocks and genital area and had refused to shower on the previous two shifts. She reported that she, staff #78 and staff #269 had assisted with showering the resident. She reported that the resident was in a shower chair and became combative when he noticed the water running. She stated she washed the resident's body with the help of the other two CNAs. The statement included that the resident's skin integrity was in danger of breaking down, if he did not get proper care. The report also included a statement from another CNA (staff #110,) who reported that she was at the nurses station and heard the resident yelling, while he was being showered. Continued review of the investigative report revealed that three staff members gave resident #110 a shower and at some point, he became resistive to care and staff should have stopped providing the shower. The report included that resident #110's right to refuse care was violated. Staff #270, staff #78 and staff #269 were put on administrative leave. An interview was conducted with staff #110 on August 16, 2017 at 9:00 a.m. She stated that she was working on the resident's unit on May 23, 2017 in the morning. Staff #110 stated three staff brought the resident to the shower in his room. She stated she did not see the resident being showered, but heard the resident yelling so loud it could be heard down the hall. An interview was conducted with staff #78 on August 16, 2017 at 9:30 a.m. Staff #78 stated she was in the shower room with the resident on May 23. She stated she was told by staff #270 that the resident was going to receive a shower. She said when the resident was brought into the shower he had feces caked on his groin area and on his buttocks. She stated when the water was turned on, the resident became very agitated. She stated the resident hit her on the arm several times. Staff #78 stated that she and staff #269 held the resident's hands down on the shower chair arms, while staff #270 cleaned the resident. She said the resident's care plan included that the resident could become agitated and physically abusive. Staff #78 stated she didn't think the resident should have been forced to receive a shower, because it was a violation of resident's rights. She stated that she felt pressured by staff #270 to shower the resident. She stated the resident refuses showers regularly and has a history of abusive behaviors towards staff during showers. An interview was conducted with the administrator (staff #4) on August 16, 2017 at 3:00 p.m. He stated that staff #270 and staff #269 were terminated. He stated staff #78 came forward and was honest and felt that staff #270 demanded that staff #78 assist with showering the resident. An interview was conducted with staff #2 (staff developer) on August 17, 2017, at 11:45. She reported that staff #78 was put on administrative leave on May 26, 2017. She stated staff #78 completed 1:1 training on resident rights/abuse and neglect on June 6, 2017, before returning to work on June 12, 2017. Staff #2 stated that staff #78 attended training in resident rights/abuse and neglect on July 28, 2016 and on January 26, 2017. An interview was conducted with staff #128 (CNA) on August 17, 2017 at 2:30 p.m. She stated that she has helped to care for the resident several times. She stated he can be very difficult to shower and change; however, she can get his shower done by reproaching him several times. An interview was conducted with staff #269 on August 18, 2017 at 11:00 a.m. He stated that he felt pressured to assist with the shower of the resident by staff #270. He stated that he felt making the resident complete a shower was a violation of his rights and that the resident is able to refuse care. On August 18, 2017, staff #270 was reached by phone. However, she stated that she did not want to discuss the incident. Review of the abuse policy and procedure revealed that all residents have the right to be free from verbal, sexual, physical, emotional and mental abuse and neglect, and that the facility will do everything in its power to prevent such occurrences.

Based on clinical record reviews, review of hospital records, staff interviews, and review of facility documentation, the facility failed to appropriately assess and care plan to ensure a safe transfer of one resident (#1) which resulted in a fall with actual harm. The facility also failed to appropriately assess and develop comprehensive care plans for two residents (#s 2 and 3) to ensure safe transfers. The sample size was five residents. Findings include: -Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physical therapy notes revealed that the last therapy assessment was completed April 2010. At that time the resident had fair standing balance and poor safety awareness. The resident was discharged from services since she was confused, not understanding directions, and she was noncompliant with services. The annual Minimum Data Set (MDS) assessment dated [DATE], documented that the resident had severely impaired cognitive skills for daily decision making. The resident was assessed to be totally dependent upon staff for transfers requiring a one person physical assistance. Per the MDS assessment walking did not occur and the resident's balance during transition and walking surface to surface transfer was documented as activity not occurring. The comprehensive care plan for activities of daily living dated April 28, documented that the resident required a Princess lift (sit to stand lift) for all transfers. Review of the clinical record revealed no assessments of the resident's ability to safely use a Princess lift. The quarterly MDS assessment dated [DATE], documented that the resident had severely impaired cognitive skills for daily decision making. The resident was assessed to require extensive assistance with transfers requiring a one person physical assistance. Per the MDS assessment the resident was involved in the activity with staff providing weight-bearing support. The resident was further assessed for balance during transition and walking surface to surface transfer as activity not occurring. The physical and psychosocial comprehensive care plan dated September 2011, documented that the resident had lower extremity weakness and paralysis. There were no goals checked or listed and there were no approaches listed or checked. The quarterly MDS assessment dated [DATE], documented that the resident had severely impaired cognitive skills for daily decision making. The resident was assessed to be totally dependent upon staff for transfers requiring a one person physical assistance. The resident was further assessed for balance during transition and walking surface to surface transfer as activity not occurring. The Certified Nursing Assistant (CNA) Daily Care Plans for the month of September and October documented that the resident was totally dependent upon staff requiring the assistance of one person for all transfers. The resident was further assessed to require a Hoyer lift (sling lift) for transfers. The Certified Nursing Assistant Daily Care Plan for the month of November documented that the resident required extensive assistance with bed mobility. The area to document how the resident transferred, or did stand/pivot was left blank. It was documented that the resident required a Hoyer lift. On November 18, the CNA initialed that she had followed the care plan. The nurse's progress note dated November 18, at 8 p.m., documented that while the resident was being transferred to a chair with a Sara lift (sit to stand lift) the resident stepped off the platform and the resident was "held in the air" by her arms. Per the progress note the resident's shoulder was slightly swollen and she complained of shoulder and arm pain. The nurse called the nurse practitioner and obtained orders for x-rays. There was no documented evidence to show that a Hoyer lift was used. The x-ray report dated November 18, at 10:14 p.m., documented that the resident had an acute fracture of the left humerus, evidence of rotator cuff insufficiency, and a possible acute fracture of the acromion. The nurse's note dated November 18, at 11:30 p.m., documented that the resident was transferred to the hospital. The hospital record dated November 19, documented that the resident was unable to move her left arm without severe pain in the shoulder area. Per the hospital record there was swelling in the upper left arm and clavicle area, her knees were retracted, and she was unable to straighten her legs. The physician documented that the resident had a left humerus fracture. An arm sling was applied and pain medications were prescribed. The resident was then transferred back to the facility. Review of the facility's investigative report, revealed that on November 18, resident #1 was transferred with a princess lift from the wheelchair to the shower chair by CNA (Certified Nursing Assistant) staff #1 and #2. Per the report the resident's legs slid off causing her to hang by her arms. Per the report the CNAs then transferred the resident to bed. The resident complained of arm pain, and x-ray was obtained which showed a fracture. The report documented that the resident was sent to the hospital for further evaluation and treatment. Further review of the investigative report revealed that the comprehensive care plan intervention dictated that a princess lift be used for the resident's transfers; however, the CNA daily care plan "mistakenly" identified the Hoyer lift as the mode of transfer. Per the report, although there was an error on the CNA daily care plan the resident was transferred with the princess lift per the comprehensive care plan. During an interview conducted on January 3, 2012, staff #1 stated that she did not usually work the unit that resident #1 resided on so she asked another CNA how to transfer the resident and she was told to use the princess lift. She further stated that the CNA instructed her to get staff #2 to assist her which she did. Staff #1 stated that she took the resident into the shower room and was about to transfer the resident when she stepped off the platform and was hanging by her arms. She stated at that time staff #2 assisted her to get the resident into bed because the resident was complaining of arm pain. Staff #1 further stated that she had not checked the CNA daily care plan for transfer instructions and was not aware that it documented that the resident was a Hoyer lift transfer until after the resident's injury. Staff #2 was interview via telephone and in person on January 3. Staff #2 stated that staff #1 asked her for help with resident #1 on November 18. Staff #2 stated that she was busy with taking care of the resident in bed A and told staff #1 to wait; however, staff #2 did not wait. She had already gotten the resident up on the princess lift by herself before staff #2 was able to assist with the resident. Per staff #2 she saw the resident "not positioned good" and hanging by her arms from the bar. Staff #2 reported that she then assisted staff #1 to put the resident into bed. Staff #2 further stated that she was not familiar with the CNA daily care plan form and was not aware that the care plan directed the CNA to use the Hoyer lift. Staff #2 stated that resident #1 sometimes did not want her shower and that she did not stand good on the stand during those times. I was new, but we always used two to transfer resident #1. During an interview conducted on January 4, staff #3 stated that she was giving another resident a shower when staff #1 asked her how to transfer the resident. She stated that she told her to use the princess lift because that was what "they always used." She further stated that she told staff #1 that two people were always used to transfer the resident. Per the CNA, the resident was not real steady on her feet and that she needed a two person princess lift for safety reasons. Staff #3 admitted that she had not checked the resident's CNA daily care plan prior to her instructing the CNA to use the princess lift. Licensed staff was interviewed on January 3, she stated that she was unsure when a princess/Sara lift was used verses a Hoyer lift. She stated that she had never personally operated the sit to stand lift and was uncertain if the resident needed to bear weight. She stated that the resident would need to be able to hold themselves up. During an interview conducted on January 3, the unit manager stated that when a resident was initially admitted a physical therapy evaluation was conducted to determine how the resident was to be transferred. She explained that if there was a change in activity of daily living ability the resident would be reassessed. She explained that there was no formal assessment tool used to determine the type of lift that a resident would require. The CNA daily care plan which directed staff to use the Hoyer lift for transfers of resident #1 was completed by the unit manager. Per the unit manager that care plan was developed from her review of the clinical record and input from the CNAs and nurses. The unit manager stated that the comprehensive care plan was her fault because the resident was on the princess lift, but the care plan had not been updated to reflect the Hoyer lift. She acknowledged that the CNAs generally do not look in the clinical record at the comprehensive care plans and that they should have used the Hoyer lift as directed in their daily care plan. Administrative staff was interviewed on January 4, she stated that the comprehensive care plan should direct the care and that the CNA daily care plans are compiled from the comprehensive care plan. She acknowledged that there was conflicting information between the comprehensive care plan and CNA daily care plan. She was unable to locate any documentation of an assessment regarding the resident's ability to safely use a sit to stand lift. The administrative staff also stated that since the CNAs were to use the CNA daily care plan interventions that the Hoyer lift should have been used. The Sara 3000 (ARJO) sit to stand lift manufacturers instruction documented that this lift is designed specifically to provide optimum activation for wheelchair users with some capacity to support themselves. The instructions further documented a caution that the patient's feet should always remain in full contact with the foot support. "When lifting, check to ensure that the patient's feet do not lift from the support or floor. If this should happen lower the patient immediately until his/her feet fully reach the support of the floor." Another caution documented: "Only use this or other methods after a satisfactory professional assessment has been carried out on the individual patient." -Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the physical therapy notes dated October 10, revealed that the resident was a stand pivot transfer with minimal assistance with transfer device if needed. The Certified Nursing Assistant Daily Care Plan for the months of December 2011 and January 2012, documented that the resident required a princess lift with the assistance of on staff member. Review of the comprehensive care plans revealed there were no care plans or interventions that addressed the residents transfers by the princess lift. On January 4, two CNAs were observed to transfer the resident from the bed to the wheelchair with the Sara lift. The CNAs lifted the resident correctly and safely. The CNA stated they always use two staff members if the resident is not real steady. -Resident #3 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The quarterly MDS assessment dated [DATE], documented the resident required total dependence upon one staff member for transfers. The resident was further assessed as no steady, only to stabilize with human assistance on surface to surface transfer. The Certified Nursing Assistant Daily Care Plan for the months of December 2011 and January 2012, documented that the resident required extensive assistance for transfers of one person and a princess lift. Review of the comprehensive care plans revealed there were no care plan that addressed the residents transfers by the princess lift. On January 4, two CNAs were observed to transfer the resident from the bed to the wheelchair with the Sara lift. The CNAs lifted the resident correctly and safely. The CNA stated that he sometimes transfers the resident by himself and on other days the resident is less steady and he asks for assistance from another CNA. He stated that he does look at the CNA daily care plans before each shift. He stated that one day a resident may require a Sara lift and the next day a Hoyer. He explained that the CNAs could transfer the resident in a safer method like using a Hoyer instead of the Sara or the use of one staff assist to two staff assist, but never the other way around. He further stated that the CNAs were to report to the nurse if the resident required more assistance with transfers. During an interview conducted on January 4, administrative staff stated that residents #2 and #3 should have had comprehensive care plans that addressed their transfer needs. She stated that the type of transfer lift should have been documented on the activities of daily living care plan. She further stated that is how the residents needs are assessed and that the daily CNA care plan is suppose to be derived from the comprehensive interdisciplinary care plan. The administrative staff member acknowledge that it appeared that the assessment process to determine the type of lift needed for residents was not being followed. The CNA daily care plan policy documented the following: "Monthly, along with Re-Caps, the licensed nurse will fill out a blank Daily Plan for the following month, obtaining information to fill the form out from the Member's/Veteran's Interdisciplinary Care Plan and Medical Record...CNAs will utilize the current month's Daily Care Plan to plan care giving for their shift..."