Every finding on record at Haven of Globe

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that an incident of staff-to-resident abuse involving one resident (#96) was thoroughly investigated. The deficient practice could result in residents being physically and emotionally harmed.Findings include:Resident #96 was admitted to the facility on [DATE], with a diagnosis that included encounter for palliative care, muscle spasms, atherosclerotic heart disease, malignant neoplasm of the cervix uteri, type 2 diabetes, hypertension, urinary incontinence, pressure ulcer of the sacral region, polyneuropathy, and generalized anxiety disorder.A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of an alert charting progress note dated June 15, 2026, at 7:02 p.m. revealed that the resident had activated her call light and that the certified nursing assistant (CNA) had responded and found the resident seated in her wheelchair. The note further revealed that the resident was slipping from her chair with both knees locked, gripping the wheelchair armrests, and demonstrating generalized body rigidity. The note revealed that the CNA attempted to reposition the resident safely, but the resident continued to maintain her rigid posture despite verbal instructions to relax. The note also revealed that the CNA requested nursing assistance, and upon entering the room, the nurse observed the resident continuing to extend her lower extremities while maintaining body rigidity, partially lifting and pushing herself from the wheelchair seat. The note revealed that the CNA remained present while attempting to provide support and prevent loss of balance, and that the resident was instructed multiple times to relax her body and bend her knees for safe repositioning. The note revealed that the resident was informed that maintaining a rigid posture during transfers and repositioning increases the risk of injury to herself and staff assisting her. The note also revealed that following repeated verbal instructions, the resident relaxed her posture and was repositioned back into the wheelchair. The note revealed that when asked what had occurred, the resident stated that her body had become weak. The note revealed that due to the observed behavior creating an increased risk for falls, loss of balance, and potential injury to both the resident and assisting staff, the resident was assisted to bed for safety. The note further revealed that no injuries were noted during assessment, the call light was placed within reach, and staff were advised to continue close monitoring and reinforce safe transfer techniques.A skin assessment dated [DATE], at 11:22 a.m. revealed that the resident had a nickel-sized blue bruise on the center of her right knee and a nickel-sized blue bruise with a 2-millimeter scab over the center of her left lateral knee cap, with both skin impairments having a side note that says patient states she probably bumped it. The skin assessment revealed an additional note of multiple red spots on the resident's bilateral arms, with a side note that says patient states she gets these from bumping into things. A care plan focus initiated on June 17, 2026, revealed that the resident was at risk for misappropriation, neglect, abuse, and/or exploitation related to her decreased mobility and neurological symptoms, with a goal to not experience misappropriation, neglect, abuse, and/or exploitation through the review date. The care plan revealed interventions to monitor for signs and symptoms of misappropriation, neglect, abuse, and/or exploitation, and report to the facility's abuse officer and medical provider. A request was made on July 1, 2026, at 7:14 a.m. for all self-reports and investigations at the facility in the last 4 months. Review of the facility investigation dated June 18, 2026, revealed that on June 15, 2026, at approximately 7 p.m., a CNA, Staff #34, reported that she responded to the resident's call light and found her slipping out of her wheelchair. The investigation revealed that the CNA called for assistance from the Licensed Practical Nurse (LPN/Staff#25), who positioned herself on the right side, and the CNA was on the left side. The investigation revealed that both staff members said that the resident's knees were locked and stiff, and that the resident reported feeling weak and unable to bend her knees. The investigation revealed that, according to the CNA, Staff #34, the LPN, Staff #25, tapped the resident's right shin area in an attempt to encourage the resident to bend her legs. The investigation revealed that staff were able to safely reposition the resident in the wheelchair and subsequently transfer the resident to bed without further difficulty. The investigation also revealed that witness interviews were taken from a CNA, Staff #34, the LPN, Staff #25, and another CNA, Staff #21, and that other records reviewed included written statements. The investigation revealed that all appropriate notifications to the family, Arizona Department of Health Services (AZDHS), Adult Protective Services (APS), local police, and the Ombudsman were made according to policy, and that during the investigation, it was determined that the allegation of abuse was unsubstantiated. The investigation revealed that corrective actions included the statement that no policies were broken, and the investigation was signed by the Operations Manager and Abuse Coordinator (OM/Staff #70) on June 22, 2026. A follow-up request was made on July 1, 2026, at 9:55 a.m. for a 5-day investigation with interviews for Resident #96. Review of the facility investigation with interviews revealed that an interview with Resident #96 was conducted on June 16, 2026, at approximately 1:30 p.m. The interview revealed that the resident spoke with the OM (Staff #70) and the Director of Nursing (DON/Staff #17) about the incident on June 15, 2026, and the resident reported that the LPN, Staff #25, touched her left leg at the knee and that the resident made a motion with her hand. The interview revealed that the OM asked the resident if they could assess her left leg, the resident agreed, and the assessment revealed an old bruise with a scab in the center on the left side of the resident's kneecap. The facility investigation further revealed that the OM and the DON met with the CNA, Staff #34, regarding the reported incident, and during the meeting, the CNA was asked to demonstrate the incident as it had been described. The interview revealed that the CNA initially stated that the nurse touched the resident's right leg and touched the OM's lower right shin, and the OM told the CNA that the resident reported that the nurse touched her left knee. The interview revealed that the CNA stated that both legs had been touched and demonstrated the interaction, stating that the nurse was standing in front of the resident, bent over, and touched both legs in the manner she demonstrated on the OM. The facility investigation also revealed an interview on June 16, 2026, at 8:37 a.m. with another CNA, Staff #21, who worked the shift on the incident date, who denied knowing of any incident that occurred on that shift. The facility investigation revealed an interview with the LPN, Staff #25, on June 16, 2026, at 9:17 a.m., during which she stated that she documented the resident's behaviors in a progress note. The interview revealed that the OM informed the LPN that a staff member reported that the LPN struck the resident on the right leg while instructing her to bend her knees, and the LPN denied striking the resident. The interview revealed that the LPN stated they were doing a two-person transfer when the resident stiffened her legs, and that she had her arm under the resident's arm and provided a tactile cue behind the resident's left knee while instructing her to bend this knee. A follow-up request was made on July 1, 2026, at 10:10 a.m. for written witness statements for the incident regarding Resident #96. Review of the requested written witness statements revealed one statement by the CNA, Staff #34, titled Incident Report was signed and dated June 16, 2026. The statement revealed that on the night shift of June 15, 2026, the CNA was putting Resident #96 back into bed as she was slipping out of her chair, and the resident's legs were stiff. The written statements revealed that the nurse on shift, Staff #25, smacked the resident's legs to get her to bend her knees between 6 and 7:20 p.m. The CNA wrote that she was in shock more than angry and to ask resident about last night please. Following an interview with the OM and abuse coordinator, Staff #70, on July 1, 2026, at approximately 1:45 p.m., a request was made for the written witness statements that the facility had not provided with the initial requests for the complete investigation. Review of the written witness statements revealed a statement from a Registered Nurse (RN/Staff #56), signed and dated June 16, 2026. The written statement from the RN revealed that shortly after breakfast, Resident #96's CNA reported to the RN that Resident #96 had described abuse that had happened to her overnight. The written statement further revealed that the RN sat down with the resident in a private place and asked what had happened, and the resident began crying and said that when staff were transferring her the night before, the nurse started yelling at her, saying, relax your legs! The written statement also revealed that the resident stated that she tried to tell the nurse that she couldn't help it and could not relax her legs, and that the nurse began hitting her legs until they relaxed. The written statement revealed that the RN asked the resident if anyone else was there when the incident happened, and the resident said that only the LPN was hitting her, but she thought it happened in front of someone else. The written statement revealed that the resident denied anyone else hitting or hurting her, and that the resident told the RN that the LPN told her that the resident was mean to staff and that the resident hurts staff with her (resident #96) behavior. The written statement further revealed that the resident told the RN that the LPN told the resident that she hurt a CNA's back by stiffening her legs and made them cry, and the resident told the RN that she was going to report the LPN to social services, but that the nurse told her that all of the nurses document her behavior, which made the resident feel that no one would listen. The written statement revealed that the RN called and reported the incident to the assistant director of nursing (ADON), and that she had spoken with the DON, who verified that the director had been notified. An interview was attempted with Resident #96 on July 1, 2026, at 8:35 a.m., but the resident was not able to answer any questions.An interview was conducted on July 1, 2026, at approximately 9 a.m., with Resident #96's roommate, Resident #14, who revealed that she had been Resident #96's roommate for 3 weeks. The resident stated that she heard a nurse yelling at Resident #96 one time, but she did not know what the nurse was yelling. The resident stated that she had not seen the nurse providing care to them since she yelled at Resident #96. A telephonic interview was attempted on July 1, 2026, at 9:26 a.m. with a CNA, Staff #21, who worked the night shift on the date of the incident, with no success. A telephonic interview was conducted on July 1, 2026, at 9:36 a.m. with Resident #96's responsible party and daughter, who stated that she was made aware of an incident at the facility where a nurse assaulted her mom. The resident's responsible party stated that the incident was reported by a CNA, that they filed a police report, and that the nurse was suspended. The resident's responsible party stated that her sister would know more about the incident and investigation and to give her a call, too. A telephonic interview was conducted on July 1, 2026, at 9:43 a.m. with Resident #96's emergency contact and other daughter, who stated that someone from the facility called her and stated that the incident involved a nurse hitting her mom. The emergency contact further stated that the resident told her that the CNA who was there reported it, and that the resident was asked about the incident, and she told them that it happened. The emergency contact stated that the police went to the facility, and that she called the police to ask about it, and they told her that it was going to be a criminal investigation now. The emergency contact stated that the nurse was identified as the LPN, Staff #25, and that the nurse did not work with her again. A telephonic interview was attempted on July 1, 2026, at 11:03 a.m. with a CNA, Staff #34, who witnessed the incident, with no success. A telephonic interview was attempted on July 1, 2026, at 11:06 a.m. with a Licensed Practical Nurse (LPN/Staff #25), who was accused of hitting the resident, with no success. An interview was conducted on July 1, 2026, at 11:22 a.m. with a Registered Nurse (RN/Staff #56), who stated that physical abuse was defined as hitting, threatening to hit, slapping, or any type of hitting, both closed- or open-hand. The RN stated that verbal abuse was defined as speaking to someone in a way that makes them feel threatened, scared, or unsafe, and that yelling and intimidation with volume were forms of verbal abuse. The RN stated that reportable allegations would be anything that makes her concerned about the possibility of abuse, and that she would tell her supervisor immediately. The RN stated that the risk of failing to report abuse per the facility policy would be that abuse could continue happening, someone could have an injury and the facility wouldn't know about it, and there could be emotional and psychological damage. The RN stated that the same risks were possible regarding reporting allegations of abuse late, and added the risk that residents may continue to work with someone who abused them. The RN stated that she had to report an allegation of abuse one morning when a CNA told her that a resident alleged that they had been abused by the night shift. The RN stated that the incident was reported to her about 2 weeks ago, and that the CNA who reported to her was Staff #40. The RN also stated that she went to check in with the resident, who reported to the RN that the night before, a nurse had hit her in the leg and was telling her to relax it because she was having a muscle spasm and was stiff. The RN stated that the resident told her the nurse hit the resident's leg until it relaxed, and that the RN did a handwritten statement at the time, and that there was a police report. The RN stated that she did not remember if the wording was slap or hit, but that she wrote a statement, and that it was a reportable incident because no resident should ever be hit, slapped or experience aggressive behavior. The RN stated that she did not do the skin assessment, but that she knew the resident was hurt emotionally by the incident because the resident was tearful and stated that it made her feel like no one cared about her and that she wasn't wanted at the facility. The RN opened Resident #96's progress notes and stated that the incident occurred on the night of June 15, 2026, and that it was reported to her on June 16, 2026. The RN stated that the nurse who hit the resident was Staff #25 and that the RN reported the incident to management between 7:45 and 8:30 a.m. on the 16th. An interview was conducted on July 1, 2026, at 11:58 a.m., with a CNA, Staff #32, who stated that there had been a recent allegation of abuse at the facility where a CNA, Staff #34, witnessed Resident #96 being hit by an LPN, Staff #25. The CNA stated that the CNA who witnessed the incident, Staff #34, mentioned to another CNA, Staff #84, that she witnessed the nurse hitting the resident. The CNA stated that when Staff #84 told her about the incident, Staff #32 reported the allegation to the resident's CNA, Staff #40, who spoke with the resident the morning after the incident. The CNA stated that when Staff #40 spoke with the resident, the resident was crying and reported to staff that the LPN punched her in the leg. An interview was conducted on July 1, 2026, at 11:40 a.m. with a Licensed Nursing Assistant (LNA/Staff #40), who stated that an allegation of abuse was reported to her by another CNA, Staff #32, who was told by a CNA, Staff #84, that CNA, Staff #34, witnessed Resident #96 being hit by LPN, Staff #25. The CNA stated that she asked Resident #96 to take a walk with her, they found a location for privacy, and the CNA told the resident she could be honest and tell her if something happened with the nurse. The CNA stated that the resident began to tear up and told the CNA that the nurse was yelling at her and hitting her in the legs the night before. The CNA stated that the resident told her that she needed help bending her knees, and when they finished talking, the CNA ran to tell the RN, Staff #56, that she had a reportable abuse allegation. The CNA stated that the RN talked with the resident, who reported the same information verbatim and demonstrated where she was punched in the right leg. The CNA stated that after they interviewed the resident, the RN reported the incident further, and the CNA brought the resident back to her room to lie down and have a brief change. The CNA stated that the resident's leg was bruised in the same area that she had pointed to in her demonstration of the hit, and that the CNA had made a handwritten statement regarding the incident that detailed the same information she just shared; however, the facility did not provide the written statement in the facility investigation. The CNA stated that her statement was dated June 16, 2026, and that her interview with the resident was between 7:30 and 8:30 a.m. that day. An interview was conducted on July 1, 2026, at 12:46 a.m., with a CNA, Staff #84, who stated that another CNA, Staff #34, recently had to report abuse that she had witnessed, and that Staff #34 pulled the CNA into a private room to get her opinion on what she witnessed. The CNA stated that Staff #34 told her that she witnessed a nurse smacking a resident's leg and telling her to bend her knees, and heard the resident saying please stop hitting me. The CNA stated that she told Staff #34 to report the incident right away and make a written statement so nothing was forgotten or lost, and as far as the CNA knew, Staff #34 told the DON and wrote the statement. An interview was conducted on July 1, 2026, at 1:09 p.m. with the DON, Staff #17, who stated that all allegations of abuse were reportable, and further stated that when an allegation was made, their process was to immediately do an investigation, suspend everyone involved, make sure the resident was safe, interview staff, interview residents, and report to APS, local police, the ombudsman, and AZDHS. The DON stated that the only instance in which a written statement would be excluded from the final investigation report would be if the staff member was interviewed and did not know anything about the incident, and that if the staff member interacted with or spoke to the resident involved, their statement would need to be included. The DON also stated that failure to include those statements in the investigation would mean that it was not a thorough investigation. The DON also stated that the risk of not thoroughly investigating, such as leaving staff statements out of the investigation, would be that the investigation wouldn't be thorough and would also put residents and staff in harm's way. The DON stated that they recently reported an incident that was reported to them by a CNA who slipped a note under the OM's door and texted that she needed to talk to them. The DON stated that administration was out of town for a conference at the time, so they had the CNA send a picture of her note, and when they read the allegation, they started the investigation. The DON stated that the facility reported the incident on June 16, 2026, but that the incident occurred on June 15th around 7:30-8 p.m. The DON further stated that the CNA reported that she witnessed a nurse slap a resident's leg during a two-person transfer from wheelchair to bed, and that the nurse slapped the resident while telling her to bend her leg. The DON stated that the CNA did not report the incident to them until the next day and that the staff's reporting of the incident was not within the facility's expectations or policy, and further stated that, as a result, the facility did not report within the required timeframe. The DON also stated that in their investigation, they talked to the CNA who witnessed the incident, the nurse who was accused, and the nurse who was on shift the next morning, who had called to tell them that there was an allegation of abuse. The DON stated that the accused nurse did not write them a statement and that the result of the investigation was unsubstantiated despite the resident saying she was hit and a CNA witnessing it, because after talking to the accused nurse, the LPN stated that she did not hit the resident, but instead was doing a tactile touch. The DON also stated that they terminated the LPN, Staff #25, on June 17, 2026, because she was not friendly with staff or residents, they had prior concerns about her behavior before the abuse incident, and she was cursing in the hallways, but denied terminating the nurse because of the incident with Resident #96. The DON stated that the resident told other staff members, including the RN, Staff #56, that she was hit by the LPN, and that there were written statements that the facility did not provide in the facility investigation request. An interview was conducted on July 1, 2026, at approximately 1:45 p.m. with the OM/Staff #70, who stated that she was the abuse coordinator and that the facility was required to report to AZHDS, the ombudsman, local police, the case manager, the administrator, and the Medicaid agency. The OM stated that if someone told her that they witnessed a staff member abusing someone, they would look into it, and that the investigation would entail interviewing staff who were around or witnessed the abuse, and residents involved, with the DON present. The OM stated that corporate required them to fill out an abuse form with questions, and that the only instance where the facility would exclude statements from the facility investigation would be if the statements did not pertain to the situation, or if the statement was not first-hand from a witness of the incident. The OM acknowledged that staff interviewing the resident about the incident would be no different from their interviews with the resident, but that she was instructed by corporate higher-ups after the recent reportable incident to not include written statements from staff who did not physically witness the incident but had interviewed the resident. The OM stated that failing to include statements in their facility investigation would be that they would not have conducted a thorough investigation. The OM stated that the facility had a reportable incident recently when a CNA, Staff #34, texted her that there was an incident and that she slid a note under the OM's door. The OM stated that they called social services to ask the resident what happened, that they suspended the nurse until they figured out the investigation was completed, and that the social worker and ADON conducted interviews. The OM stated that the incident occurred on the night of June 15, 2026, but that it wasn't reported until the morning of June 16, 2026. The OM stated that she talked with the resident on the 17th of June, and the resident told them that a staff member hit her on the leg. The OM further stated that they asked her if she could show them where the nurse hit her, to which the resident visually demonstrated a hit to the left leg and said, She just hit me. The OM stated that the resident told them that a CNA was in the room to witness the incident, but that the resident did not recall the CNA's name. The OM stated that they identified that it was CNA, Staff #34, following her report, and that the CNA told them it was the right leg, but that the CNA's demonstration of the incident did not make sense because of the side of the bed she was standing on, which led to the facility unsubstantiating their investigation. The OM stated that the CNA told them that the nurse was telling the resident to bend her knees, and that she was shocked by what she witnessed. The OM stated that she asked the CNA why she did not report the incident in a timely manner, and she got hostile and asked who she was supposed to report to if the nurse whom she would report to was being accused. The OM stated that the CNA quit during their conversation and that they terminated the LPN, Staff #25, on June 17, 2026, because they were getting feedback from staff and residents that the LPN was rude, not friendly, and lacked bedside manner, but denied that the termination was related to the abuse incident. The OM stated that they interviewed the people involved, but that they left pieces out of the facility investigation, and that it was not to hide anything. The OM further stated that it was probably not thoroughly investigated because of what was left out, and that they would change the outcome of their investigation to say it happened because of what they found out in the investigation, and that the resident and the witness both stated that it happened, in combination with the additional written statements from staff who interviewed the resident. The OM stated that the skin assessment showed that the resident did have bruising following the incident, but stated that it was an old, faded bruise that police took a photo of; however, the skin assessments and shower sheets did not show the presence of bruising before the incident. Review of a policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, was dated January 1, 2024, and revealed that all reports of resident abuse should have been reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The policy revealed that the findings of all investigations should have been documented and reported, and that the suspicion of abuse must be reported immediately to the administrator and other officials according to state law. The policy revealed that all allegations should have been thoroughly investigated, and that at a minimum, the investigation would include interviews with staff members (on all shifts) who had contact with the resident during the period of the alleged incident, any witnesses to the incident, the person(s) reporting the incident, the resident (as medically appropriate) or the resident's representative, and observations of the alleged victim, including his or her interactions with staff and other residents. The policy further revealed that witness statements should have been obtained in writing, signed, and dated. The policy also revealed that the witness was able to write his/her statement, or the investigator could obtain a statement. The policy revealed that upon conclusion of the investigation, the investigator would record the findings of the investigation on approved documentation forms and provide the completed documentation to the administrator. The policy further revealed that within five (5) business days of the incident, the administrator would provide a follow-up investigation report that would provide sufficient information to describe the results of the investigation, and indicate any corrective actions taken if the allegation was verified, and that the follow-up investigation report would provide as much information as possible at the time of submission of the report. The policy revealed that all relevant professional and licensing boards were notified when an employee was found to have committed abuse, and that if the investigation revealed that the allegation(s) of abuse were founded, the employee(s) would be terminated. The policy also revealed that any allegations of abuse would be 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, resident and staff interviews, and policy review, the facility failed to ensure that an incident of staff-to-resident abuse was reported within the required timeframe for one resident (#96). The deficient practice could result in residents being physically and emotionally harmed. Findings include:Resident #96 was admitted to the facility on [DATE], with a diagnosis that included encounter for palliative care, muscle spasms, atherosclerotic heart disease, malignant neoplasm of the cervix uteri, type 2 diabetes, hypertension, urinary incontinence, pressure ulcer of the sacral region, polyneuropathy, and generalized anxiety disorder.A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of an alert charting progress note dated June 15, 2026, at 7:02 p.m. revealed that the resident had activated her call light and that the certified nursing assistant (CNA) had responded and found the resident seated in her wheelchair. The note further revealed that the resident was slipping from her chair with both knees locked, gripping the wheelchair armrests, and demonstrating generalized body rigidity. The note revealed that the CNA attempted to reposition the resident safely, but the resident continued to maintain her rigid posture despite verbal instructions to relax. The note also revealed that the CNA requested nursing assistance, and upon entering the room, the nurse observed the resident continuing to extend her lower extremities while maintaining body rigidity, partially lifting and pushing herself from the wheelchair seat. The note revealed that the CNA remained present while attempting to provide support and prevent loss of balance, and that the resident was instructed multiple times to relax her body and bend her knees for safe repositioning. The note revealed that the resident was informed that maintaining a rigid posture during transfers and repositioning increases the risk of injury to herself and staff assisting her. The note also revealed that following repeated verbal instructions, the resident relaxed her posture and was repositioned back into the wheelchair. The note revealed that when asked what had occurred, the resident stated that her body had become weak. The note revealed that due to the observed behavior creating an increased risk for falls, loss of balance, and potential injury to both the resident and assisting staff, the resident was assisted to bed for safety. The note further revealed that no injuries were noted during assessment, the call light was placed within reach, and staff were advised to continue close monitoring and reinforce safe transfer techniques.A skin assessment dated [DATE], at 11:22 a.m. revealed that the resident had a nickel-sized blue bruise on the center of her right knee and a nickel-sized blue bruise with a 2-millimeter scab over the center of her left lateral knee cap, with both skin impairments having a side note that says patient states she probably bumped it. The skin assessment revealed an additional note of multiple red spots on the resident's bilateral arms, with a side note that says patient states she gets these from bumping into things. A care plan focus initiated on June 17, 2026, revealed that the resident was at risk for misappropriation, neglect, abuse, and/or exploitation related to her decreased mobility and neurological symptoms, with a goal to not experience misappropriation, neglect, abuse, and/or exploitation through the review date. The care plan revealed interventions to monitor for signs and symptoms of misappropriation, neglect, abuse, and/or exploitation, and report to the facility's abuse officer and medical provider. A review of a shower skin assessment sheet dated June 18, 2026, revealed that the resident had no indicated skin impairments.Review of the facility investigation dated June 18, 2026, revealed that on June 15, 2026, at approximately 7 p.m., a CNA, Staff #34, responded to Resident #96's call light and found her slipping out of her wheelchair. The investigation revealed that the CNA called for assistance from the Licensed Practical Nurse (LPN/Staff#25), who positioned herself on the right side, and the CNA was on the left side, and that the resident reported feeling weak and unable to bend her knees. The investigation revealed that, according to the CNA, Staff #34, the LPN, Staff #25, tapped the resident's right shin area in an attempt to encourage the resident to bend her legs. The investigation revealed that corrective actions included the statement that no policies were broken, and the investigation was signed by the Operations Manager and Abuse Coordinator (OM/Staff #70) on June 22, 2026. The facility investigation did not include when the allegation was reported. An interview was attempted with Resident #96 on July 1, 2026, at 8:35 a.m., but the resident was not able to answer any questions.An interview was conducted on July 1, 2026, at approximately 9 a.m., with Resident #96's roommate, Resident #14, who revealed that she had been Resident #96's roommate for 3 weeks. The resident stated that she heard a nurse yelling at Resident #96 one time, but she did not know what the nurse was yelling. The resident stated that she had not seen the nurse providing care to them since she yelled at Resident #96. A telephonic interview was attempted on July 1, 2026, at 9:26 a.m. with a CNA, Staff #21, who worked the night shift on the date of the incident, with no success. A telephonic interview was conducted on July 1, 2026, at 9:36 a.m. with Resident #96's responsible party and daughter, who stated that she was made aware of an incident at the facility where a nurse assaulted her mom. The resident's responsible party stated that the incident was reported by a CNA, that they filed a police report, and that the nurse was suspended. The resident's responsible party stated that the nurse was trying to get the resident to straighten her legs, and that the nurse told the resident she knew the resident was faking it before striking her legs to straighten them out. The resident's responsible party stated that her sister would know more about the incident and to give her a call, too. A telephonic interview was conducted on July 1, 2026, at 9:43 a.m. with Resident #96's emergency contact and other daughter, who stated that someone from the facility called her and stated that the incident involved a nurse hitting her mom. The emergency contact stated that her sister told her to visit their mom that evening and when she did go to visit the resident told her that she did not report what happened to her, but that for two nights, the nurse was telling the resident that no one wanted to come into her room to help because she was always asking for help and that they all know that she was pretending. The emergency contact stated that she had asked the resident how the facility found out about the incident if she did not report it, and the resident told her that the CNA who was there reported it.A telephonic interview was attempted on July 1, 2026, at 11:03 a.m. with a CNA, Staff #34, who witnessed the incident, with no success. A telephonic interview was attempted on July 1, 2026, at 11:06 a.m. with a Licensed Practical Nurse (LPN/Staff #25), who was accused of hitting the resident, with no success. An interview was conducted on July 1, 2026, at 11:22 a.m. with a Registered Nurse (RN/Staff #56), who stated that physical abuse was defined as hitting, threatening to hit, slapping, or any type of hitting, both closed- or open-hand. The RN stated that verbal abuse was defined as speaking to someone in a way that makes them feel threatened, scared, or unsafe, and that yelling and intimidation with volume were forms of verbal abuse. The RN stated that reportable allegations would be anything that makes her concerned about the possibility of abuse, and that she would tell her supervisor immediately. The RN stated that the risk of failing to report abuse per the facility policy would be that abuse could continue happening, someone could have an injury and the facility wouldn't know about it, and there could be emotional and psychological damage. The RN stated that the same risks were possible regarding reporting allegations of abuse late, and added the risk that residents may continue to work with someone who abused them. The RN stated that she had to report an allegation of abuse one morning when a CNA told her that a resident alleged that they had been abused by the night shift. The RN stated that the incident was reported to her about 2 weeks ago, and that the CNA who reported to her was Staff #40. The RN also stated that she went to check in with the resident, who reported to the RN that the night before, a nurse had hit her in the leg and was telling her to relax it because she was having a muscle spasm and was stiff. The RN stated that the resident told her the nurse hit the resident's leg until it relaxed, and that the RN did a handwritten statement at the time, and that there was a police report. The RN stated that she did not remember if the wording was slap or hit, but that she wrote a statement, and that it was a reportable incident because no resident should ever be hit, slapped or experience aggressive behavior. The RN stated that she did not do the skin assessment, but that she knew the resident was hurt emotionally by the incident because the resident was tearful and stated that it made her feel like no one cared about her and that she wasn't wanted at the facility. The RN opened Resident #96's progress notes and stated that the incident occurred on the night of June 15, 2026, and that it was reported to her on June 16, 2026. The RN stated that the nurse who hit the resident was Staff #25 and that the RN reported the incident to management between 7:45 and 8:30 a.m. on the 16th. An interview was conducted on July 1, 2026, at 11:58 a.m., with a CNA, Staff #32, who stated that the timeframe for reporting an allegation of abuse was two hours and that she would need to report to the DON and ADON. The CNA stated that any type of abuse was reportable, but especially physical abuse. The CNA stated that the risk of failing to report abuse as per the abuse policy was that someone could get an injury, abuse could continue, it could happen to another resident, and it could make the resident scared or not trusting. The CNA also stated that there had been a recent allegation of abuse at the facility where a CNA, Staff #34, witnessed Resident #96 being hit by an LPN, Staff #25. The CNA stated that the CNA who witnessed the incident, Staff #34, mentioned to another CNA, Staff #84, that she witnessed the nurse hitting the resident, and that it was not reported within the required timeframe because she was scared to have to report it to the nurse on the floor that night, whom she accused of hitting the resident. The CNA stated that when Staff #84 told her about the incident, Staff #32 reported the allegation to the resident's CNA, Staff #40, who spoke with the resident the morning after the incident and reported it further.An interview was conducted on July 1, 2026, at 11:40 a.m. with a Licensed Nursing Assistant (LNA/Staff #40), who stated that the timeframe for reporting an allegation of abuse was two hours, but that the expectation was to report immediately to your superior. The CNA stated that the risk of failing to report an allegation of abuse, per the facility policy, would be continued abuse to residents, and that the resident might experience a mental or physical decline, might lack trust, and could feel like no one was listening to them and continue to endure abuse because of not wanting to report. The CNA stated that an allegation of abuse was reported to her by another CNA, Staff #32, who was told by a CNA, Staff #84, that CNA, Staff #34, witnessed Resident #96 being hit by LPN, Staff #25. The CNA stated that she asked Resident #96 to take a walk with her, they found a location for privacy, and the CNA told the resident she could be honest and tell her if something happened with the nurse. The CNA stated that the resident began to tear up and told the CNA that the nurse was yelling at her and hitting her in the legs the night before. The CNA stated that the resident told her that she needed help bending her knees, and when they finished talking, the CNA ran to tell the RN, Staff #56, that she had a reportable abuse allegation. The CNA stated that the RN talked with the resident between 7:30 and 8:30 a.m. on June 16th, 2026, who reported the same information verbatim and demonstrated where she was punched in the right leg. The CNA stated that after they interviewed the resident, the RN reported the incident further, and the CNA brought the resident back to her room to lie down and have a brief change.An interview was conducted on July 1, 2026, at 12:46 a.m., with a CNA, Staff #84, who stated that the timeframe for reporting abuse was two hours and that she would have to report to the DON and ADON. The CNA further stated that all allegations of abuse were reportable, and that the risk of failing to report an allegation of abuse was that the staff could get in trouble, lose their license, and anything could happen to the resident. The CNA also stated that a potential risk of delaying the reporting of an abuse allegation could be that the incident details could be forgotten or twisted, and that residents could lose their sense of security or feel ignored. The CNA stated that another CNA, Staff #34, recently had to report abuse that they had witnessed, and that Staff #34 pulled the CNA into a private room to get her opinion on what she witnessed. The CNA stated that Staff #34 told her that she witnessed a nurse smacking a resident's leg and telling her to bend her knees, and heard the resident saying please stop hitting me. The CNA stated that she told Staff #34 to report the incident right away and make a written statement so nothing was forgotten or lost, and as far as the CNA knew, Staff #34 told the DON about the allegation. An interview was conducted on July 1, 2026, at 1:09 p.m. with the DON, Staff #17, who stated that verbal abuse was defined as screaming, yelling, cussing, and belittling someone. The DON stated that the timeframe for reporting an allegation of abuse was immediately to their direct supervisor, and that administration had two hours to report per the facility policy. The DON stated that all allegations of abuse were reportable, and further stated that when an allegation was made, their process was to immediately do an investigation, suspend everyone involved, make sure the resident was safe, interview staff, interview residents, and report to APS, local police, the ombudsman, and AZDHS. The DON stated that the risk of failing to report abuse as per the facility policy was that abuse could continue to happen and put residents and staff in harm's way. The DON stated that they recently reported an incident that was reported to them by a CNA who slipped a note under the OM's door and texted that she needed to talk to them. The DON stated that administration was out of town for a conference at the time, so they had the CNA send a picture of her note, and when they read the allegation, they started the investigation. The DON stated that the facility reported the incident on June 16, 2026, but that the incident occurred on June 15th around 7:30-8 p.m. The DON further stated that the CNA reported that she witnessed a nurse slap a resident's leg during a two-person transfer from wheelchair to bed, and that the nurse slapped the resident while telling her to bend her leg. The DON stated that the CNA did not report the incident to them until the next day and that the staff's reporting of the incident was not within the facility's expectations or policy, and further stated that, as a result, the facility did not report within the required timeframe. An interview was conducted on July 1, 2026, at approximately 1:45 p.m. with the OM/Staff #70, who stated that physical abuse was defined as when someone inflicts physical harm on someone, with examples being hitting, pulling hair, grabbing, and slapping someone with intent to harm. The OM stated that verbal abuse was defined as using vulgar language, curse words, someone's demeanor, and belittling someone. The OM stated that she was the abuse coordinator, and that the timeframe for reporting an allegation was two hours to AZHDS, the ombudsman, local police, the case manager, the administrator, and the Medicaid agency. The OM stated that if someone told her that they witnessed a staff member abusing someone, they would look into it, and that the investigation would entail interviewing staff who were around or witnessed the abuse, and residents involved, with the DON present. The OM stated that the risk of failing to report abuse as per the facility policy would be a delay in a proper investigation, and not following the policy. The OM stated that the facility had a reportable incident recently when a CNA, Staff #34, texted her that there was an incident and that she slid a note under the OM's door. The OM stated that they called social services to ask the resident what happened, that they suspended the nurse until they figured out the investigation was completed, and that the social worker and ADON conducted interviews. The OM stated that the incident occurred on the night of June 15, 2026, but that it wasn't reported until the morning of June 16, 2026. The OM further stated that the reporting of this incident was not within the facility's expectations for reporting. The OM stated that she asked the CNA why she did not report the incident in a timely manner, and she got hostile and asked who she was supposed to report to if the nurse whom she would report to was being accused. Review of a policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, was dated January 1, 2024, and revealed that all reports of resident abuse should have been reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The policy revealed that the findings of all investigations should have been documented and reported, and that the suspicion of abuse must be reported immediately to the administrator and other officials according to state law. The policy revealed that reporting immediately was defined as within two hours of an allegation involving abuse or an allegation resulting in serious bodily injury.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that the abuse policy was implemented following an incident of staff-to-resident abuse for one resident (#96). The deficient practice could result in residents being physically and emotionally harmed.Findings include:Resident #96 was admitted to the facility on [DATE], with a diagnosis that included encounter for palliative care, muscle spasms, atherosclerotic heart disease, malignant neoplasm of the cervix uteri, type 2 diabetes, hypertension, urinary incontinence, pressure ulcer of the sacral region, polyneuropathy, and generalized anxiety disorder.A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. Review of an alert charting progress note dated June 15, 2026, at 7:02 p.m. revealed that the resident had activated her call light and that the certified nursing assistant (CNA) had responded and found the resident seated in her wheelchair. The note further revealed that the resident was slipping from her chair with both knees locked, gripping the wheelchair armrests, and demonstrating generalized body rigidity. The note revealed that the CNA attempted to reposition the resident safely, but the resident continued to maintain her rigid posture despite verbal instructions to relax. The note also revealed that the CNA requested nursing assistance, and upon entering the room, the nurse observed the resident continuing to extend her lower extremities while maintaining body rigidity, partially lifting and pushing herself from the wheelchair seat. The note revealed that the CNA remained present while attempting to provide support and prevent loss of balance, and that the resident was instructed multiple times to relax her body and bend her knees for safe repositioning. The note revealed that the resident was informed that maintaining a rigid posture during transfers and repositioning increases the risk of injury to herself and staff assisting her. The note also revealed that following repeated verbal instructions, the resident relaxed her posture and was repositioned back into the wheelchair. The note revealed that when asked what had occurred, the resident stated that her body had become weak. The note revealed that due to the observed behavior creating an increased risk for falls, loss of balance, and potential injury to both the resident and assisting staff, the resident was assisted to bed for safety. The note further revealed that no injuries were noted during assessment, the call light was placed within reach, and staff were advised to continue close monitoring and reinforce safe transfer techniques.A skin assessment dated [DATE], at 11:22 a.m. revealed that the resident had a nickel-sized blue bruise on the center of her right knee and a nickel-sized blue bruise with a 2-millimeter scab over the center of her left lateral knee cap, with both skin impairments having a side note that says patient states she probably bumped it. The skin assessment revealed an additional note of multiple red spots on the resident's bilateral arms, with a side note that says patient states she gets these from bumping into things. A care plan focus initiated on June 17, 2026, revealed that the resident was at risk for misappropriation, neglect, abuse, and/or exploitation related to her decreased mobility and neurological symptoms, with a goal to not experience misappropriation, neglect, abuse, and/or exploitation through the review date. The care plan revealed interventions to monitor for signs and symptoms of misappropriation, neglect, abuse, and/or exploitation, and report to the facility's abuse officer and medical provider. Review of the facility investigation dated June 18, 2026, revealed that on June 15, 2026, at approximately 7 p.m., a CNA, Staff #34, reported that she responded to the resident's call light and found her slipping out of her wheelchair. The investigation revealed that the CNA called for assistance from the Licensed Practical Nurse (LPN/Staff#25), who positioned herself on the right side, and the CNA was on the left side. The investigation revealed that both staff members said that the resident's knees were locked and stiff, and that the resident reported feeling weak and unable to bend her knees. The investigation revealed that, according to the CNA, Staff #34, the LPN, Staff #25, tapped the resident's right shin area in an attempt to encourage the resident to bend her legs. The investigation revealed that staff were able to safely reposition the resident in the wheelchair and subsequently transfer the resident to bed without further difficulty. The investigation also revealed that witness interviews were taken from a CNA, Staff #34, the LPN, Staff #25, and another CNA, Staff #21, and that other records reviewed included written statements. The investigation revealed that all appropriate notifications to the family, Arizona Department of Health Services (AZDHS), Adult Protective Services (APS), local police, and the Ombudsman were made according to policy, and that during the investigation, it was determined that the allegation of abuse was unsubstantiated. The investigation revealed that corrective actions included the statement that no policies were broken, and the investigation was signed by the Operations Manager and Abuse Coordinator (OM/Staff #70) on June 22, 2026. A follow-up request was made on July 1, 2026, at 9:55 a.m. for a 5-day investigation with interviews for Resident #96. Review of the facility investigation with interviews revealed that an interview with Resident #96 was conducted on June 16, 2026, at approximately 1:30 p.m. The interview revealed that the resident spoke with the OM, Staff #70, and the Director of Nursing (DON/Staff #17) about the incident on June 15, 2026, and the resident reported that the LPN, Staff #25, touched her left leg at the knee and that the resident made a motion with her hand. The interview revealed that the OM asked the resident if they could assess her left leg, the resident agreed, and the assessment revealed an old bruise with a scab in the center on the left side of the resident's kneecap. The facility investigation further revealed that the OM and the DON met with the CNA, Staff #34, regarding the reported incident, and during the meeting, the CNA was asked to demonstrate the incident as it had been described. The interview revealed that the CNA initially stated that the nurse touched the resident's right leg and touched the OM's lower right shin, and the OM told the CNA that the resident reported that the nurse touched her left knee. The interview revealed that the CNA stated that both legs had been touched and demonstrated the interaction, stating that the nurse was standing in front of the resident, bent over, and touched both legs in the manner she demonstrated on the OM. The facility investigation also revealed an interview on June 16, 2026, at 8:37 a.m. with another CNA, Staff #21, who worked the shift on the incident date, who denied knowing of any incident that occurred on that shift. The facility investigation revealed an interview with the LPN, Staff #25, on June 16, 2026, at 9:17 a.m., during which she stated that she documented the resident's behaviors in a progress note. The interview revealed that the OM informed the LPN that a staff member reported that the LPN struck the resident on the right leg while instructing her to bend her knees, and the LPN denied striking the resident. The interview revealed that the LPN stated they were doing a two-person transfer when the resident stiffened her legs, and that she had her arm under the resident's arm and provided a tactile cue behind the resident's left knee while instructing her to bend this knee.A follow-up request was made on July 1, 2026, at 10:10 a.m. for written witness statements for the incident regarding Resident #96. Review of the requested written witness statements revealed that a statement by a CNA, Staff #34, titled Incident Report was signed and dated June 16, 2026. The statement revealed that on the night shift of June 15, 2026, the CNA was putting Resident #96 back into bed as she was slipping out of her chair, and the resident's legs were stiff. The written statements revealed that the nurse on shift, Staff #25, smacked the resident's legs to get her to bend her knees between 6 and 7:20 p.m. The CNA wrote that she was in shock more than angry and to ask resident about last night please. Following an interview with the OM and abuse coordinator, Staff #70, on July 1, 2026, at approximately 1:45 p.m., a request was made for the written witness statements that the facility had not provided with the initial requests for the complete investigation. Review of the written witness statements revealed a statement from a Registered Nurse (RN/Staff #56), signed and dated June 16, 2026. The written statement from the RN revealed that shortly after breakfast, Resident #96's CNA reported to the RN that Resident #96 had described abuse that had happened to her overnight. The written statement further revealed that the RN sat down with the resident in a private place and asked what had happened, and the resident began crying and said that when staff were transferring her the night before, the nurse started yelling at her, saying, relax your legs! The written statement also revealed that the resident stated that she tried to tell the nurse that she couldn't help it and could not relax her legs, and that the nurse began hitting her legs until they relaxed. The written statement revealed that the RN asked the resident if anyone else was there when the incident happened, and the resident said that only the LPN was hitting her, but she thought it happened in front of someone else. The written statement revealed that the resident denied anyone else hitting or hurting her, and that the resident told the RN that the LPN told her that she was mean to staff and that the resident hurts staff with her behavior. The written statement further revealed that the resident told the RN that the LPN told the resident that she hurt a CNA's back by stiffening her legs and made them cry, and the resident told the RN that she was going to report the LPN to social services, but that the nurse told her that all of the nurses document her behavior, which made the resident feel that no one would listen. The written statement revealed that the RN called and reported the incident to the assistant director of nursing (ADON), and that she had spoken with the DON, who verified that the director had been notified. An interview was attempted with Resident #96 on July 1, 2026, at 8:35 a.m., but the resident was not able to answer any questions.An interview was conducted on July 1, 2026, at approximately 9 a.m., with Resident #96's roommate, Resident #14, who revealed that she had been Resident #96's roommate for 3 weeks. The resident stated that she heard a nurse yelling at Resident #96 one time, but she did not know what the nurse was yelling. The resident stated that she had not seen the nurse providing care to them since she yelled at Resident #96. A telephonic interview was attempted on July 1, 2026, at 9:26 a.m. with a CNA, Staff #21, who worked the night shift on the date of the incident, with no success. A telephonic interview was conducted on July 1, 2026, at 9:36 a.m. with Resident #96's responsible party and daughter, who stated that she was made aware of an incident at the facility where a nurse assaulted her mom. The resident's responsible party stated that the incident was reported by a CNA, that they filed a police report, and that the nurse was suspended. The resident's responsible party stated that the nurse was trying to get the resident to straighten her legs, and that the nurse told the resident she knew the resident was faking it before striking her legs to straighten them out. The resident's responsible party stated that her sister would know more about the incident and to give her a call, too. A telephonic interview was conducted on July 1, 2026, at 9:43 a.m. with Resident #96's emergency contact and other daughter, who stated that someone from the facility called her and stated that the incident involved a nurse hitting her mom. The emergency contact stated that she was told that a nurse jabbed her mom's leg and did not leave a mark. The emergency contact stated that her sister told her to visit their mom that evening and when she did go to visit the resident told her that she did not report what happened to her, but that for two nights, the nurse was telling the resident that no one wanted to come into her room to help because she was always asking for help and that they all know that she was pretending. The emergency contact stated that she had asked the resident how the facility found out about the incident if she did not report it, and the resident stated that she was being transferred from her chair to the bed when she had a leg spasm, and that the nurse nudged her knee and told her to quit pretending, but that the resident could not move her leg. The emergency contact further stated that the resident told her that the CNA who was there reported it, and that the resident was asked about the incident, and she told them that it happened. The emergency contact stated that the police went to the facility, and that she called the police to ask about it, and they told her that it was going to be a criminal investigation now. The emergency contact stated that the nurse was identified as the LPN, Staff #25, and that the nurse did not work with her again. The emergency contact stated that since the incident, her mother is not acting like herself, she is not really talking, and she will not eat or drink now. A telephonic interview was attempted on July 1, 2026, at 11:03 a.m. with a CNA, Staff #34, who witnessed the incident, with no success. A telephonic interview was attempted on July 1, 2026, at 11:06 a.m. with a Licensed Practical Nurse (LPN/Staff #25), who was accused of hitting the resident, with no success. An interview was conducted on July 1, 2026, at 11:22 a.m. with a Registered Nurse (RN/Staff #56), who stated that physical abuse was defined as hitting, threatening to hit, slapping, or any type of hitting, both closed- or open-hand. The RN stated that verbal abuse was defined as speaking to someone in a way that makes them feel threatened, scared, or unsafe, and that yelling and intimidation with volume were forms of verbal abuse. The RN stated that the timeframe for reporting an allegation of abuse was 4 hours when someone was injured, and that she would report to the DON and administrator. The RN stated that reportable allegations would be anything that makes her concerned about the possibility of abuse, and that she would tell her supervisor immediately. The RN stated that the risk of failing to report abuse per the facility policy would be that abuse could continue happening, someone could have an injury and the facility wouldn't know about it, and there could be emotional and psychological damage. The RN stated that the same risks were possible regarding reporting allegations of abuse late, and added the risk that residents may continue to work with someone who abused them. The RN stated that she had to report an allegation of abuse one morning when a CNA told her that a resident alleged that they had been abused by the night shift. The RN stated that the incident was reported to her about 2 weeks ago, and that the CNA who reported to her was Staff #40. The RN also stated that she went to check in with the resident, who reported to the RN that the night before, a nurse had hit her in the leg and was telling her to relax it because she was having a muscle spasm and was stiff. The RN stated that the resident told her that the nurse hit her leg until it relaxed, and that the RN did a handwritten statement at the time, and that there was a police report. The RN stated that she did not remember if the wording was slap or hit, but that she wrote a statement, and that it was a reportable incident because no resident should ever be hit, slapped or experience aggressive behavior. The RN stated that she did not do the skin assessment, but that she knew the resident was hurt emotionally by the incident because the resident was tearful and stated that it made her feel like no one cared about her and that she wasn't wanted at the facility. The RN opened Resident #96's progress notes and stated that the incident occurred on the night of June 15, 2026, and that it was reported to her on June 16, 2026. The RN stated that the nurse who hit the resident was Staff #25 and that the RN reported the incident to management between 7:45 and 8:30 a.m. on the 16th.An interview was conducted on July 1, 2026, at 11:58 a.m., with a CNA, Staff #32, who stated that physical abuse was defined as putting hands on a resident in a manner that would hurt them, including hitting, slapping, pinching, and poking. The CNA stated that verbal abuse was defined as yelling, cussing, putting someone down, or using negative words towards a person. The CNA stated that the timeframe for reporting an allegation of abuse was two hours and that she would need to report to the DON and ADON. The CNA stated that any type of abuse was reportable, but especially physical abuse. The CNA stated that the risk of failing to report abuse as per the abuse policy was that someone could get an injury, abuse could continue, it could happen to another resident, and it could make the resident scared or not trusting. The CNA also stated that there had been a recent allegation of abuse at the facility where a CNA, Staff #34, witnessed Resident #96 being hit by an LPN, Staff #25. The CNA stated that the CNA who witnessed the incident, Staff #34, mentioned to another CNA, Staff #84, that she witnessed the nurse hitting the resident, and that it was not reported within the required timeframe because she was scared to have to report it to the nurse on the floor that night, whom she accused of hitting the resident. The CNA stated that when Staff #84 told her about the incident, Staff #32 reported the allegation to the resident's CNA, Staff #40, who spoke with the resident the morning after the incident. The CNA stated that when Staff #40 spoke with the resident, the resident was crying and reported to staff that the LPN punched her in the leg. An interview was conducted on July 1, 2026, at 11:40 a.m. with a Licensed Nursing Assistant (LNA/Staff #40), who stated that physical abuse was defined as hitting, being too rough, restraining, and pulling hair. The CNA stated that verbal abuse was defined as screaming, yelling, cussing, demeaning, and belittling a resident. The CNA stated that the timeframe for reporting an allegation of abuse was two hours, but that the expectation was to report immediately to your superior. The CNA stated that the risk of failing to report an allegation of abuse, per the facility policy, would be continued abuse to residents, and that the resident might experience a mental or physical decline, might lack trust, and could feel like no one was listening to them and continue to endure abuse because of not wanting to report. The CNA stated that an allegation of abuse was reported to her by another CNA, Staff #32, who was told by a CNA, Staff #84, that CNA, Staff #34, witnessed Resident #96 being hit by LPN, Staff #25. The CNA stated that she asked Resident #96 to take a walk with her, they found a location for privacy, and the CNA told the resident she could be honest and tell her if something happened with the nurse. The CNA stated that the resident began to tear up and told the CNA that the nurse was yelling at her and hitting her in the legs the night before. The CNA stated that the resident told her that she needed help bending her knees, and when they finished talking, the CNA ran to tell the RN, Staff #56, that she had a reportable abuse allegation. The CNA stated that the RN talked with the resident, who reported the same information verbatim and demonstrated where she was punched in the right leg. The CNA stated that after they interviewed the resident, the RN reported the incident further, and the CNA brought the resident back to her room to lie down and have a brief change. The CNA stated that the resident's leg was bruised in the same area that she had pointed to in her demonstration of the hit, and that the CNA had made a handwritten statement regarding the incident that detailed the same information she just shared; however, the facility did not provide the written statement in the facility investigation. The CNA stated that her statement was dated June 16, 2026, and that her interview with the resident was between 7:30 and 8:30 a.m. that day. An interview was conducted on July 1, 2026, at 12:46 a.m., with a CNA, Staff #84, who stated that physical abuse was defined as hitting, punching, physical touch, or hitting with objects, all of which could be with either a closed fist or an open hand. The CNA stated that verbal abuse was defined as yelling, screaming, cussing, degrading someone, or humiliating them. The CNA stated that the timeframe for reporting was two hours and that she would have to report to the DON and ADON. The CNA further stated that all allegations of abuse were reportable, and that the risk of failing to report an allegation of abuse was that the staff could get in trouble, lose their license, and anything could happen to the resident. The CNA also stated that a potential risk of delaying the reporting of an abuse allegation could be that the incident details could be forgotten or twisted, and that residents could lose their sense of security or feel ignored. The CNA stated that another CNA, Staff #34, recently had to report abuse that they had witnessed, and that Staff #34 pulled the CNA into a private room to get her opinion on what she witnessed. The CNA stated that Staff #34 told her that she witnessed a nurse smacking a resident's leg and telling her to bend her knees, and heard the resident saying please stop hitting me. The CNA stated that she told Staff #34 to report the incident right away and make a written statement so nothing was forgotten or lost, and as far as the CNA knew, Staff #34 told the DON and wrote the statement. An interview was conducted on July 1, 2026, at 1:09 p.m. with the DON, Staff #17, who stated that physical abuse was defined as touching someone when they do not want to be touched, and gave examples of physical abuse, such as slapping, hitting, punching, kicking, and grabbing. The DON stated that verbal abuse was defined as screaming, yelling, cussing, and belittling someone. The DON stated that the timeframe for reporting an allegation of abuse was immediately to their direct supervisor, and that administration had two hours to report per the facility policy. The DON stated that all allegations of abuse were reportable, and further stated that when an allegation was made, their process was to immediately do an investigation, suspend everyone involved, make sure the resident was safe, interview staff, interview residents, and report to APS, local police, the ombudsman, and AZDHS. The DON stated that the only instance in which a written statement would be excluded from the final investigation report would be if the staff member was interviewed and did not know anything about the incident, and that if the staff member interacted with or spoke to the resident involved, their statement would need to be included. The DON also stated that failure to include those statements in the investigation would mean that it was not a thorough investigation. The DON stated that the risk of failing to report abuse as per the facility policy was that abuse could continue to happen and put residents and staff in harm's way. The DON also stated that the risk of not thoroughly investigating, such as leaving staff statements out of the investigation, would be that the investigation wouldn't be thorough and would also put residents and staff in harm's way. The DON stated that they recently reported an incident that was reported to them by a CNA who slipped a note under the OM's door and texted that she needed to talk to them. The DON stated that administration was out of town for a conference at the time, so they had the CNA send a picture of her note, and when they read the allegation, they started the investigation. The DON stated that the facility reported the incident on June 16, 2026, but that the incident occurred on June 15th around 7:30-8 p.m. The DON further stated that the CNA reported that she witnessed a nurse slap a resident's leg during a two-person transfer from wheelchair to bed, and that the nurse slapped the resident while telling her to bend her leg. The DON stated that the CNA did not report the incident to them until the next day and that the staff's reporting of the incident was not within the facility's expectations or policy, and further stated that, as a result, the facility did not report within the required timeframe. The DON also stated that in their investigation, they talked to the CNA who witnessed the incident, the nurse who was accused, and the nurse who was on shift the next morning, who had called to tell them that there was an allegation of abuse. The DON stated that the accused nurse did not write them a statement and that the result of the investigation was unsubstantiated despite the resident saying she was hit and a CNA witnessing it, because after talking to the accused nurse, the LPN stated that she did not hit the resident, but instead was doing a tactile touch. The DON also stated that they terminated the LPN, Staff #25, on June 17, 2026, because she was not friendly with staff or residents, they had prior concerns about her behavior before the abuse incident, and she was cursing in the hallways, but denied terminating the nurse because of the incident with Resident #96. The DON stated that the resident told other staff members, including the RN, Staff #56, that she was hit by the LPN, and that there were written statements that the facility did not provide in the facility investigation request. An interview was conducted on July 1, 2026, at approximately 1:45 p.m. with the OM/Staff #70, who stated that physical abuse was defined as when someone inflicts physical harm on someone, with examples being hitting, pulling hair, grabbing, and slapping someone with intent to harm. The OM stated that verbal abuse was defined as using vulgar language, curse words, someone's demeanor, and belittling someone. The OM stated that she was the abuse coordinator, and that the timeframe for reporting an allegation was two hours to AZHDS, the ombudsman, local police, the case manager, the administrator, and the Medicaid agency. The OM stated that if someone told her that they witnessed a staff member abusing someone, they would look into it, and that the investigation would entail interviewing staff who were around or witnessed the abuse, and residents involved, with the DON present. The OM stated that corporate required them to fill out an abuse form with questions, and that the only instance where the facility would exclude statements from the facility investigation would be if the statements did not pertain to the situation, or if the statement was not first-hand from a witness of the incident. The OM acknowledged that someone interviewing the resident about the incident would be no different from their interviews with the resident, but that she was instructed by corporate higher-ups after the recent reportable incident to not include written statements from staff who did not physically witness the incident. The OM stated that the risk of failing to report abuse as per the facility policy would be a delay in a proper investigation, and not following the policy. The OM stated that failing to include statements in their facility investigation would be that they would not have conducted a thorough investigation. The OM stated that the facility had a reportable incident recently when a CNA, Staff #34, texted her that there was an incident and that she slid a note under the OM's door. The OM stated that they called social services to ask the resident what happened, that they suspended the nurse until they figured out the investigation was completed, and that the social worker and ADON conducted interviews. The OM stated that the incident occurred on the night of June 15, 2026, but that it wasn't reported until the morning of June 16, 2026. The OM further stated that the reporting of this incident was not within the facility's expectations for reporting. The OM stated that she talked with the resident on the 17th of June, and the resident told them that a staff member hit her on the leg. The OM further stated that they asked her if she could show them where the nurse hit her, to which the resident visually demonstrated a hit to the left leg and said, She just hit me. The OM stated that the resident told them that a CNA was in the room to witness the incident, but that the resident did not recall her name. The OM stated that they identified that it was CNA, Staff #34, following her report, and that the CNA told them it was the right leg, but that the CNA's demonstration of the incident did not make sense because of the side of the bed she was standing on, which led to the facility unsubstantiating their investigation. The OM stated that the CNA told them that the nurse was telling the resident to bend her knees, and that she was shocked by what she witnessed. The OM stated that she asked the CNA why she did not report the incident in a timely manner, and she got hostile and asked who she was supposed to report to if the nurse whom she would report to was being accused. The OM stated that the CNA quit during their conversation and that they terminated the LPN, Staff #25, on June 17, 2026, because they were getting feedback from staff and residents that the LPN was rude, not friendly, and lacked bedside manner, but denied that the termination was related to the abuse incident. The OM stated that they interviewed the people involved, but that they left pieces out of the facility investigation, and that it was not to hide anything. The OM further stated that it was probably not thoroughly investigated because of what was left out, and that they would change the outcome of their investigation to say it happened because of what they found out in the investigation, and that the resident and the witness both stated that it happened, in combination with the additional written statements from staff who interviewed the resident. The OM stated that the skin assessment showed that the resident did have bruising following the incident, but stated that it was an old, faded bruise that police took a photo of; however, the skin assessments and shower sheets did not show the presence of bruising before the incident. Review of a policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, was dated January 1, 2024, and revealed that all reports of resident abuse should have been reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The policy revealed that the findings of all investigations should have been documented and reported, and that the suspicion of abuse must be reported immediately to the administrator and other officials according to state law. The policy revealed that reporting immediately was defined as within two hours of an allegation involving abuse or an allegation resulting in serious bodily injury. The policy revealed that all allegations should have been thoroughly investigated, and that at a minimum, the investigation would include interviews with staff members (on all shifts) who had contact with the resident during the period of the alleged incident, any witnesses to the incident, the person(s) reporting the incident, the resident (as medically appropriate) or the resident's representative, and observations of the alleged victim, including his or her interactions with staff and other residents. The policy further revealed that witness statements should have been obtained in writing, signed, and dated. The policy also revealed that the witness was able to write his/her statement, or the investigator could obtain a statement. The po

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to protect one resident's (#96) rights to be free from staff-to-resident physical abuse. The deficient practice could result in residents being physically and emotionally harmed.Findings include:Resident #96 was admitted to the facility on [DATE], with a diagnosis that included encounter for palliative care, muscle spasms, atherosclerotic heart disease, malignant neoplasm of the cervix uteri, type 2 diabetes, hypertension, urinary incontinence, pressure ulcer of the sacral region, polyneuropathy, and generalized anxiety disorder.A Medicare 5-Day Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 11, which indicated moderate cognitive impairment. A skin assessment dated [DATE], revealed that the resident did not have any skin impairments.Review of an alert charting progress note dated June 15, 2026, at 7:02 p.m. revealed that the resident had activated her call light and that the certified nursing assistant (CNA) had responded and found the resident seated in her wheelchair. The note further revealed that the resident was slipping from her chair with both knees locked, gripping the wheelchair armrests, and demonstrating generalized body rigidity. The note revealed that the CNA attempted to reposition the resident safely, but the resident continued to maintain her rigid posture despite verbal instructions to relax. The note also revealed that the CNA requested nursing assistance, and upon entering the room, the nurse observed the resident continuing to extend her lower extremities while maintaining body rigidity, partially lifting and pushing herself from the wheelchair seat. The note revealed that the CNA remained present while attempting to provide support and prevent loss of balance, and that the resident was instructed multiple times to relax her body and bend her knees for safe repositioning. The note revealed that the resident was informed that maintaining a rigid posture during transfers and repositioning increases the risk of injury to herself and staff assisting her. The note also revealed that following repeated verbal instructions, the resident relaxed her posture and was repositioned back into the wheelchair. The note revealed that when asked what had occurred, the resident stated that her body had become weak. The note revealed that due to the observed behavior creating an increased risk for falls, loss of balance, and potential injury to both the resident and assisting staff, the resident was assisted to bed for safety. The note further revealed that no injuries were noted during assessment, the call light was placed within reach, and staff were advised to continue close monitoring and reinforce safe transfer techniques.A review of a shower skin assessment sheet dated June 16, 2026, revealed that the resident had no indicated skin impairments. A skin assessment dated [DATE], at 11:22 a.m. revealed that the resident had a nickel-sized blue bruise on the center of her right knee and a nickel-sized blue bruise with a 2-millimeter scab over the center of her left lateral knee cap, with both skin impairments having a side note that says patient states she probably bumped it. The skin assessment revealed an additional note of multiple red spots on the resident's bilateral arms, with a side note that says patient states she gets these from bumping into things. A care plan focus initiated on June 17, 2026, revealed that the resident was at risk for misappropriation, neglect, abuse, and/or exploitation related to her decreased mobility and neurological symptoms, with a goal to not experience misappropriation, neglect, abuse, and/or exploitation through the review date. The care plan revealed interventions to monitor for signs and symptoms of misappropriation, neglect, abuse, and/or exploitation, and report to the facility's abuse officer and medical provider. A review of a shower skin assessment sheet dated June 18, 2026, revealed that the resident had no indicated skin impairments.A request was made on July 1, 2026, at 7:14 a.m. for all self-reports and investigations at the facility in the last 4 months. Review of the facility investigation dated June 18, 2026, revealed that on June 15, 2026, at approximately 7 p.m., a CNA, Staff #34, reported that she responded to the resident's call light and found her slipping out of her wheelchair. The investigation revealed that the CNA called for assistance from the Licensed Practical Nurse (LPN/Staff#25), who positioned herself on the right side, and the CNA was on the left side. The investigation revealed that both staff members said that the resident's knees were locked and stiff, and that the resident reported feeling weak and unable to bend her knees. The investigation revealed that, according to the CNA, Staff #34, the LPN, Staff #25, tapped the resident's right shin area in an attempt to encourage the resident to bend her legs. The investigation revealed that staff were able to safely reposition the resident in the wheelchair and subsequently transfer the resident to bed without further difficulty. The investigation also revealed that witness interviews were taken from a CNA, Staff #34, the LPN, Staff #25, and another CNA, Staff #21, and that other records reviewed included written statements. The investigation revealed that all appropriate notifications to the family, Arizona Department of Health Services (AZDHS), Adult Protective Services (APS), local police, and the Ombudsman were made according to policy, and that during the investigation, it was determined that the allegation of abuse was unsubstantiated. The investigation revealed that corrective actions included the statement that no policies were broken, and the investigation was signed by the Operations Manager and Abuse Coordinator (OM/Staff #70) on June 22, 2026. A follow-up request was made on July 1, 2026, at 9:55 a.m. for a 5-day investigation with interviews for Resident #96. Review of the facility investigation with interviews revealed that an interview with Resident #96 was conducted on June 16, 2026, at approximately 1:30 p.m. The interview revealed that the resident spoke with the OM (Staff #70) and the Director of Nursing (DON/Staff #17) about the incident on June 15, 2026, and the resident reported that the LPN, Staff #25, touched her left leg at the knee and that the resident made a motion with her hand. The interview revealed that the OM asked the resident if they could assess her left leg, the resident agreed, and the assessment revealed an old bruise with a scab in the center on the left side of the resident's kneecap. The facility investigation further revealed that the OM and the DON met with the CNA, Staff #34, regarding the reported incident, and during the meeting, the CNA was asked to demonstrate the incident as it had been described. The interview revealed that the CNA initially stated that the nurse touched the resident's right leg and touched the OM's lower right shin, and the OM told the CNA that the resident reported that the nurse touched her left knee. The interview revealed that the CNA stated that both legs had been touched and demonstrated the interaction, stating that the nurse was standing in front of the resident, bent over, and touched both legs in the manner she demonstrated on the OM. The facility investigation also revealed an interview on June 16, 2026, at 8:37 a.m. with another CNA, Staff #21, who worked the shift on the incident date, who denied knowing of any incident that occurred on that shift. The facility investigation revealed an interview with the LPN, Staff #25, on June 16, 2026, at 9:17 a.m., during which she stated that she documented the resident's behaviors in a progress note. The interview revealed that the OM informed the LPN that a staff member reported that the LPN struck the resident on the right leg while instructing her to bend her knees, and the LPN denied striking the resident. The interview revealed that the LPN stated they were doing a two-person transfer when the resident stiffened her legs, and that she had her arm under the resident's arm and provided a tactile cue behind the resident's left knee while instructing her to bend this knee.A follow-up request was made on July 1, 2026, at 10:10 a.m. for written witness statements for the incident regarding Resident #96. Review of the requested written witness statements revealed one statement by the CNA, Staff #34, titled Incident Report was signed and dated June 16, 2026. The statement revealed that on the night shift of June 15, 2026, the CNA was putting Resident #96 back into bed as she was slipping out of her chair, and the resident's legs were stiff. The written statements revealed that the nurse on shift, Staff #25, smacked the resident's legs to get her to bend her knees between 6 and 7:20 p.m. The CNA wrote that she was in shock more than angry and to ask resident about last night please. Following an interview with the OM and abuse coordinator, Staff #70, on July 1, 2026, at approximately 1:45 p.m., a request was made for the written witness statements that the facility had not provided with the initial requests for the complete investigation. Review of the written witness statements revealed a statement from a Registered Nurse (RN/Staff #56), signed and dated June 16, 2026. The written statement from the RN revealed that shortly after breakfast, Resident #96's CNA reported to the RN that Resident #96 had described abuse that had happened to her overnight. The written statement further revealed that the RN sat down with the resident in a private place and asked what had happened, and the resident began crying and said that when staff were transferring her the night before, the nurse started yelling at her, saying, relax your legs! The written statement also revealed that the resident stated that she tried to tell the nurse that she couldn't help it and could not relax her legs, and that the nurse began hitting her legs until they relaxed. The written statement revealed that the RN asked the resident if anyone else was there when the incident happened, and the resident said that only the LPN was hitting her, but she thought it happened in front of someone else. The written statement revealed that the resident denied anyone else hitting or hurting her, and that the resident told the RN that the LPN told her that the resident was mean to staff and that the resident hurts staff with her (resident #96) behavior. The written statement further revealed that the resident told the RN that the LPN told the resident that she hurt a CNA's back by stiffening her legs and made them cry, and the resident told the RN that she was going to report the LPN to social services, but that the nurse told her that all of the nurses document her behavior, which made the resident feel that no one would listen. The written statement revealed that the RN called and reported the incident to the assistant director of nursing (ADON), and that she had spoken with the DON, who verified that the director had been notified. An interview was attempted with Resident #96 on July 1, 2026, at 8:35 a.m., but the resident was not able to answer any questions.An interview was conducted on July 1, 2026, at approximately 9 a.m., with Resident #96's roommate, Resident #14, who revealed that she had been Resident #96's roommate for 3 weeks. The resident stated that she heard a nurse yelling at Resident #96 one time, but she did not know what the nurse was yelling. The resident stated that she had not seen the nurse providing care to them since she yelled at Resident #96. A telephonic interview was attempted on July 1, 2026, at 9:26 a.m. with a CNA, Staff #21, who worked the night shift on the date of the incident, with no success. A telephonic interview was conducted on July 1, 2026, at 9:36 a.m. with Resident #96's responsible party and daughter, who stated that she was made aware of an incident at the facility where a nurse assaulted her mom. The resident's responsible party stated that the incident was reported by a CNA, that they filed a police report, and that the nurse was suspended. The resident's responsible party stated that the nurse was trying to get the resident to straighten her legs, and that the nurse told the resident she knew the resident was faking it before striking her legs to straighten them out. The resident's responsible party stated that her sister would know more about the incident and to give her a call, too. A telephonic interview was conducted on July 1, 2026, at 9:43 a.m. with Resident #96's emergency contact and other daughter, who stated that someone from the facility called her and stated that the incident involved a nurse hitting her mom. The emergency contact stated that she was told that a nurse jabbed her mom's leg and did not leave a mark. The emergency contact stated that her sister told her to visit their mom that evening and when she did go to visit the resident told her that she did not report what happened to her, but that for two nights, the nurse was telling the resident that no one wanted to come into her room to help because she was always asking for help and that they all know that she was pretending. The emergency contact stated that she had asked the resident how the facility found out about the incident if she did not report it, and the resident stated that she was being transferred from her chair to the bed when she had a leg spasm, and that the nurse nudged her knee and told her to quit pretending, but that the resident could not move her leg. The emergency contact further stated that the resident told her that the CNA who was there reported it, and that the resident was asked about the incident, and she told them that it happened. The emergency contact stated that the police went to the facility, and that she called the police to ask about it, and they told her that it was going to be a criminal investigation now. The emergency contact stated that the nurse was identified as the LPN, Staff #25, and that the nurse did not work with her again. The emergency contact stated that since the incident, her mother is not acting like herself, she is not really talking, and she will not eat or drink now. A telephonic interview was attempted on July 1, 2026, at 11:03 a.m. with a CNA, Staff #34, who witnessed the incident, with no success. A telephonic interview was attempted on July 1, 2026, at 11:06 a.m. with a Licensed Practical Nurse (LPN/Staff #25), who was accused of hitting the resident, with no success. An interview was conducted on July 1, 2026, at 11:22 a.m. with a Registered Nurse (RN/Staff #56), who stated that physical abuse was defined as hitting, threatening to hit, slapping, or any type of hitting, both closed- or open-hand. The RN stated that verbal abuse was defined as speaking to someone in a way that makes them feel threatened, scared, or unsafe, and that yelling and intimidation with volume were forms of verbal abuse. The RN stated that reportable allegations would be anything that makes her concerned about the possibility of abuse, and that she would tell her supervisor immediately. The RN stated that the risk of failing to report abuse per the facility policy would be that abuse could continue happening, someone could have an injury and the facility wouldn't know about it, and there could be emotional and psychological damage. The RN stated that the same risks were possible regarding reporting allegations of abuse late, and added the risk that residents may continue to work with someone who abused them. The RN stated that she had to report an allegation of abuse one morning when a CNA told her that a resident alleged that they had been abused by the night shift. The RN stated that the incident was reported to her about 2 weeks ago, and that the CNA who reported to her was Staff #40. The RN also stated that she went to check in with the resident, who reported to the RN that the night before, a nurse had hit her in the leg and was telling her to relax it because she was having a muscle spasm and was stiff. The RN stated that the resident told her the nurse hit the resident's leg until it relaxed, and that the RN did a handwritten statement at the time, and that there was a police report. The RN stated that she did not remember if the wording was slap or hit, but that she wrote a statement, and that it was a reportable incident because no resident should ever be hit, slapped or experience aggressive behavior. The RN stated that she did not do the skin assessment, but that she knew the resident was hurt emotionally by the incident because the resident was tearful and stated that it made her feel like no one cared about her and that she wasn't wanted at the facility. The RN opened Resident #96's progress notes and stated that the incident occurred on the night of June 15, 2026, and that it was reported to her on June 16, 2026. The RN stated that the nurse who hit the resident was Staff #25 and that the RN reported the incident to management between 7:45 and 8:30 a.m. on the 16th.An interview was conducted on July 1, 2026, at 11:58 a.m., with a CNA, Staff #32, who stated that physical abuse was defined as putting hands on a resident in a manner that would hurt them, including hitting, slapping, pinching, and poking. The CNA stated that verbal abuse was defined as yelling, cussing, putting someone down, or using negative words towards a person. The CNA stated that any type of abuse was reportable, but especially physical abuse. The CNA stated that the risk of failing to report abuse per the abuse policy was that someone could get an injury, abuse could continue, it could happen to another resident, and it could make the resident scared or not trusting. The CNA also stated that there had been a recent allegation of abuse at the facility where a CNA, Staff #34, witnessed Resident #96 being hit by an LPN, Staff #25. The CNA stated that the CNA who witnessed the incident, Staff #34, mentioned to another CNA, Staff #84, that she witnessed the nurse hitting the resident, and that it was not reported within the required timeframe because she was scared to have to report it to the nurse on the floor that night, whom she accused of hitting the resident. The CNA stated that when Staff #84 told her about the incident, Staff #32 reported the allegation to the resident's CNA, Staff #40, who spoke with the resident the morning after the incident. The CNA stated that when Staff #40 spoke with the resident, the resident was crying and reported to staff that the LPN punched her in the leg. An interview was conducted on July 1, 2026, at 11:40 a.m. with a Licensed Nursing Assistant (LNA/Staff #40), who stated that physical abuse was defined as hitting, being too rough, restraining, and pulling hair. The CNA stated that verbal abuse was defined as screaming, yelling, cussing, demeaning, and belittling a resident. The CNA stated that the risk of failing to report an allegation of abuse, per the facility policy, would be continued abuse to residents, and that the resident might experience a mental or physical decline, might lack trust, and could feel like no one was listening to them and continue to endure abuse because of not wanting to report. The CNA stated that an allegation of abuse was reported to her by another CNA, Staff #32, who was told by a CNA, Staff #84, that CNA, Staff #34, witnessed Resident #96 being hit by LPN, Staff #25. The CNA stated that she asked Resident #96 to take a walk with her, they found a location for privacy, and the CNA told the resident she could be honest and tell her if something happened with the nurse. The CNA stated that the resident began to tear up and told the CNA that the nurse was yelling at her and hitting her in the legs the night before. The CNA stated that the resident told her that she needed help bending her knees, and when they finished talking, the CNA ran to tell the RN, Staff #56, that she had a reportable abuse allegation. The CNA stated that the RN talked with the resident, who reported the same information verbatim and demonstrated where she was punched in the right leg. The CNA stated that after they interviewed the resident, the RN reported the incident further, and the CNA brought the resident back to her room to lie down and have a brief change. The CNA stated that the resident's leg was bruised in the same area that she had pointed to in her demonstration of the hit, and that the CNA had made a handwritten statement regarding the incident that detailed the same information she just shared; however, the facility did not provide the written statement in the facility investigation. The CNA stated that her statement was dated June 16, 2026, and that her interview with the resident was between 7:30 and 8:30 a.m. that day. An interview was conducted on July 1, 2026, at 12:46 a.m., with a CNA, Staff #84, who stated that physical abuse was defined as hitting, punching, physical touch, or hitting with objects, all of which could be with either a closed fist or an open hand. The CNA stated that verbal abuse was defined as yelling, screaming, cussing, degrading someone, or humiliating them. The CNA further stated that all allegations of abuse were reportable, and that the risk of failing to report an allegation of abuse was that the staff could get in trouble, lose their license, and anything could happen to the resident. The CNA also stated that a potential risk of delaying the reporting of an abuse allegation could be that the incident details could be forgotten or twisted, and that residents could lose their sense of security or feel ignored. The CNA stated that another CNA, Staff #34, recently had to report abuse that they had witnessed, and that Staff #34 pulled the CNA into a private room to get her opinion on what she witnessed. The CNA stated that Staff #34 told her that she witnessed a nurse smacking a resident's leg and telling her to bend her knees, and heard the resident saying please stop hitting me. The CNA stated that she told Staff #34 to report the incident right away and make a written statement so nothing was forgotten or lost, and as far as the CNA knew, Staff #34 told the DON and wrote the statement. An interview was conducted on July 1, 2026, at 1:09 p.m. with the DON, Staff #17, who stated that physical abuse was defined as touching someone when they do not want to be touched, and gave examples of physical abuse, such as slapping, hitting, punching, kicking, and grabbing. The DON stated that verbal abuse was defined as screaming, yelling, cussing, and belittling someone. The DON stated that all allegations of abuse were reportable, and further stated that when an allegation was made, their process was to immediately do an investigation, suspend everyone involved, make sure the resident was safe, interview staff, interview residents, and report to APS, local police, the ombudsman, and AZDHS. The DON stated that the only instance in which a written statement would be excluded from the final investigation report would be if the staff member was interviewed and did not know anything about the incident, and that if the staff member interacted with or spoke to the resident involved, their statement would need to be included. The DON also stated that failure to include those statements in the investigation would mean that it was not a thorough investigation. The DON stated that the risk of failing to report abuse as per the facility policy was that abuse could continue to happen and put residents and staff in harm's way. The DON also stated that the risk of not thoroughly investigating, such as leaving staff statements out of the investigation, would be that the investigation wouldn't be thorough and would also put residents and staff in harm's way. The DON stated that they recently reported an incident that was reported to them by a CNA who slipped a note under the OM's door and texted that she needed to talk to them. The DON stated that administration was out of town for a conference at the time, so they had the CNA send a picture of her note, and when they read the allegation, they started the investigation. The DON stated that the facility reported the incident on June 16, 2026, but that the incident occurred on June 15th around 7:30-8 p.m. The DON further stated that the CNA reported that she witnessed a nurse slap a resident's leg during a two-person transfer from wheelchair to bed, and that the nurse slapped the resident while telling her to bend her leg. The DON stated that the CNA did not report the incident to them until the next day and that the staff's reporting of the incident was not within the facility's expectations or policy, and further stated that, as a result, the facility did not report within the required timeframe. The DON also stated that in their investigation, they talked to the CNA who witnessed the incident, the nurse who was accused, and the nurse who was on shift the next morning, who had called to tell them that there was an allegation of abuse. The DON stated that the accused nurse did not write them a statement and that the result of the investigation was unsubstantiated despite the resident saying she was hit and a CNA witnessing it, because after talking to the accused nurse, the LPN stated that she did not hit the resident, but instead was doing a tactile touch. The DON also stated that they terminated the LPN, Staff #25, on June 17, 2026, because she was not friendly with staff or residents, they had prior concerns about her behavior before the abuse incident, and she was cursing in the hallways, but denied terminating the nurse because of the incident with Resident #96. The DON stated that the resident told other staff members, including the RN, Staff #56, that she was hit by the LPN, and that there were written statements that the facility did not provide in the facility investigation request. An interview was conducted on July 1, 2026, at approximately 1:45 p.m. with the OM/Staff #70, who stated that physical abuse was defined as when someone inflicts physical harm on someone, with examples being hitting, pulling hair, grabbing, and slapping someone with intent to harm. The OM stated that verbal abuse was defined as using vulgar language, curse words, someone's demeanor, and belittling someone. The OM stated that if someone told her that they witnessed a staff member abusing someone, they would look into it, and that the investigation would entail interviewing staff who were around or witnessed the abuse, and residents involved, with the DON present. The OM stated that corporate required them to fill out an abuse form with questions, and that the only instance where the facility would exclude statements from the facility investigation would be if the statements did not pertain to the situation, or if the statement was not first-hand from a witness of the incident. The OM acknowledged that someone interviewing the resident about the incident would be no different from their interviews with the resident, but that she was instructed by corporate higher-ups after the recent reportable incident to not include written statements from staff who did not physically witness the incident. The OM stated that the risk of failing to report abuse as per the facility policy would be a delay in a proper investigation, and not following the policy. The OM stated that failing to include statements in their facility investigation would be that they would not have conducted a thorough investigation. The OM stated that the facility had a reportable incident recently when a CNA, Staff #34, texted her that there was an incident and that she slid a note under the OM's door. The OM stated that they called social services to ask the resident what happened, that they suspended the nurse until they figured out the investigation was completed, and that the social worker and ADON conducted interviews. The OM stated that the incident occurred on the night of June 15, 2026, but that it wasn't reported until the morning of June 16, 2026. The OM stated that she talked with the resident on the 17th of June, and the resident told them that a staff member hit her on the leg. The OM further stated that they asked her if she could show them where the nurse hit her, to which the resident visually demonstrated a hit to the left leg and said, She just hit me. The OM stated that the resident told them that a CNA was in the room to witness the incident, but that the resident did not recall her name. The OM stated that they identified that it was CNA, Staff #34, following her report, and that the CNA told them it was the right leg, but that the CNA's demonstration of the incident did not make sense because of the side of the bed she was standing on, which led to the facility unsubstantiating their investigation. The OM stated that the CNA told them that the nurse was telling the resident to bend her knees, and that she was shocked by what she witnessed. The OM stated that she asked the CNA why she did not report the incident in a timely manner, and she got hostile and asked who she was supposed to report to if the nurse whom she would report to was being accused. The OM stated that the CNA quit during their conversation and that they terminated the LPN, Staff #25, on June 17, 2026, because they were getting feedback from staff and residents that the LPN was rude, not friendly, and lacked bedside manner, but denied that the termination was related to the abuse incident. The OM stated that they interviewed the people involved, but that they left pieces out of the facility investigation, and that it was not to hide anything. The OM further stated that it was probably not thoroughly investigated because of what was left out, and that they would change the outcome of their investigation to say it happened because of what they found out in the investigation, and that the resident and the witness both stated that it happened, in combination with the additional written statements from staff who interviewed the resident. The OM stated that the skin assessment showed that the resident did have bruising following the incident, but stated that it was an old, faded bruise that police took a photo of; however, the skin assessments and shower sheets did not show the presence of bruising before the incident. Review of a policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, was dated January 1, 2024, and revealed that all reports of resident abuse should have been reported to local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. The policy revealed that the findings of all investigations should have been documented and reported, and that the suspicion of abuse must be reported immediately to the administrator and other officials according to state law. The policy revealed that all relevant professional and licensing boards were notified when an employee was found to have committed abuse, and that if the investigation revealed that the allegation(s) of abuse were founded, the employee(s) would be terminated. The policy also revealed that any allegations of abuse would be 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.Review of a policy titled, Resident Rights/Dignity: Resident Rights, was dated January 1, 2024, and revealed that federal and state laws guarantee certain basic rights to all residents in the facility, including the resident's right to be free from abuse, neglect, misappropriation of property, and exploitation.

Based on observations, staff interviews, and policy review, the facility failed to ensure that drugs and biologicals were stored, secure, and inaccessible to unauthorized staff and residents in accordance with facility policy, state, and federal laws for four of eighteen sampled residents (#5, #22, #69, #89). The universe was seventy-one. The deficient practice could lead to medications being incorrectly administered or accidentally ingested by a resident. Findings Include: -Regarding Resident #5 Resident #5 was admitted on [DATE] with diagnosis including bipolar disorder, current episode-depressed, dementia-unspecified severity without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, psychosis not due to a substance or known psychological condition, schizoaffective disorder, essential hypertension, edema, dermatitis, cellulitis and pruritis. A review of the annual MDS (minimum data set) dated March 23, 2026 revealed a BIMS (brief interview of mental status) score of 99, indicating the interview could not be completed. A review of the physician orders revealed an order dated July 26, 2024 for Nystatin powder 100,000 unit/gm (gram) to apply topically every shift for fungal infection related to candidiasis-unspecified. However, there was no evidence of an order for self-administration of medications. Review of the care plan revealed a focus area including an alteration in neurological status due to dementia which was initiated on June 7, 2022 which noted interventions including to administer medications as ordered and monitor/ document for side effects and effectiveness. A further focus area was documented, noting that the resident has impaired cognitive function/ dementia or impaired thought process due to dementia initiated on June 16, 2024. Intervention included to administer medications as ordered, and that the resident is able to recall one/ two or three instructions. However, the care plan revealed no evidence of a focus area documenting the resident's ability to self-administer medications. A review of the electronic health record revealed no evidence of an assessment for self-administration of medication. An observation was conducted on June 7, 2026 at 10:00 AM in the resident's room. A bottle of Nystatin topical powder 100,000 usp (United States Pharmacopeia) was observed on the resident's bedside table, noting to apply to navel for skin infection for 14 days dated October 15, 2025 with an expiration date of April 13, 2026. An interview was conducted with resident #5 on June 7, 2026 at 10:07 AM. Resident #5 stated that she did not know that the Nystatin powder was there or what it was for. An interview was conducted on June 7, 2026 AM with Certified Nursing Assistant (CNA/ staff #91). Staff #91 stated that medications should not be at bedside. Staff #91 further stated that if she did not know with certainty if something was a medication she would notify the nurse. Staff #91 stated that Nystatin was a medication and should not be at bedside. An interview was conducted on June 7, 2026 at 10:12 AM with Licensed Practical Nurse (LPN/ staff #56). Staff #56 stated that Nystatin was deemed a medication and that a doctor's note would be required for the medication to be authorized at the bedside table. Staff #56 stated that she was unsure if it required an assessment but stated that she was certain that it required a physician order. Staff #56 stated if medications are found at bedside, they are 'pulled' from the resident's room and reported to the DON (Director of Nursing). The LPN reviewed the medication and further stated that it was prescribed in October of 2025 and had a use-by date of April 13, 2026. She stated that the medication should have been disposed of. Staff #56 stated that the risk could include ingestion, if a resident was not oriented enough. An interview was conducted on June 9, 2026 at 8:34 AM with the DON, staff #83. The DON stated that a medication is anything with an active ingredient, ordered by a physician, but could also include over the counter medications. She further stated that medication administration routes could include oral, nasal, vaginal, intravenous, topical, and sublingual. The DON stated that the expectation for self-administration of medications was that an order must be in place, an assessment must be conducted, it must be care planned and the medication must be in a lock box. She stated that the aforementioned would be documented in the resident's electronic health record. The DON reviewed the electronic health record for resident #5 and stated that there were no current orders for the Nystatin and stated that there was no assessment or care plan entry for self-administration for medications. The DON stated that the general expectation for self-administration included the physician order, assessment, care planning and for a lock box to be in place to store the medication. The DON stated that the lock box is there so that medications cannot be accessed by other residents and further stated that individuals should not self-administer medications if they are cognitively impaired. Staff #83 further stated that no one in the facility is self-administering medications. The DON stated that the risk to the resident could include improper use or ingesting the medication. Staff #83 stated that she was aware that there was an issue regarding medications at bedside and that there is currently a PIP (performance improvement plan) in place, citing that education had already been completed by 99% of the nursing staff, with only 3 staff members remaining to be trained. -Regarding Resident #89: Resident #89 was admitted to the facility on [DATE], with diagnoses that included weakness, unstageable pressure ulcer of the sacral region, essential hypertension and glaucoma. A review of the Resident's hospital record dated June 2, 2026, revealed that over the last 1 to 2 months, the Resident had a slow decline in her mental status, and she was often confused and forgetful. The Resident's care plan dated June 4, 2026, revealed that the resident was at risk for functional self-care deficit and or functional mobility limitations, and at risk for skin impairment and or pressure injury. The interventions included to have physical therapy, occupational therapy, and speech therapy evaluation and treatment as per the provider orders, to encourage the Resident's participation to the fullest extent possible with each interaction, and to follow the facility policies and protocols for the prevention and treatment of skin breakdown. A review of the nursing health status progress note dated June 4, 2026, revealed that the Resident arrived to the facility for a 4-days of respite, and the Resident brought her own medications from home. The nurse practitioner progress notes dated June 5, 2026, revealed per the document that the Resident had a slow decline in her mental status, being forgetful and confused for 1 to 2 months. On June 7, 2026, at 8:47 AM, an observation was made, in the Resident's room by the vanity sink there was a white with red and green colored container. The container had a front label that read Treat Antifungal Powder For skin with a fungal infection. An interview was conducted on June 7, 2026, at 9:01 AM, with a Licensed Practical Nurse (LPN/Staff #56) who held the previously held container and stated that it was an antifungal powder and that somebody must have left it. She stated that the bottle belonged to Resident #89. Staff #56 stated that she would double check the Resident's order for antifungal orders. She also stated that she would double check if it was prescribed to the Resident. She stated that it should not have been left in the room because if the medication was left in the room, the resident might not be able to use it appropriately and that it could cause harm to the resident. At 9:06 AM, Staff #56 was observed by her medication cart, and after checking the orders in the electronic medical record, she stated that she did not see an order for the antifungal powder in the Resident's electronic medical record. An interview was conducted on June 9, 2026, at 8:16 AM with a Registered Nurse (RN/Staff #58). Staff #58 stated that she would not leave an antifungal powder at bedside unless there was a care plan to do so. She stated that some residents could have a care plan for self-administration of medication for medications such as an eye drop, and she stated that an antifungal powder is still a medication and she would not leave it at the bedside because the nurses apply the antifungal powder to the resident, a certified nursing assistant (CNA) could not apply the medication, and a resident could not apply it unless there was a care plan for self-administration. On June 9, 2026, at 8:34 AM, an interview was conducted with the Director of Nursing (DON/Staff #83). The DON stated that her expectation for self-administration of medications was that there must be an order, an assessment, must be care planned, the medications must be in a lock box, and the corresponding documentation would be housed in the resident's electronic health record. The DON stated that topicals are also considered medications. She also stated that unless assessed, ordered and care planned, antifungals should not be at bedside. The DON also reviewed the electronic record of Resident #89, and she stated that there were no orders in place for the antifungal, current or past orders, and she stated that there was no assessment in place for self-administration of medications for the Resident. The DON stated that the risk of leaving the medication at bedside could lead to ingesting and misuse. Furthermore, the DON stated that her expectation for self-administration is that an order, assessment, care planning and lock box are in place. She stated that the lock box is there so that medications could not be accessed by other residents. She also stated that individuals should not self-administer if they were cognitively impaired. She stated that no Resident in the facility was currently self-administering medications. -Regarding Resident #69 (medications unattended at bedside): Resident #69 was re-admitted on [DATE] with diagnoses that included vascular dementia, Type 2 Diabetes Mellitus, and major depressive disorder. A quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 13, which indicated intact cognition. A care plan initiated, August 5, 2025, revealed no evidence of a focus or interventions related to medication self- administration. Further review of the care plan revealed the following: Diabetes focus with interventions that included medication as ordered by doctor. Antiplatelet medication with interventions to give medication as ordered. Clinical records dated August 5, 2025 through June 7, 2026, revealed no evidence of: A medication self-administration assessment or IDT meeting related to medication self-administration Physician orders for Medication Self Administration Medication self-administration in care planned focus or interventions Provider orders revealed the following: Eliquis 5 mg tablet, give tow times a day related to atherosclerotic heart disease, ordered August 5, 2025. Aspirin Chewable 81 mg, give 162 milligrams one time a day, ordered August 5, 2025. Vitamin D3, give 2000 units by mouth one time a day for supplement, ordered August 5, 2025. Glipizide 5 mg tablet, give 1 tablet by mouth one time a day for diabetes, dated May 28, 2026. Donepezil HCL 5 mg tablet, give 10mg by mouth one time a day ordered November 9, 2025. Losartan Potassium 50 mg tablet, give 2 one time a day for hypertension, ordered March 7, 2026. During an initial observation conducted on June 07, 2026 at 8:39 a.m. in the room of Resident #69, a meal tray was observed sitting unopened on the resident walker seat across from the resident's bed and a clear medication cup with 6 pills was sitting on the food tray. The resident was lying on the bed and no staff were in the room. The medications observed in the medication cup included 2 pink tablets, 1 clear yellow tablet, 1 oval white tablet, 1 round white tablet, and 1 white tablet. The surveyor went to the resident's door and asked staff or the medication nurse. An interview was conducted with Resident #69 at 8:44 a.m. who stated that staff usually wake her up to let her know that her meal is ready, and that staff leave her medications on her meal tray, then leave the room. An interview was conducted with a Registered Nurse (RN/staff #65) in the resident's room at 8:45 a.m., who stated that it is not following the policy to leave medications unattended in a resident's room. The RN also stated that nursing staff are expected to wait until the resident has swallowed all of the medications in front of nurse or med tech. The RN further stated that the risk of leaving mediations unattended at the bedside could result in medications taken outside of schedule which could lead to lower blood pressure or glucose levels, and also could increase the risk of resident's receiving medications too close together. An interview was conducted on 8:45 a.m. with a Certified Medical Assistant/Medication Technician (CMA/Staff #54), who stated that she left the resident's medications at the bedside about 5 minutes previously. The CMA stated that she woke up the resident, told her about the medications, and left the medications in the resident's room. The CMA further stated that the facility expectation is to watch the residents take all medications before leaving the room. The CMA stated that she got caught up with another resident. The CMA identified the medications in the medication cup left at the bedside as: Pink- Eliquis for blood clot prevention. Pink Chewable aspirin Clear yellow - Vitamin d 3 White oval – Amlodipine Small round white – Glipizide for blood sugar White – Cardivol The CMA also stated that the risk of leaving medications unattended at the bedside could result in another resident taking the medication without staff knowing. Further review of the June 2026 revealed that that there were no orders for the medications that the CMA identified as Cardivol or Amlodipine in the medication cup that had been left unattended. However, the MAR revealed orders Donepezil and Losartan. An interview was conducted on June 9, 2026 at 1:40 p.m., with a Licensed Nursing Assistant (LNA/staff #14), who stated that residents should not be left alone in the room with medications at the bedside. The LNA stated that if she found medications at the bedside, she would stay with the medications, and ask another staff member to get the nurse. The LNA further stated that she was not aware of any residents in the facility that have been assessed to take keep their medications unattended at the bedside. The LNA also stated that Resident #69 would not be safe for self-administering medications, of for medications to be left unattended in her room. The LNA stated that there had been medications left unattended in the resident's room approximately 3 weeks ago, they were on the resident's bedside table, and when she pointed the medications out to the resident, the resident said she did not know that the medications had been left. The LNA stated that she removed the medications from the resident's bedside table and took them to the nurse. An interview was conducted on June 9, 2026 at 11:52 a.m. with a Licensed Practical Nurse (LPN/staff #22), who stated that medications are not to be left unattended at a resident's bedside per the facility policy. She also stated that residents would require an assessment for medication self-administration with discussions/education on medication storage, the care plan would be updated, and a physician order would be required. The LPN stated that the risk of leaving medications unattended at the bedside could result in another resident taking the medication. The LPN stated the Resident #69 was alert with a poor memory, and that medications were not supposed to be left unattended in the resident's room. The LPN reviewed the resident's records and stated that there was no evidence of a provider order, medication self-administration assessment, or care plan update for the resident to self-administer medications. An interview was conducted with the Director of Nursing (DON/staff #83) on June 9, 2026 at 1:36 p.m., who stated that in order for residents to self-administer medication there needs to be a provider order, an assessment, a care plan developed and the medications must be kept in a lock box. She further stated that all of this would be documented in the resident's clinical record. The DON also stated that she expected nursing staff and medication technicians to staff with each resident until the medication is administered. She also stated that it did not meet her expectation for medications to be left unattended at a resident's bedside. The DON stated that the risk of leaving medication unattended in a resident's room could result in someone else taking the medication, the medication could be spilled or dropped on the floor. -Regarding resident #22: Resident #22 was admitted on [DATE] with diagnoses including spastic hemiplegic cerebral palsy, epilepsy, and gastro-esophageal reflux disease without esophagitis. A review of IDT (interdisciplinary team) notes from September 26, 2019 through June 8, 2026 revealed no evidence that resident #22 was authorized to self-administer medications. A review of the comprehensive care plan dated September 27, 2019 revealed no evidence that resident #22 was authorized to self-administer medications. A review of the MDS (minimum data set) dated March 9, 2026 revealed a BIMS (brief interview of mental status) score of 14, which revealed intact cognition. A review of physician orders from May 1, 2026 through June 8, 2026 revealed no evidence of orders for medication self-administration. Further review of physicians orders revealed an order, dated August 14, 2024, for Tums Oral Tablet Chewable 500 mg (Calcium Carbonate (Antacid)). Give 2 tablets by mouth two times a day for GERD (gastro-esophageal reflux disease) without esophagitis. Additionally, an order was implemented May 16, 2023, for Calcium Carbonate Oral Tablet, give 750 mg by mouth every 6 hours as needed for Heart burn related to gastro-esophageal reflux disease without esophagitis. A review of assessments on June 8, 2026 within the electronic health record revealed no evidence that resident #22 was assessed to self-administer medications. During an observation conducted in resident #22's room on June 7, 2026 at 9:31 a.m., a plastic cup with 4.5 quarter-sized round tablets was observed to be present on the wooden dresser. Resident #22 stated the medication was Tums for her acid reflux and it was given to her by the nurse but she hadn't gotten around to taking them. During a follow up observation conducted in resident #22's room on June 7, 2026 at 11:23 a.m., the resident stated she had already taken the Tums in the plastic cup. Following this observation, an interview was conducted with a Certified Medication Aide (CMA/staff #54) on June 7, 2026 at 11:37 a.m Staff #54 stated that she had left a plastic cup of Tums in resident #22's room during morning medication pass and presented a bottle of Tums from the bottom drawer of the medication cart. Staff #54 further stated that resident #22 was able to self administer medications. Staff #54 reviewed the electronic health record and stated that the resident had an order for Tums and calcium carbonate tablets, but stated that she was unable to find self administration of medications in the care plan, orders, or kardex. Staff #54 stated that the risk of leaving the Tums in the residents room include the possibility of other people ingesting the tablets when the resident isn't looking and the resident could choke on the medication if she does not chew it properly. A review of the medication administration record from June 1, 2026 to June 8, 2026 revealed Tums was administered to resident #22 on June 7, 2026 in the morning by Staff #54. An interview was conducted on June 9, 2026 at 8:34 a.m. with the Director of Nursing (DON/staff #83). The DON stated that the expectation for self-administration of medications is that there must be an order, an assessment, it must be care-planned and the medications must be in a lock box. The DON further stated that the corresponding documentation would be housed in the electronic health record. The DON also stated that she considered Tums to be a medication and that they should not be bedside unless the process of orders, assessment, care planning and lock box had been followed. The DON then reviewed the electronic health record for resident #22 and stated that the resident had an order for Tums but not for self-administration of Tums and further stated that there was no assessment and no care planning for self-administration. The DON stated the risks for medications at bedside include medication not being taken as prescribed, another resident taking them, or spilling. The DON also stated no one in the facility is currently self-administering medications. The facility's policy titled, Medication Labeling and Storage, dated January 1, 2024, revealed that the facility stores all medications and biologicals in locked compartments under proper temperature, humidity and light controls. Only personnel have access to keys. The facility's policy titled, Self-Administration of Medications, dated January 1, 2024, revealed as part of the evaluation comprehensive assessment, the interdisciplinary team (IDT) assesses each resident's cognitive and physical abilities to determine whether self-administering medication is safe and clinically appropriate for the resident. If the resident is deemed able to self-administer medications, the medications are stored in a safe and secure place, which is not accessible by other residents. If safe storage is not possible in the resident's room, the medications of residents permitted to self-administer are stored on a central medication cart or in the medication room. A licensed nurse transfers the unopened medication to the resident when the resident requests them. The policy further states any medications found at the bedside that are not authorized for self-administration are turned over to the nurse in charge for return to the family or responsible party. A policy titled, Medications: Administering Medications, revealed that medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. The individual administering medications verifies the resident's identity before giving the resident his/her medications. Resident's may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. For residents not in their rooms or otherwise unavailable to receive medication on the pass, the nurse will return to the missed resident to administer the medication.

Based on review of the facility assessment, facility documentation, interviews, and policy review, the facility failed to ensure there was sufficient staff to meet the needs of the residents. The deficient practice could result in residents not receiving the appropriate care to maintain safety, and the highest practicable physical, mental, and psychological well-being as determined by resident assessments and individual plans of care.Findings include:The PBJ (Payroll-Based Journal) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing for all four quarters in 2025, and the first quarter of 2026. The facility assessment reviewed on June 9,2026, revealed the facility was licensed to provide care for 104 residents, had an average daily census of 78-85, and had an average number of 3-6 weekday admissions and 1-2 weekend admissions, and 2-5 weekday discharges and 0-3 weekend discharges. Staffing plan included the following:-full time Director of Nursing (DON)-full time Assistant Director of Nursing (ADON)-3 full time Registered Nurses (RN)/Licensed Practical Nurse (LPN) on AM shift (6:00 a.m. to 6:00 p.m.)-1 Certified Nursing Aide (CNA) for 10-13 residents on AM shift (6:00 a.m. to 6:00 p.m.)-2 full time RNs/LPNs on PM shift (6:00 p.m. to 6:00 a.m.)-1 CNA for 13-16 residents on PM shift (6:00 p.m. to 6:00 a.m.) The daily staffing assignment for May 9, 2026, revealed the following:-Census of 74:2 RN/LPNs were scheduled for the AM shift, which resulted in 37 residents, per nurse.4 CNAs were scheduled for the PM shift, which resulted in 18 Residents, per CNA.1 Certified Medication Aide (CMA) was scheduled for the AM and PM shifts.No [NAME], (staff who are responsible for answering to call bells, refill water pitchers, restock briefs and gloves, and empty the dirty laundry bins), was scheduled for either AM or PM shift. The daily staffing assignment for May 10, 2026, revealed the following:-Census of 75:2 RN/LPNs were scheduled for the AM shift, which resulted in 37 residents, per nurse.4 CNAs were scheduled for the AM and PM shifts, which resulted in 18 to 19 residents, per CNA.1 CMA was scheduled for the AM and PM shifts.1 [NAME] was scheduled for the AM shift. The daily staffing assignment for May 16, 2026, revealed the following:-Census of 77:2 RN/LPNs were scheduled for the AM shift, which resulted in 38 residents, per nurse.5 CNAs were scheduled for the AM shift, which resulted in 15 residents, per CNA.1 CMA was scheduled for the AM and PM shifts.1 [NAME] was scheduled for the PM shift. The daily staffing assignment for May 17, 2026, revealed the following:-Census of 77:2 RN/LPNs were scheduled for the AM shift, which resulted in 38 residents, per nurse.4 CNAs were scheduled for the AM and PM shifts, which resulted in 19 residents, per CNA.1 CMA was scheduled for the AM and PM shifts.2 Valets were scheduled for the AM shift. The daily staffing assignment for May 23, 2026, revealed the following:-Census of 78:2 RN/LPNs were scheduled for the AM shift, which resulted in 39 residents, per nurse.5 CNAs were scheduled for the AM shift, which resulted in 15 residents, per CNA.1 CMA was scheduled for the AM and PM shifts.1 [NAME] was scheduled for the AM shift. The daily staffing assignment for May 24, 2026, revealed the following:-Census of 77:2 RN/LPNs were scheduled for the AM shift, which resulted in 38 residents, per nurse.5 CNAs were scheduled for the AM shift, which resulted in 15 residents, per CNA.1 CMA was scheduled for the AM and PM shifts.1 [NAME] was scheduled for the AM shift. The daily staffing assignment for May 30, 2026, revealed the following:-Census of 72:2 RN/LPNs were scheduled for the AM shift, which resulted in 36 residents, per nurse.4 CNAs were scheduled for the PM shift, which resulted in 18 residents, per CNA.1 CMA was scheduled for the AM shift.1 [NAME] was scheduled for the PM shift. The daily staffing assignment for May 31, 2026, revealed the following:-Census of 71:2 RN/LPNs were scheduled for the AM shift, which resulted in 35 residents, per nurse.4 CNAs were scheduled for the AM shift, which resulted in 18 residents, per CNA.1 CMA was scheduled for the AM and PM shift.1 [NAME] was scheduled for the AM shift. The daily staffing assignment for June 5, 2026, revealed the following:-Census of 74:4 RN/LPNs were scheduled for the AM shift. The ADON and the DON were also scheduled.4 CNAs were scheduled for the PM shift, which resulted in 18 to 19 residents, per CNA.1 CMA was scheduled for the PM shift.1 [NAME] was scheduled for the AM and PM shift. The daily staffing assignment for June 6, 2026, revealed the following:-Census of 73:3 RN/LPNs were scheduled for the AM shift.5 CNAs were scheduled for the AM shift, which resulted in 14 residents, per CNA.1 CMA was scheduled for the AM and PM shifts.1 [NAME] was scheduled for the PM shift. The daily staffing assignment for June 7, 2026, revealed the following:-Census of 71:2 RN/LPNs were scheduled for the AM shift, which resulted in 35 residents, per nurse.5 CNAs were scheduled for the AM shift, which resulted in 14 residents, per CNA.1 CMA was scheduled for the AM and PM shifts.1 [NAME] was scheduled for the AM shift.On December 15, 2025, the State Agency (SA) received a complaint that stated the facility was so short staffed that CNAs had 4 separate hallways of Residents to care for and Hoyer lifts were used by only 1 staff member, when 2 staff are required.An interview was conducted on June 9, 2026, at 9:39 AM, with the RN, staff #65. The RN stated staffing was low for nurses and CNAs. The RN stated it was typical to have a caseload of 35 plus Residents during a shift. The RN stated some of the CNAs have been trained as a CMA so they could aid the nurses in medication pass. The RN stated there are many tasks that cannot be completed during the shift; for example, a full set of vitals are not always completed, however, if a Resident is on a blood pressure medication, before the RN administered the medication, she would get a blood pressure reading but not have time to complete a full set of vitals. The RN stated getting weights on Residents were missed often due to not having enough time to complete the task. The RN stated on night shift, it was typical to run out of protein ice cream and calcium drinks due to the staff not having access to the supply room. The RN explained that night shift was not always stocked with supplies because day shift would not have enough staff to stock supplies for night shift. The RN stated the CNAs would not take lunch breaks due to not having enough time, however, she would take a lunch because she needed it. The RN stated she had stayed past her shift if there was a new admission or if a Resident sustained a fall.An interview was conducted on June 9, 2026, at 9:58 AM, with LPN, staff #85. The LPN stated there has been a struggle with staffing nurses and CNAs. She stated some CNAs had been trained for CMA to aid the nurses with medication pass. The LPN stated there were times the facility would ask sister facilities to assist with staffing. The LPN stated most times she does not take a break or a lunch break and Administration would ask her why. The LPN stated her response was I don't have time. The LPN stated she had stayed past her shifts to complete tasks she had been too busy to finish during her shift. An interview was conducted on June 9, 2026, at 10:11 AM, with Licensed Nurse Aide (LNA). The LNA stated her tasks were completed by the end of her shift, however there were days when a curveball would be thrown and change things. The LNA stated the protocol for a staff call-off was to notify the Staffing Coordinator/CNA, staff #66, who would contact other staff members. The LNA stated if other staff were not able to work the shift, then staff #66 would cover the shift. She stated she is scheduled for 4-12-hour days a week but typically works 5-12-hour days.An interview was conducted on June 9, 2026, at 10:34 AM, with Staffing Coordinator/CNA, staff #66. She stated the typical staffing plan for weekdays and weekends were as follows:-1 to 2 RNs for AM and PM shifts-1 to 2 LPNs for AM and PM shifts-5 CNAs for the PM shift-6 CNAs for the AM shift-1 [NAME] for the AM and PM shiftsStaff #66 stated staffing is done in my head. Staff #66 stated she had not used a computer program to determine staffing and did not know what the facility assessment was. She stated she thinks staffing is good. She stated if there were call-offs she would begin texting or calling other staff to see if they were able to pick up a shift, if she cannot find anyone she will pick up the shift.An interview was conducted on June 9, 2026, at 10:56 AM with DON, staff #83. The DON stated staffing was adequate. She stated the staff schedule is completed by using the facility assessment and the current census. Review of the staff schedules for weekends revealed the staff numbers dropped compared to during the week, however, the DON stated staffing is adequate due to the Valets and CMAs.An interview was conducted on June 9, 2026, at 1:34 PM, with the Administrator. She stated that staffing was adequate, however, call offs were a problem. She stated the goal was to have 4-5 CNAs on night shift and 5-6 on day shift, and 3 nurses per shift, however, that goal was not always achieved so the CMAs were implemented. She stated staff #66 was good at reaching out to other staff members to pick up shifts, and the group messages also went to the department heads. If needed, department heads would come in and answer call bells. The Administrator stated incentives are offered to staff for working extra shifts. She stated the CNAs that were interested in becoming a CMA were cross-trained. Review of the staff schedule, daily staff postings, and the facility assessment for weekends, the Administrator stated she clearly saw they were short staffed on the weekends and the schedule did not match the facility assessment. She stated the CNAs who had a caseload of 19 Residents each was too much. Review of the facility's policy on Administrative Policies: Staffing, Sufficient and Competent Nursing dated January 1, 2024 stated Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to provide nursing and related care and services for all residents in accordance with resident care plans and the facility assessment. Licensed nurses are required to supervise nurse aids/nursing assistants and are scheduled in such a way that permits adequate time to do so.

Based on an observation, clinical record review, interviews, facility documentation and policies, and review of the State Agency (SA) database, the facility failed to protect the rights of 3 out of 18 sampled residents (#92, #93, #8) to be free from physical and verbal abuse by another resident. The deficient practice could result in further resident abuse.Findings included:-Regarding Resident #92 (alleged victim) and Resident #12 (alleged perpetrator) -Resident #92 was admitted on [DATE] with diagnosis that included Type 2 Diabetes Mellitus, dementia, and blindness of one eye.Review of clinical records dated December 21, 2022 through December 29, 2022 revealed that the resident had to be redirected back to her room several times, and wandered multiple times throughout residents' rooms and on various hallways. wandering required supervision.A daily skilled evaluation progress note dated December 30, 2022 revealed that the resident required supervision and guidance due to intermittent periods of wandering, redirection and distraction usually effective.A care plan initiated on December 20, 2022, revealed a focus due to: Risk for Functional Self Care and mobility deficits related to dementia, decreased mobility.Risk for falls related to decreased mobility, dementia, right eye blindness, and wandering.A care plan initiated on December 28, 2022, revealed a focus for:Behavior problem related to wandering/exit-seeking, verbal behaviors, with interventions that included if issues arise, remove from situation, explain/reinforce why the behavior is inappropriate and/or unacceptable, intervene as necessary to protect the rights and safety of others. Impaired cognitive function/dementia or impaired thought processes related to dementia, neurological symptomsImpaired visual function related to diabetic retinopathy and right eye blindness.Further record review dated January 1, 2023 through April 29, 2023 revealed dementia with wandering, A care planned intervention was initiated on March 18, 2023 related to the focus for falls related to decreased mobility, dementia, right eye blindness, and wandering. The interventions included to have resident in common areas for closer supervision as often as possible. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status of 99, which indicated that the assessment could not be completed. A Staff Assessment for Mental Status assessment revealed Short-Term and Long-Term memory problems, and severely impaired daily decision making. The MDS also revealed the presence of verbal behavior toward others, and that wandering occurred 1-3 days during the assessment period.An Alert Charting progress note dated April 30, 2023, revealed that it was reported to the nurse by the CNA and [NAME] that a physical altercation took place. The note indicated that the CNA, reported that a scream was heard, and the CNA went to investigate and found Resident #92 in her wheelchair just outside the door of Resident #12's room. The CNA reported that Resident #12 stated that she pulled Resident #92's hair because Resident #92 keeps coming in Resident #12's room. The note included that the two residents were then separated and that neither of the resident's had any visible markings or signs of injury. The note further revealed that the provider, Director of Nursing, case manager and the residents' families were notified. The note included that a police report was initiated, statements were taken, and both residents would be monitored and kept at a safe distance.A behavior care plan revealed on April 30, 2023 that wandering places the resident at risk for receiving physical aggression from other residents. Interventions initiated on April 30, 2023 included to keep arms-length away from other residents, and minimize potential for disruptive behaviors of wandering into other residents' rooms by offering tasks which divert attention. dated includedA care plan dated June 14, 2023, revealed a focus for communication problem related to dementia. Interventions included to be conscious of the resident's position when in groups, activities, dining room to promote proper communication with others. -Resident #12 was admitted on [DATE] with diagnoses of Dementia, major depressive disorder, schizophrenia, anxiety disorder, hallucinations and blindness.An admission MDS dated [DATE], revealed a BIMS score of 14, which indicted intact cognition. The assessment also revealed no evidence of behavioral symptoms related to physical or verbal behaviors directed toward others.A care planned focus initiated April 1, 2023, revealed a behavior problem related to physical and verbal aggression towards other residents, resident is not to be within arm's reach of other residents at any time, resistive to care, verbal behavior and wandering.A behavior progress note dated April 2, 2023 revealed that a nurse heard the resident raising her voice at another resident, swinging her coffee cup around above her head yelling at the resident. An Alert Charting progress note dated April 30, 2023, revealed that a CNA, reported that a scream was heard, and the CNA went to investigate, and found Resident #92 in her wheelchair just outside the door of Resident #12's room. The CNA reported that Resident #12 stated that she pulled Resident #92's hair because Resident #92 kept coming into Resident #12's room. The note included that the two residents were then separated and that neither of the resident's had any visible markings or signs of injury. The note further revealed that the provider, Director of Nursing, case manager and the residents' families were notified. The note included that a police report was initiated, statements were taken, and both residents would be monitored and kept at a safe distance.A care planned focus for behavior problems revealed updated interventions initiated on May 17, 2023, which revealed: if issues arise, remove from situation, and if reasonable, discuss my behavior and explain/reinforce why the behavior is inappropriate and/or unacceptable, and intervene as necessary to protect the rights and safety of others. An interview was conducted on June 9, 2026 at 11:52 a.m. with a Licensed Practical Nurse (LPN/staff #22), who reviewed the records of Resident #12 and Resident #92 and stated that according to a progress note Resident #12 pulled the hair of Resident #92, at that this would be considered resident to resident abuse. The LPN further stated that Resident #92 is very protective of her space, and was aware of her actions.An interview was conducted on June 9, 2026 at 1:40 p.m. with a Certified Nursing Assistant (CNA/staff #14), who stated that one resident pulling another resident's hair would be considered physical abuse. An interview was conducted on June 9, 2026 at 1:36 p.m. with the Director of Nursing (DON/staff #83), described physical abuse as including pulling hair, kicking or shoving. The DON also stated that the resident's care plan should be updated with new interventions and current interventions evaluated for the perpetrator, but not the victim. The DON reviewed Resident #12's clinical record and stated that there was no evidence that the resident's care plan had been evaluated/updated regarding the incident that occurred on April 30, 2023. - Regarding Resident #8 (alleged victim) and Resident #93 (alleged victim):Resident #8 re-admitted on [DATE] with diagnosis including dementia, Type 2 Diabetes Mellitus, major depressive disorder, and anxiety disorder.An admission MDS dated [DATE] revealed a BIMS score of 99, which indicated that the resident was unable to complete the BIMS assessment. A Staff Assessment for Mental Status assessment revealed that the resident exhibited short and long-term memory problems, and the resident's cognitive skill for daily decision making was severely impaired. A care plan dated November 6, 2023 revealed the following areas of focus:Communication problem related to history of cerebrovascular accident (CVA) and confusionImpaired cognitive function/dementia or impaired thought processes related to BIMS score, history of CVA.Further review of the clinical record revealed no evidence the incident had been reported to a supervisor after it was reported by Resident #93 to a nurse, or documented in nursing progress notes.A Skin assessment dated [DATE] revealed no new or ongoing skin impairments.A late entry Nurse Practitioner (NP) progress note dated November 9, 2023, revealed that staff reported an incident with Resident #8's son yesterday, and that the resident did not want to discuss the incident. The note included that the resident denied any symptoms of pain or discomfort.An interview was conducted on June 9, 2026 at 11:52 a.m. with a Licensed Practical Nurse (LPN/staff #22), who reviewed Resident #8's clinical record and stated that there was no evidence that the nurse who received Resident #93's allegation related to Resident #8's son on November 8, 2023, documented the allegation or reported it to the charge nurse. The LPN further stated that Resident #8's special instructions profile in the EMR relayed that Resident #8 was able to go out on pass with her son, and her son can now visit Resident #8.An interview was conducted on June 9, 2026 at 1:36 p.m. with the Director of Nursing (DON/staff #83), who stated that there was no evidence in Resident #8's clinical record regarding the alleged incident that occurred on November 8, 2023, or that the resident's provider had been notified. The DON further stated that she expected there to have been a nursing progress note regarding the incident and of provider notification, however there was an NP note that the incident had been reported. The DON reviewed the clinical record and stated that there was no evidence in #8's progress notes regarding the resident's report to a nurse, and this did not meet the DON's expectations. However, there was a NP progress note that indicated that there had been an incident regarding Resident #8's son.-Resident #93: Resident #93 was re-admitted on [DATE] with diagnoses that included Type 2 Diabetes Mellitus, anemia, major depressive disorder, opioid dependence, and post-traumatic stress disorder (PTSD).A care plan initiated on October 23, 2023 revealed the following areas of focus:Anti-anxiety medications use related to PTSD.Antidepressant medication use related to depression, fibromyalgiaAn admission MDS dated [DATE] revealed a BIMS score of 13, which indicated intact cognitive function. The assessment revealed no evidence of verbal/physical behavioral symptoms directed toward others.A daily skilled evaluation progress note dated November 3, 2023, revealed that the resident refuses to participate in social activities, prefers to stay in her room.Review of the nursing progress notes revealed no evidence related to the incident that occurred on November 8, 2023 related to Resident #93 and Resident #8's son. Despite the resident reporting her concerns several times to nursing.Further review of the clinical record revealed no evidence that the nurse reported Resident #93's concerns to a supervisor or the Director of Nursing.Further review of the Facility 5-day report revealed a type written interviews conducted on November 9, 2023 regarding the incident:Resident #93 reported in an interview statement to the Administrator (staff #300) that on November 8, 2023 she was lying in bed and heard loud yelling and cussing coming from Resident #8's room, and Resident #93 got up and told the nurse. The resident reported that after that she went wheeling around, and as she was on her way back to her room Resident #8's son was walking to the door shaking his head and Resident #93 told him you don't need to talk to your mom that way, and then Resident #8's son stepped towards her and said fuck you bitch don't tell me how to talk to my mom. Resident #93 further stated that she explained to Resident #93's son that they knew each other from the reservation, and the resident further stated that Resident #93's son was angry.Resident #8 reported during an interview statement dated November 9, 2023 to the Administrator (staff #300) that she thought that her son visited her last night, and she stated that her son always talked loudly and cussed. Resident #8 relayed that her son was on a drinking binge, and that there was an incident in the dining room with her son being loud and saying cuss words. The interview included that her sister said that Resident #8's son was drunk and she would take him home.On November 9, 2023 a Certified Nursing Assistant (CNA/staff #310) reported in a written interview statement that on November 8, 2023, while in the dining room Resident #8's son was using the fuck word, and she asked him to stop cussing, that it is not okay.On November 10, 2023 a Registered Nurse (RN/staff #320) wrote a statement and wrote that she was sitting at the nurses' station charting on November 8, 2023 and a visitor of Resident #8 said, hey you go a mop, I spilled shit all over my mom's room. The RN wrote that she stated she did not have a mop but she offered to get the male visitor towels and he said well that's your fucking problem not mine, I don't give a fuck about that shit. The RN also relayed that while she was cleaning up the spill the man continued to use foul language and seemed to be upset.A written witness statement from LPN (staff #57), who wrote that she received noise complaints from Resident #93 and another resident that Resident #8's male visitor was cursing a lot and speaking very loudly. The LPN wrote that when she entered Resident #8's room the male visitor was speaking loudly and using inappropriate language, and she asked them to keep the volume down. The statement included that Resident #93 reported to the LPN that Resident #8's male visitor began to cuss at Resident #93 when Resident #93 told him not to talk to Resident #8 like that.A Licensed Practical Nurse (LPN/staff #305) wrote in an interview statement that as he was escorting Resident #8's son out of the facility on November 8, 2023, Resident #8's son continued to say, fuck you and fuck everyone here, fucking pussy.A written statement dated November 14, 2023 by the Assistant Director of Nursing (ADON/staff #83), relayed that she had received a report from Resident #93's daughter that Resident #93 texted her a message that Resident #8's son was drunk and cussing when he visited on November 8, 2023. The ADON reported that she spoke with Resident #93 who reported that Resident #8's son was in the dining room and was drunk, belligerent and cussing, and Resident #8 told him not to talk like that around the elders. The statement relayed that Resident #93 also reported that she heard Resident #8's son cussing at Resident #8 several times, and that Resident #8's son later approached Resident #93 as she was passing the room and cussed at her, and she felt that Resident #8's son went at her, so she stood up from her wheelchair and backed him down, then reported to the nurse.An interview was conducted on June 8, 2026 at 12:10 p.m. with the Administrator (staff #300), who stated that nurses should document reports of abuse in the resident's clinical records, and should also update the resident's care plan.An interview was conducted on June 9, 2026 at 11:52 a.m. with a Licensed Practical Nurse (LPN/staff #22), who stated that the facility Abuse policy is to separate the residents from danger, and immediately report the incident to the supervisor. The LPN also stated that verbal abuse could include talking down to a resident, calling names, berating and anything that would make a resident feel unsafe. The LPN further stated that anytime alleged abuse is reported the incident should be documented by nursing in the resident's progress notes along with notification of the family and provider. The LPN stated that the resident's care plan should also be updated with any new interventions, and evaluation of current interventions. The LPN relayed that when an incident occurs staff complete 72-hour alert charting, and document in progress notes. The LPN also stated that when a family member or visitor yells at a resident staff would remove the resident from harm, notify the supervisor, social services and that the family/visitor would be removed. The LPN also stated that a family member or visitor calling a resident a stupid bitch would be considered abuse. The reviewed Resident #93's clinical record and stated that there was no evidence in the resident's progress notes regarding her allegation of abuse related to Resident #8's son to the nurse, and that the LPN would have expected the nurse to have documented the allegation in Resident #93's progress notes.An interview was conducted on June 9, 2026 at 1:40 p.m. with a Certified Nursing Assistant (CNA/staff #14), who stated that abuse allegations should be reported to the charge nurse. She further stated that abuse could be verbal or physical, and included restraints and emotional harm. The CNA also stated that abuse could be resident to resident or visitor/family to resident. The CNA stated that a family member was yelling obscenities at a resident would be considered verbal abuse.An interview was conducted on June 9, 2026 at 1:36 p.m. with the Director of Nursing (DON/staff #83), who stated that abuse can be verbal, sexual, physical or misappropriation. She further stated that verbal abuse could include calling a resident a stupid bitch, or other cussing or swearing. The DON also stated that all abuse allegations should be documented in the clinical record in a progress note, and in an incident note, along with documentation of provider/family notification of the allegation. The DON stated that the resident's care plan should be updated with new interventions and current interventions evaluated for the perpetrator, but not the victim. The DON stated that she would have expected there to be a progress note in Resident #93's chart regarding her allegations about Resident #8's son because she reported that the family member was drunk and felt that he was getting aggressive with Resident #8. However, the DON reviewed Resident #93's clinical records and stated that there was no evidence that the nurse documented Resident #93's allegation or notified the charge nurse or DON.A facility policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revealed that residents have the right to be free from abuse. The resident abuse prevention program to protect residents from abuse by anyone including other residents, visitors and family members. Identify and investigate all possible incidents of abuse, and report any allegations within timeframes required by federal requirements. A facility policy titled, Abuse Policy, revealed that the facility strives to prevent the abuse of all residents, and that situations may arise where it is not possible to completely prevent all incidents of abuse. Abuse can be verbal physical or mental, and potential abusers can be residents, family members, visitors or any other person who comes into the facility. The policy included that none of the types of abuse are condoned in the facility and the objective is to provide a safe have for the residents. The policy revealed that abuse is the willful infliction of injury, and willful was defined as the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Verbal abuse includes yelling, screaming, cursing. Physical abuse includes hitting, kicking, grabbing, scratching, pushing/shoving, biting. Mental abuse is defined as verbal or nonverbal behavior that results in the infliction of anguish, mental pain, fear or distress, such as intent to humiliate, control or threaten.

Based on record review, staff interviews, review of facility documents and policy, the facility failed to ensure one out of eighteen sampled residents (#47) received treatment and care related to insulin and blood pressure medications in accordance with the provider's order, professional standards of practice and the resident's comprehensive person-centered care plan. The deficient practice could place the residents' health at risk.Findings include:Resident #47 was readmitted to the facility on [DATE], with diagnoses that included essential hypertension, type 2 diabetes mellitus, and end stage renal disease requiring hemodialysis treatment. The Resident's care plan revealed that the Resident had diabetes mellitus and hypertension. The goal was for the Resident to have no complications related to his diagnoses of diabetes and hypertension. The interventions included for the staff to administer medications for diabetes and anti-hypertensive as ordered by the doctor, obtain fasting blood sugar test as ordered by the doctor, and obtain blood pressure readings under the same conditions each time and use the Resident's right arm to take his blood pressure.A review of the Resident's Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 12.0, indicating that the Resident cognition was moderately intact. The assessment also revealed that the Resident required hemodialysis treatment, and the Resident also used hypoglycemic, including insulin medications.A review of the physician's orders revealed the following orders:Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML, inject 15 unit subcutaneously one time a day for diabetes, and hold if blood glucose is less than 110. Isosorbide Mononitrate Oral Tablet ER (Extended Release) 24 Hour 30 MG (milligram). Give 2 tablets by mouth one time a day for hypertension, and hold if the systolic blood pressure is less than 110.A review of the April 2026 Medication Administration Record (MAR) revealed a transcribed physician order for Isosorbide Mononitrate Oral Tablet ER (Extended Release) 24 Hour 30 MG (milligram), give 2 tablets by mouth one time a day for hypertension, and hold if the systolic blood pressure is less than 110. The MAR also revealed that on April 15, 2026, the Resident's blood pressure was 99/63. The Resident's systolic blood pressure was 99. Despite an order to hold the medication if the systolic blood pressure is less than 110, the MAR revealed that the medication was administered to the Resident.A review of the May 2026 MAR revealed a transcribed physician orders for Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML, inject 15 unit subcutaneously one time a day for diabetes, and hold if blood glucose is less than 110 and Isosorbide Mononitrate Oral Tablet ER (Extended Release) 24 Hour 30 MG (milligram), give 2 tablets by mouth one time a day for hypertension, and hold if the systolic blood pressure is less than 110.Regarding the administration of these medications, the following were noted during the MAR review:Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML, inject 15 unit subcutaneously one time a day for diabetes, and hold if blood glucose is less than 110, the May 2026 MAR revealed that on:May 8, 2026, the Resident's blood glucose was 109, the insulin medication was administered to the Resident despite an order to hold if blood glucose is less than 110.May 12, 2026, the Resident's blood glucose was 95, the insulin medication was administered to the Resident despite an order to hold if blood glucose is less than 110.May 13, 2026, the Resident's blood glucose was 92, the insulin medication was administered to the Resident despite an order to hold if blood glucose is less than 110.May 19, 2026, the Resident's blood glucose was 85, the insulin medication was administered to the Resident despite an order to hold if blood glucose is less than 110.May 25, 2026, the Resident's blood glucose was 93, the insulin medication was administered to the Resident despite an order to hold if blood glucose is less than 110.May 27, 2026, the Resident's blood glucose was 103, the insulin medication was administered to the Resident despite an order to hold if blood glucose is less than 110.May 28, 2026, the Resident's blood glucose was 108, the insulin medication was administered to the Resident despite an order to hold if blood glucose is less than 110.May 29, 2026, the Resident's blood glucose was 105, the insulin medication was administered to the Resident despite an order to hold if blood glucose is less than 110. Isosorbide Mononitrate Oral Tablet ER (Extended Release) 24 Hour 30 MG (milligram). Give 2 tablets by mouth one time a day for hypertension, and hold if the systolic blood pressure is less than 110, the May 2026 MAR revealed that on:May 9, 2026, the Resident's blood pressure was 105/63, the systolic blood pressure was 105, the blood pressure medication was administered to the Resident despite an order to hold if systolic blood pressure is less than 110.May 22, 2026, the Resident's blood pressure was 99/43, the systolic blood pressure was 99, the blood pressure medication was administered to the Resident despite an order to hold if systolic blood pressure is less than 110.A review of the June 2026 MAR revealed a transcribed physician order for Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML, inject 15 unit subcutaneously one time a day for diabetes, and hold if blood glucose is less than 110. The MAR also revealed that on June 4, 2026, the Resident's blood glucose was 96. Despite an order to hold the medication if the blood glucose is less than 110, the MAR revealed that the medication was administered to the Resident.An interview was conducted on June 9, 2026, at 8:16 AM with a Registered Nurse (RN/Staff #58). The RN stated that regarding medication administration process, she made sure to give the correct medications to the right resident, right time, and the right route. She stated that she should have the resident's medication profile screen open on her computer so she could check the medications, look at the Resident's recorded vital signs, and to check if anything could contraindicate the medication such as if the Resident might have low respiration, low blood pressure, and low pulse. She stated that depending on the type of medication, for example, if a Resident had a low blood pressure, she would hold the medication so the Resident's blood pressure would not go any lower. She also stated that regarding long acting insulin, with a parameter to hold if the blood sugar is less than 110, she stated that if the Resident's blood sugar is below the parameter order of 110, she would hold the insulin, so the Resident's blood sugar would not go lower, and because she was following the doctor's order. She further stated that if the insulin was administered outside the ordered parameter, the blood sugar would not go lower right away, but throughout the day the Resident's blood sugar could drop.During the interview with Staff #58, she stated that Resident #47 used long and short acting insulin for his diabetes. While Staff #58 was reviewing Resident #47's May 2026 MAR in the electronic medical record, she stated that on May 19, the Resident's blood sugar was 85, the Resident's insulin should not have been administered because the Resident's blood sugar was under 110, and the order was to hold if the blood sugar was under 110. She also stated that on May 8, May 12, May 13, May 16, May 19, May 25, May 27, May 28, and May 29, the insulin should not have been administered because it was not safe to give and it was outside the ordered parameter. She further stated that the scheduled time MD M found in the MAR meant before 6:00 AM during the night shift administration time schedule, and that the code 5 meant to hold and see the nurses' notes.An interview was conducted on June 9, 2026, at 9:04 AM with the Director of Nursing (DON/Staff #83). The DON stated that regarding the medication administration process, she expects her staff to follow the physician's orders, make sure the right medication, right dose, right time, right resident, right route, and right documentation were followed. She stated that if the process was not followed, there would be a potential for medication errors, the resident if medications are left at bedside could not take the medications, and the medication left at bedside could be taken by another resident. She also stated that if a medication was administered outside the ordered parameter, such as for insulin not to give if the blood sugar was less than 110, the result could lead to hypoglycemia.During the interview, the DON was looking at Resident #47's electronic medical record for the Resident's long acting insulin order, Insulin Glargine Subcutaneous Solution Pen-injector 100 UNIT/ML, inject 15 unit subcutaneously one time a day for diabetes, and hold if blood glucose less than 110. While reviewing the Resident's MAR, the DON stated that on:May 8, the blood sugar was 109, the medication was administered, and the order was not followed.May 12, the blood sugar was 95, the medication was administered, and the order was not followed.May 13, the blood sugar was 92, the medication was administered, and the order was not followed.May 19, the blood sugar was 85, the medication was administered, and the order was not followed.May 25, the blood sugar was 93, the medication was administered, and the order was not followed.May 27, the blood sugar was 103, the medication was administered, and the order was not followed.May 28, the blood sugar was 108, the medication was administered, and the order was not followed.May 29, the blood sugar was 105, the medication was administered, and the order was not followed.June 4, the blood sugar was 96, the medication was administered outside the parameter, and the order was not followed.The DON stated that if the insulin medication was administered outside the ordered parameter, the Resident could get hypoglycemic (low blood sugar). The DON stated that the MID M schedule time in the MAR meant after midnight, and the night shift staff administers the medications between 12:15 AM to 6:00 AM. She stated that the insulin medications were administered between 5:00 AM-6:00 AM on night shift, and breakfast arrives at 7:00 AM. She also stated that the medication administered outside the ordered parameter did not meet her expectation. Further, the DON stated that she has a PIP (Performance Improvement Project) on medication administration which included passing medication, giving the right medications, following doctors' orders, and that the PIP was started on May 26, 2026. She stated that there was no specific medication being looked at for this PIP, and that she did not review Resident #47's insulin concerns because she was not aware of the Resident's insulin medication administration issues.A follow up interview was conducted on June 9, 2026, at 9:55 AM with the DON. After the DON reviewed Resident #47's MAR in the electronic medical record, the DON stated that Resident #47's order for Isosorbide Mononitrate Extended Release 24 Hour 30 MG, give 2 tablets by mouth one time a day for hypertension and to hold if the systolic blood pressure is less than 110, the DON stated that on:April 15, the blood pressure was 99/63, the medication was administered, and the order was not followed.May 9, the blood pressure was 105/63, the medication was administered, and the order was not followed.May 22, the blood pressure was 99/43, the medication was administered, and the order was not followed.The DON stated that her expectation was for the staff to follow the doctor's order and to hold the medication if the systolic blood pressure was less than 110, or if it was outside the parameter. She stated that the resident could have hypotension if the medication was given below a systolic blood pressure of 110. She also stated that hypotension is low blood pressure, and that a low blood pressure is lower than 110.Review of the facility policy titled Quality of Care: Medication and Treatment Orders in effect on January 1, 2024, revealed a statement that orders for medications and treatments will be consistent with principles of safe and effective order writing. Per policy, medications shall be administered only upon the written orders of a person duly licensed and authorized to prescribe such medications.

Based on record review, staff interviews, observations, and review of facility policies and procedures, the facility failed to ensure that 2 out of 18 sampled residents (#1 and #2) received appropriate treatments and services to prevent urinary tract infections. The deficient practice could lead to a high risk of CAUTI (catheter-associated urinary tract infections), contamination transfer, tube obstruction or resident injury. Findings Include: -Regarding Resident #1 Resident #1 was admitted on [DATE] with diagnosis including type 2 diabetes mellites without complications, encephalopathy, end stage renal disease, bacteriuria, paroxysmal atrial fibrillation, dependence on renal dialysis, urinary tract infection, systemic inflammatory response syndrome of non-infectious origin, epilepsy, dementia with other behavioral disturbance, and obstructive and reflux uropathy. A review of the 5-day MDS (minimum data set) dated May 17, 2026 revealed a BIMS (brief interview of mental status) score of 6, indicated that the resident had severe cognitive impairment. The MDS further revealed that the resident had an indwelling catheter. A review of the physician orders revealed an order noting that the resident had Foley catheter, size 16 french and 10 cc (cubic centimeter) balloon dated May 14, 2026 as well as further orders noting catheter care with soap and water or wipes and directives to change the foley drainage bag as needed dated May 14, 2026. A review of the care plan revealed a focus area noting that the resident was on enhanced barrier precautions (EBP) due to a dialysis port/ catheter, PEG (percutaneous endoscopic gastrostomy)/ NG (nasogastric) tube and indwelling catheter, initiated May 16, 2026. An additional focus area revealed that the resident had an indwelling catheter, initiated May 16, 2026 and that interventions included that the catheter bag and tubing are to be positioned below the level of the bladder, changed as ordered, EBP in place and monitored for pain and or discomfort due to the catheter. An observation was conducted on June 8, 2026 at 11:56 AM while resident #1 was being transported from the secured unit to the main dining room. It was observed that the door from the secured unit was opened by a Certified Occupational Therapy Assistant (COTA/ staff #217) and that resident #1 was being pushed, via his wheelchair, through the door. It was subsequently observed that while pushing the resident through the door the wheelchair ran over the catheter bag and the resident said 'ouch'. The bag was observed to be dragging on the floor. While being transported to the main dining room, the bag continued to drag on the floor. Staff #217 positioned the resident against the back of the room and left the resident seated with the bag still touching the floor. An interview was conducted on June 8, 2026 at 11:59 AM with staff #217. Staff #217 stated that the expectation is that a catheter bag is properly situated and not touching the floor. She stated that when she picked up the patient up for lunch, he had already been transferred to the wheelchair and was given to her that way. Staff #217 was asked to observe the position of resident #1's catheter bag and stated that the catheter bag was touching the floor and should not have been. Staff #217 further stated that the risk to the resident could include the catheter bag getting yanked out, infection control issues and safety issues for the resident. An interview was conducted on June 9, 2026 at 7:21 AM with Registered Nurse (RN/ staff #58). Staff #58 stated that regarding catheter care, it was important to make sure that the bag is secured and off the ground. She stated that if a catheter bag was accidently rolled over, she would make sure to assess if there is any trauma and advise the provider and change the catheter out. She further stated that the risk for a bag being on the floor is infection. An interview was conducted on June 9, 2026 at 8:34 AM with the Director of Nursing (DON/ staff #83). Staff #83 stated that a catheter bag has to be kept off the floor, covered and safely secured. The DON further stated that the bag either had to be safely secured to the bed/ wheelchair/ Geri-chair. The DON stated that that if a catheter bag is run over, the expectation is that the catheter be changed. Staff #83 stated that during this event, the catheter bag was not changed immediately, but it was changed later in the day. The DON stated that the risk for a catheter bag being on the floor could include infection. Staff #217 further stated that anyone on the nursing or therapy team are responsible to ensure that the catheter bags are safely secured and covered for privacy. -Regarding resident #2: Resident #2 was admitted on [DATE] with diagnoses including displaced fracture of greater tuberosity of left humerus, chronic kidney disease, obstructive and reflux uropathy, and retention of urine. A review of the MDS (minimum data set) dated April 10, 2026 revealed a BIMS (brief interview of mental status) score of 9, which revealed moderate cognitive impairment. Further MDS record review revealed resident #2 had an indwelling catheter. A review of the Catheter Evaluation dated April 24, 2026 revealed the resident's medical condition/diagnosis of Obstructive Uropathy-Urinary Tract Obstruction supported the use of a catheter. A review of the residents care plan dated April 27, 2026, revealed a focus area including having an indwelling catheter related to obstructive uropathy, enhanced barrier precautions related to indwelling catheter, being at risk for functional self care deficits and/or functional mobility limitation related to urinary catheter use, and being at risk for skin impairment related to foley catheter use. A review of active physician orders on June 8, 2026 revealed orders for changing foley catheter as needed, change foley drainage bag as needed for poor drainage, leaking, soilage, blocking, or as ordered by provider, and to provide catheter care with soap and water or wipe, and that resident was on enhanced barrier precautions for catheter. During an observation conducted in resident #2's room on June 7, 2026 at 10:30 a.m., the resident was laying in bed and the catheter bag was observed making direct contact with the floor while the bed was in the lowest position. During an interview conducted in resident #2's room on June 7, 2026 at 10:31 a.m., resident #2 stated that the Certified Nursing Assistant (CNA) emptied the catheter bag a couple of hours ago and he did not know if the catheter bag had been in the same position since then. During an observation conducted in resident #2's room on June 8, 2026 at 1:59 p.m., the resident was laying in bed and the catheter bag was observed making direct contact with the floor while the bed was in the lowest position. An interview was conducted on June 8, 2026 at 2:02 p.m. with CNA (staff #43). Staff #43 stated that resident #2 liked to sit on the side of the bed often and would move around as needed and wanted. He further stated that he only knows of the blood being present in his urine every once in a while and he would tell the nurses if there was anything wrong regarding the catheter. The CNA was then called to the floor to provide care and no further questioning was conducted. An interview was conducted on June 8, 2026 at 2:18 p.m. with Registered Nurse (RN/staff #65). Staff #65 stated that the resident has a difficult time with his catheter, often being angry, dragging the catheter bag around, leaving it on the floor, and attempting to rip it out. Staff #65 also stated that the implemented standards of practice for infection control procedures regarding catheters includes cleansing the area and changing any parts of the catheter as needed. Staff #65 further stated that if the resident's bed was in the lowest position and the catheter bag was touching the floor she would implement the typical interventions as documented in the resident's care plan while keeping the bag below the bladder. During an interview conducted in resident #2's room on June 8, 2026 at 2:50 p.m., staff #65 stated that resident #2's catheter bag was making contact with the floor and the bag should not be on the floor. Staff #65 also stated the process to correct it would be to raise the height of the bed and be more vigilant of the bag for infection control purposes. Staff #65 then woke resident #2, asked if he was okay, and raised the height of the bed. Staff #65 also stated that she looks in on the residents three times a shift on average and had recently checked his blood glucose but could not recall seeing the catheter bag on the floor and stated that she was questioning herself if it was on the floor during that time. Staff #65 further stated the CNA's are more involved by being with the residents a majority of the shift and that the risk of the catheter bag being on the floor would be infection, death from sepsis, bacteremia, change of mentation, fever, and long term renal failure. During an interview conducted on June 8, 2026 at 3:08 p.m. with Director of Nursing (DON/staff #83) and RN #65, the DON stated that the process of seeing a catheter bag on the floor would be to pick it up, clean it, and make sure it is no longer on the floor. The DON further stated that it is the responsibility of all nursing staff to continue monitoring the catheter and that the risk of a catheter bag being on the floor would be an infection. The DON then called CNA (staff #43) into the DON's office to conduct further interviewing. During an interview conducted on June 8, 2026 at 3:19 p.m. with staff #43, the CNA stated that he had not seen any issues with resident #2's catheter and stated that he conducts monitoring before and after each meal. Staff #43 also stated that catheter care consists of wearing personal protective equipment in accordance with enhanced barrier precautions, properly cleaning the area of catheter insertion, and ensuring the bag is below the bladder. Staff #43 further stated that the risk of the catheter bag being on the floor would be infection. The interview was then moved to resident #2's room, where the DON stated that the anchor for the catheter bag was broken, that the drainage spout was touching the floor, and she would have staff #43 replace the catheter bag. Staff #43 then explained that he was going to change the bag completely and place the bag on the bed frame where it would not be above the bladder and also not touch the floor. A review of the treatment administration record from May 1, 2026 to June 8, 2026, revealed that catheter care was conducted two times every day, with no replacement of the catheter bag or catheter tubing. The facilities policy titled, Infection Control Policy and Procedures, dated 2013, revealed that Haven Health takes an Interdisciplinary Team (IDT) approach to infection control involving the Physician, Director of Nursing (DON), Housekeeping, Dietary, Maintenance, as well as direct care staff. The policy further states all facility staff will be educated on hand hygiene, infection control, and isolation precautions on hire and annually. The facilities policy titled, Urinary/Renal Conditions: Catheter Care, Urinary, dated January 1, 2024, revealed to use aseptic technique when handling or manipulating the drainage system, to be sure catheter tubing and drainage bag are kept off the floor, and to change catheters and drainage bags based on clinical indication such as infection, obstruction or when the closed system is compromised.

Based on clinical record review, interviews, facility documentation and policy review, the facility failed to ensure four residents (#50, #150, #100 and #250) were free from abuse from other residents (#100, #250, #200). The deficient practice could lead to other resident to resident altercations which could result in harm. Findings include: Resident #100 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disburbances, chronic kidney disease, alcohol abuse and major depressive disorder. Review of the MDS (Minimum Data Set) dated August 14, 2022 reveals a BIMS (Brief Interview for Mental Status) score of 99, indicating resident #100 to be severely cognitively impaired. Resident #250 was admitted to the facility on [DATE] with a diagnosis of vascular dementia with behavioral disturbance and post-traumatic stress disorder. Review of the MDS dated [DATE] reveals a BIMS score of 99, indicating resident #250 to be severely cognitively impaired. On the morning of March 13, 2022, resident #250 woke up from sleeping in his chair and saw his shoelace was broken lying on the floor next to him. He got out of his chair and started punching resident #100 in the face. Resident #100 began swinging back at resident #250. This incident was witnesssed by a staff member #82, who immediately seperated the residents. Resident #100 sustained minor injury to his lip. Resident #200 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disturbances, wandering and difficulty walking. Review of the MDS dated [DATE] reveals a BIMS score of 99, indicating resident #200 to be severely cognitively impaired. Resident #150 admitted to the facility on [DATE] with a diagnosis of vascular dementia with anxiety, wandering, anxiety disorder and major depressive disorder. Review of the MDS dated [DATE] reveals a BIMS score of 99, indicating resident #150 to be severely cognitively impaired. On June 11, 2022, staff #5 was at the medication cart when he heard resident #200 and #150 speaking to each other. The conversation appeared to be getting louder. Staff #5 told the residents to move away from each other. Resident #200 grabbed the back of resident #150's wheelchair and began slapping resident #150 several times in the back of the head. Staff #5 seperated both residents but resident #200 continued to yell at resident #150 claiming he stole her shoes. Resident #150 did not have any shoes with him and were not found in his room. Resident #50 was admitted to the facility on [DATE] with a diagnosis of dementia with behavioral disturbances, major depressive disorder, age related macular degeneration, adult failure to thrive and alzheimers disease. Review of the MDS dated [DATE] reveals a BIMS score of 99, indication resident #50 to be severely cognitively impaired. On August 15, 2022 as residents were exiting the dining room, resident #50 and resident #100 wheelchairs became caught up on each other. As staff were approaching to seperate the residents, resident #100 punched resident #50 with a closed fist on the right cheek of her face. Staff immediately seperated both residents. Resident #50 was noted to have a reddish/pink discoloration to her face. Review of the facility investigation for all three incidents reveal that each one was substantiated by the facility.

Based on observations, staff interview, and policy, the facility failed to ensure the kitchen (lower kitchen) and the serving area (upstairs kitchen) was clean and sanitary when preparing food for residents. The deficient practice could increase the risk of foodborne illness. Findings include: The initial lower kitchen observation conducted on February 2, 2025 at 9:54 am revealed an open ceiling tile towards the dishwashing sink, and three other ceiling tiles with discolorations. Vents in the kitchen were covered in blackish/gray fuzzy particles. The dishwashing sink and counter area was unattended. The counter had a red sanitizer disinfectant bucket towards the top left corner, and a saturated kitchen towel towards the bottom left corner. The counter has a covering of a mix of suds and left-over food particles. The sink drain was clogged with a discolored fluid, suds, and food particles which flooded over into the sink. Small flying insects were in area and landing intermittently on the wall. Two square clear containers were also present in the sink. The initial upper kitchen observation revealed fans and vents covered in a layer of blackish/ gray fuzzy particles. During the puree demonstration on February 3, 2025 at approximately 11:00 a.m., observed with dietary aide (Staff # 89) and the dietary manager (Staff #95) a deceased small brown insect was removed from the wall in the puree prep area. A facility walk-through began at 11:46 a.m. on February 3, 2025, with the [NAME] President (Staff # 125), the Director of Nursing (Staff # 80), the Dietary Manager (Staff # 75), the Maintenance Director (Staff # 113), and Maintenance Technician (Staff # 146). The group fan blades and vents were still covered in blackish/grayish particles in the upper kitchen. The lower kitchen same ceiling tile was partially opened, and three ceiling tiles with discolorations, and vents covered with blackish/grayish fuzzy particles. Reviewed Extermination Services receipts for kitchen visits on the dates of : [DATE], [DATE], [DATE], [DATE], and February 2, 2025. Work Order #2576 was initiated on February 3, 2025 and completed by February 4, 2025 by 11:11 am for kitchen and serving area ceiling, fans, doors, and vents. A joint interview was conducted with the Dietary Manager, and the Registered Dietitian (RD/Staff # 126) on February 4, 2025 at 10:08am. The dietary manager stated that multi-tasking is an expected skill to have when working in the kitchen. Multi-tasking involves being able to simultaneously prepare, serve, and clean up after meals. The dietary manager feels they have enough staff to meet expectations, as well as fulfilling deep cleaning tasks on a routine basis. In regards to the condition of the vents and fans, the dietary manager revealed this task was initially not on the deep cleaning list, but will be immediately added. The manager and dietitian stated the issues with dust on fan blades and vents include contamination of the food. The manager and dietitian also identified insects are unwelcomed in the food prep and service areas due to food contamination and spread of diseases. The manager stated that they are in process of fixing all the ceiling tiles, and that insects can hide in the open tiles. The manager does admit that she is unaware of how long the roach was on the wall in the puree station, but there is no acceptable reason for it to be present at any time. The dietary manager and dietitian were both asked if they would patronize their own kitchen with the knowledge of the insect and cleanliness issues, both parties declined to provide a response. The dietary manager is grateful that the facility has had no food borne outbreaks over the past year. Both parties do admit that the findings in the upper and lower kitchen does not meet facility expectations. The dietary manager reported having no food borne outbreak over the past year. An interview with the [NAME] President Staff # 125 during the facility walk through revealed that the dust on the fan blades can introduce contaminants in the food, which does not meet facility expectations. The General Sanitation of Kitchen policy reveled the sanitation of the kitchen through compliance with a written, comprehensive cleaning schedule. In addition, on the cleaning schedule, employees will initial and date tasks when completed. The Infection Control Program aim is to maintain a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection.

Based on observation, interviews, and review of facility documentation and policy, the facility failed to ensure an effective pest control program was maintained. This deficient practice can result in the spread of disease, and not promoting a home like environment for the residents. Findings include, An initial kitchen walkthrough was conducted on February 2, 2025 at 9:54 a.m. During the walkthrough, observed multiple small flying insects in the area of the dishwashing sink. The sink area was unattended and contained standing discolored solution with food remnants clogged in the drain, which pooled into the sink. During walkthrough of the dry storage, encountered additional small flying insects in the area. Observed on February 2, 2025 at 10:06 a.m. with the dietary aid (Staff # 89), the sink with standing fluid and food and flying insects in the area. During observation of the lunch puree process on February 3, 2025 at approximately 11:00 a.m., observed alongside the dietary aide (Staff #89), the dietary manager (Staff #95) remove a deceased small brown insect from the wall, close to the red sanitizer solution bucket. During medication pass, accompanied with a Licensed Practical Nurse (LPN/Staff #65), on February 3, 2025 at 12:38 p.m.; small flying insects were observed in the 600 Hall, living room area, and the Gila unit medication room. Observed with the rehab manager (Staff #15) on February 4, 2024 at 7:55 a.m. inside the rehab services room, surveyor was able to kill a flying insect at the meeting desk. The Safety Data Sheet was provided to the surveyor with the revision date of [DATE] for the facility use of Maxforce FC Insect Control Roach Killer Bait Gel. The hazard statement includes to Keep exposed gel away from open food and food contact services. The receipt from the workorder dated February 2, 2025 from the facility's pest control provider referenced the service was for call-out gnats. A signed statement from the Operations Manager revealed no cleaning logs were available for the Gila medication room. An interview regarding the cleanliness and pest present in the Gila medication room, was conducted with the housekeeping supervisor (Staff 35) revealed housekeeping is responsible for cleaning the room daily. An interview with the Dietary Manager on February 3, 2025 at approximately 11:00 a.m. revealed the exterminator service treated the facility the day before and will return again the next day. A joint interview, conducted with the Dietary Manager, and the Dietary Resource/Registered Dietitian (Staff #126) was conducted on February 4, 2025 at 10:08 a.m. The discussion revealed that the facility expectation to be an insect free environment was not met. The panel further explained that insects can harbor disease and they would not want any pest contaminating the food which could cause illness. A joint interview was conducted on February 4, 2024 at 4:02 p.m. , with the Operations Manager (Staff #94) and the [NAME] President of Clinical Operations (Staff #125). It was revealed that the facility increased the number of exterminator visits from monthly to weekly back in October or November of 2024, however an official Performance Improvement Plan (PIP) was not implemented. The facility's Infection Control Program revealed the focus of the program is to provide safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. The facility's Pest Control policy requires the facility to maintain an on-going pest control program to ensure that the building is kept free from insects and rodents.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that a resident's representative was notified of a transfer. The deficient practice could result in resident's representative being unaware of residents discharge. Findings include: Resident #147 was admitted on [DATE] with diagnoses of metabolic encephalopathy, schizoaffective disorder bipolar type, dementia and major depressive disorder. This resident discharged on May 21, 2021. A care plan dated May 5, 2021 included resident and spouse/representative have expressed wish for discharge home to prior living with supportive services in home depending on outcome and care needs with interventions to set up home health service per resident/representative choice. However, this resident was not discharged to home. A clinical resident profile included that this resident had a Power of Attorney (POA) designated for financial and care, and that this POA was also the emergency contact. An alert charting note dated May 8, 2021 included that the resident was in a physical altercation and included that this resident's POA was notified via phone. An activity progress note dated May 19, 2021 included that this resident was transferred to Haven Health Showlow and the pick up time for the discharge. This note included that the staff Gathered medications and instructed patient of the transfer. However, review of the clinical record did not find any record that the resident's representative was informed of the transfer, or whether the resident received her belongings A Complaint/Incident Investigation Report was filed with Arizona Department of Health Services on May 27, 2021 that included that this resident was transferred to another facility without informing the resident's representative and that the resident' s belongs were missing. An interview was conducted on February 4, 2025 at 01:53 PM with Resident Relations (staff #98) who said that as soon as a resident arrives it populates a form and it includes questions such as, Is your goal to go home, or to long term care? Do you need transport, and do need you equipment?. This staff said this form gives her the basics and that she will follow up 3-4 days later to see the resident's progress because sometime the residents are weaker than expected, and that she will ask Is the plan the same?. This staff said that she will meet back with them in another 2 weeks, see if any obstacles, and ask are we going to look at long term, are they meeting therapy goals or insurance restrictions, and when it gets close to discharge a Notice of Medical Non-Coverage (NOMNC) is provided 3 days in advance. This staff said that some of the required items for discharge she can order through hospital and that insurance determines home health. This staff said that she then gets the scripts signed and determines who will be providing transport, whether it is family or the facility vehicle or a transport company. This staff said that she may have the records of this resident locked in the back. An interview was conducted on February 4, 2025 at 2:48 PM with the Assistant Director of Nursing (ADON/staff #104) who said that they would get the discharge information from Resident Relations (staff #98) and that they would do half and the nurses would do the other half, and that they would get the prescription form the doctor. This nurse said that if resident is alert and oriented, they do not need to call family, if not that they do and that the family are usually transporting the resident. This staff said that family should know about it before they are ever discharged . This staff reviewed the resident record and said that the patient had dementia and was pretty dependent, as well as encephopathy and that normally with someone who is impaired the staff would notify the family. This staff said that she did not see anything in the record that says the family knows where this resident is going and that her family should have been notified. An interview was conducted on February 4, 2025 at 4:36 P.M. with the Operations Manager (staff #94) who said that the facility does not have a record of resident representative notification of transfer or that the belongings were returned to the resident or representative. An interview was conducted on February 4, 2024 at 3:29 PM with the Director of Nursing (DON/staff #80) who said that staff should be referred for any outpatient needs including home health, therapy, be provided discharge planning and then be given discharge medications, NOMNC notices and physician orders. This DON reviewed the clinical record and stated that the resident's Brief Interview for Mental Status score was 9 (indicating moderate impairment) and that she had schizophrenia, metabolic encephalopathy, dementia and Major Depressive Disorder, and that all she saw in the record regarding discharge is that she was transferred. She said that her expectation was that family would be notified and that the resident's belongs would be transferred with them. A policy titled Admissions/Transfers/Discharges: Transfer or Discharge- Preparing a Resident for Discharge in effect January 1, 2024 included that residents will be prepared in advance for discharge and included a post-discharge plan is developed for each resident prior to his or her transfer or discharge. This document included this plan will be reviewed with the resident, and/or his or her family, before the resident's discharge or transfer from the facility and that nursing services was responsible for packing and collecting personal possessions if the resident is not expected to return.

Based on clinical record review, interviews, and review of facility policies and procedures, the facility failed to ensure necessary blood pressure medications and insulin were administered according to provider instruction for one resident (#68). This deficient practice could result in side effects leading to negative resident outcomes. Findings include: -Resident # 68 was admitted to the facility on [DATE], with diagnoses that include hypertension, Type 2 Diabetes Mellitus, dysphagia (difficulty swallowing), and dependence on renal dialysis. The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, which indicated the resident had mild cognitive impairment. The resident care plan dated November 19, 2024, required that anti-hypertensive medications to be given as ordered, and to monitor for side effects such as orthostatic hypotension (low blood pressure caused by position change) and tachycardia (increased heart rate). A physician order dated November 6, 2024 revealed Hydralazine HCL 25 mg (milligrams) to be given three times a day for hypertension (high blood pressure) unless the systolic blood pressure is less than 100. A physician order dated November 6, 2024 revealed Metoprolol Tartrate 50 mg to be given twice a day for hypertension unless the systolic blood pressure is less than 100. A physician order dated November 20, 2024 revealed Insulin Glargine to be given every day for Type 2 Diabetes Mellitus unless the blood sugar was less than 110. Review of the Medication Administration Record (MAR) for December 2024 revealed multiple dates (December 6, 19, 20, and 30) where Insulin Glargine was administered with a blood sugar less than 110. Review of the clinical record failed to support the medication being given out of parameter. Review of the Medication Administration Record (MAR) for January 2025 revealed two dates (January 7 and 14) where Hydralazine HCL was administered with a systolic blood pressure lower than 100. Review of the Medication Administration Record (MAR) for February 2025 revealed Hydralazine HCL was administered with a systolic blood pressure lower than 100 on three dates (February 1, 7, and 14). Review of the clinical record failed to support the medication (Hydralazine) being given out of parameter. An interview was conducted with the resident #68 on February 3, 2025 at 8:50 a.m. The resident stated that he trusts that the nursing staff are administering their medications as ordered. The resident stated he would feel let down if he was to find out otherwise because he depends on them (nurses). An interview with Registered Nurse (RN/Staff # 19) was conducted on February 4, 2025 at 8:47 a.m. The nurse reviewed the clinical record with the surveyor and reviewed the clinical documentation for resident # 68's Hydralazine HCL, Metoprolol Tartrate, and Insulin Glargine administrations. The nurse was able to identify episodes when the blood pressure and insulin were given outside of parameters, which she stated goes against facility expectation, and can cause adverse side effects in the resident. The nurse further explained that if a medication was to be given out of parameter, the provider would have to be notified and then documented in the clinical record. The nurse stated that there are quite a few interruptions that occurs during medication pass, and feels that if these interruptions were minimized, greater focus can be devoted to ensuring medication errors do not occur. An interview with the Assistant Director of Nursing (ADON/Staff # 112) was conducted on February 4, 2025 at approximately 11:00 a.m. The ADON reviewed the clinical record with the surveyor identified incidents of medications given out of parameter for resident #68. The ADON was unable to produced documentation to support the administration of medications outside of parameter for this resident. The assistant director revealed that interruptions during med pass does occur, however that should not impact any nurse's ability to administer medications correctly as long as the nurse adheres to the Rights of Medication Administration. An interview was completed with Licensed Practical Nurse (LPN/Staff # 110) on February 4, 2025 at 11:44 a.m. The LPN revealed that when following the MAR and if the order needs clarification, the provider is contacted. When giving insulin and blood pressure medicine, the nurse prefers to reassess blood pressure and blood sugars before the medication is administered.The nurse admits to being interrupted with various incidents during medication administration times and will stop med pass in order to address the issue. The nurse feels that enough staff support is available to administer medications. In addition, the nurse feels that there is a problem that may be too much to handle, they have other staff who are able to help during med pass. The facility's Resident Examination and Assessment policy advises that the orders are to be completed in accordance with physician orders determined at the resident's time of admission or throughout the resident stay. The facility's Administering Medications policy advises that staffing schedules are arranged to ensure that medications are administered without unnecessary interruptions. In addition, it revealed vital signs, if necessary, are to checked/verified for each resident prior to administering medications. The facility's Adverse Consequences and Medication Errors revealed a medication error can include administering a drug without a physician's order. In addition, documentation of the clinical rationale for using the medication if prescribed outside the accepted standard of practice is required.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision was provided for two residents (#3) and (#4) to prevent further resident to resident altercations. The deficient practice could result in further incidents of inadequate resident supervision. Findings include: Regarding residents #1 and #2: -Resident #1 was admitted to the facility August 27, 2024 with diagnosis including unspecified dementia, unspecified severity, with other behavioral disturbance, dementia in other diseases classified elsewhere, moderate, with agitation. A care plan initiated in April 2023 and revised July 2023 revealed the resident had a focus for behavior problems related to resistance to care and wandering and impaired cognitive function/dementia or impaired thought processes related to short and long-term memory loss and dementia. Interventions included administer meds as ordered, intervening as necessary to protect the rights and safety of others. Approach and speak in a calm manner, divert attention, remove from situation and take to alternate location as needed. The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 07, indicating severe cognitive impairment. Further review of the MDS revealed no indicators for mood or behaviors. The progress notes dated April 19, 2024 documented an incident note that revealed CNA reported that resident #1 was struck by another resident and that the patients were separated from each other. The note further states resident #1 had no marks on her and denied pain. Appropriate staff and providers notified of the incident. The provider notes dated April 20, 2024 revealed resident #1 reported no complaints of right shoulder pain due to being punched by a resident. Per the provider note staff were to monitor pain and level of consciousness (LOC). -Resident #2 was admitted to the facility March 14, 2016 with diagnosis including dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, mild. A care plan initiated in April 2024 revealed the resident had a focus for use of mood stabilizer medication (Depakote) r/t dementia with behaviors and potential to demonstrate physical behaviors hitting others r/t Anger, Dementia, Poor impulse control, physical behaviors. Interventions included to Give mood stabilizer medications ordered by physician. Monitor/document side effects and effectiveness, target symptoms/Behavior Tracking:(mood swings) and Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 99 indicating resident was unable to complete the interview. Further review of the MDS revealed a diagnosis for dementia with no indicators for behaviors. The progress notes dated April 19, 2024 revealed resident #2 struck another resident after she bumped his wheelchair while ambulating and attempting to pass resident #2 who was seated in his wheelchair in the hallway. The note states that resident #2 struck the resident on her left arm and that both residents were immediately separated while resident was assessed for injuries. A physician note dated April 20, 2024 revealed resident was seen for being aggressive. The note revealed resident did not recall his punching on one of the residents. The note further documents increasing aggressive behavior. Review of the facility investigation with discover date of April 19, 2024 included that both resident #1 and #2 were interviewed. Per the documentation, resident #1 stated when asked how she was doing that she was a little sore. When asked what happened resident #1 stated I got bucked off a horse, but I am doing better. Resident #2 was interviewed and when asked how he was doing resident #2 stated yeah. Resident #2 was asked if he had any run-in with another resident, resident #2 laughed and stated no, no, no. Continued review of the facility investigation included that the facility identified this incident was unsubstantiated due to the fact that there was no willful intent to cause harm from either of the residents and that both residents are wandering risk, impaired thought process, and unaware of own safety needs. An observation was conducted December 6, 2024 at 3: 26 p.m. of the behavioral unit where both residents #1 and #2 reside. Observed both resident's in the dining area with other unidentified residents unsupervised. No staff present. This surveyor continued observation of the residents. Two staff later identified as certified nursing assistant (Staff#61/CNA) and Activities Manager (Staff #10/Activities) walked by at 3:31 p. m. An interview was conducted on December 6, 2024 at 3: 32 p.m. with Activities Manager (Staff #10/Activities) Staff #10 stated she had provided activities on the unit and had left the unit at 2:00 p. m. Staff #10 stated the residents were left in the dining room and that the staff were somewhere on the unit. An interview was conducted on December 6, 2024 at 3:33 p.m. with (Staff#61/CNA). Staff #61 stated she had taken the CNA course at the facility and was a [NAME] for the facility prior to that. She stated the staff receive report every morning for any resident that needs an extra eye on them and to keep them close to us and to keep staff on the unit. Staff #61 stated she was unaware of any altercations with any of the residents currently in the dining area. Staff #61 stated she was unaware of the incident with resident #1 and #2 and they should not be left alone unsupervised. Staff #61 stated if there was an altercation with any of the residents she is to de-escalate the situation - remove the residents and report the incident. Staff #61 stated the residents #1 and #2 had been left alone approximately 20 minutes while she provided care for another resident that required the assist of two. Staff #61 stated residents who had a prior altercation require supervision and monitoring because they are a high risk- staff #61 further stated the risk of not supervising or monitoring those residents can be cause for recurrent incidents. An interview was conducted on December 6, 2024 at 4:12 p.m. with (Staff#12/LPN) Staff # 12 stated he could not recall the incident but the information he documented in the progress note is correct. Staff #12 stated resident #2 has behavior issues he likes his space becomes verbally aggressive and tries to intimidate the other residents. Staff #12 stated resident #2 should not be left alone unsupervised, not monitored with other residents. Staff #12 stated there are two CNA's on the unit plus a nurse. Staff #12 stated it is difficult to monitor the residents when he is down the hallway or outside of the unit passing medications. Staff #12 stated there is not enough staff on the unit to supervise and monitor the residents, given that some of the residents require two people to provide their care. Staff #12 stated the risk of leaving residents on the unit unsupervised or monitored is they can become verbally and physically aggressive. Regarding residents #3 and #4: -Resident #3 was admitted to the facility September 16, 2020 with diagnosis including unspecified dementia, unspecified severity, with mood disturbance, unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, unspecified. A care plan initiated in April 2024 had a focus for impaired cognitive function/dementia or impaired thought processes r/t short term memory loss, dementia and at risk for misappropriation, neglect, abuse, and/or exploitation related to dementia, resides in wandering unit, physical aggression received from another resident. Interventions included provide with compatible staff whenever possible, separate resident from an aggressor, administer meds as ordered. The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 05 indicating severe cognitive impairment with no indicators for behaviors or mood. An alert charting note dated March 1, 2024 for change of condition summary revealed the following documentation; At approximately 1210 while passing noon medications, I heard resident #3 as she was seated to her usual dining table talking loudly, I looked over and saw resident #4 standing behind her wheelchair tugging at the handle trying to pull it backwards. resident #3 continues to state, leave me alone, stop it, don't do that. I then proceeded to walk towards the two resident's when resident #3 tells resident #4 to leave her alone, is when I witnessed him bend down, push his left forearm into her neck, and punched resident #3 twice in the right shoulder arm and proceeded to hit her in the face when I placed my hands on his chest and grabbed both arms to block his arm and held his chest to place space between resident #4 and resident #3 , resident #4 stumbled backwards, where I was able to get resident #3 away when the other CNA's in the Unit came to assist with getting resident #4 out of the dining room. Incident was reported to DON, Charge Nurse and Administrator. Resident #3 was visibly and emotionally upset and distraught by the incident, resident #4 was removed and redirected down the hall by CNA's in the unit. Resident #3 was assessed and taken back to her room. Resident #3 was assessed, did not have any bruising noted to her right upper arm, shoulder or face. No cuts or open areas to her body. Resident #3 vital signs are stable. Review of the physician progress note dated March 2, 2024 stated reason for visit - resident got hit by a male resident and complained of shoulder pain with a recommendation for Voltaren for symptom management. Review of the facility investigation with discover date of March 1, 2024 included that both resident #3 and #4 were interviewed. Resident #3 reported that she was sitting in the dining room at the table and a man came to her and started tugging on her wheelchair, she stated stop, don't do that and resident #3 stated he reached down trying to mess with the brakes then she reached down with her hand to stop him and when she did he leaned into her and punched her twice in the right upper arm she stated after the incident she went straight to her room. An attempt was made to interview resident #4 but revealed resident cognitively understand and continued to wander away from the interviewers. Additional review of the facility investigation revealed a witness statement dated March 1, 2024. Witness states he observed the incident from 20-25 ft. The statement details resident #4 initially circled resident #4 and became verbally loud while standing above resident #3. The witness states resident #3 became frightened and raised her voice asking resident #4 to get away from her. Resident #4 then placed his forearm in a blocking fashion against her neck and pushed. The witness states resident #3 became extremely frightened and became louder when resident #4 proceeded to cuss and 'landed 2-3 punches about resident #3 upper body. The witness states staff separated resident # 3 by removing her from the dining room and that resident #4 remained in a defensive mode for the next 15 minutes or more. A telephonic interview was conducted on December 6, 2024 at 1:36 p.m. with registered nurse (Staff #30/RN). Staff # 30 had provided a previous interview regarding another incident in the facility. Staff # 30 stated she could not continue with the interview as she was on vacation and her family was waiting on her, but that everything is documented in my nursing note, I saw resident #4 hit resident #3 multiple times. An interview was conducted on December 6, 2024 at 3:33 p.m. with (Staff #61/CNA). Staff #61 stated she had taken the CNA course at the facility and was a [NAME] for the facility prior to that. She stated the staff receive report every morning for any resident that needs an extra eye on them and to keep them close to us and to keep staff on the unit. Staff #61 stated she was unaware of any altercations with any of the residents currently in the dining area. Staff #61 stated she was unaware of the incident with resident #1 and #2 and they should not be left alone unsupervised. Staff #61 stated if there was an altercation with any of the residents she is to de-escalate the situation - remove the residents and report the incident. Staff #61 stated the residents #1 and #2 had been left alone approximately 20 minutes while she provided care for another resident that required the assist of two. Staff #61 stated residents who had a prior altercation require supervision and monitoring because they are a high risk- staff #61 further stated the risk of not supervising or monitoring those residents can be cause for recurrent incidents. An interview was conducted on December 6, 2024 at 3:58 p.m. with Director of Nursing (DON/staff #43) stated staff are informed during report about resident incidents and any supervision or monitoring needed. Residents should be observed for escalation of any behaviors and remove from the situation. The DON stated the risks associated with not providing supervision is verbal or physical aggression and feel there is sufficient staff to provide these preventative measures. Review of the facility policy titled Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program states Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: 1. Protect residents from abuse, neglect, exploitation or misappropriation of property by anyone including, but not necessarily limited to: b. other residents

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure adequate supervision was provided for two residents (#3) and (#4) to prevent further resident to resident altercations. The deficient practice could result in further incidents of inadequate resident supervision. Findings include: Regarding residents #1 and #2: -Resident #1 was admitted to the facility August 27, 2024 with diagnosis including unspecified dementia, unspecified severity, with other behavioral disturbance, dementia in other diseases classified elsewhere, moderate, with agitation. A care plan initiated in April 2023 and revised July 2023 revealed the resident had a focus for behavior problems related to resistance to care and wandering and impaired cognitive function/dementia or impaired thought processes related to short and long-term memory loss and dementia. Interventions included administer meds as ordered, intervening as necessary to protect the rights and safety of others. Approach and speak in a calm manner, divert attention, remove from situation and take to alternate location as needed. The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 07, indicating severe cognitive impairment. Further review of the MDS revealed no indicators for mood or behaviors. The progress notes dated April 19, 2024 documented an incident note that revealed CNA reported that resident #1 was struck by another resident and that the patients were separated from each other. The note further states resident #1 had no marks on her and denied pain. Appropriate staff and providers notified of the incident. The provider notes dated April 20, 2024 revealed resident #1 reported no complaints of right shoulder pain due to being punched by a resident. Per the provider note staff were to monitor pain and level of consciousness (LOC). -Resident #2 was admitted to the facility March 14, 2016 with diagnosis including dementia in other diseases classified elsewhere, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, mild. A care plan initiated in April 2024 revealed the resident had a focus for use of mood stabilizer medication (Depakote) r/t dementia with behaviors and potential to demonstrate physical behaviors hitting others r/t Anger, Dementia, Poor impulse control, physical behaviors. Interventions included to Give mood stabilizer medications ordered by physician. Monitor/document side effects and effectiveness, target symptoms/Behavior Tracking:(mood swings) and Analyze of key times, places, circumstances, triggers, and what de-escalates behavior and document. The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 99 indicating resident was unable to complete the interview. Further review of the MDS revealed a diagnosis for dementia with no indicators for behaviors. The progress notes dated April 19, 2024 revealed resident #2 struck another resident after she bumped his wheelchair while ambulating and attempting to pass resident #2 who was seated in his wheelchair in the hallway. The note states that resident #2 struck the resident on her left arm and that both residents were immediately separated while resident was assessed for injuries. A physician note dated April 20, 2024 revealed resident was seen for being aggressive. The note revealed resident did not recall his punching on one of the residents. The note further documents increasing aggressive behavior. Review of the facility investigation with discover date of April 19, 2024 included that both resident #1 and #2 were interviewed. Per the documentation, resident #1 stated when asked how she was doing that she was a little sore. When asked what happened resident #1 stated I got bucked off a horse, but I am doing better. Resident #2 was interviewed and when asked how he was doing resident #2 stated yeah. Resident #2 was asked if he had any run-in with another resident, resident #2 laughed and stated no, no, no. Continued review of the facility investigation included that the facility identified this incident was unsubstantiated due to the fact that there was no willful intent to cause harm from either of the residents and that both residents are wandering risk, impaired thought process, and unaware of own safety needs. An observation was conducted December 6, 2024 at 3: 26 p.m. of the behavioral unit where both residents #1 and #2 reside. Observed both resident's in the dining area with other unidentified residents unsupervised. No staff present. This surveyor continued observation of the residents. Two staff later identified as certified nursing assistant (Staff#61/CNA) and Activities Manager (Staff #10/Activities) walked by at 3:31 p. m. An interview was conducted on December 6, 2024 at 3: 32 p.m. with Activities Manager (Staff #10/Activities) Staff #10 stated she had provided activities on the unit and had left the unit at 2:00 p. m. Staff #10 stated the residents were left in the dining room and that the staff were somewhere on the unit. An interview was conducted on December 6, 2024 at 3:33 p.m. with (Staff#61/CNA). Staff #61 stated she had taken the CNA course at the facility and was a [NAME] for the facility prior to that. She stated the staff receive report every morning for any resident that needs an extra eye on them and to keep them close to us and to keep staff on the unit. Staff #61 stated she was unaware of any altercations with any of the residents currently in the dining area. Staff #61 stated she was unaware of the incident with resident #1 and #2 and they should not be left alone unsupervised. Staff #61 stated if there was an altercation with any of the residents she is to de-escalate the situation - remove the residents and report the incident. Staff #61 stated the residents #1 and #2 had been left alone approximately 20 minutes while she provided care for another resident that required the assist of two. Staff #61 stated residents who had a prior altercation require supervision and monitoring because they are a high risk- staff #61 further stated the risk of not supervising or monitoring those residents can be cause for recurrent incidents. An interview was conducted on December 6, 2024 at 4:12 p.m. with (Staff#12/LPN) Staff # 12 stated he could not recall the incident but the information he documented in the progress note is correct. Staff #12 stated resident #2 has behavior issues he likes his space becomes verbally aggressive and tries to intimidate the other residents. Staff #12 stated resident #2 should not be left alone unsupervised, not monitored with other residents. Staff #12 stated there are two CNA's on the unit plus a nurse. Staff #12 stated it is difficult to monitor the residents when he is down the hallway or outside of the unit passing medications. Staff #12 stated there is not enough staff on the unit to supervise and monitor the residents, given that some of the residents require two people to provide their care. Staff #12 stated the risk of leaving residents on the unit unsupervised or monitored is they can become verbally and physically aggressive. Regarding residents #3 and #4: -Resident #3 was admitted to the facility September 16, 2020 with diagnosis including unspecified dementia, unspecified severity, with mood disturbance, unspecified dementia, unspecified severity, with other behavioral disturbance, major depressive disorder, recurrent, unspecified. A care plan initiated in April 2024 had a focus for impaired cognitive function/dementia or impaired thought processes r/t short term memory loss, dementia and at risk for misappropriation, neglect, abuse, and/or exploitation related to dementia, resides in wandering unit, physical aggression received from another resident. Interventions included provide with compatible staff whenever possible, separate resident from an aggressor, administer meds as ordered. The quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (Brief Interview for Mental Status) score of 05 indicating severe cognitive impairment with no indicators for behaviors or mood. An alert charting note dated March 1, 2024 for change of condition summary revealed the following documentation; At approximately 1210 while passing noon medications, I heard resident #3 as she was seated to her usual dining table talking loudly, I looked over and saw resident #4 standing behind her wheelchair tugging at the handle trying to pull it backwards. resident #3 continues to state, leave me alone, stop it, don't do that. I then proceeded to walk towards the two resident's when resident #3 tells resident #4 to leave her alone, is when I witnessed him bend down, push his left forearm into her neck, and punched resident #3 twice in the right shoulder arm and proceeded to hit her in the face when I placed my hands on his chest and grabbed both arms to block his arm and held his chest to place space between resident #4 and resident #3 , resident #4 stumbled backwards, where I was able to get resident #3 away when the other CNA's in the Unit came to assist with getting resident #4 out of the dining room. Incident was reported to DON, Charge Nurse and Administrator. Resident #3 was visibly and emotionally upset and distraught by the incident, resident #4 was removed and redirected down the hall by CNA's in the unit. Resident #3 was assessed and taken back to her room. Resident #3 was assessed, did not have any bruising noted to her right upper arm, shoulder or face. No cuts or open areas to her body. Resident #3 vital signs are stable. Review of the physician progress note dated March 2, 2024 stated reason for visit - resident got hit by a male resident and complained of shoulder pain with a recommendation for Voltaren for symptom management. Review of the facility investigation with discover date of March 1, 2024 included that both resident #3 and #4 were interviewed. Resident #3 reported that she was sitting in the dining room at the table and a man came to her and started tugging on her wheelchair, she stated stop, don't do that and resident #3 stated he reached down trying to mess with the brakes then she reached down with her hand to stop him and when she did he leaned into her and punched her twice in the right upper arm she stated after the incident she went straight to her room. An attempt was made to interview resident #4 but revealed resident cognitively understand and continued to wander away from the interviewers. Additional review of the facility investigation revealed a witness statement dated March 1, 2024. Witness states he observed the incident from 20-25 ft. The statement details resident #4 initially circled resident #4 and became verbally loud while standing above resident #3. The witness states resident #3 became frightened and raised her voice asking resident #4 to get away from her. Resident #4 then placed his forearm in a blocking fashion against her neck and pushed. The witness states resident #3 became extremely frightened and became louder when resident #4 proceeded to cuss and 'landed 2-3 punches about resident #3 upper body. The witness states staff separated resident # 3 by removing her from the dining room and that resident #4 remained in a defensive mode for the next 15 minutes or more. A telephonic interview was conducted on December 6, 2024 at 1:36 p.m. with registered nurse (Staff #30/RN). Staff # 30 had provided a previous interview regarding another incident in the facility. Staff # 30 stated she could not continue with the interview as she was on vacation and her family was waiting on her, but that everything is documented in my nursing note, I saw resident #4 hit resident #3 multiple times. An interview was conducted on December 6, 2024 at 3:33 p.m. with (Staff #61/CNA). Staff #61 stated she had taken the CNA course at the facility and was a [NAME] for the facility prior to that. She stated the staff receive report every morning for any resident that needs an extra eye on them and to keep them close to us and to keep staff on the unit. Staff #61 stated she was unaware of any altercations with any of the residents currently in the dining area. Staff #61 stated she was unaware of the incident with resident #1 and #2 and they should not be left alone unsupervised. Staff #61 stated if there was an altercation with any of the residents she is to de-escalate the situation - remove the residents and report the incident. Staff #61 stated the residents #1 and #2 had been left alone approximately 20 minutes while she provided care for another resident that required the assist of two. Staff #61 stated residents who had a prior altercation require supervision and monitoring because they are a high risk- staff #61 further stated the risk of not supervising or monitoring those residents can be cause for recurrent incidents. An interview was conducted on December 6, 2024 at 3:58 p.m. with Director of Nursing (DON/staff #43) stated staff are informed during report about resident incidents and any supervision or monitoring needed. Residents should be observed for escalation of any behaviors and remove from the situation. The DON stated the risks associated with not providing supervision is verbal or physical aggression and feel there is sufficient staff to provide these preventative measures. Review of the facility policy titled Resident Safety: Safety and Supervision of Residents states Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Based on clinical record review, staff interviews, and review of facility policies, the facility failed to ensure oxygen was administered as ordered by the physician for one of 3 sampled residents (#21). The deficient practice could result in residents not receiving adequate oxygen to prevent hypoxia. Findings include: Resident #21 was admitted on [DATE] and discharged [DATE] with diagnoses chronic obstructive pulmonary disease, unspecified, unspecified asthma, uncomplicated, dependence on supplemental oxygen, chronic respiratory failure with hypoxia, unspecified symptoms and signs involving cognitive functions and awareness, legal blindness, as defined in USA). Review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 8, indicating resident's cognitive status moderately impaired. Further review of the MDS revealed resident receiving oxygen therapy. Review of the Care Plan date-initiated March 3, 2023 revealed resident receiving oxygen therapy related to Chronic Obstructive Pulmonary Disease (COPD). Interventions included when eating, oxygen must still be given to the resident but in a different manner (e.g., changing from mask to nasal cannula). Return resident to usual oxygen delivery method after the meal and monitor for signs and symptoms of respiratory distress. A physician's order dated March 8, 2023 included an order for oxygen at 3 liters per minute as needed to keep saturation level above 90%. every shift for Oxygen Therapy A physician's order dated September 20, 2023 included an order for oxygen at 3 liters per minute via NC. May titrate as needed to keep saturation lever greater than 90%. every shift for oxygen therapy. A physician's order dated November 20, 2023 included an order for oxygen at 1-5 liters per minute as needed to keep saturation level above 90%. every shift for oxygen therapy related to chronic obstructive pulmonary disease, unspecified (j44.9) This order was transcribed onto the MAR (medication administration record) for November 2024 and revealed that the resident had O2 sat levels of greater than 90% at 2 liters per minute. The nursing progress note dated November 23, 2024 revealed that CNA (Certified Nursing Assistant) was being taking resident #21 to breakfast, when stopped by another CNA due to resident being slumped over in her wheelchair and leaning to the left side. This nurse was called to the 500 hallway by CNA who informed resident did not have her oxygen on, breathing was labored and uneven. VS (vital stats) were taken, Resident #21 VS: 172/74, P-122, R-22, T-98.9, oxygen was at 57% RA. Resident's eyes were glassy and watery, resident's breathing was labored, oxygen VI simple mask was placed on resident with oxygen turned on to 10 L. Resident was noncoherent, speech was garbled and breathing continues to be labored, resident was taken to her room, assisted by two CNA's into bed, oxygen turned on and VS continued to monitor, called 911 for transport to hospital. Further review of the progress notes revealed an entry dated 11/21/2024 by the provider. The note states resident #21 was seen due to shortness of breath with exertion during therapy oxygen in use and noting last labs were done in June with noted hyponatremia, and elevated A1C- rechecking bmp. The hospital history and physical note for visit date of November 23, 2024 included that the resident respiratory exam findings- no respiratory distress, unremarkable stable chest x-ray, Hyponatremia (chronic), hyperkalemia diagnosis, likely UTI- at baseline 2 L O2- Pt required 4 L and BiPAP-repeat chest x-ray showed pulmonary edema bilaterally. 11/24/24- Pt transferred by air to Banner Glendale. A telephonic interview was conducted on December 6, 2024 at 1:28 p.m. with the registered nurse (RN/staff #30) who stated the certified nursing assistant (CNA) was bringing the resident out of the room approximately 20 ft from her room when she had noticed the resident was leaning and told the CNA to make sure resident has O2. Staff #30 stated the resident did not have the nasal cannula or oxygen on her, the CNA had the cannula it in her hand. Staff #30 stated she informed the CNA that the resident needed the oxygen hooked up to her now, on three liters. Staff #30 stated the resident was leaning to her left side when the CNA proceeded to take the resident to the dining room. Staff #30 state she did not see the residents face nor did she assess the resident. Staff #30 stated the resident was up at 4:45 a.m. and when she started her shift the resident was in her wheelchair, but was unsure if the resident had her oxygen on or when they got the resident up. Staff #30 stated when she asked the CNA to administer the resident oxygen that the resident's cannula was in her nose but was unhooked from the E tank with the tubing in the NA's hand. Staff #30 stated the CNA is responsible for changing out the tanks the NA was not certified at the time and was working with a CNA that was training her. Staff #30 stated the NA and resident #21 did not make it to the dining room and was observed by another nurse who asked if staff #30 had looked at the resident. Staff #30 stated when she observe the resident the resident was leaning, lethargic and mumbling when her head fell forward. Staff #30 stated she took resident #21 vital signs revealing a high blood pressure and saturation levels at 57. Resident #21 was taken back to her room and administer 5 liters of oxygen elevated head, O2 went up to 92% and called emergency services. An interview was conducted on December 6, 2024 at 3:10 p.m. with Licensed Practical Nurse (Staff #15/LPN) who stated the signs of symptoms of hypoxia are shortness of breath, confusion, cyanotic lips and fingertips. Staff #15 stated CNA's can place the resident oxygen and tubing, but it is the responsibility of the nurse in ensuring the residents oxygen is on at the right liters per minute (LPN). Staff #15 stated CNA's are to ask the nurse what the orders are for the resident's oxygen levels. Staff #15 stated the nurse is responsible to make sure the right mask or cannula are used and that CNA's do not have the qualifications to place oxygen on a resident and would need to test for it. An interview was conducted with Certified nursing assistant (Staff #61/CNA) on December 6, 2024 at 3:33 p.m. Staff #61 stated the responsibilities as a CNA for residents with oxygen, is to make sure tank is full, that the resident is plugged in on their concentrator, always check their vitals, switch from concentrator to the tank, check with the nurse to adjust the oxygen level and that a CNA is not allowed to change or administer oxygen to residents. An interview was conducted with the Director of Nursing (Staff #43/DON) on December 6, 2024 at 3:58 p.m. Staff #43 stated both RN's and LPN's are responsible for administering and ensuring the correct LPN's are being administered and that the nurse should be present and assessing the resident. Staff #43 stated it is her expectation that the nurse call for services, transfer for appropriate services and that the nurse should have stopped the NA and assessed the resident and sent back to their room instead of proceeding to the dining room. The DON further stated it was inexcusable for the nurse to state that she did not see the residents face. The DON stated NA's are not allowed to administer oxygen and the risks of not administering oxygen as ordered could lead to patient decline or death. A review of the facility's policy's titled Respiratory/Pulmonary Conditions: Oxygen Administration state; 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. 7. Check the tubing connected to the oxygen cylinder to assure that it is free of kinks. 8. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. 9. Place appropriate oxygen device on the resident (i.e., mask, nasal cannula and/or nasal catheter). 10. Adjust the oxygen delivery device so that it is comfortable for the resident and the proper flow of oxygen is being administered. 11. Securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the A review of the facility's policy's titled - Medications: Administering Medications Policy Statement Medications are administered in a safe and timely manner, and as prescribed. 1. Only persons licensed or permitted by this state to prepare, administer and document the administration of medications may do so. Medications are administered in a safe and timely manner, and as prescribed.

Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure one resident (#7) was free from abuse involving resident (#33). Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses which included: Major Depressive disorder, recurrent; Schizophrenia and Unspecified Dementia. The Quarterly assessment dated [DATE] revealed that the resident is severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 99. An Incident note dated August 14, 2023 at 6:40 PM indicated that the nurse was notified by a Certified Nursing Assistant the the resident (#7) was on the floor in another residents room (#33). When entering the room resident #7 was lying face down on the floor with visible blood pooling under her face. Upon assessing the resident she had a gash on the bridge of her nose and a wound on the left side of her head. A physician progress note dated August 15, 2023 at 2:03 PM noted that the resident was sent to the hospital for treatment and had suffered a nasal laceration and a broken nose. Resident #7 was care planned for wandering behaviors. Resident #33 was admitted to the facility on [DATE] with diagnoses which included: Major Depressive Disorder; Hallucinations; Anxiety Disorder and Unspecified Dementia with other behavioral disturbance. The Quarterly assessment dated [DATE] revealed that the resident was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13. She also exhibited behaviors such as hitting, scratching self, pacing as well as wandering behaviors. The resident is cared planned for behavior problems related to physical and verbal aggression towards other residents. Resident is not to be within arm's reach of other residents at anytime, initiated on April 1, 2023. An incident progress note dated Augurs 14, 2023 at 6:40 PM documented that a resident (#7) was found on the floor in her room. The Certified Nursing Assistant who remained in the room to clean up the blood on the floor reported that resident #33 stated that she had hit the other resident in the head and tried to push her out of the room when the other resident (#7) fell out of her chair. The resident then used her call light to call for help. The facility moved the resident (#33) to a room change on another unit to separate the resident to provide safety. During an interview conducted on August 16, 2023 at 2:13 PM with a Licensed Practical Nurse (staff #41) he stated that the incident occurred during shift change when a Certified Nursing Assistant came to him and told him that resident #7 was on the floor of resident #33 room. He further stated that they had not had any previous episodes of aggression with resident #33 but that she was very territorial about her room. He further stated that the incident was unwitnessed as both residents were in a room. During an interview conducted on August 16, 2023 at 2:27 PM with a Certified Nursing Assistant (staff #56), he stated that he did not witness the incident but was called to the room by the nurse to help getting resident #7 off the floor. He stated that after resident #7 was removed from the room, he remained in the room which was when resident #33 told him that resident #7 had entered her room and they began to argue and that she struck resident #7 on the side of her head and then tried to push resident #7 out of her room when she fell out of her chair. During an interview conducted on August 16, 2023 at 3:50 PM with resident #7, she was unable to state what had happened. Her comments were just that her nose itched. During an interview conducted on August 16, 2023 at 4:15 PM with resident #33, she was lying in her bed, but would not answer any questions. Review of the facility's Abuse Policy revealed that Haven Health facilities strive to prevent the abuse of all their residents. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse.

Based on clinical record review, resident and staff interviews, facility documentation and policy review, the facility failed to ensure that two residents (#7 and #33) were provided adequate supervision to prevent wandering behaviors leading to abuse. Findings include: Resident #7 was admitted to the facility on [DATE] with diagnoses which included: Major Depressive disorder, recurrent; Schizophrenia and Unspecified Dementia. The Quarterly assessment dated [DATE] revealed that the resident is severely cognitively impaired with a BIMS (Brief Interview for Mental Status) score of 99. Resident #7 was care planned for wandering behaviors and was known to wander into other resident's rooms. An Incident note dated August 14, 2023 at 6:40 PM indicated that the nurse was notified by a Certified Nursing Assistant the the resident (#7) was on the floor in another residents room (#33). When entering the room resident #7 was lying face down on the floor with visible blood pooling under her face. Upon assessing the resident she had a gash on the bridge of her nose and a wound on the left side of her head. Resident #33 was admitted to the facility on [DATE] with diagnoses which included: Major Depressive Disorder; Hallucinations; Anxiety Disorder and Unspecified Dementia with other behavioral disturbance. The Quarterly assessment dated [DATE] revealed that the resident was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 13. She also exhibited behaviors such as hitting, scratching self, pacing as well as wandering behaviors. An incident progress note dated Augurs 14, 2023 at 6:40 PM documented that a resident (#7) was found on the floor in her room. The Certified Nursing Assistant who remained in the room to clean up the blood on the floor reported that resident #33 stated that she had hit the other resident in the head and tried to push her out of the room when the other resident (#7) fell out of her chair. The resident then used her call light to call for help. During an interview conducted on August 16, 2023 at 2:13 PM with a Licensed Practical Nurse (staff #41) he stated that the incident occurred during shift change when a Certified Nursing Assistant came to him and told him that resident #7 was on the floor of resident #33 room. He further stated that they had not had any previous episodes of aggression with resident #33 but that she was very territorial about her room. He further stated that the incident was unwitnessed as both residents were in a room. During an interview conducted on August 16, 2023 at 2:27 PM with a Certified Nursing Assistant (staff #56), he stated that he did not witness the incident but was called to the room by the nurse to help getting resident #7 off the floor. He stated that after resident #7 was removed from the room, he remained in the room which was when resident #33 told him that resident #7 had entered her room and they began to argue and that she struck resident #7 on the side of her head and then tried to push resident #7 out of her room when she fell out of her chair. During an interview conducted on August 16, 2023 at 3:50 PM with resident #7, she was unable to state what had happened. Her comments were just that her nose itched. During an interview conducted on August 16, 2023 at 4:15 PM with resident #33, she was lying in her bed, but would not answer any questions. Review of the facility's Abuse Policy revealed that Haven Health facilities strive to prevent the abuse of all their residents. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse.

Based on clinical record review, staff interviews, facility documentation and review of policy, the facility failed to ensure a physician order for an X-ray was carried out timely for one resident (#46) and failed to ensure physician was notified regarding a change in condition for one resident (#76). The sample size was 18. The deficient practice may increase the risk for residents to sustain complications including hospitalization and/or death. Findings include: -Resident #46 admitted on [DATE] with diagnoses of primary hypertension, unspecified osteoarthritis and chronic pain. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 99 indicating severe cognitive impairment. The MDS also included that the resident required extensive one-person physical assistance for most activities of daily living, had no falls since admission and/or the prior assessment and had displayed rejection of care on 1-3 days out of the 7-day look-back period. A Fall Risk Evaluation dated February 22, 2023 revealed the resident sustained 1-2 falls within the prior 6 months and was assessed to be at high risk for further falls. An Interdisciplinary Team (IDT) Fall Review dated March 3, 2023 at 6:16 p.m. included the resident had sustained a fall with no injury at 6:06 p.m.; and that, the resident was found sitting upright on the floor. Per the documentation, there were no clutter or spills noted in the area; and that, the resident attempted a self-transfer without success. New intervention included the resident's bed was placed next to the wall. According to the investigation, no abuse or neglect was suspected; and that, the resident was placed on alert charting, fall risk assessment was completed and the care plan was updated. Further, the documentation included that the Medical Doctor (MD)/Practitioner, responsible party, and case manager were notified. An Alert Charting Change of Condition Summary dated March 3, 2023 revealed that the resident's neurological checks remained within baseline with no decline in status. The note indicated that the resident had complaints of pain in her right knee; however, there were no swelling, redness, abrasion or bruising was noted. Per the documentation, the nurse practitioner (NP) was notified and an order for a right knee x-ray (2 views) was received. Further, the noted included that the administrator on call and transportation were also notified. An electronic MAR (eMAR) note dated March 4, 2023 revealed that a call to transportation was made to see when they were going to take the resident to the hospital for x-rays of the right knee. According to the documentation, the transportation driver (staff #71) stated that if the order was not STAT, that they would not see the resident. Further, the documentation included that the resident was checked and there was no redness or swelling, and scrapes to the left or right knee. An Alert Charting Change of Condition Summary dated March 4, 2023 included the resident was status post fall with no visible signs or symptoms of injury. The documentation included the resident had complaints of pain and had refused pain medication. Despite the resident's complain of pain to the right knee and staff knowledge that transportation would not pick up the resident for X-ray unless the order was a STAT order, the clinical record revealed no evidence that the provider was informed or asked to modify the order to address the resident's issue. A health status note dated March 5, 2023 revealed nurse received a report from night shift that the resident had sustained a fall on March 3, 2023 and had right knee pain with an x-ray pending. According to the documentation, the resident had complained of pain with any movement of the right lower extremity; and, had severe pain when the right hip was palpated, with no internal or external rotation or shortening identified. The note included that the NP was notified and an order for a STAT right hip and right knee X-ray was received. A health status note dated March 5, 2023 included that X-ray report showed displaced right hip fracture and an order to send the resident to the emergency room for evaluation and treatment was received. A discharge summary dated March 5, 2023 revealed the resident was transferred to the hospital via ambulance. Per the documentation, the resident had a fall and had increased pain. A fall care plan initiated on March 5, 2023 revealed the resident had a right hip fracture related to fall. Interventions included to follow physician orders for weight bearing status. A hospital History and Physical dated March 5, 2023 included that the resident was sent to the hospital in order to get an imaging study done and was noted to have a hip fracture. According to the documentation, the resident was incredibly reactive and agitated at times with her history of dementia and that she was refusing a physical exam. An admission evaluation noted dated March 7, 2023 revealed the resident was readmitted to the facility. An interview was conducted on May 18, 2023 at 11:58 a.m. with a Licensed Practical Nurse (LPN/staff #118). She stated that if a resident had an unwitnessed fall she would complete a head to toe assessment, including whether or not the resident had an altered mental status, broken bones, skin tears, pain with range of motion or any injury. She stated that a resident with a broken hip would wince, scream, holler in pain or give non-verbal signs of pain. The LPN said that if the resident complained of pain, she would have therapy look at them; and that, if there is actual or suspicion of injury, she would call the doctor and ask for a STAT order. She stated that when a resident fall, it will be documented in the progress notes. Regarding resident #46, the LPN stated she would have called the provider, called 911 and send the resident sent out in the morning the resident complained of pain. She stated that she thinks the care that resident #46 received the day and after the fall would not have met her expectations. She stated that after an order for an x-ray had been received they should have done it immediately. Further, the LPN stated that resident #46 had to deal with the pain for a couple of days with the risk of throwing a blood clot before the resident was sent out to the hospital. An interview was conducted on 05/18/23 at 2:01 p.m. with the Director of Nursing (DON/staff #25) who stated that they try to have continuity of care on the dementia unit so that the nurses could recognize when a resident has a change in status. She stated that after a fall, she expected the staff to follow the fall protocol which included a head to toe assessment, notify all the appropriate parties and to start neuro checks. She stated she would anticipate the resident to be on 72-hour alert charting, which includes assessing the resident every shift. The DON stated that residents with dementia express pain with facial grimacing, abnormal movements, redness, swelling, and pain during repositioning. Regarding resident #46, the DON stated that when the resident's pain was noted, nursing staff called the NP and obtained an order for x-ray. However, she stated that the x-ray had not been completed by 5:00 p.m. the following day which did not meet her expectation. The DON stated that the x-ray should have only taken a couple of hours to complete. She stated that it did not meet her expectation that resident #46 waited so long to go to the hospital for and x-ray and treatment. She stated that after the incident with resident #46, a new process began that include that if a resident fall and an x-ray was ordered, the resident will be to send to the hospital through 911. -Resident #76 admitted on [DATE] with diagnoses of unspecified kidney failure, acute cystitis with hematuria and type 2 diabetes mellitus without complications. A care plan initiated on December 2, 2022 included the resident had hypertension related to lifestyle. The goal was that the resident will remain free of complications related to hypertension. Interventions included to give antihypertensive medications as ordered and to monitor for side effects such as orthostatic hypertension, increased heart rate and effectiveness. A physician history and physical note dated December 5, 2022 included an assessment of hypertension. Plan was to continue amlodipine (antihypertensive), carvedilol (antihypertensive), Lasix (furosemide/diuretic) and potassium (supplement). Further, the plan included to monitor vitals and notify of abnormal trends. The admission MDS (minimum data set) assessment dated [DATE] revealed a BIMS score of 12 indicating resident had moderately impaired cognition. The assessment also included resident required extensive one to two-person physical assistance for most activities of daily living. A physician order dated December 13, 2022 revealed the following orders: -Amlodipine besylate 10 milligrams (mg) one time a day for hypertension; -Lisinopril 40 mg one time a day for hypertension; and, -Furosemide 40 mg one time a day for edema related to hypertension. A physician order dated December 14, 2022 included an order for Carvedilol 25 mg, 1 tablet two times a day for hypertension and to give it with meals. These orders were transcribed onto the MAR (medication administration record) for December 2022, January and February 2023. Per the documentation in the MAR, these medications were administered as ordered. Review of the blood pressure (BP) summary for January and February 2023 revealed there were multiple dates that the systolic blood pressure (SBP) was recorded to be less than 110. The NP note dated February 26, 2023 included the resident had increased back pain, required 1:1 assistance with feeding, no longer wished for interventional treatment, was electing for palliative care and refused to allow blood draws or invasive procedures. Further review of the BP summary for February 2023 revealed that the following information: -February 27 at 6:43 a.m., the SBP was recorded as 91/54 millimeters of mercury (mmHg); and, -February 28, at 7:10 a.m., the SBP was recorded as 85/47. Review of the MAR for February 2023 included that carvedilol, amlodipine and furosemide were administered as ordered. In the space provided for nursing documentation related to the 8:00 a.m. administration of lisinopril, a code 9 was documented - indicating Other/See Nurse Note; and that, the medication was held. Despite documentation of low BP readings, the clinical record revealed no evidence the provider was notified. The health status note dated February 28, 2023 at 9:34 a.m. revealed that the resident's oxygen (O2) saturation levels was 89%; and that, oxygen was applied at 2 liters via nasal cannula and the O2 saturation increased to 94%. Per the documentation, the resident had increased wheezing, weakness and confusion; and that, hospice was contacted and will be admitting the resident to their services for diagnosis of protein calorie malnutrition. The health status note dated February 28, 2023 at 6:16 p.m. revealed the resident had absent of vital signs which was verified by two nurses. The late entry discharge summary dated February 28, 2023 included that the resident had an expected decline with natural death that occurred on February 28, 2023 at 6:16 p.m. An interview was conducted on May 18, 2023 at 8:22 a.m. with an LPN (staff #3) who stated that if a resident's blood pressure was extremely low or high, he would notify the physician. He stated that if the resident's blood pressure was in the 90's (systolic) over 50's (diastolic) he would hold the antihypertensives and call the doctor. He stated that it was part of his assessment as a nurse to see if the medication was safe to give. The LPN also said that giving antihypertensive medications to residents with low blood pressure would not be appropriate and might increase the risk that the resident might die. In an interview with another LPN (staff #129) conducted on May 18, 2023 at 8:30 a.m. the LPN stated that residents' blood pressures are checked/reviewed before giving their antihypertensive medications. She stated that if a medication does not have a parameter, she would still check the blood pressure and pulse; and that, if the systolic blood pressure were less than 100 and/or the pulse was less than 60, she would check with the physician before giving the medications. She stated that if the resident's blood pressure was frequently 110 or less, she would check with the doctor to see if they wanted to adjust the medication; and, would definitely contact the physician. During an interview conducted with the DON (staff #25) on May 18, 2023 at 8:44 a.m., the DON stated that when physician orders do not have parameters on them, she would not expect the nurse to assess the blood pressure. The DON said she would expect the nurse to ask the resident questions such as whether or not they were dizzy or lethargic, and just to talk to the resident. She stated that if the medication did not have parameters, it would be at the nurses' discretion whether or not to give the medication. She stated that they do not always take the resident's blood pressure; and, if nothing triggered they would not know if a change of condition had happened. She stated that if the resident's blood pressures were 91/54 or 85/47 mmHg she hopes that the nurse would hold the medication, call the provider and follow orders. However, the DON said that if the nurse did not take the blood pressure she would not know to hold the med. She stated that when nurses consult with the provider, it was her expectation that the nurse would document the conversation/notification. She stated that risks associated with administering antihypertensive medications to a resident with low blood pressure readings would include an altered level of consciousness, lethargy and potentially death. The facility's policy on Conformity with Laws and Professional Standards policy, revised April 2007, included that the facility operates and provides services in compliance with current federal, state and local laws, regulations, codes and professional standards of practice that apply to the facility and types of services provided. The facility's policies, procedures and operational practices are developed and maintained in accordance with current accepted professional standards and principles as well as current commonly accepted health standards established by national organizations, boards and councils. The facility policy on Change in Resident's Condition or Status included that regardless of the resident's current mental or physical condition, a nurse or healthcare provider will inform the resident of any changes in his/her medical care or nursing treatments. The Nurse Management of Change of Condition policy/procedure, dated 2018, included that residents in our facilities depend on us to provide quality care and to ensure their safety. This includes monitoring residents for change of conditions (COC). According to the American Medical Directors Association (AMDA) (2005 p. 22) the definition for an acute change of condition is a sudden, clinically important deviation from a resident's baseline in physical, cognitive, behavioral or functional domains . that without intervention, may result in complications or death. According to the policy, what constituted a COC included a fall with or without injury, increased or unrelieved pain and blood pressure out of normal range. Per the policy anything out of the normal limits and baseline for the resident constituted COC. They can be related to an acute condition or chronic condition that is getting worse such as changes in vital signs i.e., blood pressure out of normal range. It also included that when COC is identified, the information regarding the COC and any orders received must be communicated to other members of the health care team; and that, notifications need to be documented in the resident's chart.

Based on clinical record reviews, observations, staff interviews, facility documentation, and policy and procedures, the facility failed to ensure that 2 out of 3 sampled residents (#57 and #40) received care and services, consistent with professional standards of practice, to prevent, treat, and/or heal pressure ulcers. The deficient practice could result in residents developing pressure ulcers or worsening of pressure ulcers. Findings include: -Resident #57 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A risk for pressure ulcer development care plan dated 03/25/15 related to [CONDITION(S)], incontinence and immobility had a goal for intact skin, free of redness and discoloration. Interventions included following the facility policies/protocols for the prevention/treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the Pressure Ulcer Documentation and assessment dated [DATE] revealed a facility acquired unstageable pressure ulcer to the left ischium measuring 3.5 centimeters (cm) x 4.0 cm. The progress note stated that the wound was found on 12/23/21 during a brief change. According to the documentation, the etiology of the wound was likely poor positioning of the resident and the wheelchair cushion in the resident's chair. Review of the clinical record revealed thorough pressure ulcer assessments were completed on 01/08/22 and 01/15/22. Review of the Treatment Administration Record (TAR) dated January 2022 revealed treatments and repositioning were provided daily as ordered, with the exception of 01/17, when there was no documentation to indicate whether or not the resident received treatment on that date. Review of the Pressure Ulcer Documentation and assessment dated [DATE] included clarification that the left ischial pressure ulcer was to the sacrum. A Pressure Ulcer Documentation and Assessment was completed on 02/04/22. The Pressure Ulcer Documentation and assessment dated [DATE] revealed the sacral wound was a stage 4 pressure ulcer which measured 12.0 cm x 10.0 cm x 9.0 cm, with a large amount of drainage (no description), no odor, and a wound base of 30% yellow slough, 70% red. The treatment included Dakin's (dilute sodium hypochlorite) solution. Review of the clinical record included Pressure Ulcer Documentation and Assessment on 02/18/22 and 02/25/22. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Per the February 2022 TAR treatments to the sacrum were provided in accordance with the physician orders. Review of the clinical record revealed Pressure Ulcer Documentation and Assessments for 03/05/22, 03/11/22 and 03/17/22. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Pressure Ulcer Documentation and assessment dated [DATE] revealed for a stage 4 sacral pressure ulcer which measured 12.0 x 10.0 x 8.7 cm, with no tunneling. A large amount of brown/green drainage was noted in the wound vac, with no odor identified. The wound bed was described as 100% red/pink. Review of the March 2022 TAR revealed that sacral treatments were provided as ordered, with the exception of 03/16, 03/21, and 03/23. Review of the clinical record did not reveal evidence to indicate whether or not the resident received treatment on those dates, and/or the rationale for why the treatments were not provided. Pressure Ulcer Documentation and Assessment was completed on 04/01 and 04/05. A Wound Clinic progress note dated 04/06/22 included the wound appeared better than at the last visit and that the resident was to continue wound vac therapy. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The Pressure Ulcer Documentation and assessment dated [DATE] revealed that wet-to-dry dressings to the sacral wound would be implemented temporarily while the wound vac was being shipped. An additional Pressure Ulcer Documentation and Assessment was completed on 04/19. Review of the April 2022 TAR revealed that wound treatments to the sacrum were not provided on 04/12, 04/14, 04/15, 04/16, 04/17, 04/18, 04/19, 04/21, and 04/25. Review of the clinical record revealed no evidence to provide a rationale for why the resident did not receive wound care. The quarterly Minimum Data Set Assessment (MDS) assessment dated [DATE] revealed the resident scored 14 on the Brief Interview for Mental Status (BIMS), indicating intact cognition. The resident exhibited no behaviors, including rejection of care and required extensive 2-person physical assistance for most activities of daily living. Per the assessment, the resident had one stage 3 pressure ulcer, one stage 4 pressure ulcer, and 8 unstageable pressure ulcers. A change of condition summary dated 04/27/22 at 7:55 p.m. revealed the resident was sent to the emergency room for a high temperature. The resident returned on 04/29/22. Review of a nurse practitioner progress note dated 05/01/22 revealed the resident had a stage 4 decubitus ulcer and a large plantar ulcer at the posterior calcaneus that were suspicious for [CONDITION(S)]. The resident returned to the facility with [CONDITION(S)] due to stage 4 decubitus ulcers and that the resident had refused therapy at the medical center. A Pressure Ulcer Documentation and Assessment was done on 05/02/22. Per the documentation, no signs or symptoms of infection were noted. Review of the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The Wound Clinic progress note dated 05/04/22 revealed that a sharp debridement of the sacrum, dressings, and education had been provided that day. The Director of Nursing (DON/staff #127) had initialed the document and written Noted next to her initials. The note also included the wound vac was changed out and should be changed every other day or 3 times a week. Review of the May 2022 TAR revealed that pressure ulcer care and treatment with the wound vac had not been provided on 05/06. The documentation included 9 which meant other/see nurse notes. Review of the nurse notes did not reveal an entry for 05/06/22. A nurse practitioner (NP) progress note dated 05/08/22 at 9:21 p.m. indicated that the reason for the visit was related to no wound vac canister. The note included that the resident reported that the wound vac canister was full with drainage, but there was no canister in the facility to change. The note revealed that the NP discussed this with a Registered Nurse (RN/staff #67). The note stated that dressings were to be changed daily and as needed due to full drainage in the canister of the vac to reduce potential of infection. Review of the TAR for May 2022 revealed the treatment was provided to the sacrum on 05/09/22. On 05/10/22 at 2:49 p.m., the resident was observed lying in the bed. A wound vac, with a canister that appeared to be almost completely filled with drainage, was observed on the bed beside the resident. A wound care observation was conducted on 05/11/22 at 9:00 a.m. with the wound Registered Nurse (RN/staff #79) who was assisted by a RN (staff #67). The wound nurse removed the old dressing and described the wound as a full-thickness stage 4 pressure ulcer. She stated that the wound had moderate serosanguinous drainage with foul odor. She said the wound bed was 40% necrotic/black tissue and 60% red, with wound borders denuded, and moisture-associated skin damage to the perimeter. After cleansing the wound with normal saline, she stated that the wound measured 10.0 cm x 11.0 cm x 3.5 cm with tunneling at 2 o'clock which measured 4.5 cm. On 05/11/22 at 9:34 a.m., the wound vac was observed laying on a chair at the foot of the resident's bed. Rotted, clotted-looking debris was noted in the canister. The resident stated that he did not know how often the canister was changed. An interview was conducted on 05/11/22 at 9:51 a.m. with the wound RN (staff #79). She stated that if the resident had agreed to have the wound vac on that she would use the one that was sitting on the resident's chair. She stated the resident would get a new canister whenever the one on the wound vac got filled up. She stated that she did not think that there was a record of when the canister was replaced. The RN stated that she had never read up on it, but she thought that placing a wound vac onto a wound with a canister that was filled with debris might pose a risk for infection to the resident. On 05/12/22 at 11:13 a.m., an interview was conducted with an RN (staff #67). She stated that the resident's dressings are changed twice per day and that the wound vac is changed on the night shift. She stated that the resident absolutely wears the wound vac every day on the day shift. She stated that the wound vac is supposed to be on every day. She stated that the canister is changed every 24 hours, whenever it is needed, or when it is full. The RN stated that she thought that the resident's sacrum had been infected since March. She stated that placing a wound vac over necrotic tissue was acceptable because the wound nurse does it. She stated that she would assume that someone would tell her if it was not appropriate. She said the resident's sacral wound was debrided on 05/04/22 and that the sacrum was not necrotic until towards the end of that week. She stated that when the resident's sacral wound became necrotic she did not notify the physician. The RN stated that she would not necessarily have noticed when the wound became necrotic because the wound vac was on. She stated that the change in wound status would be considered a change of condition. She stated that she was not sure when the provider was notified. She stated that the resident does not refuse wound care from her. The RN said that dressing changes should be provided daily or it should be documented that the resident refused. She stated that she had not really heard anything about the resident refusing. An interview was conducted on 05/12/22 at 1:06 p.m. with the Director of Nursing (DON/staff #127). She stated that it would not meet her expectation for a full canister to be utilized on the resident's wound. She stated that if the resident had gone to the wound clinic to have the wound debrided on 05/04/22 she would question the wound nurse's definition of necrosis. She stated that the wound nurse is an RN and that she is qualified to assess wounds. But, she stated, she was not sure that the wound nurse had received sufficient training to be able to identify necrotic tissue. She stated that she could not say whether or not the wound nurse was qualified to assess wounds. The DON reviewed the resident's clinical record and stated that she could not identify when the resident's sacral wound became necrotic. She stated that she did not see a progress note indicating that the wound had a change in status or that the provider had been notified. She stated that this did not meet her expectations. The DON stated that she understood that it did not meet professional standards to place a wound vac on a necrotic wound, that the policy stated such, and that the manufacturer's instructions said the same thing. She reviewed the resident's record and indicated that incomplete documentation in the TAR, not completing dressing changes as ordered, and/or not documenting when the resident refused treatment did not meet her expectations. On 05/13/22 at 9:28 a.m., an interview was conducted with the wound nurse (staff #79). She stated that wound assessments are required to be completed weekly. She stated that she documents the assessments on the Pressure Ulcer Documentation and Assessment. She stated that pressure ulcer assessments include wound measurements, description of the wound bed and perimeter of the wound, signs and symptoms of infection, type and amount of drainage, and whether or not there is odor. She stated that when she identifies symptoms of infection she will speak to the provider about it in person. She stated that she will note symptoms of infection on the weekly wound report and pressure ulcer documentation. Staff #79 stated that she was not sure that she had documented the conversations in the clinical record, but if there was a change in the wound she would note that. She stated that the necrosis on the sacral wound was a new change that occurred between 05/05 and 05/11. She stated that she spoke with the physician regarding the changes to the wound. She stated that she did not document the conversation. The RN stated that she put the wound vac on hold on 05/12/22 with the authorization of the physician. She stated that she completes wound assessments and dressing changes for the resident on Mondays. She said that on Monday, 05/09/22, she did note that the wound had become necrotic but did not include that in her documentation. She stated that she had not notified the provider until yesterday. The wound nurse stated that she would consider it to be a change of condition/status of the wound. She stated that she did not feel like it was an immediate danger because she had placed a wet-to-dry dressing on the sacral wound. She said she thought she had placed a hold on the wound vac then (05/09), but she had not. The RN stated that it did not meet the standard of professional practice to place a wound vac on a necrotic wound and that she thought the risks might include [CONDITION(S)]. The facility policy titled Negative Pressure Wound Therapy included that the purpose of the procedure was to provide guidelines for establishing and maintaining negative pressure wound therapy (NPWT). The general guidelines included that NPWT was contraindicated in residents who have wounds with necrotic tissue with eschar, untreated [CONDITION(S)], non-[MEDICATION(S)] fistula or malignancy in the wound. Reporting included marked changes in the wound from baseline or previous dressing change. The V.A.C. Therapy System Safety Information included that V.A.C. therapy is contraindicated for wounds that included untreated [CONDITION(S)] and necrotic tissue with eschar present. -Resident #40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Health Status Note dated April 5, 2022 included Multiple limb contractures noted, which have obvious effects on gross & fine motor function. A Weekly Skin Check dated April 5, 2022 included a left-hand middle digit wound that measured 1 cm x 1.5 cm x .5 cm. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the TAR for April 2022 revealed the treatment was provided as ordered. A Care Plan initiated on April 5, 2022 and revised on May 5, 2022 revealed the resident had a potential impairment to skin integrity related to [CONDITION(S)], decreased mobility and had an actual impairment to skin integrity related to the right heel deep tissue injury and ring finger and middle finger pressure ulcer. Interventions stated to monitor/document location, size and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . to the physician and follow facility protocols for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] A Physician History and Physical Note dated April 7, 2022 included Early contractures of legs, and severe Left arm, Ltd movement of R arm. An admission MDS assessment dated [DATE] revealed the resident had a BIMS score of 8 which indicated moderate cognitive impairment. This assessment also included the resident had one unstageable pressure injury that was present on admission. A Pressure Ulcer Documentation and assessment dated [DATE] included a left-hand middle digit stage 2 pressure wound that measured 1 cm x 1.5 cm x 0.5 cm. This document stated On initial exam I believed that the patients wound on her finger was an injury sustained by force prior to admission but after further assessment of patients lack of mobility and natural laying position I believe it is a pressure injury from the position her hand lays in. This PU was present upon admission. Order placed to tx and float when in bed. However, a review of the clinical record revealed no order for floating the resident's hand or that the physician was informed that the wound was determined to be a pressure ulcer until May 7, 2022. A Pressure Ulcer Documentation and assessment dated [DATE] revealed this resident had a left-hand middle finger stage 2 pressure wound that measured 1.5 cm x 2 cm x 0.2 cm with 100% red/open/granulation and a left-hand ring finger stage 2 pressure wound that measured 1 cm x 1.2 cm x 0.2 cm with 100% red/open/granulation. A review of the clinical record revealed no evidence that the physician was informed of this new pressure ulcer on the left-hand ring finger until May 7, 2022. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Weave xeroform between fingers and pad so that the fingers are separated. Wrap with kerlix between fingers and around hand followed by an ace wrap to keep in place every day shift for the open wound. A Weekly Skin Check and Wound assessment dated [DATE] included that this resident had a left-hand middle finger wound that measured 1 cm x 1.4 cm x UTD (unable to determine) and a left-hand ring finger wound that measured 1.1 cm x 1.2 cm x UTD. A wound observation was conducted on May 12, 2022 at 12:52 PM with the Wound RN (staff #79). The RN sanitized her hands, put on gloves and spoke with the resident about the procedure. She then removed the wrap from the resident's hand and disposed of it. The RN then cut the kerlix off of the resident's hand with scissors and asked the resident to tell her if it hurt. This RN said that the way the resident's hand is curled up, they have an order to float the hand when possible. She said that the wound is full thickness and that last week she could see the wound bed. She said that the wounds have no odor. She measured the ring finger wound to be 1 cm x 1 cm and stated that she was unable to determine the depth due to eschar. She measured the middle finger wound to be 1.2 cm x 1.2 cm and stated that she was unable to determine the depth, and said that the wound was improving because before it had a foul odor and that she feels the xeroform has caused it to have gotten much better. The RN said that she does a weekly wound report to track whether a wound is declining or improving and that she tracks the significant wounds. She also stated that she has been the wound nurse at this facility since mid-March. During an interview conducted on March 13, 2022 at 9:49 AM with the Wound RN (staff #79), she said that heel protectors and frequent positioning were some of the interventions required for a pressure ulcer. She said that she was not sure of the facility protocols for a pressure wound. She reviewed this resident electronic record and said that the order to float the resident's hands should be in there, but that she did not see it. Staff #79 stated the physician should be informed right away of new wounds and worsening wounds. She said that she had been informing the DON right away about the wounds and that she believed that the DON had spoken to a provider about the wounds. The RN said that improvement and decline are components of the wound report that goes out weekly and that the nutritionist is on the list to receive the report but that she did not see that the physician was on the list. She said that since she had performed the wound care on May 12, she had spoken to a provider about the resident's heel but she had not spoken to the provider about the resident's finger pressure wounds. This staff said that eschar is a downgrade from granulation. An interview was conducted on March 13, 2022 at 10:26 AM with the DON (staff #127), who said that any staff can notify the physician and that the Wound Nurse should be working closely with the physician. She said that the Wound Nurse should be notifying the physician about downgrades in wounds. She said that she did not notify the physician on May 3 or 4 about the new pressure wound on this resident's finger but that she believed the Wound Nurse had notified him. The DON said the Wound Nurse should be talking to the physician about all wounds. A facility policy titled Wound Management program revealed that it is the goal of the facility that all residents with wounds receive treatment and services consistent with the resident's goals of treatment. The Wound Management Program is structured and implemented using processes founded on accepted standards of practice, research driven clinical guidelines and interdisciplinary involvement. A facility policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol revealed the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). The physician will help identify factors contributing or predisposing residents to skin breakdown; for example, medical comorbidities such as diabetes or congestive heart failure, overall medical instability, cancer or [CONDITION(S)] causing a catabolic state, and macerated or friable skin. This document included that the physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. A facility policy titled Change in a Resident's Condition or Status revealed that this facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. This policy included the nurse will notify the resident's Attending Physician or physician on call when there has been a need to alter the resident's medical treatment significantly or specific instruction to notify the physician of changes in the resident's condition.

Based on observations, clinical record review, staff interviews, and policy reviews, the facility failed to ensure one sampled resident (#40) with an indwelling urinary catheter was provided care and services to prevent skin impairment. The deficient practice could result in residents with indwelling urinary catheters having skin breakdown issues. Findings include: Resident #40 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a care plan initiated on April 5, 2022 revealed the resident had an indwelling suprapubic catheter. The goal was that the resident would be/remain free from catheter-related trauma. Interventions stated to change the catheter every 4 weeks and to monitor/document for pain/discomfort due to the catheter. Review of another care plan initiated on April 5, 2022 revealed the resident had potential for impairment to skin integrity related to [CONDITION(S)], decreased mobility. The goal was that the resident would have no complications related to skin injury. Interventions stated to keep body parts from excessive moisture, educate resident/family/caregivers of causative factors and measures to prevent skin injury, keep skin clean and dry, report abnormalities, maceration etc. to the physician, and turn and reposition the resident frequently while sitting in a chair or lying in bed. An admission Minimum Data Set (MDS) assessment dated [DATE] included that this resident had a Brief Interview for Mental Status (BIMS) score of 8 which indicated moderate cognitive impairment. This assessment also included this resident had an indwelling catheter and required total dependence with 2+ person physical assistance for toilet use. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The order did not include applying a split gauze. The suprapubic catheter care plan was revised on April 13, 2022 and included positioning the catheter bag and tubing below the level of the bladder and away from the entrance door. Review of the Treatment Administration Record (TAR) dated April 2022 revealed catheter care was performed as ordered. Review of the TAR for May 2022 revealed catheter care was provided as ordered. The TAR included the suprapubic drainage bag was changed on May 4 and the suprapubic catheter was changed May 6. Review of the clinical record revealed Weekly Skin Check and Wound Assessments were completed from April 5, 2022 through May 10, 2022. The Skin Observation Tasks dated May 8, 9, and 10, 2022 indicated this resident had a skin issue of an open area that was not on the arms, leg, back, buttocks, heels. An observation was conducted on May 12, 2022 at 9:17 AM with a Certified Nursing Assistant (CNA/staff #112) who spoke with the resident, then raised the bed. This staff removed the resident's brief, and wiped around the urinary catheter which was surrounded by a sanguineous exudate. A Unit Manager who was assisting stated that the resident had some irritation and that she would have the wound nurse assess the resident. The CNA left the room and spoke with the Licensed Practical Nurse (LPN/Staff #45) at the desk who said that the resident has had bloody drainage for a while, it was normal. Observations revealed no method of securing this catheter and no gauze or other dressing was observed around the catheter site. The CNA returned to the room and continued to perform the catheter care, measured the output, cleaned the area and repositioned the resident. However, review of the clinical record revealed no evidence regarding this skin issue or that the skin issued had been assessed. An observation was conducted on May 12, 2022 at 12:52 with the Wound Registered Nurse (RN/staff #79) who sanitized her hands, changed her gloves, and then used gauze with wound cleanser to clean the sanguineous drainage from around the catheter and folds. The RN said that she saw some skin breakdown and bright red bloody discharge. She said that she had not been informed of the wound prior to being asked to measure it by the surveyor. The RN measured the area and said that it was 0.5 centimeters (cm) x 1.5 cm with a bright red wound bed. This nurse would not state the depth. She said that the area was possibly shearing. She told the resident that she would speak with the physician. The RN stated the red area was towards 9 o'clock where the urinary catheter tube was laying. The wound was observed to be full thickness with a beefy red wound bed and had moderate sanguineous exudate. The wound was observed in the groove where the catheter had been left on the skin approximately 2 cm from the catheter insertion site. An interview was conducted on May 13, 2022 with a [NAME] (staff #93) who said she did not think that it was bloody yesterday but that she was moved around the facility a lot. She said that she was surprised that the resident did not have a split gauze around the catheter site and that she would let the nurse know so he could place one. An interview was conducted on May 13, 2022 at 8:33 AM with an LPN (staff #45), who said that this resident has had a bloody discharge and that he noticed it last week on Friday. He said that he had put a split gauze around the catheter on that Friday. He said that he was having trouble getting the split gauze because the facility is having such issues with their supply because the person who does central supply also does transportation. He said that the facility has leg bands to secure catheters and that they were talking about getting clamps because the leg bands tend to migrate down. When asked when he had informed the physician, he looked nervous and said that he told the doctor. He reviewed the progress notes and the orders and then retracted and said that the bloody discharge was discovered yesterday during the catheter care performed by staff #112. An interview was conducted on May 13, 2022 at 9:49 AM with the Wound RN (staff #79) who said that this wound was irritation from the catheter rubbing there, not sitting there. She said that she does not know if there should be a drainage sponge or gauze cover around the catheter or if the catheter should be secured because the nursing staff cares for that. She said that she put in a treatment after speaking with the physician. She said that she could see that having a cover around the catheter could help. She said that the physician should be informed of new wounds right away. An interview was conducted on May 13, 2022 at 10:26 AM with the Director of Nursing (DON/staff #127), who said that her expectation for suprapubic catheters is to follow the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . She said that if the catheter was not a new placement then there may not be an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She said that they need to be better with securing them. A facility policy titled Suprapubic Catheter Care included that the purpose of this procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. This policy included that staff should notify their supervisor immediately in the event of hemorrhage and to include a drainage sponge if ordered by a physician. A policy titled Urinary Catheter Care revealed that the staff should ensure that the catheter remains secured with a leg strap to reduce friction and movement at the insertion site.

Based on clinical record review, staff interviews, hospital documentation, and review of facility policy, the facility failed to ensure one resident (#1) was given the correct dosage of tube feeding, resulting in hospitalization . Findings include: Resident #1 was admitted to the facility on [DATE] around 8:30 p.m. [DIAGNOSES REDACTED]. Admission physician's orders [REDACTED]. The order did not include the amount or how often the resident was to receive the [MEDICATION NAME] feedings. Review of the September 2013 Medication Administration Record (MAR) revealed this order was not transcribed on to this record on September 28. Review of the Nutrition at Risk Review signed by a Registered Dietician (RD) dated September 29, 2013 revealed the following regarding the tube feedings: [MEDICATION NAME] 240 milliliter (ml) x 6 per day, flush with 60 ml of water before and after feeding, and 240 ml of water twice a day. Fluid needs were calculated at 2200 ml per day. Further review of the MAR revealed the [MEDICATION NAME] 240 ml x 6 per day was not documented on the MAR. According to a dietary note dated September 29, 2013, the RD had received a call at 11:22 a.m.,. from a staff member for a consult regarding the tube feeding recommendations, as the "multiple orders were confusing." The note included the resident was on an intermittent [MEDICATION NAME] feeding and being titrated up to goal rates for formula and fluid flushes. This note included to refer to an RD chart entry for September 29 at 11:57 a.m., for complete recommendations. Review of the RD's note dated September 29 at 11:57 a.m., included the resident was admitted from the hospital on [MEDICATION NAME] feedings. The current tube feeding regimen was [MEDICATION NAME] 240 ml (1 can) 6 times a day with 60 ml of water flush before and after each feeding, and an additional 240 ml flush twice a day. Per the note, this would provide 2334 ml fluid with additional 360 ml water total from med passes for a daily total of 2694 ml free fluid. Nutritional needs were estimated as needing 2200 ml fluid and that the above regimen could be modified to allow more time off the pump and to avoid fluid overload. The note further included the following recommendation: [MEDICATION NAME] 1.5 cal, set pump at 360 ml/hr with four scheduled feeding times per day, flush with 30 ml water before and after each feeding, flush with 250 ml water twice a day, flush with 30 ml water before and after each med (six meds scheduled daily). This would provide a total of 2194 ml free fluids per day. The note also included nursing and therapy to work together to schedule meal times for feedings. This recommendation did not include how long the tube feeding was to run (i.e. 360 ml/hr over one hour or over two hours). A physician's orders [REDACTED]. 360 ml/hour with four scheduled feeding times a day through the [DEVICE], flush with 30 mL of water before and after each feeding, and flush with 250 ml of water twice a day for hydration. The order still did not specify how long the feedings were to run. According to the September 2013 MAR, the tube feeding orders were as follows: [MEDICATION NAME] liquid 360 ml/hr four times a day, flush with 30 ml water before and after each feeding. The times scheduled were at 6 a.m., 2 p.m., and 10 p.m., instead of four times a day as ordered. The MAR did not specify how long to run the tube feeding. Review of the tube feeding care plan dated September 29, 2013, revealed the resident had tube feedings with the potential for nutritional impairment. The goal included that the resident will tolerate feedings and maintain nutrition/hydration status over the next 90 days. Interventions included to check proper tube placement and residual feeding before each feeding, RD to review adequacy of feeding regimen, ensure resident is sitting up or height of bed is elevated for 30-45 min after feeding is administered, and to administer feeding and flushes as ordered. According to the social service assessment from September 30, 2013, the resident was able to express and understand information. Review of the RD's progress note dated September 30, 2013 at 2:09 p.m., revealed that she received a call from staff #1. Staff #1 stated that the resident "...is getting 360 mL/hr continuous and I think that's too much." The RD explained to staff #1 that the order was not to be continuous, it was to be four times a day. The note further included that the RD reminded her to "set the pump to shut off at 1 hr with the rate of 360 for one hour." Staff #1 then stated that their pumps did not work that way and asked if they could change his feedings so it was continuous at night like another residents were. The RD response was that they could but there was a chance he would need future changes, as he's scheduled for PT/OT/ST and possible transition off the tube feeding. Staff #1 responded "well nobody set up the stop + start times." The RD responded by saying that nursing and therapy should review schedules and space the tube feedings four hours apart. Another staff member then came on the phone to clarify the start and stop times, the rate for the pump and flush amounts. A physician's clarification order dated September 30, 2013, included for [MEDICATION NAME] 1.5 cal liquid at 90 ml per hour everyday via pump, to check for placement, and flush with 60 ml of water before starting feeding at 3 p.m. The orders also included to stop feeding, and flush with 60 ml of water at 7 a.m. In addition, 250 ml water flush was ordered for twice daily at 8 a.m. and 8 p.m. for hydration. Review of the nurse's note written by staff #1 at 5:15 p.m. on September 30, 2013, revealed that at 10 a.m., the resident had been alert and oriented. [MEDICATION NAME] was infusing at 360 ml/hr via pump and flushes were done. At 10:30 a.m., the resident complained of stomach pain. The RD was called for verification of pump rate for feeding infusion and new orders were received for the rate to be decreased to 90 ml/hr. At 4:15 p.m., staff #1 was made aware that the resident needed something for pain and when she went in to see the resident, he was having rapid breathing. Resident #1's oxygen saturation was 80 percent on room air. Oxygen was applied and he was having increased chest pain and respiratory discomfort. The Nurse Practitioner was informed of the change of condition. The resident's family requested for him to be sent to the hospital. The resident was sent out to the hospital at 4:50 p.m. A physician's orders [REDACTED]. Review of the facility investigative documentation revealed that staff #1 administered the wrong amount of tube feeding to the resident causing fluid overload, resulting in hospitalization . Instead of administering [MEDICATION NAME] 360 ml for 1 hour, four times a day, staff #1 had administered the [MEDICATION NAME] at 360 ml/hr continuously. Staff #1 had arrived at work at 6:00 a.m. on September 30, and noticed the resident was hooked up to the tube feeding pump; however, she did not check the order at that time. Staff #1 could not remember if the pump beeped to let her know the feeding was finished at 7:00 a.m. She reported that she had allowed the pump to run until the bag of nutrition ran out. At that time she flushed the tube and gave water as ordered, and then proceeded to restart the pump to run another bag. Further review of the facility documentation revealed that staff #1 clarified the order with the RD at approximately 2:00 p.m., and was given a new order. When staff #1 realized that the resident was not doing well she notified the charge nurse. The charge nurse assessed the resident and stated to call 911 to have the resident transferred to the hospital and to notify the physician. Staff #1 did not recall ever mentioning to the RD, the charge nurse, the physician, emergency medical personnel, or any other staff of the mistake regarding the tube feeding and the possibility of the resident having fluid overload. It was also discovered that staff #1 did not stop the feeding and start the new order, when the new order was received. The feeding was not stopped until the resident was sent out to the hospital. The hospital Emergency Department record dated September 30, 2013, documented that the resident came from the nursing home with dyspnea. The resident's family stated he recently had emesis and choked on the fluid. [DIAGNOSES REDACTED]." A radiology report dated October 1, included atypical [MEDICAL CONDITIONS] may be present versus bilateral pneumonia. The resident was transferred to an acute care hospital on October 1, 2013. Review of the hospital admission documentation from October 1, 2013, revealed that the resident was "gravely ill, [MEDICATION NAME] and hypotensive" and his prognosis was "dismal". According to a consultation report from October 1, the resident became septic and hypoxemic with bilateral [MEDICAL CONDITION] airspace findings suggestive of aspiration. The resident had no known history of coronary or other structural [MEDICAL CONDITION]; however, his echocardiogram revealed moderate left ventricular dysfunction and some right-sided chamber enlargement. Another consultation report from October 1, 2013, revealed that the resident had no history of kidney disease; however, he was noted to be in [MEDICAL CONDITION]. He also had severe respiratory and metabolic acidosis and was intubated. During an interview conducted on October 17, 2013 at 10:05 a.m., the Administrator stated that the facility does not usually have very many residents requiring tube feedings. She reported that the nurse who put in the orders the night the resident was admitted was a newer nurse and did not realize tube feedings needed to be documented on the MAR. She stated that the tube feeding order was not transcribed onto the MAR until September 29, 2013. Later, the Administrator stated that the night nurse set the pump so it would beep at 7:00 a.m. when the feeding was finished; however, staff #1 did not recall the beeping. She stated that this issue would be brought up at their next Quality Assessment and Assurance meeting and that staff had already been in-serviced. An interview was conducted with the charge nurse and Director of Nursing (DON) on October 17, 2013 at 11:50 a.m. When asked about the amount of tube feeding staff#1 administered to the resident the charge nurse stated that she would have questioned an order that high. At the time both stated that they had never seen an order for [REDACTED]. The charge nurse reported that a nurse would have to consciously change the pump to continuous from the [MEDICATION NAME] setting and that a nurse could not change it "with a push of a button". During an interview conducted on October 17, 2013 at 12:05 p.m., the RD stated she believed she received a call from nursing on September 29, 2013. She stated they were confused by the tube feeding orders from the hospital. She also recalled a phone call from staff #1 and remembered clarifying that the order was not continuous. She reported that she gave new orders at that time. The RD was given an example of a resident receiving 200 ml/hr continuously and was asked if that amount would be too much for a resident, to which she replied "yes". Staff #1 was unable to be reached for an interview during the course of the investigation. Review of the facility's policy on "medication/treatment orders/transcriptions" included "proper channels of communication are used to ensure accurate delivery of medications and treatments to all residents. This is achieved by using the Physician order [REDACTED]."