Every finding on record at Haven of Safford

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the resident's (#10) rights to be free from physical abuse by another resident (#5). This deficient practice could result in further incidents of resident-to-resident abuse. Findings include: -Resident #5 (Perpetrator) was admitted to the facility on [DATE], with diagnoses that include dementia, urinary tract infection, anxiety, heart disease, insomnia, and weakness. The 5-day Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 04 which indicated the resident had significant cognitive impairment. A review of Resident #5's care-plan revealed Resident #5 had a behavior problem related to impaired cognitive function, resistiveness to care, physically aggressive behaviors and verbal outbursts, with a noted goal of Resident #5 will verbalize understanding of need to control behaviors and noted intervention to encourage Resident #5 to follow the plan of care. -Resident #10 (Victim) was admitted to the facility on [DATE], with diagnoses that include acute kidney failure, chronic obstructive pulmonary disease, diabetes mellitus type 2, asthma, and weakness. The Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had mild cognitive impairment. A review of resident #10's care-plan revealed resident #10 has a behavior problem related to impaired cognitive function, impaired safety awareness, physical behaviors, verbal behaviors, making false accusations, and resistiveness to care. The noted goal was resident #10 will verbalize understanding of need to control behaviors and noted interventions of administer medications as ordered and anticipate and meet the needs of resident #10. The progress note for resident #10 dated August 21, 2026 at 5:53 p.m. by staff #25 revealed the writer witnessed resident #10 being struck in the face by Resident #5, and that this led to both residents striking each other. The writer continued that both residents were separated immediately, assessed for injuries, and that no injuries were noted. The writer concluded that resident #10 continuously tried to continue the physical altercation and had to be separated multiple times by staff. An interview was conducted on August 27, 2026 at 1:00 p.m. with resident #10. Resident #10 stated I didn't want to hit her but I did, she made me mad and called me a bitch. Resident #10 further stated Resident #5 hit her in both eyes and that she tore Resident #5's clothes. Resident #10 stated that she has had some physical altercations with other residents before but none of them were recent. Resident #10 concluded that she has been trying to stay away from resident #5, because the cops came and she was scared she will get into it with her again. An interview was conducted with a Registered Nurse (RN/staff #1) on August 27, 2026 at 1:10 p.m. Staff #1 stated that the whole incident was kind of out of nowhere. She stated that Resident #10 was in a good mood all day that day, and that Resident #10 was kind of up and down with her moods. Staff #1 stated that Resident #5 usually just wheels around and waves at people and just tries to say hi. Staff #1 stated that she was at the nursing station training another staff member, when she looked up and saw Resident #10 and Resident #5 hitting each other. Staff #1 further stated that she immediately separated both residents and checked them for injuries, got vitals, and notified the director of nursing and the administrator. Staff #1 stated that neither resident had injuries and were both okay. Staff #1 agreed that was abuse and that both residents were swinging at each other, contacting 3 to 4 times each between them. Staff #1 defined abuse as anything that could cause harm to a resident, physically, emotionally, verbally, or financially. An interview was conducted on August 27, 2026 at 1:33 p.m. with Resident #5. Resident #5 stated that she didn't remember the incident at all, and that her memory wasn't great depending on the day and time. Resident #5 was observed to be pleasantly confused during the interview, and spoke mostly about her family. Resident #5 concluded she did feel safe in the facility. An interview was conducted with the Director of Nursing (RN/staff #50) on August 27, 2026 at 2:50 p.m. Staff #50 stated she was aware of the incident, and that she had left the facility 15 minutes before it happened. Staff #50 stated that Resident #5 tried to ambulate too close to Resident #10, and then Resident #5 struck Resident #10. Staff #50 stated that she was called by staff #1 immediately after the incident. Staff #50 stated that she came back to the facility with the administrator and started an investigation. Staff #50 stated that they put both residents on 15-minute checks, did assessments on both residents, and updated care plans for both residents. Staff #50 concluded that she feels like it can be seen as abuse because of the physical contact. A review of facility policy titled 'Resident Rights/Dignity: Abuse and Neglect - clinical protocol' effective January, 2024 revealed abuse is defined at S483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on resident and staff interviews, facility documentation, staffing records, and policy review, the facility failed to ensure sufficient nursing staff were available to provide care and services to meet residents' needs. The deficient practice could result in delayed or unmet care needs for residents requiring staff assistance.Findings include:Review of the Payroll-Based Journal (PBJ) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing during three reporting quarters in 2025. The facility assessment dated [DATE], revealed that the facility was licensed to provide care for 106 residents and had an average daily census of 70 to 80 residents. The average census included 10 to 25 short-stay residents and 30 to 45 long-stay residents. The facility assessment further identified 65 residents who required at least two-person assistance.The facility assessment staffing plan identified the following nursing staffing structure:Full-time Director of Nursing (DON);Full-time Registered Nurse Assistant Director of Nursing (ADON);Full-time Minimum Data Set Registered Nurse (RN);Full-time wound care Registered Nurse;Full-time direct-care Certified Nursing Assistants (CNAs);CNA staffing ratio of 1:8-15 on days;CNA staffing ratio of 1:8-15 on evenings;CNA staffing ratio of 1:15-20 on nights;One full-time equivalent Lead CNA providing direct care;1.5 full-time equivalent Restorative Nursing Assistants providing direct care;Five Registered Nurses/Licensed Practical Nurses (RN/LPNs) for the 6:00 AM to 6:00 PM shift;Two RN/LPNs for the 6:00 PM to 6:00 AM shift;Six CNAs for the 6:00 AM to 6:00 PM shift; andFour CNAs for the 6:00 PM to 6:00 AM shift.The staff schedule revealed that the facility consisted of six halls/units: East A, East B, East C, West, Transitional Care Unit, and Protective Care Unit. Clinical staff worked 12-hour shifts.The assignment sheets, Daily Staffing Postings, and punch-in records was conducted for selected dates from January through September 2025.The assignment sheets and Daily Staffing Postings generally reflected scheduled nursing staffing levels. However, comparison of these records with the corresponding punch-in records revealed a pattern of nursing staff call-offs and staff not completing their scheduled 12-hour shifts because they clocked out early.Staffing reviewed included:From January 10 through January 12, 2025, the facility census ranged from 78 to 81 residents. The Daily Staffing Postings reflected between three and four RN/LPNs, up to one Certified Medication Assistant (CMA), and six to eight CNAs on the day shift. The night shift reflected two RN/LPNs and four CNAs. Punch-in records for the three-day period reflected a total of 203.35 RN/LPN hours and 365.67 CNA hours.From February 7 through February 9, 2025, the facility census ranged from 72 to 73 residents. The Daily Staffing Postings reflected four RN/LPNs and six to seven CNAs on the day shift. Night staffing reflected one to two RN/LPNs and four CNAs. Punch-in records for the three-day period reflected 209.30 RN/LPN hours and 430.60 CNA hours.From February 21 through February 23, 2025, the facility census ranged from 72 to 77 residents. Day staffing reflected four RN/LPNs and five to eight CNAs, while night staffing reflected two RN/LPNs and four to five CNAs. Punch-in records reflected 207.58 RN/LPN hours and 340.60 CNA hours.From March 6 through March 8, 2025, the census ranged from 74 to 76 residents. Day staffing reflected four to five RN/LPNs and six to seven CNAs, while night staffing reflected two RN/LPNs and four to five CNAs. Punch-in records reflected 228.75 RN/LPN hours and 359.38 CNA hours.From March 13 through March 15, 2025, the census ranged from 72 to 75 residents. Day staffing reflected three to four RN/LPNs, up to two CMAs, and five to eight CNAs. Night staffing reflected two to three RN/LPNs and four CNAs. Punch-in records reflected 213.75 RN/LPN hours and 347.67 CNA hours.From May 8 through May 10, 2025, the census ranged from 73 to 75 residents. Day staffing reflected three to four RN/LPNs and six to seven CNAs, while night staffing reflected two RN/LPNs and four CNAs. Punch-in records reflected 216.43 RN/LPN hours and 375.65 CNA hours.From May 22 through May 24, 2025, the census ranged from 70 to 71 residents. Day staffing reflected four RN/LPNs and six to seven CNAs. Night staffing reflected one to two RN/LPNs, up to one CMA, and four CNAs. Punch-in records reflected 204.68 RN/LPN hours and 391.58 CNA hours.From June 5 through June 7, 2025, the census ranged from 68 to 69 residents. Day staffing reflected four RN/LPNs and five to seven CNAs, while night staffing reflected two RN/LPNs and four CNAs. Punch-in records reflected 190.45 RN/LPN hours and 374.98 CNA hours.From June 19 through June 21, 2025, the census ranged from 72 to 75 residents. Day staffing reflected three to four RN/LPNs, up to one CMA, and five CNAs. Night staffing reflected two RN/LPNs and four CNAs. Punch-in records reflected 181.17 RN/LPN hours and 369.07 CNA hours.From July 3 through July 5, 2025, the census ranged from 80 to 82 residents. Day staffing reflected three to four RN/LPNs, up to one CMA, and five to six CNAs. Night staffing reflected one to two RN/LPNs, up to two CMAs, and four CNAs. Punch-in records reflected 207.67 RN/LPN hours and 407.38 CNA hours.From July 17 through July 19, 2025, the census ranged from 77 to 79 residents. Day staffing reflected three RN/LPNs and six CNAs, while night staffing reflected two RN/LPNs and four CNAs. Punch-in records reflected 247.05 RN/LPN hours and 435.15 CNA hours.From August 7 through August 9, 2025, the census was 79 residents. Day staffing reflected three to four RN/LPNs and six CNAs, while night staffing reflected two RN/LPNs and four CNAs. Punch-in records reflected 218.85 RN/LPN hours and 353.93 CNA hours.From August 21 through August 23, 2025, the census ranged from 75 to 77 residents. Day staffing reflected three to four RN/LPNs and five to six CNAs, while night staffing reflected two RN/LPNs and four CNAs. Punch-in records reflected 211.42 RN/LPN hours and 392.28 CNA hours.From September 4 through September 6, 2025, the census ranged from 82 to 84 residents. Day staffing reflected three RN/LPNs and five to six CNAs, while night staffing reflected two RN/LPNs and four CNAs. Punch-in records reflected 219.22 RN/LPN hours and 410.67 CNA hours.From September 25 through September 27, 2025, the census ranged from 77 to 79 residents. Day staffing reflected three to four RN/LPNs, up to one CMA, and six to seven CNAs, while night staffing reflected two RN/LPNs and four CNAs. Punch-in records reflected 178.68 RN/LPN hours and 440.20 CNA hours.Comparison of the Daily Staffing Postings and assignment sheets with the punch-in records revealed that, although the scheduled staffing initially reflected sufficient staffing levels, actual staffing levels identified were affected by a high rate of call-offs among RNs, LPNs, CNAs, LNAs, and CMAs. The punch-in records further revealed that some nursing staff did not complete their scheduled 12-hour shifts because they clocked out early.As evidenced by the comparison of the staffing records with the staffing levels identified in the facility assessment revealed multiple review dates on which actual nursing staffing was below the staffing levels identified in the facility assessment. On August 3, 2026, at 9:46 AM, an interview was conducted with Licensed Nursing Assistant (LNA/Staff #72), who stated there were shortages of CNAs/LNAs on every shift, particularly on weekends. Staff #72 stated that on some days staff were able to complete their tasks before the end of the shift; however, on other days it was difficult to complete their tasks on time because of staffing shortages.On August 4, 2026, at 8:43 AM, an interview was conducted with a certified nursing assistant (CNA/Staff #113), who also worked as the staffing schedule coordinator. Staff #113 stated clinical staff worked from 6:00 AM to 6:30 PM and 6:30 PM to 6:00 AM. Staff #113 stated employees had two hours to notify him if they needed to call off and that call-offs occurred mostly on weekends. Staff #113 stated that, as the staffing schedule coordinator, he was responsible for finding coverage when an employee called off. If he could not find someone to cover the shift, he had to cover it himself. Staff #113 stated the DON and ADON oversaw the staffing schedule.On August 4, 2026, at 9:00 AM, a Resident Council meeting was conducted. During the meeting, residents discussed nursing staff coverage and staffing adequacy. The Resident Council President, Resident #50, reported there were not enough nursing staff to adequately meet residents' needs, particularly during the PM and nocturnal shifts.The Resident Council President reported that only two CNAs were available to assist residents who ate in the dining hall while several residents required assistance, resulting in concern that the available staff could not adequately address all residents' needs.Resident #50 further stated that she did not believe there was enough staff and had previously addressed the staffing concern with facility management. Resident #50 stated there were many residents complaining or needing assistance.On August 4, 2026, at 9:43 AM, an interview was conducted with Registered Nurse Staff (RN/staff #171). Staff #171 stated there were days when there were CNA shortages on the floor. Staff #171 stated she had observed numerous CNA call-offs during the preceding weeks and that when the facility was short staffed, it was difficult for the CNAs working that shift to complete their assigned tasks because of the CNA shortage.On August 4, 2026, at 10:40 AM, an interview was conducted with the DON, (DON/Staff #51). The DON stated that when staff called off, the facility contacted employees who were not scheduled to attempt to fill the vacant shifts. The DON stated she oversaw the staffing schedule and staffing hours and that clinical staffing depended on the facility census and resident acuity. The DON stated that LNAs and CNAs had the same job description. The DON further stated that CMAs were licensed staff who could administer medications with RN oversight. The DON stated that during 2025 and 2026, the facility experienced a higher turnover rate and that some turnover occurred when staff advanced from CNA/LNA positions to CMA or LPN positions and eventually became RNs.Review of the facility policy titled Administrative Policies: Staffing, in effect on January 1, 2024, revealed that the facility was required to provide sufficient numbers of staff with the skills and competencies necessary to provide care and services to all residents in accordance with resident care plans and the facility assessment.

Based on clinical record review, staff interviews, facility documentation, and review of applicable policies and procedures, the facility failed to ensure two of five sampled resident's (Resident #75 and Resident #52) right to be free from physical abuse by another resident (Resident #43 and Resident #6). The deficient practice had the potential to result in additional incidents of abuse and failure to take appropriate measures to protect the residents. Findings included: Regarding resident #75 and Resident #43: -Regarding Resident #75 Resident #75 was admitted to the facility on [DATE] with pertinent diagnoses including dementia, chronic heart disease, anxiety disorder, chronic pain syndrome, visual hallucinations, generalized muscle weakness, and other related comorbidities. A care plan dated June 26, 2025, revealed that Resident #75 had impaired cognitive function related to dementia, which affected her ability to make her own decisions, with noted interventions to reduce distractions, such as television volume, radio, and keeping the door closed, which had been initiated on June 26, 2025. A behavioral care plan dated July 4, 2025, revealed that Resident #75 had psychosocial well-being concerns related to anxiety, dependent behavior, distractibility, and inability to concentrate. The behavioral treatment plan directed staff to encourage participation by Resident #75, who depended on others to assist with decision-making. The targeted goals for these cognitive and behavioral concerns had a target date of March 31, 2026. The quarterly Minimum Data Set (MDS) assessment dated [DATE], indicated that Resident #75 had a Brief Interview for Mental Status (BIMS) score of 12, which indicated moderate cognitive impairment. The assessment also indicated that Resident #75 required substantial assistance with sit-to-stand, bed-to-chair, toilet, and shower transfers. A review of a skin assessment for Resident #75 dated July 12, 2026 at 3:13 p.m., identified a new skin impairment consisting of a small scratch on the left hand at the joint of the ring finger. The area was cleansed and left open to air (OTA). An additional skin assessment dated [DATE] at 10:20 a.m., revealed no new skin impairment; however, slight redness was noted under Resident #75's breasts. -Regarding Resident #43 Resident #43 was admitted to the facility on [DATE], with pertinent diagnoses of Wernicke's encephalopathy, generalized muscle weakness, abnormalities of gait and mobility, brachial plexus disorders, neuromuscular dysfunction of the bladder, attention-deficit/hyperactivity disorder, anxiety disorder, major depressive disorder, and other related comorbid conditions. At the time of the investigation, Resident #43 remained at the facility. The care plan revealed resident #43 had impaired thought processes related to difficulty initiating activities and making decisions. The care plan also included interventions to reduce distractions, such as television volume, radio, and keeping the door closed, which had been initiated on September 4, 2024. A behavioral care plan initiated on September 9, 2024, revealed resident #43 had behavioral concerns related to impaired cognitive function and thought processes, impaired safety awareness, wandering and exit-seeking behaviors, making false accusations toward staff and the facility, and fabrication of events or fictitious circumstances. The targeted goals for these behavioral and cognitive concerns had a target date of April 27, 2026. The quarterly MDS assessment dated [DATE], indicated that Resident #43 had a BIMS score of 13, which indicated intact cognition with little to no impairment. The MDS also indicated verbal behavioral symptoms, including threatening others, screaming, and cursing directed toward others. A review of intakes from the State Agency (SA) reporting system revealed a facility Incident Report Summary 5-Day Report dated July 12, 2026. The report indicated that Resident #43 attempted to take the TV remote control from Resident #75 during a disagreement regarding the TV volume. During the incident, Resident #43 struck Resident #75 with an open hand while attempting to take the remote control, and Resident #75 responded by scratching Resident #43's arms. The incident report indicated that the disagreement regarding the TV escalated to physical contact between the residents. A nursing note dated July 12, 2026, at 2:30 p.m., indicated that Staff #9 documented an escalation in behavior involving Resident #43 and her roommate, Resident #75, which resulted in a conflict. The note further indicated that both residents were separated to ensure their safety and that 15-minute checks were initiated for both residents. A nursing note by staff #51 dated July 12, 2026, at 3:30 p.m., indicated that Resident #43 reported she had not been sleeping and was frustrated by her roommate's television (TV) volume, which she stated had triggered the resident-to-resident altercation. A nursing note dated July 12, 2026, at 3:30 p.m., documented that Resident #75 no longer wanted to share a room with Resident #43 and had been moved to a different room. A nursing note dated July 12, 2026, at 9:38 p.m., documented that Resident #43 had been moved to a new room and that Staff #50 applied dressings to Resident #43's left forearm and right hand as a result of the altercation. A review of Resident #43's weekly skin-check dated July 12, 2026 at 3:19 p.m., revealed a new skin impairment that detailed 63 mm scratch on the forearm. The area was cleaned and a silicone dressing was applied. Smaller scratches were also noted between the thumb and first finger; these areas were cleaned and treated with bordered gauze dressings. The skin impairment had not been documented during an earlier assessment and was managed routinely until the wound healed on or about July 21, 2026. An interview was conducted with Certified Nursing Assistant (CNA/staff #180), on August 3, 2026 at 2:58 p.m. Staff #180 stated they had been present on the floor at the time of the altercation on July 12, 2026. Staff #180 stated that she was on the floor when the altercation occurred, and immediately contacted the nurse to report the incident. An interview and observation of Resident #43 in her room was conducted on August 3, 2026, at 3:05 p.m. Resident #43 appeared to be in good spirits and showed the discoloration from a scar that remained on her left hand. She stated that she felt safe and comfortable in her current room. An interview and observation of Resident #75 was conducted on August 3, 2026, at 3:21 p.m. Resident #75 recalled the incident and stated that Resident #43 had come to her bed, struck her left leg, chest, and the left side of her face, and attempted to take the remote control from her. Resident #75 stated that she scratched Resident #43's hands in response. During the observation, Resident #75 stated that she felt safe and that the nursing staff had been helpful. A telephone interview with a Registered Nurse (RN/staff #9) was conducted on August 3, 2026, at 3:53 p.m. Staff #9 stated that she responded with Staff #180 to the resident's room, where they observed a physical altercation accompanied by verbal exchanges and discord between the residents. Staff #9 stated that Resident #43 had an injury to her left arm that was a skin tear, but was not bleeding profusely, which was dressed accordingly and did not require referral to the emergency room. Staff #9 also stated that she conducted a thorough assessment of Resident #75 and did not observe any obvious injury requiring immediate emergency medical care. An interview with the Director of Nursing Services, (DON/Staff #51), was conducted on August 5, 2026, at 9:37 a.m. Staff #51 stated that she had been notified by staff immediately following the altercation on July 12, 2026. Staff #51 stated that the facility conducted an internal investigation and reported the incident to the appropriate authorities within the required timeframe. Staff #51 further stated that Resident #43 had previously made general comments regarding odors but had not directed those comments specifically toward anyone, including her roommate. Staff #51 also stated that room assignments were based on residents' similarities in terms of their needs and care plans. Staff #51 defined abuse as a willful act intended to harm another person and stated that abuse could occur between staff and residents, between residents, or between residents and visitors through verbal, physical, financial, or physical restraint-related actions. Staff #51 agreed that when one resident hit another resident on the head or hands, or scratched or slapped another resident, the action could constitute physical abuse when there was an intent to cause harm. This understanding of physical abuse was consistent among the staff members interviewed during the investigation. -Regarding Resident #6 and Resident #52: -Regarding Resident #6 Resident #6 (Perpetrator) was admitted to the facility on [DATE], with diagnoses that included dementia, anxiety, hypertension, a history of fractures and malnutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had significant cognitive impairment. The care-plan revealed the resident had a behavior problem related to impaired safety awareness, verbal behavior, and physically aggressive behaviors, with a goal of maintain resident safety and notable interventions of intervening as necessary to protect the rights and safety of others, approach the resident and speak in a calm manner, divert the resident's attention, and remove from the situation and take to alternate location as needed. The progress notes dated July 26, 2026 at 1:49 p.m. revealed a struck-out note that stated while the nurse was on break, the CNA reported that resident #6 clawed her roommate (resident #52) in the face. Upon assessment, resident #52 was noted to have superficial scratches under the right side of her chin and red marks on the cheek. No active bleeding was observed. Resident #6 was also observed kicking another resident's wheelchair in an apparent attempt to get the other resident to move out of the way. A behavior notes dated July 26, 2026 at 1:56 p.m. revealed resident #6 displayed increased escalated behaviors, redirected, reduced environmental stimuli. However, the behavior note provided no details regarding the incident documented in the struck-out progress note, and no additional details regarding the incident were found in the clinical record. -Regarding resident #52: Resident #52 (Victim) was admitted to the facility on [DATE], with diagnoses that included dementia, heart failure, anemia, malnutrition, and urinary tract infections. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 which indicated the resident had significant cognitive impairment. The progress notes dated July 26, 2026 at 2:01 p.m. revealed Resident reported increasing behaviors. Resident was checked. Skin assessment done. However, the note gave no indication as to why the skin assessment was completed. A weekly skin check and wound assessment note dated July 26, 2026 at 3:37 p.m. revealed the resident had a new skin impairment to the face, described as superficial red marks to right chin. A progress note dated July 26, 2026 at 10:11 p.m. revealed resident #52 was on change of condition monitoring for a scratch to the left chin area, that resident #52 had no complaints of pain, was open to air, and that the plan of care was ongoing as tolerated. A progress note dated July 27, 2026 at 1:08 p.m. revealed resident #52 was on change of condition monitoring related to scratches on the chin from another resident. It further revealed resident #52 had no complaints of pain, was open to air, and that the plan of care was ongoing as tolerated. A progress note dated July 27, 2026 at 9:35 p.m. revealed resident #52 was on change of condition for scratch on left side of neck area, and that resident #52 had no signs or symptoms of infection, was open to air, had no complaints of pain or discomfort, and that the plan of care was ongoing as tolerated. A weekly skin check and wound assessment note dated July 28, 2026 at 3:37 p.m. revealed resident had a new skin impairment to the face, described as healing red superficial marks to chin A progress note dated July 28, 2026 at 6:56 p.m. revealed resident #52 remains on change of condition monitoring for scratches to the left chin sustained from another resident. It further revealed the area remains clean, dry, and intact with no signs or symptoms of infection noted, and that resident #52 tolerated monitoring well and voiced no complaints or concerns this shift. It concludes that the plan of care remains ongoing. An interview was conducted with resident #52 on August 3, 2026 at 1:20 p.m. Resident #52 stated she recalls the incident but was not sure who the perpetrator was. Resident #52 stated she cried when it happened because she did not know why the other resident was being mean to her. Resident #52 concluded that they had gotten up to go to breakfast and the other resident just reached her fingernails up and ran them across her face. Resident #52 pointed to her face and stated right here referencing where she had been scratched. An interview was conducted with a Licensed Practical Nurse (LPN/staff #74) on August 3, 2026 at 1:35 p.m. Staff #74 stated she was familiar with the incident and confirmed the perpetrator was resident #6. Staff #74 stated that there are different types of abuse, like verbal or physical, not allowing residents to do things, especially anything physical. Staff #74 stated that resident #52 was largely not alert and oriented but able to have a conversation, and only confused sometimes. Staff #74 stated that resident #52 is very nice to everyone on the unit, but does have some behaviors. Staff #74 stated that resident #6 was moved onto the secured unit where the incident occurred after some wandering behaviors, and using a bedside table as a walker. Staff #74 stated that after the incident, resident #6 was moved back off the secured unit. Staff #74 concluded that of course the incident is abuse, and that it was reported to management. An interview was conducted with the Resident's Representative (RR) on August 3, 2026 at 2:20 p.m. The RR stated that she is the POA (Power of Attorney) for resident #52. The RR stated that the facility notified her after the incident occurred, and that resident #52's roommate (resident #6) had grabbed ahold of resident #52's face and scratched her. The RR stated that resident #52 always said that resident #6 was mean to her. The RR stated that she told resident #52 if someone is mean to you, you need to report it, and that she wasn't sure if resident #52 did because they are having these issues now. The RR stated that she brings resident #52 snacks she likes, like fruit, and that she was there the very day the incident occurred. The RR stated that she didn't know why it happened, but that she thinks it's because resident #52 had goodies and the other resident didn't. The RR concluded that resident #52 had scratch marks on her face. An interview was conducted with a Certified Nursing Assistant (CNA/staff #75) on August 3, 2026 at 3:27 p.m. Staff #75 stated that she was the one that reported the incident between resident #52 and resident #6. Staff #75 stated that she was putting a resident's clothes away, when resident #52 came up to her and stated her neighbor had grabbed her face. Staff #75 stated that she looked at resident #52's face and that it had scratches or red marks on it. Staff #75 stated that she notified the nurse to look at it, and resident #52 had again stated resident #6 had grabbed her. Staff #75 concluded that she notified the management about the incident. An interview was conducted with the Director of Nursing (RN/staff #51) on August 5, 2026 at 8:00 a.m. Staff #51 stated she was familiar with the incident, and that as she understood resident #52 was in her room by her bed, when resident #6 ended up scratching resident #52 on the face. Staff #51 stated that resident #52 had superficial red marks on her chin, so she assumes it did happen. Staff #51 stated that she was aware of the struck out note about the incident and that she didn't instruct the staff to strike the note out. Staff #51 stated the note was already struck out when she found it, and that only the nurse who documented it could strike it out. Staff #51 concluded that the whole incident and the inconsistent documentation is unfortunate and doesn't meet her expectations or meet policy. A review of facility policy titled 'Abuse - Prevention' revised May 6, 2025 revealed it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. A review of facility policy titled 'Resident Rights/Dignity: Abuse and Neglect – clinical protocol' effective January, 2024 revealed abuse is defined at 483.5 as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, and mental abuse including abuse facilitated or enabled through the use of technology.

Based on record review, resident interview, staff interview and facility policy and procedures the facility failed to ensure the facility policy for abuse was followed for 1 of 5 sampled residents. The deficient practice could result in allegations of abuse not being accurately identified, reported, investigated, and addressed, thereby placing residents at risk for further abuse, physical harm, pain, mental anguish, or emotional distress. Findings include: - Regarding resident #6: Resident #6 (Perpetrator) was admitted to the facility on [DATE], with diagnoses that included dementia, anxiety, hypertension, a history of fractures and malnutrition. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 07, which indicated the resident had significant cognitive impairment. The care-plan revealed the resident has a behavior problem related to impaired safety awareness, verbal behavior, and physically aggressive behaviors, with a goal of maintain resident safety and notable interventions of intervening as necessary to protect the rights and safety of others, approach the resident and speak in a calm manner, divert the resident's attention, and remove from the situation and take to alternate location as needed. The progress notes dated July 26, 2026 at 1:49 p.m. revealed a struck-out note that stated while the nurse was on break, the CNA reported that resident #6 clawed her roommate (resident #52) in the face. Upon assessment, resident #52 was noted to have superficial scratches under the right side of her chin, red marks on the cheek, and no active bleeding was observed. Resident #6 was also observed kicking another resident's wheelchair in an apparent attempt to get the other resident to move out of the way. A behavior notes dated July 26, 2026 at 1:56 p.m. revealed resident #6 displayed increased escalated behaviors, redirected, reduced environmental stimuli. However, the behavior note provided no details regarding the incident documented in the struck-out progress note, and no additional details regarding the incident were found in the clinical record. - Regarding resident #52: Resident #52 (Victim) was admitted to the facility on [DATE], with diagnoses that included dementia, heart failure, anemia, malnutrition, and urinary tract infections. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 08 which indicated the resident had significant cognitive impairment. A review of progress notes dated July 26, 2026 at 2:01 p.m. revealed Resident reported increasing behaviors. Resident was checked. Skin assessment done. However, the note gave no indication as to why the skin assessment was completed. A weekly skin check and wound assessment note dated July 26, 2026 at 3:37 p.m. revealed the resident had a new skin impairment to the face, described as superficial red marks to right chin. A progress note dated July 26, 2026 at 10:11 p.m. revealed resident #52 was on change of condition monitoring for a scratch to the left chin area, that resident #52 had no complaints of pain, was open to air, and that the plan of care was ongoing as tolerated. A progress note dated July 27, 2026 at 1:08 p.m. revealed resident #52 was on change of condition monitoring related to scratches on the chin from another resident. It further revealed resident #52 had no complaints of pain, was open to air, and that the plan of care was ongoing as tolerated. A progress note dated July 27, 2026 at 9:35 p.m. revealed resident #52 was on change of condition for scratch on left side of neck area, and that resident #52 had no signs or symptoms of infection, was open to air, had no complaints of pain or discomfort, and that the plan of care was ongoing as tolerated. A weekly skin check and wound assessment note dated July 28, 2026 at 3:37 p.m. revealed resident had a new skin impairment to the face, described as healing red superficial marks to chin A progress note dated July 28, 2026 at 6:56 p.m. revealed resident #52 remains on change of condition monitoring for scratches to the left chin sustained from another resident. It further revealed the area remains clean, dry, and intact with no signs or symptoms of infection noted, and that resident #52 tolerated monitoring well and voiced no complaints or concerns this shift. It concludes that the plan of care remains ongoing. An interview was conducted with resident #52 on August 3, 2026 at 1:20 p.m. Resident #52 stated she recalls the incident but was not sure who the perpetrator was. Resident #52 stated she cried when it happened because she did not know why the other resident was being mean to her. Resident #52 concluded that they had gotten up to go to breakfast and the other resident just reached her fingernails up and ran them across her face. Resident #52 pointed to her face and stated right here referencing where she had been scratched. An interview was conducted with a Licensed Practical Nurse (LPN/staff #74) on August 3, 2026 at 1:35 p.m. Staff #74 stated she was familiar with the incident and confirmed the perpetrator was resident #6. Staff #74 stated that there are different types of abuse, like verbal or physical, not allowing residents to do things, especially anything physical. Staff #74 stated that resident #52 was largely not alert and oriented but able to have a conversation, and only confused sometimes. Staff #74 stated that resident #52 is very nice to everyone on the unit, but does have some behaviors. Staff #74 stated that resident #6 was moved onto the secured unit where the incident occurred after some wandering behaviors, and using a bedside table as a walker. Staff #74 stated that after the incident, resident #6 was moved back off the secured unit. Staff #74 concluded that of course the incident is abuse, and that it was reported to management. An interview was conducted with the Resident's Representative (RR) on August 3, 2026 at 2:20 p.m. The RR stated that she is the POA (Power of Attorney) for resident #52. The RR stated that the facility notified her after the incident occurred, and that resident #52's roommate (resident #6) had grabbed ahold of resident #52's face and scratched her. The RR stated that resident #52 always said that resident #6 was mean to her. The RR stated that she told resident #52 if someone is mean to you, you need to report it, and that she wasn't sure if resident #52 did because they are having these issues now. The RR stated that she brings resident #52 snacks she likes, like fruit, and that she was there the very day the incident occurred. The RR stated that she didn't know why it happened, but that she thinks it's because resident #52 had goodies and the other resident didn't. The RR concluded that resident #52 had scratch marks on her face. An interview was conducted with a Certified Nursing Assistant (CNA/staff #75) on August 3, 2026 at 3:27 p.m. Staff #75 stated that she was the one that reported the incident between resident #52 and resident #6. Staff #75 stated that she was putting a resident's clothes away, when resident #52 came up to her and stated her neighbor had grabbed her face. Staff #75 stated that she looked at resident #52's face and that it had scratches or red marks on it. Staff #75 stated that she notified the nurse to look at it, and resident #52 had again stated resident #6 had grabbed her. Staff #75 concluded that she notified the management about the incident. An interview was conducted with the Director of Nursing (RN/staff #51) on August 5, 2026 at 8:00 a.m. Staff #51 stated she was familiar with the incident, and that as she understood resident #52 was in her room by her bed, when resident #6 ended up scratching resident #52 on the face. Staff #51 stated that resident #52 had superficial red marks on her chin, so she assumes it did happen. Staff #51 stated that she was aware of the struck out note about the incident and that she didn't instruct the staff to strike the note out. Staff #51 stated the note was already struck out when she found it, and that only the nurse who documented it could strike it out. Staff #51 concluded that the whole incident and the inconsistent documentation is unfortunate and doesn't meet her expectations or meet policy. A review of facility policy titled 'Abuse - Prevention' revised May 6, 2025 revealed it is the policy of this facility to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation.A review of facility policy titled 'Resident Rights/Dignity: Abuse and Neglect - clinical protocol' effective January, 2024 under the section titled Treatment / Management revealed the facility management and staff will institute measures to address the needs of residents and minimize the possibility of abuse and neglect. It further states that the management and staff, with physician support, will address situations of suspected or identified abuse and report them in a timely manner to appropriate agencies, consistent with applicable laws and regulations.

Based on clinical record reviews, facility documentation, resident, family, and staff interviews, and policy review, the facility failed to protect the rights of two residents (#10) and (#20) to be free from abuse by another Resident (#50). This deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #10 (Victim #1) was admitted to the facility on [DATE], with diagnosis that include hemiplegia, cerebral vascular accident, dementia, urinary tract infection, diabetes mellitus type 2, and sepsis. Review of the Quarterly Minimum Data Set (MDS) assessment dated November December 8, 2025 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. A review of the care-plan for Resident #10 revealed the resident has a behavior problem related to impaired cognitive function, impaired safety awareness, and verbal behaviors with noted interventions of anticipate and meet the resident's needs, allow resident to make decisions about the plan of care, and give resident a clear explanation of all care activities prior to and as they occur during each contact. A review of progress notes for Resident #10 revealed no evidence of any incident involving resident's #20, or #50 in the clinical record. A review of skin assessments for Resident #10 dated January 23, 2026 at 4:05 p.m. revealed the finding for the skin assessment was a small scratch / abrasion noted to right forearm, however there are no other details listed in the assessment as to the cause of the scratch and abrasion. -Resident #20 (Victim #2) was admitted to the facility on [DATE], with diagnoses that include Cerebral ischemia, chronic obstructive pulmonary disease, metabolic acidosis, quadriplegia, transient ischemic attack, and depression. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment. A review of the care-plan for Resident #20 revealed the resident has been the recipient of physical and verbal behaviors from another resident, with noted interventions of provide for safety and attempt to prevent interactions from being target of resident behaviors. A review of progress notes for Resident #20 revealed no evidence of any incident involving resident's #10, or #50 in the clinical record. -Resident #50 (Perpetrator) was admitted to the facility on [DATE] with diagnoses that include Vascular dementia, diabetes mellitus type 2, metabolic encephalopathy, urinary tract infection, adjustment disorder with anxiety, and metabolic acidosis. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15 which indicated the resident had no cognitive impairment. A review of the care-plan for Resident #20 revealed the resident has a behavior problem related to impaired cognitive function, impaired safety awareness, physical behaviors, verbal behaviors, and resistance to care. There are noted interventions of administer medications as ordered, monitor and document for side effects and effectiveness, and anticipate and meet the resident's needs. A review of progress notes for Resident #50 dated January 21, 2026 at 2:43 p.m. revealed Resident #50 while being redirected by staff during a separate elopement incident, and notes Resident #50 was attempting to closed- fist hit a staff member per report, and the note concludes that Resident #50 requires 24-hour supervision for safety. A review of progress notes for Resident #50 dated January 23, 2026 at 2:44 p.m. revealed the executive director called to receive verbal report at 2:35 p.m. The verbal report given to the emergency department (ED), states Resident #50 is stable in the ED at this time, and going to get a urine sample. The RN (registered nurse) was able to answer questions as to events leading up to the incident and states no further concerns / questions at this time. However, there were no details related to the incident before, during, or after what led to the above listed verbal report, or any details as to what occurred during the incident. An observation was made with Resident #20 on February 10, 2026 at 8:35 a.m. during an interview with Resident #20, the resident was observed to be startled and initially withdrawn when surveyor initially entered the room. When the interview began and the initial topic of the incident was broached, resident became visibly distraught, tearful, and began crying. Resident #20's distraught behavior continued through the end of the above interview. An interview was conducted with Resident #20 on February 10, 2026 at 8:35 a.m. The resident stated that Resident #50 grabbed her and started hitting her, and stated that I can't do nothing, I'm disabled. Resident #20 further stated that Resident #50 started making fun of her, and that she was afraid. Resident #20 stated she was praying to God, and that Resident #50 grabbed her and hurt her arm. Resident #20 further stated that she can't even walk, and I can't do anything because my arm doesn't work. Resident #20 stated that I should speak to Resident #10, as she would have further information. Resident #20 stated further that Resident #50 is mean, and the police came and she told them what happened. Resident #20 concluded that she feels abused, and that she is afraid with Resident #50 here. An interview was conducted with a Resident #10 on February 10, 2026 at 8:50 a.m. Resident #10 stated that during the incident Resident #20 was sitting down in the hallway by the corner, and that Resident #50 went looking for her family. Resident #10 stated that everyone likes to sit in that section of the hall because that's where the family likes to come in, and later Resident #50 came back down the hall and started hitting Resident #20 in the head. Resident #10 stated she yelled for help and then staff #25 got between Resident #50 and resident #20. Resident #20 further stated that staff #45 saw this and showed up to help, and then the DON also came. Resident #10 stated that she was sitting in her doorway after the incident and the staff had resident #50 down the hallway. Resident #10 stated that Resident #50 then came back down the hall and initially smiled at her, and then Resident #50 hit me in the arm and in the head, and stated multiple staff members were there. Resident #10 also stated that when Resident #50 hit her the DON grabbed her arm to move it in the way and try to block Resident #50. Resident #10 stated that she was fine after the incident and further stated that she wasn't hurt other than the bruise on her arm, and that the police came and talked to her and took pictures, took her statement, and sent Resident #50 to the hospital. Resident #10 concluded that she felt Resident #50 had the advantage because she was standing up, and Resident #10 stated that she is in a wheelchair and wasn't expecting it. An observation was made during the above interview with Resident #10, the resident's arm was observed to show reddish / grey marks on right forearm, one approximate 1.5-inch reddish mark and one 2-centimeter grey mark, that the resident attributed to the incident. An interview was conducted with the Ombudsman on February 10, 2026 at 10:23 a.m. The Ombudsman stated she was in the building during the incident, and that she was in a care conference with the social worker and a family when the incident occurred. She further stated that during the conference staff members came around the corner as if startled, and that she went into the social worker's office for unrelated issues. The ombudsman stated she heard screaming coming from the hall and that she could hear them talking to Resident #50, and staff #45 came back into the office and said Resident #50 was upset because her family had taken off. The ombudsman stated that a few minutes later staff #45 took off running and when she came back, stated that Resident #50 had struck two other residents, but that they didn't give her the resident's names. The Ombudsman stated that she wasn't aware of any injuries but was aware the police had come into the building after it happened. An interview was conducted with the social services director (staff/#45) on February 10, 2026 at 10:38 a.m. Staff #45 stated that prior to the incident she was in her office in a care conference with a difficult family member when she saw someone run past her office, then she jumped up and stated what is going on and Resident #50's daughter ran past. Staff #45 stated that they were trying to get away from Resident #50 because she was in the bathroom. Staff #45 stated she finished with the ombudsman and heard commotion coming from outside her office and Resident #50 was pushing her wheelchair with blankets in it and said Resident #50 stated fuck this I'm leaving and then started screaming about her daughter, and stating you made them leave. Staff #45 stated that she and one of the nurses got Resident #50 back to her room and went back to her office. Staff #45 stated a few minutes later she heard someone hollering and when she checked in the hallway, Resident #50 was yelling at Resident #20. Staff #45 stated that she told the residents to knock it off and stated that at that point resident #50 started swinging on resident #20. She stated that staff #25 was there and got between them and helped defuse the situation and redirected resident #50 back to her room. Staff #45 stated that while on the way back to her room Resident #10 was sitting in her doorway and saw Resident #50 bundle up her hand and swung at Resident #10. Staff #45 further stated that the DON was standing right there and grabbed Resident #10's arm to try to guard herself. Staff #45 clarified that she tried to pull resident #50 away, and the DON tried to block Resident #50's swing towards resident #10. Staff #45 stated that nothing related to the incident was documented in the chart, and further stated that she is new to the position and was not confident in precisely what to document in the chart with regards to the incident. Staff #45 concluded that the behavior was not appropriate. An interview was attempted with Resident #50 on February 10, 2026 at 11:23 a.m., The resident was not alert and oriented and wasn't able to interview. An interview was conducted with a Certified Nursing Assistant (CNA/staff#25) on February 10, 2026 at 12:00 p.m. The CNA stated that while she was pouring drinks and getting ready for tray pass, Resident #10 got their attention and saw Resident #50 and Resident #20 arguing, and stated they previously don't seem to like each other so they try to keep them separate. The CNA stated that the whole situation escalated really fast. The CNA stated I put myself between them, I go got hit a couple of times but I was trying to be a barrier. The CNA stated that after the initial contact the DON came to check on Resident #20, and staff #45 was taking Resident #50 back to her room, and Resident #10 was sitting in the hallway when Resident #50 stopped and got into Resident #10's face, and then slapped her. The CNA stated that the DON attempted to intervene and that Resident #10 didn't respond at all to being struck. The CNA stated that they then separated all the residents again and took Resident #50 to her room. The CNA stated that Resident #50 really doesn't like Resident #20 for some reason so they tend to argue and it leads to that escalation. The CNA concluded that I don't feel residents should be scared to live where they live, and stated this feels like abuse, and that once it crosses a physical barrier that's too much. An interview was conducted with the Director of Nursing (RN/staff #90) on February 10, 2026 at 2:30 p.m. The DON stated that she was aware of the incident between Residents #50, #20, and #10. She stated that received a call from the receptionist that Resident #50 was upset her family had left, and stated that she redirected Resident #50 back to her room, and waited back up at the front in case Resident #50 attempted to leave the building, so she stayed up at the front expecting her to come back to the front door. The DON stated that she heard a commotion down the hall and that's when she saw Resident #20 initially, and stated that staff #45 and staff #25 were standing between Resident #50 and Resident #20. The DON then stated that staff #45 started to assist Resident #50 back to her room, and out of the corner of her eye saw Resident #50 lunge at Resident #10. The DON stated that she was able to break that contact but there was still an attempt. The DON stated that after the incident the police came and interviewed Resident #20, and that she stayed with Resident #50 until she went to the emergency room. The DON stated that Resident #50 was sent to the emergency room to stabilize and evaluate her, and states she was found to have a urinary tract infection. The DON stated that she did the single skin assessment noted above on Resident #10, but that there was no other documentation in the clinical record related to the incident. The DON stated that she did the self-report, an incident report in risk management, and not in the clinical record. The DON stated that it is not the standard to document that way and that there should have been documentation in the clinical record. The DON stated that abuse is any physical, verbal, financial, or emotional behavior towards a resident, and further stated that yes this was abuse. The DON concluded that their policy was not followed with regards to documentation. A review of facility policy titled 'Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program effective January 1, 2024 revealed 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.

Based on clinical record reviews, facility documentation, resident, family, and staff interviews, and policy review, the facility failed to protect the rights of a resident (#10) to be free from misappropriation from staff. This deficient practice could result in further incidents of staff to resident abuse. Findings Include: -Resident #10 was admitted to the facility on [DATE], with diagnosis that include hemiplegia, cerebral vascular accident, dementia, urinary tract infection, diabetes mellitus type 2, and sepsis. Review of the Quarterly Minimum Data Set (MDS) assessment dated November December 8, 2025 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. A review of the care-plan for resident #10 revealed the resident is at risk for functional care deficits and functional mobility limitations with noted interventions of requiring assistance with ambulation, and require supervision and assistance with various activities of daily living. A review of the SA complaint system on January 27, 2026 at 4:43 p.m. revealed a facility reported incident that resident #10 needed to speak with the administrator about a concern. At 3:00 p.m. the administrator spoke to resident #10 and reported that a former employee identified as staff #200 was supposed to open a bank account for resident #10, and that resident #10 had set up two transfers to come out monthly of $500, for a total of $1000.An attempt to call and interview staff #200 was made on February 10, 2026 at 1:00 p.m., but there was no answer, and no way to leave a voicemail.An interview was conducted with a registered nurse (RN/staff #65) on February 10, 2026 at 1:40 p.m. The RN stated that she was not involved in the incident but was aware of it. The RN stated that given the details RN agreed that would constitute abuse. The RN stated that abuse is a violation of a resident's rights, either sexual, financial, emotional, or physical. The RN concluded that if abuse is suspected they would notify the administrator, and the Director of Nursing. An interview was conducted with resident #10 on February 10, 2026 at 1:50 p.m. Resident #10 stated that she had money taken from her by an employee in the facility. The staff member was identified as staff #200. Resident #10 identified the staff member by name as staff #200. Resident #10 stated she thinks staff #200 walked out after the incident, and that she trusted staff #200. Resident #10 stated that staff #200 had agreed to help her set up a checking account, and that she set up two transfers for $500 each over 2 months, and then it got stopped. Resident #10 thinks her son is the one who stopped the transfers when he saw it on her accounts. Resident #10 stated that it was in may and June of last year (2025), and that it came to his attention so the police got involved. Resident #10 stated she kept asking staff #200 for the money back and that staff #200 stated that It was only money, and that she had a problem with that. Resident #10 then stated that the law showed up to staff #200's house and then suddenly staff #200 was blowing up her phone and that the police told her not to react if staff #200 called her. Resident #10 stated that she refused to press charges and that she later got the money back in two payments of $500. Resident #10 stated that she felt she was abused and that staff #200 took advantage of her. Resident #10 concluded that she felt embarrassed, and given how much she trusted staff #200 felt the whole thing was a big slap in the face. An interview was conducted with the Director of Nursing (RN/staff #90) on February 10, 2026 at 2:30 p.m. The DON stated that she was aware of the incident with resident #10, and stated that it was staff #200 who was involved. The DON stated that her understanding was that resident #10 had asked staff #200 to set up an account that was not linked to her family. The DON further stated that staff #200 agreed to that and that the payments would be used to set up a new account in resident #10's name. The DON stated that the account was never created, and that when they found out about it they notified the local police department. The DON stated that staff #200 had resigned from the facility prior to them being made aware of the incident. The DON also stated that they investigated it and did their due diligence, and confirmed the money was sent to staff #200. The DON stated that the money was returned, but that yes it was financial abuse.A review of facility policy titled 'Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program effective January 1, 2024 revealed 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.

Based on record review, observations, interviews, and review of the facility's policies and procedures the facility failed to implement their abuse prohibition policy when there was an allegation of sexual abuse of one resident (#5). The deficient practice could lead to residents not being protected from abuse.Findings include:Resident #5 was admitted to the facility on [DATE] with diagnoses that include early onset Alzheimer's disease, aphasia, and depression.A quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident #5 had severe cognitive impairment.A care plan, initiated on August 11, 2025 indicated Resident #5 had behavior problems that included poor safety awareness, wandering, and exit seeking. Interventions included intervening as necessary to protect the rights and safety of others.The same care plan was updated on January 5, 2026 to include lifting shirt exposing breasts at times. However, there were no revisions made to the interventions related the Resident #5's behaviors. Review of the Progress Notes revealed there were no entries related to the alleged incident or related to Resident #5's tendency to lifting her shirt to expose her breasts.Related to Resident #8:Resident #8 was admitted to the facility on [DATE] with diagnoses that include Dementia with behavioral disturbances, Type 2 Diabetes, and depression.A quarterly MDS, dated [DATE], revealed Resident #8 had a BIMS score of 09 which indicated he had moderate cognitive impairment.Review of a Care Plan, revised on August 14, 2025, indicated Resident #8 had behavior problems related to his cognition status. Identified behaviors included wandering, exit seeking, and sexually inappropriate. Interventions included intervening as necessary to protect the rights and safety of others. However, there was no indication that the Care Plan was revised, post incident, to reflect modified interventions related to sexual behaviors.Review of the Progress Notes revealed a Behavior Note, dated January 1, 2026 at 3:17 P.M. that indicated Resident #8 was on 1:1 activity for increased supervision and monitoring.Review of a second Behavior Note, dated January 2, 2026 at 1:01 A.M. indicated that the resident needed redirection from staff and supervision among being around other residents.Review of a third Behavior Note, dated January 2, 2026 at 10:41 A.M. The note indicated that Resident #8 was noted to be kissing (Resident #5) and that person was reciprocating. However, no other Progress Notes were identified in the chart related to the alleged incident.Additional review of the Progress Notes revealed a Health Status Note, dated January 7, 2026 at 5:49 P.M. that indicated Resident #8 was sent to a hospital due to medical event.An observation was made on January 8, 2026 at 11:57 A.M. of the resident rooms in the unit. It was observed that the room of Resident #5 was directly across the hallway from the room of Resident #8.Review of the State Agency's (SA) complaint portal on January 8, 2025 at 12:00 P.M., revealed no Facility Reported Incident related to Resident #5 and #8.An interview was conducted on January 8, 2026 at 1:26 P.M. with Certified Nursing Assistant (CNA/Staff #22). Staff #22 shared that suspected abuse is reported to the administrator (ADM/Staff #2). She described Resident #5 as someone who isn't verbal but will make sounds. Staff communicate with her by verbal and non-verbal gestures such as patting on the hips tells her that staff will be changing her briefs. She also shared that Resident #5 is not able to give consent because she was cognitively impaired. Staff #22 explained that Resident #8 and #5 were residing in rooms directly across from each other. She also shared that she would not consider that safe for resident #5 because of the close proximity to him and he could easily get access to her.An interview was conducted on January 8, 2026 at 1:39 P.M. with Registered Nurse (RN/Staff #83). Staff #83 shared that suspected abuse is reported to the Staff #2 and that he was the abuse coordinator. She revealed that when she came onto shift this morning, she was told, during shift change, that there was inappropriate behavior between Resident #5 and Resident #8 but she was not sure what took place. Staff #83 indicated that Resident #8 was currently in the hospital and she was not sure if and when he was returning to the facility. Staff #83 also added that the residents should be moved because they were both in rooms across the hallway from each other.An interview was conducted on January 8, 2026 at 2:50 P.M. with RN/Staff #40. She stated that she was working two units on January 2nd when it was reported to her that Resident #8 was kissing Resident #5 on the cheek. She said that she had reported to management that both residents should be moved to different rooms away from each other because their rooms were right next to each other. She added that she was told to just keep the residents separated from each other.An interview was conducted on January 9, 2026 at 1:00 P.M. with the Director of Nursing (DON/Staff #17). Staff #17 shared that staff #2 was the abuse officer staff would report suspected abuse to him and if he wasn't available, staff would report it to her. They would then initiate an investigation to see if the situation was needing to be reported to the appropriate agencies. She explained that both residents were found in Resident #8's room and Resident #5 had her shirt up. She added that the residents were separated and they had found that no sexual abuse had occurred. She explained that RN/Staff #9 had witnessed the incident and she reported that the residents had gone into Resident #8's room when she went to the storage closet. Staff #17 shared that staff #9 had lost sight of them for two minutes and that it was highly unlikely that anything happened in those two minutes because both residents are slow moving. When asked if this incident was reported to the State, she stated it wasn't because based on their investigation, there was no sexual contact or abuse based on the staffs' statements. However, Staff #17 couldn't say with 100% certainly that nothing took place between the two residents. When asked to see the facility's investigative report, Staff #17 stated that the report was not a part of the clinical record and it was considered a part of quality measurement and she would need to check with Staff #2 to see if it could be shared with Surveyor.An interview was conducted on January 9, 2026 at 1:28 P.M. with Staff #2. Staff #2 confirmed that staff are to report suspected abuse to him as he is the abuse coordinator. He explained that once something is reported to him, he does a full investigation and then determines if it is something that needs to be reported based on what took place. He also shared that there is a leadership team in the corporate office that they will review situations with and then determine the best plan of action. When asked to describe the situation in question related to Residents #5 and #8, Staff #2 shared that that RN/Staff #9 had reported that Resident #8 was in bed with Resident #5 and they were both separated. He added that staff reported that both residents had their clothes on and they liked to flirt but nothing inappropriate had happened. Staff #2 explained that based on their investigation, they did not believe the situation was considered abuse based on what Staff #9 had described. He did confirm that Resident #5 would not be able to consent to being in bed with another person because she was not alert and oriented. However, he added, he did not feel that the situation was unsafe and he did not believe it needed to be reported. Staff #2 shared the investigative report with Surveyor and was asked to read the statement written by Staff #9. He stated that the statement indicated Resident #5 was in bed with her shirt up and Resident #8 was hovering or leaning over her. Staff #2 shared that he did not consider Resident #5 having her shirt up and Resident #8 looking at her as abuse even if she could not consent to it.A telephonic interview was conducted on January 14, 2026 at 3:12 P.M. with Staff #9. Staff #9 explained that she was in the activity room and had to leave to go to the medication cart. She had seen both Resident #5 and Resident #8 in the activity room. A few minutes later she heard giggling and went to Resident #8's room where she found Resident #5 in bed with her shift off and Resident #8 hovering over her. She then separated the two residents and then called Staff #17 and reported it to her. She added that she did not consider this situation as sexual abuse because both residents were two consenting adults and both residents were in the room for 2 minutes and there wasn't enough time for them to do anything. Staff #9 admitted that both residents were not alert and oriented and that was why she reported the incident. She then admitted that the residents were not able to consent which is why she separated them. She added that maybe Resident #5 wanted to do something but they are not allowed to because they cannot consent. Staff #9 wasn't sure if the incident was reported to the State and added that her job was to report it to the DON (Staff #17) and it was not her place to determine if this was some type of abuse. She added that once she reports it to the DON, it was their job to determine if they needed to report it.Review of the facility's policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program indicated it took effect on January 1, 2024. The policy indicated that Residents have the right to be free from abuse. It also indicated that abuse included but wasn't limited to .sexual or physical abuse. The policy outlines that the facility needed to investigate and report any allegations within timeframes required by federal requirements and both residents were to be protected from any further harm during investigations.

Based on record review, interviews, and review of the facility's policies and procedures the facility failed to report an allegation of sexual abuse of one resident (#5). The deficient practice could lead to residents not being protected from abuse.Findings include:Resident #5 was admitted to the facility on [DATE] with diagnoses that include early onset Alzheimer's disease, aphasia, and depression.A quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident #5 had severe cognitive impairment.A care plan, initiated on August 11, 2025 indicated Resident #5 had behavior problems that included poor safety awareness, wandering, and exit seeking. Interventions included intervening as necessary to protect the rights and safety of others.The same care plan was updated on January 5, 2026 to include lifting shirt exposing breasts at times. However, there were no revisions made to the interventions related the Resident #5's behaviors. Review of the Progress Notes revealed there were no entries related to the alleged incident or related to Resident #5's tendency to lifting her shirt to expose her breasts.Resident #8 was admitted to the facility on [DATE] with diagnoses that include Dementia with behavioral disturbances, Type 2 Diabetes, and depression.A quarterly MDS, dated [DATE], revealed Resident #8 had a BIMS score of 09 which indicated he had moderate cognitive impairment.Review of a Care Plan, revised on August 14, 2025, indicated Resident #8 had behavior problems related to his cognition status. Identified behaviors included wandering, exit seeking, and sexually inappropriate. Interventions included intervening as necessary to protect the rights and safety of others. However, there was no indication that the Care Plan was revised, post incident, to reflect modified interventions related to sexual behaviors.Review of the Progress Notes revealed a Behavior Note, dated January 1, 2026 at 3:17 P.M. that indicated Resident #8 was on 1:1 activity for increased supervision and monitoring.Review of a second Behavior Note, dated January 2, 2026 at 1:01 A.M. indicated that the resident needed redirection from staff and supervision among being around other residents.Review of a third Behavior Note, dated January 2, 2026 at 10:41 A.M. The note indicated that Resident #8 was noted to be kissing (Resident #5) and that person was reciprocating. However, no other Progress Notes were identified in the chart related to the alleged incident.Additional review of the Progress Notes revealed a Health Status Note, dated January 7, 2026 at 5:49 P.M. that indicated Resident #8 was sent to a hospital due to medical event.An observation was made on January 8, 2026 at 11:57 A.M. of the resident rooms in the unit. It was observed that the room of Resident #5 was directly across the hallway from the room of Resident #8.Review of the State Agency's (SA) complaint portal on January 8, 2025 at 12:00 P.M., revealed no Facility Reported Incident related to Resident #5 and #8.An interview was conducted on January 8, 2026 at 1:26 P.M. with Certified Nursing Assistant (CNA/Staff #22). Staff #22 shared that suspected abuse is reported to the administrator (ADM/Staff #2). She described Resident #5 as someone who isn't verbal but will make sounds. Staff communicate with her by verbal and non-verbal gestures such as patting on the hips tells her that staff will be changing her briefs. She also shared that Resident #5 is not able to give consent because she was cognitively impaired. Staff #22 explained that Resident #8 and #5 were residing in rooms directly across from each other. She also shared that she would not consider that safe for resident #5 because of the close proximity to him and he could easily get access to her.An interview was conducted on January 8, 2026 at 1:39 P.M. with Registered Nurse (RN/Staff #83). Staff #83 shared that suspected abuse is reported to the Staff #2 and that he was the abuse coordinator. She revealed that when she came onto shift this morning, she was told, during shift change, that there was inappropriate behavior between Resident #5 and Resident #8 but she was not sure what took place. Staff #83 indicated that Resident #8 was currently in the hospital and she was not sure if and when he was returning to the facility. Staff #83 also added that the residents should be moved because they were both in rooms across the hallway from each other.An interview was conducted on January 8, 2026 at 2:50 P.M. with RN/Staff #40. She stated that she was working two units on January 2nd when it was reported to her that Resident #8 was kissing Resident #5 on the cheek. She said that she had reported to management that both residents should be moved to different rooms away from each other because their rooms were right next to each other. She added that she was told to just keep the residents separated from each other.An interview was conducted on January 9, 2026 at 1:00 P.M. with the Director of Nursing (DON/Staff #17). Staff #17 shared that staff #2 was the abuse officer staff would report suspected abuse to him and if he wasn't available, staff would report it to her. They would then initiate an investigation to see if the situation was needing to be reported to the appropriate agencies. She explained that both residents were found in Resident #8's room and Resident #5 had her shirt up. She added that the residents were separated and they had found that no sexual abuse had occurred. She explained that RN/Staff #9 had witnessed the incident and she reported that the residents had gone into Resident #8's room when she went to the storage closet. Staff #17 shared that staff #9 had lost sight of them for two minutes and that it was highly unlikely that anything happened in those two minutes because both residents are slow moving. When asked if this incident was reported to the State, she stated it wasn't because based on their investigation, there was no sexual contact or abuse based on the staffs' statements. However, Staff #17 couldn't say with 100% certainly that nothing took place between the two residents. When asked to see the facility's investigative report, Staff #17 stated that the report was not a part of the clinical record and it was considered a part of quality measurement and she would need to check with Staff #2 to see if it could be shared with Surveyor.An interview was conducted on January 9, 2026 at 1:28 P.M. with Staff #2. Staff #2 confirmed that staff are to report suspected abuse to him as he is the abuse coordinator. He explained that once something is reported to him, he does a full investigation and then determines if it is something that needs to be reported based on what took place. He also shared that there is a leadership team in the corporate office that they will review situations with and then determine the best plan of action. When asked to describe the situation in question related to Residents #5 and #8, Staff #2 shared that that RN/Staff #9 had reported that Resident #8 was in bed with Resident #5 and they were both separated. He added that staff reported that both residents had their clothes on and they liked to flirt but nothing inappropriate had happened. Staff #2 explained that based on their investigation, they did not believe the situation was considered abuse based on what Staff #9 had described. He did confirm that Resident #5 would not be able to consent to being in bed with another person because she was not alert and oriented. However, he added, he did not feel that the situation was unsafe and he did not believe it needed to be reported. Staff #2 shared the investigative report with Surveyor and was asked to read the statement written by Staff #9. He stated that the statement indicated Resident #5 was in bed with her shirt up and Resident #8 was hovering or leaning over her. Staff #2 shared that he did not consider Resident #5 having her shirt up and Resident #8 looking at her as abuse even if she could not consent to it. When asked why the alleged abuse not reported to the State, he stated that there was no allegation of abuse. This was just a nurse (Staff #9) going to him and telling him that this incident took place. He added that even the nurse was unsure of the situation. A telephonic interview was conducted on January 14, 2026 at 3:12 P.M. with Staff #9. Staff #9 explained that she was in the activity room and had to leave to go to the medication cart. She had seen both Resident #5 and Resident #8 in the activity room. A few minutes later she heard giggling and went to Resident #8's room where she found Resident #5 in bed with her shift off and Resident #8 hovering over her. She then separated the two residents and then called Staff #17 and reported it to her. She added that she did not consider this situation as sexual abuse because both residents were two consenting adults and both residents were in the room for 2 minutes and there wasn't enough time for them to do anything. Staff #9 admitted that both residents were not alert and oriented and that was why she reported the incident. She then admitted that the residents were not able to consent which is why she separated them. She added that maybe Resident #5 wanted to do something but they are not allowed to because they cannot consent. Staff #9 wasn't sure if the incident was reported to the State and added that her job was to report it to the DON (Staff #17) and it was not her place to determine if this was some type of abuse. She added that once she reports it to the DON, it was their job to determine if they needed to report it.Review of the facility's policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program indicated it took effect on January 1, 2024. The policy outlines that the facility needed to investigate and report any allegations within timeframes required by federal requirements.

Based on record review, observations, interviews, and review of the facility's policies and procedures, the facility failed to thoroughly investigate allegations of abuse for one resident (#5) and take steps to correct it. The deficient practice could lead to residents being subjected to continued abuse. Findings include:Resident #5 was admitted to the facility on [DATE] with diagnoses that include early onset Alzheimer's disease, aphasia, and depression.A quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 00 which indicated Resident #5 had severe cognitive impairment.A care plan, initiated on August 11, 2025 indicated Resident #5 had behavior problems that included poor safety awareness, wandering, and exit seeking. Interventions included intervening as necessary to protect the rights and safety of others.The same care plan was updated on January 5, 2026 to include lifting shirt exposing breasts at times. However, there were no revisions made to the interventions related the Resident #5's behaviors. Review of the Progress Notes revealed there were no entries related to the alleged incident or related to Resident #5's tendency to lifting her shirt to expose her breasts.Review of Resident #5's clinical chart reveals a skin assessment was completed on December 22, 2025 and the next assessment was completed on January 5, 2026. There were no skin issues noted. However, there was no other skin assessments done on or around the time of the alleged incident. Related to Resident #8:Resident #8 was admitted to the facility on [DATE] with diagnoses that include Dementia with behavioral disturbances, Type 2 Diabetes, and depression.A quarterly MDS, dated [DATE], revealed Resident #8 had a BIMS score of 09 which indicated he had moderate cognitive impairment.Review of a Care Plan, revised on August 14, 2025, indicated Resident #8 had behavior problems related to his cognition status. Identified behaviors included wandering, exit seeking, and sexually inappropriate. Interventions included intervening as necessary to protect the rights and safety of others. However, there was no indication that the Care Plan was revised, post incident, to reflect modified interventions related to sexual behaviors.Review of the Progress Notes revealed a Behavior Note, dated January 1, 2026 at 3:17 P.M. that indicated Resident #8 was on 1:1 activity for increased supervision and monitoring.Review of a second Behavior Note, dated January 2, 2026 at 1:01 A.M. indicated that the resident needed redirection from staff and supervision among being around other residents.Review of a third Behavior Note, dated January 2, 2026 at 10:41 A.M. The note indicated that Resident #8 was noted to be kissing (Resident #5) and that person was reciprocating. However, no other Progress Notes were identified in the chart related to the alleged incident.Additional review of the Progress Notes revealed a Health Status Note, dated January 7, 2026 at 5:49 P.M. that indicated Resident #8 was sent to a hospital due to medical event.An observation was made on January 8, 2026 at 11:57 A.M. of the resident rooms in the unit. It was observed that the room of Resident #5 was directly across the hallway from the room of Resident #8.Review of the State Agency's (SA) complaint portal on January 8, 2025 at 12:00 P.M., revealed no Facility Reported Incident related to Resident #5 and #8.An interview was conducted on January 8, 2026 at 1:26 P.M. with Certified Nursing Assistant (CNA/Staff #22). Staff #22 shared that suspected abuse is reported to the administrator (ADM/Staff #2). She described Resident #5 as someone who isn't verbal but will make sounds. Staff communicate with her by verbal and non-verbal gestures such as patting on the hips tells her that staff will be changing her briefs. She also shared that Resident #5 is not able to give consent because she was cognitively impaired. Staff #22 explained that Resident #8 and #5 were residing in rooms directly across from each other. She also shared that she would not consider that safe for resident #5 because of the close proximity to him and he could easily get access to her.An interview was conducted on January 8, 2026 at 1:39 P.M. with Registered Nurse (RN/Staff #83). Staff #83 shared that suspected abuse is reported to the Staff #2 and that he was the abuse coordinator. She revealed that when she came onto shift this morning, she was told, during shift change, that there was inappropriate behavior between Resident #5 and Resident #8 but she was not sure what took place. Staff #83 indicated that Resident #8 was currently in the hospital and she was not sure if and when he was returning to the facility. Staff #83 also added that the residents should be moved because they were both in rooms across the hallway from each other.An interview was conducted on January 8, 2026 at 2:50 P.M. with RN/Staff #40. She stated that she was working two units on January 2nd when it was reported to her that Resident #8 was kissing Resident #5 on the cheek. She said that she had reported to management that both residents should be moved to different rooms away from each other because their rooms were right next to each other. She added that she was told to just keep the residents separated from each other.An interview was conducted on January 9, 2026 at 1:00 P.M. with the Director of Nursing (DON/Staff #17). Staff #17 shared that staff #2 was the abuse officer staff would report suspected abuse to him and if he wasn't available, staff would report it to her. They would then initiate an investigation to see if the situation was needing to be reported to the appropriate agencies. She explained that both residents were found in Resident #8's room and Resident #5 had her shirt up. She added that the residents were separated and they had found that no sexual abuse had occurred. She explained that RN/Staff #9 had witnessed the incident and she reported that the residents had gone into Resident #8's room when she went to the storage closet. Staff #17 shared that staff #9 had lost sight of them for two minutes and that it was highly unlikely that anything happened in those two minutes because both residents are slow moving. When asked if this incident was reported to the State, she stated it wasn't because based on their investigation, there was no sexual contact or abuse based on the staffs' statements. However, Staff #17 couldn't say with 100% certainly that nothing took place between the two residents. When asked to see the facility's investigative report, Staff #17 stated that the report was not a part of the clinical record and it was considered a part of quality measurement and she would need to check with Staff #2 to see if it could be shared with Surveyor.An interview was conducted on January 9, 2026 at 1:28 P.M. with Staff #2. Staff #2 confirmed that staff are to report suspected abuse to him as he is the abuse coordinator. He explained that once something is reported to him, he does a full investigation and then determines if it is something that needs to be reported based on what took place. He also shared that there is a leadership team in the corporate office that they will review situations with and then determine the best plan of action. When asked to describe the situation in question related to Residents #5 and #8, Staff #2 shared that that RN/Staff #9 had reported that Resident #8 was in bed with Resident #5 and they were both separated. He added that staff reported that both residents had their clothes on and they liked to flirt but nothing inappropriate had happened. Staff #2 explained that based on their investigation, they did not believe the situation was considered abuse based on what Staff #9 had described. He did confirm that Resident #5 would not be able to consent to being in bed with another person because she was not alert and oriented. However, he added, he did not feel that the situation was unsafe and he did not believe it needed to be reported. Staff #2 shared the investigative report with Surveyor. Upon review of the investigative report, it was found to consist of a written statement of Staff #9, who witnessed the incident, CNA/Staff #5 who was working the unit and did not witness it, and Staff #17, who received the initial report. Staff #2 was asked to read the statement written by Staff #9. He stated that the statement indicated Resident #5 was in bed with her shirt up and Resident #8 was hovering or leaning over her. Staff #2 shared that he did not consider Resident #5 having her shirt up and Resident #8 looking at her as abuse even if she could not consent to it.A telephonic interview was conducted on January 14, 2026 at 3:12 P.M. with Staff #9. Staff #9 explained that she was in the activity room and had to leave to go to the medication cart. She had seen both Resident #5 and Resident #8 in the activity room. A few minutes later she heard giggling and went to Resident #8's room where she found Resident #5 in bed with her shift off and Resident #8 hovering over her. She then separated the two residents and then called Staff #17 and reported it to her. She added that she did not consider this situation as sexual abuse because both residents were two consenting adults and both residents were in the room for 2 minutes and there wasn't enough time for them to do anything. Staff #9 admitted that both residents were not alert and oriented and that was why she reported the incident. She then admitted that the residents were not able to consent which is why she separated them. She added that maybe Resident #5 wanted to do something but they are not allowed to because they cannot consent. Staff #9 wasn't sure if the incident was reported to the State and added that her job was to report it to the DON (Staff #17) and it was not her place to determine if this was some type of abuse. She added that once she reports it to the DON, it was their job to determine if they needed to report it.Review of the State Operations Manual (SOM), Appendix PP indicates that the facility must thoroughly collect evidence to determine what actions are needed to protect the residents. It continues to highlight that, depending on the type of allegation, while there was no specific investigation process it was expected that the facility collects evidence which would include observations of the residents, interviews, and record reviews for pertinent information. The SOM also explains that the facility must immediately put measures into place to protect the residents from further abuse while the investigation was in process.Review of the facility's policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program indicated it took effect on January 1, 2024. The policy outlines that the facility needed to investigate and report any allegations within timeframes required by federal requirements.

Based on observations, interviews, facility documentation, and policy, the facility failed to ensure that safeguards and systems were in place to ensure accurate reconciliation and accounting for all controlled substances for one of three medication carts sampled. The deficient practice could result in inventory loss and potential diversion. A medication cart observation was conducted on December 9, 2025, at 10:24 a.m. with Licensed Practical Nurse (LPN/Staff # 46). Photographic images were obtained, with Staff # 46 present, of the Progressive Care Units (PCU) Narcotic Count Reconciliation Sheets. The narcotic sheets were reviewed with Staff # 46 for the months of October 2025 to December 2025. Staff #46 identified multiple entries with either no nurse signatures or only one nurse signature. The review of the Narcotic Count Reconciliation Sheet was conducted for two weeks, October 1-14, 2025 revealed the following:-Two nurses' signatures were not present on 2 shifts between October 1 and 14, 2025.-One nurse's signature was not present on 9 shifts between October 1 and 14, 2025.Review of the Narcotic Count Reconciliation Sheet for October 27- 31, 2025, revealed:- One missing nurse signature, October 27, 2025- Two missing nurse signatures, October 28, 2025- Two missing nurse signatures, October 29, 2025- Three missing nurse signatures, October 30, 2025- Four missing nurse signatures, October 31, 2025 Review of the Shift Change Sign-off Sheet for November 1-15, 2025, revealed:-Four missing nurse signatures on November 1, 2025.-One missing nurse signature on November 2, 2025. Review of the Narcotic Count Reconciliation Sheet for November 1-15 revealed:- One missing nurse signature on November 1, 2025.- Three missing nurse signatures on November 2, 2025.- Three missing nurse signatures on November 7, 2025.- November 6-7, 2025, has no entries.- November 8-15 has no entries. Review of the Shift Change Sign-Off Sheet for November 1-15 revealed-One missing nurse signature on November 4, 2025- Two missing nurse signatures on November 6, 2025- One missing nurse signature on November 7, 2025.- Two missing nurse signatures on November 8, 2025.- One missing nurse signature on November 10, 2025.-One missing nurse signature on November 11, 2025.-Two missing nurse signatures on November 13, 2025.-One missing nurse signature on November 15, 2025.Review of the Count Reconciliation Sheet for December 1- 8, revealed: No entries.Review of the Shift Change Sign-Off Sheet for December 1-8, 2025, revealed:- Two missing nurse signatures on December 1, 2025.- One missing nurse signature on December 2, 2025.- One missing nurse signature on December 3, 2025.- Two missing nurse signatures on December 4, 2025.- Two missing nurse signatures on December 6, 2025.- Two missing nurse signatures on December 7, 2025.- Two missing nurse signatures on December 8, 2025A surveyor request, dated December 9, 2025, at 4:10 p.m., called for copies of medication cart logs for 3 months for all 3 medication carts, including the shift change sign-off sheet and the narcotic count logs. The facility only submitted Shift Change Sign-Off sheets.Review of a follow-up e-mail correspondence, dated December 11, 2025, with the facility's Pharmacist representative revealed that nurses should be doing a count together at shift change for an accurate reconciliation. An interview was conducted on December 9, 2025, at 10:24 a.m. with LPN staff # 46 revealed that there are two nurses required to count and sign off each shift. The LPN revealed not knowing why so many entries were missing, but stated her is signed off today. The purpose of two nurse signatures is to verify their narcotic count accuracy, but they do have two different narcotic count sheets; some nurses sign on one form, and some sign on the other. Upon reviewing the PCU narcotic log, Staff #46 identified multiple entries with missing signatures and stated that the missing signatures did not meet facility expectations. An interview was conducted on December 9, 2025, at 2:49 p.m. with Registered Nurse/Staff #51. Staff #51 stated that the narcotic count process involves both the day shift and night shift nurses conducting the count together to verify accuracy. Staff #51 further stated that if a discrepancy is identified, the procedure is to notify one of the nurse supervisors. Staff #51 explained that the purpose of a dual-nurse count is to ensure narcotic counts are accurate and that any discrepancies are identified promptly. Staff #46 stated that the established procedure is to complete the narcotic count immediately after shift report and then sign the narcotic log. The nurse further explained that the off-going nurse references the narcotic log while the oncoming nurse counts the medication cards and narcotics.An interview was conducted on December 9, 2025, at 3:41 p.m. with the Director of Nursing (DON/Staff #24). Regarding the missing entries present on narcotic count sheets, the DON revealed that any missing entry does not meet the facility's expectations. The DON stated the expectation is for both nurses to count and sign to avoid the possibility of missing medications.The facility's Medications: Controlled Substances policy, effective January 1, 2024, dictates that the nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record. In addition, the consultant pharmacist or designee routinely monitors controlled substance storage records.

Based on a review of records and staff interviews, it was revealed that the facility failed to follow infection control guidelines for laundry services, medication preparation, and medication storage. This deficient practice can result in the failure to prevent and control infection transmission amongst a vulnerable population.Findings include:-Regarding the Laundry AreaRe: Laundry RoomAn observation of the facility's laundry room was conducted on December 9, 2025, at 10:15 a.m., with a laundry services employee (Staff #16). During the observation, the following deficiencies were identified on the dirty (soiled) side of the laundry department:1. The linen cart designated for dirty items contained loose articles of clothing that were uncovered.2. Two folded white blankets with visible debris and areas of dark soiling were located underneath both the washer and dryer.3. A blue and white fitted sheet was uncovered inside a gray mobile storage container.4. Two of the three yellow mobile storage containers were uncovered, containing soiled laundry. The third yellow container had its lid inverted on top, not fully closing the container, with colored laundry protruding beneath the inverted lid.5. A gray mobile storage container, positioned near the sink and the dryer, was uncovered and overfilled beyond its intended capacity. A blue blanket and a gray, white, and black patterned blanket were placed on top of other soiled laundry within the container.6. A gray storage container, underneath the yellow Laundry Trash Only!!! sign, had trash that reached the top of the container. A dark gray lid was present beside the wall on the floor, next to the container. A complaint received September 5, 2025, on the online Arizona Department of Health Complaint portal, revealed concern that the facility was not following infection control guidelines, in order to provide residents with a safe environment from infectious diseases. A review of a maintenance work order dated November 16, 2025, revealed the facility's washing machine required a new seal on the appliance's door. A review of a maintenance work order, dated December 10, 2025, repeated the request for the facility's washing machine seal replacement, the day after the survey exit. An interview was conducted with laundry personnel (Staff #16) on December 9, 2025, at 10:05 a.m. Staff #16 stated uncertainty regarding whether dirty laundry was required to be covered in the dirty area of the laundry room and indicated they would clarify this with management. However, Staff #16 stated that trash cans should be covered to avoid contamination.Staff #16 continued that a work order had been placed for a leaking washing machine and that a blanket was placed on the floor to keep it dry and prevent slips. Staff #16 further stated that the gray container with the blankets on top in the dirty section of the laundry room was not covered because it had just been unloaded from the washer while the staff member prepared the next load. The washed laundry was placed in the gray container until the dryer became available.An interview was conducted on December 9, 2025, at 2:28 p.m. with CNA (Staff #94). Staff #94 stated that when dirty laundry is removed from a resident's room, it is bagged, tied, and placed inside the large laundry bin. Staff #94 explained that laundry is bagged to prevent contamination and reduce the spread of illness within the facility.An interview was conducted on December 9, 2025, at 2:58 p.m. with RN/Staff # 51. Staff # 51 revealed dirty laundry can spread infection, so it is important to follow infection control guidelines. Staff #51 stated having no need to go to the soiled utility area, but knows that laundry, when transported down the hallway, has to be bagged and tied to decrease the spread of infection. An interview was conducted on December 9, 2025, at 3:20 p.m. with the Environmental Services Director (Staff # 77). Staff # 77 revealed that trash cans in the laundry room are expected to be covered to prevent contamination and smells. Staff #77 revealed the expectation for CNAs is to make sure laundry is bagged and contained properly before placing the bag in the dirty laundry bin. Staff # 77 continued that while in the laundry area, the dirty laundry is covered at all times to avoid an infection control issue. When the laundry is being sorted, Staff #77 revealed that the staff is required to wear Personal Protective Equipment (PPE) to also decrease the risk of contamination. Staff # 77 also stated that clean laundry should never be stored in the dirty side of the laundry area, in order to avoid cross-contamination.Staff #77 stated that the washing machine leak was a new issue, and that blankets were placed on the floor to prevent the drainage from spreading. Staff #77 explained that whenever the blanket becomes wet or soiled, Staff #16 would replace it with a clean one. Staff #77 noted that having the blanket on the floor near the washing machine and dryer posed a risk of contaminating clean laundry if it came into contact with the dirty blanket.Staff #77 stated that Staff #16 reported placing a load of laundry that completed the wash cycle in the gray container while waiting for the dryer, as the next load needed to start. Staff # 77 stated this practice was problematic because wet laundry can stagnate, develop odors, and host bacteria. In addition, Staff # 77 stated clean laundry should not be left in the dirty area; instead, once the laundry has completed the dry cycle, it is placed in the clean bin and immediately covered for transport to the clean area of the laundry area. Staff #77 reported providing immediate education to the laundry assistant regarding deficiencies discovered during the laundry area tour today. Immediate plans also include ongoing education and audits for housekeeping staff to ensure the laundry department minimizes the risk of infection transmission within the facility.An interview was conducted on December 9, 2025, at 3:41 p.m. with the Director of Nursing (Staff #24), who also serves as the facility's Infection Preventionist (IP). The DON reviewed photographic evidence of the laundry room and identified laundry handling practices that failed to meet infection control expectations. The DON/Staff #26 stated that when staff bring soiled articles to the laundry area, the dirty laundry should be bagged at the source and tied individually to avoid contamination when going down the hallway. This process, as well as keeping dirty laundry covered and separate from the clean area, is intended to prevent contaminants from spreading throughout the facility. Staff #26 further stated that trash cans in the laundry room are expected to have lids to reduce the risk of cross-contamination. Staff #26 also indicated that dirty blankets on the floor are never acceptable and can cause cross-contamination. Staff #26 continued that wet blankets-whether wet from water or bodily fluids-are not acceptable, as moisture can stagnate and increase the risk of contamination. Staff # 26 concluded infection control practices in the laundry services area did not meet expectations, which could contaminate or spread illness in the facility. Regarding Medication Preparation and Storage- A facility observation was conducted on December 9, 2025, at approximately 10:31 a.m., in the Progressive Care Unit (PCU)medication cart with LPN (Staff #12). An open multi-dose vial of Insulin Glargine (expiration January 2027), with the handwritten date of November 17, 2025, was observed without any resident identifiers.A facility observation was conducted on December 9, 2025, at approximately 10:39 a.m., during an East Cart check with Registered Nurse (Staff #51). Two insulin pens were observed in the medication cart without patient identifiers: a Lantus Solostar pen (100 units), with a handwritten date of November 29; expiration July 21, 2027; and an Insulin Multi-Dose pen dated November 15, 2025, expiration May 31, 2027. During the observation, the Registered Nurse demonstrated to the surveyor how unused insulin syringes are used to draw insulin from the pen cartridges after the tops of the cartridges are cleaned with alcohol at the facility.Continued observation of the East Cart's bottom drawer revealed a cluttered gray basin with medication bottles and a pill organizer stored together without the minimum facility label requirements. A rainbow colored, 7 day multi compartment pill organizer with labeled days and AM/PM sections contained various pills and was surrounded by multiple prescription and over the counter medication bottles.An interview was conducted on December 9, 2025, at approximately 10:31 a.m. with Licensed Practical Nurse (LPN/Staff # 46). The LPN stated being unable to identify which resident the unlabeled multi dose insulin pen observed in the PCU medication cart belonged to. The LPN verbalized immediate plans to dispose of the unlabeled multidose pen. The LPN revealed that all medications in the cart are supposed to be labeled with resident identifiers to prevent accidents. The LPN also stated that having a used multi-dose insulin pen, without any resident identifiers, could also present an infection control issue, so the pen cannot be used on any other resident.An interview was conducted on December 9, 2025, at 10:39 a.m. with RN/Staff #51. The RN explained that because house stock vials of insulin were not available, staff had been using insulin pens as a replacement source of insulin. The RN stated, We do not use the needle on the pen; we swab the top of the pen cartridge and draw the insulin from the multi use cartridge into an unused insulin syringe. The insulin drawn into the syringe is then administered to the resident as normal. The RN added that the multi use pen itself never touches the resident, so infection control protocols are maintained. The RN further stated that nurses were introduced to this practice in December 2024 and referred to it as common practice. The RN described being taught that multi dose for single use only meant the pen could be used multiple times in a single setting, and that multi dose pens were acceptable replacements for insulin vials.An interview was conducted on December 9, 2025, at 2:28 p.m. with Certified Nurse Assistant (CNA/Staff #96). The CNA stated that, although their job responsibilities do not include administering medications, they were aware that medications without correct labeling could result in mix ups and potentially harm a resident.An interview was conducted on December 9, 2025, at 3:41 p.m. with the Director of Nursing (DON/Staff #24). The DON stated that staff were never approved to draw insulin from multi-use pens due to infection control risks. The DON further revealed that any insulin pens stored in a drawer should have been labeled with the resident's name and the date opened to prevent mix-ups.Staff #24 also stated that Resident #99's home medications were initially stored in the medication room but were moved to the medication cart due to that area undergoing renovations. The DON acknowledged that the resident's son was contacted to retrieve the home medications, but this was not completed. The DON stated that unlabeled home medications should not be stored in a nurse's cart due to safety risks and infection control concerns.The facility's Infection Control Program policy, copyrighted 2013, set the expectation that the infection control program had the focus to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection.The facility's Medication Labeling and Storage policy, effective January 1, 2024, revealed that medications and biologicals must be stored in the packaging, containers, or other dispensing systems in which they are received, and that only the issuing pharmacy is authorized to transfer medications between containers. The policy further states that medication labels must include, at a minimum, the medication name (generic and/or brand), prescribed dose, strength, expiration date (when applicable), resident's name, route of administration, and appropriate instructions and precautions. If medication containers have missing, incomplete, improper, or incorrect labels, staff are directed to contact the dispensing pharmacy for instructions regarding returning or destroying these items. In addition, the policy restricts medications from being transferred between containers. The facility's Medications: Administering Medications policy, effective January 1, 2024, specifies that vials labeled as single dose or single use are to be used for one resident in a single procedure only. The policy further requires that repackaging unopened single-use vials for use for more than one resident or procedure must comply with USP <797> standards, and that the consultant pharmacist be contacted if repackaging is necessary. The policy also states that insulin pens containing multiple doses of insulin are for single-resident use only; changing the needle does not make them safe for use on more than one resident. Insulin pens must be clearly labeled with the resident's name or other identifying information, and the nurse must verify the correct insulin pen is used for each resident prior to administration.

Based on clinical record review, interviews, review of facility documentation and policies, the facility failed to protect the rights of one resident (# 76) to be free from verbal abuse by a staff member (Staff # 30). The deficient practice has the potential to violate the resident's right to safety and prevent further harm. Based on clinical record review, interviews, review of facility documentation and policies, the facility failed to protect the rights of one resident (# 76) to be free from verbal abuse by a staff member (Staff # 30). The deficient practice has the potential to violate the resident's right to safety and prevent further harm. Findings include,Resident #76 was originally admitted to the facility on [DATE], with the most recent admission date being July 19, 2025, with diagnoses that included cerebral infarction, unspecified; legal blindness, as defined in USA; chronic pain syndrome, adjustment disorder with mixed anxiety and depressed mood, other bipolar disorder, restlessness and agitation, and unspecified otitis externa, right ear. A care plan revealed the following areas of focus:Communication Impairment care plan, related to a hearing deficit and slurred speech, initiated on April 10, 2025, revealed interventions focused on maintaining the resident's current level of communication. These interventions included making sounds, using appropriate gestures, and responding to yes/no questions. In addition, staff are directed to anticipate and meet the resident's needs to support effective communication and overall comfort.Impaired Cognitive Function and Dementia Care Plan, initiated April 10, 2025, revealed interventions focused on supporting the resident's ability to communicate basic needs through daily activities, including following one-to-three step instructions, navigating their room, reading, doing puzzles, administering medications, and communicating with staff and family regarding the resident's capabilities.A quarterly Minimum Data Set (MDS) assessment, dated October 7, 2025, revealed a Brief Interview for Mental Status (BIMS) score was 11, indicating moderate cognitive impairment. The assessment indicated the resident had minimal difficulty with hearing, defined as difficulty in some environments, such as when a person speaks softly or the setting is noisy. A Behavior Management care plan, with the revised date of November 11, 2025, addressed behaviors related to impaired cognitive function and safety awareness related to the resident exhibition of physical and verbal behaviors.A nursing progress note, dated November 11, 2025, revealed that the resident was referred to telepsychology services due to increased agitation.A pharmacist medication regimen review form, dated November 12, 2025, identified an increase in the resident's distressed behaviors. The review noted that behaviors documented in the progress notes (self-isolation and delusions) did not align with those being tracked for medication orders. The pharmacist advised the facility to update the target behavior tracking, prior to making any medication changes. Additionally, the pharmacist requested documentation of non-pharmacological interventions to address these behaviors.A Tracking Target Symptoms/Behavior order, dated November 16, 2025, called for the number of false accusations made to be tracked every shift.Resident council minutes dated November 18,2025 included that Certified Nursing Assistant's (CNA) need to be more respectful. A Psychiatric follow-up note dated November 18, 2025, revealed the resident experienced pain and distress after falling on two separate occasions while being assisted by staff. The note also commented that the resident expressed overall dissatisfaction with quality of life at the facility. In addition, the note referenced that the resident's family member filed a complaint with the facility in regards to the injuries sustained. However, grievance logs submitted by the facility revealed no evidence of the concerns from the resident's representative. A behavior progress note, dated November 18, 2025 at 1:30 p.m., revealed that a nurse heard the resident yell and scream while CNAs attempted to provide care. The note indicated that the resident called the CNA's stupid fucking bitch, and they were unable to diffuse the situation after multiple attempts. A nursing progress note, dated November 19, 2025, indicated that throughout the shift, the resident repeatedly called for the nurse and CNA, and used the call light inappropriately. The note further revealed the resident directed profane language toward staff and was noted to be difficult to redirect. Staff interventions were documented as continuing to follow the resident's established plan of care to manage these behaviors.A Treatment Administration Record (TAR) dated November 19-21, 2025 revealed that the resident made 10 false accusations during that time.Review of the clinical record revealed no evidence of verbal abuse by staff on November 19, 2025. However, facility investigations revealed that a student nurse (#1) reported observations of verbal abuse on November 20, 2025 related to Resident #76 and Staff #30.A police report for the incident dated November 19, 2025, revealed law enforcement was contacted by the Executive Director (ED/Staff # 84) on November 19, 2025 at 12:24 p.m. to report a civil offense. The report stated that CNA # 30 was accused of yelling at a resident to Shut the Fuck up!. The report further stated that the allegation was investigated internally, and that the facility wanted documentation that supported police involvement. A five-day report, dated November 25, 2025, concluded the allegation of staff-to-resident verbal abuse was inconclusive/undetermined. The investigation indicated that the facility was unable to identify a specific incident in which verbal abuse occurred. The report included an interview with CNA / Staff #30, in which, she denied yelling at the resident in the hallway, and did not argue with residents, but rather conversed with them. However, the report acknowledged that the CNA /Staff #30 was observed arguing with the resident in the hallway and speaking loudly. The report also indicated the facility could not verify whether yelling or profanity was used even though the investigation provided firsthand accounts of staff hearing CNA/ Staff #30 argue with the resident in the hallway and the resident's room.Further review of the facility's investigation revealed most witnesses reportedly could not substantiate verbal abuse; however, the report included that a student staff member (staff #100) reported overhearing Staff #30 tell the resident to shut the fuck up and observed yelling between Staff #30 and the resident in the hallway. Another interview conducted by the Social Worker on November 24, 2025, at 11:32 a.m., reported that the resident told her that Staff #30 yelled the phrase shut the fuck up to the resident. The report also included an interview with the resident conducted by the Director of Nursing, which that the resident confirmed that a staff member told her to shut the fuck up but could not identify the staff involved, the time, or surrounding circumstances. The interview also revealed the resident redirected to an unrelated situation during this interview. The 5-day report, revealed that Staff #30 was on leave pending investigation and was eligible for reinstatement The facility 5-day report, concluded that the resident required staff to speak loudly due to a hearing deficit.Review of Inservice Training and sign-in sheets dated August 25, 2025 through December 9, 2025, revealed no evidence that staff #33 attended.An observation of the resident was conducted on December 9, 2025 at 10:55 a.m. The resident was lying in bed and was able to respond readily and appropriately without assistance from the staff or by the surveyor. An interview was conducted with Resident #76 on December 9, 2025, at 10:55 a.m. During the interview, the resident reported ongoing concerns regarding staff interactions to the Executive Director (ED/staff #42), and facility management, stating that CNAs frequently yell at her and use profanity. The resident also revealed that CNA (staff # 30), always yell and cuss at me! and that the latest occurrence was nothing new!. The resident continued, alleging that a CNA (staff #30) told her to shut the fuck up and stated revealed the yelling and profanity was not an isolated event, but rather frequent occurrence they talk to me like that all the time. The resident was able to respond readily and appropriately without assistance, without difficulty hearing, during the conversation.An interview was conducted on December 9, 2025, at 1:06 p.m. with a student Certified Nurse Assistant (Staff #1). The student reported that on December 18, 2025, while near Resident #76's room, she overheard an argument in which Staff #30 yelled at the resident, Shut the Fuck Up. The student stated that she was unsure as to how to respond to that type of interaction, and felt uncomfortable reporting the incident with staff #30 still in the unit, so she kept the incident to herself. The student stated that Staff #30 arguing with the resident and using profanity was inappropriate, and reported feeling bothered and upset so she checked-in on the resident throughout the remainder of the day. The student also stated that later while at the nursing station, she heard Staff #30 say Shut the fuck up., while residents were in close proximity to the nurse station. The student reported disclosing the incident to her instructor and four other students during a class debriefing at end of day. An interview was conducted on December 9, 2025 at 1:26 p.m., with the student Certified Nurse Assistant's (Staff # 1) instructor (Staff # 88). The instructor stated that the student did not report anything to her until the end of the day, and that looking back she should have gathered more information about the students' concern at the class debriefing session. The instructor stated that after speaking further with the student the next day, she determined that the situation of CNA/Staff # 30 cussing at a resident, could be considered abuse and needed to be reported to the abuse coordinator for follow up. The instructor stated that resident # 76 is quite difficult to care for and is known for resistance to care, and yelling at staff. However, the instructor stated that staff should never yell or cuss at residents, as that is very unprofessional and disrespectful. An attempt was made to contact CNA/Staff #30 on December 9, 2025, at 1:47 p.m.; a voicemail was left. No response was received from the staff member by the conclusion of the complaint survey investigation period.An interview was conducted on December 9, 2025, at 2:09 p.m. with the Social Worker Director (Staff #99). The social worker stated that it was not acceptable for staff to demean residents in public or in private, as the facility's role is to help, not harm, residents. She explained that demeaning behavior, such as staff arguing with residents, compromises resident dignity and rights and is unprofessional and should be reported immediately. The director further stated that when disagreements occur between staff and residents, staff are expected to separate from the resident and immediately notify their nurse supervisor or management. She noted that situations involving staff verbal outbursts could be considered verbal abuse, and reiterated that if staff witness such actions, they should intervene by separating the individuals, securing the resident's safety, and reporting the event to management. She continued that if a staff member yelled at or cussed at a resident that would be verbal abuse because you are talking in anger. The social worker revealed that if a staff member told a resident to shut the f up, that would constitute verbal abuse, and an extreme lack of professionalism. The social worker stated that if staff at risk for frustration are encouraged to take a break or request reassignment if necessary. The social worker stated that residents with a history of behavioral concerns that include making false accusations, using derogatory language toward staff or other residents, and refusing care are at increased risk for abuse and may be more vulnerable because their allegations may not be taken seriously. The social worker described her familiarity with CNA (Staff #30's) performance, characterizing it as less than exemplary, and stated that Staff #30 failed to meet expectations for resident attentiveness and displayed a significant negative attitude when asked to perform additional tasks. The social worker verbalized having the responsibility for conducting safety interviews following allegations of abuse. She stated these interviews assess the resident's sense of safety, concerns about staff, and concerns involving other residents. The social worker recalled interviewing Resident #76 for the Facility's 5-day investigation report, regarding the allegation of verbal abuse against CNA/Staff #30 and documented accurately recorded the resident's response.An interview was conducted with CNA (Staff #94) on December 9, 2025, at 2:30 p.m. The CNA stated that abuse and neglect are addressed in facility training and conducted every few months and when abuse was witnessed or suspected, staff are instructed to notify one of the three abuse coordinators. The CNA reported that the incident between CNA/Staff #30 and Resident #76 began when the resident requested that CNA/Staff #30 help her lay her down. The CNA stated while leaving the area, she overheard Staff #30 decline the request, and left the resident in the wheelchair. The CNA stated not being able to hear everything between CNA/Staff # 30 and resident # 76, but heard both parties arguing with each other. The CNA revealed that CNA/ Staff #30 spoke loudly and argued with residents and staff pretty often at work, so the argument was not unusual. The CNA reported that, to her knowledge, no one reported CNA/Staff #30's behavior to management, as the incident was considered typical behavior for CNA/Staff #30. The CNA stated that they did not report the interactions to the abuse coordinators because the resident and the CNA did not escalate into anything physical. The CNA further stated that the behavior of cussing and yelling at residents was a lack of professionalism, rather than reportable abuse. The CNA stated that it is not acceptable for staff to argue with residents, and if staff feel the need to argue with a resident, that staff member should step away, involve another staff member, and report any problems to their nurse. The CNA also stated that arguing with a resident can be considered verbal abuse depending on the intent, as words may cause harm.An interview was conducted on December 9, 2025, at 2:5 8 p.m. with Registered Nurse (RN/Staff #51). The RN described CNA/Staff #30 as generally able to complete assigned tasks, and provide assistance when requested but was not consistently a team-focused employee. The RN stated that Resident #76, was upset frequently, difficult to work with, and demonstrated limited patience when in a bad mood. The RN further stated that when the resident was in a positive mood, interactions with staff and other residents could be playful. The RN stated that staff should not argue with residents, stating that every resident has the right to express autonomy and that staff are responsible for providing care in a professional manner. The RN stated that verbal abuse is defined as any behavior intended to harm, belittle, or demoralize a resident. If an allegation of abuse is received, staff are instructed to contact the facility's abuse coordinators. The RN confirmed that, in the event of an imminent threat or abuse allegation, the resident would be removed from the situation to ensure safety. The nurse did not view what was transpiring between the staff and resident as verbal abuse, but rather staff #30 had the need to speak louder because of the resident's hearing deficit. The RN stated that the event involved Staff #30 and Resident #76, regarding the resident's request to be laid down. The RN further stated that the resident had an upcoming appointment and transportation was in-route, so the CNA/Staff # 30 informed the resident that the request could not be accommodated at that time. The RN also heard the CNA/ Staff #30 speaking loudly at the nurses' station, but stated the CNA did not appear to be yelling in a malicious manner and that it sounded more explanatory. The RN stated that the nurses' station is was a fair distance from the resident's room and was not an optimal vantage point from which to hear everything that was said. An interview was conducted on December 9, 2025 at 3:30 with the Environmental Services Manager (ESM/Staff # 8). The environmental services manager, stated they receive abuse training at the facility upon hire and throughout the year. The ESM stated that if a staff member was yelling and cussing at a resident, he would report it to the Executive Director . The ESM vocalized that yelling and cussing at a resident is considered verbal abuse, and is very unprofessional. An interview was conducted on December 9, 2025, at 3:56 p.m. with the Director of Nursing (Staff #24). The DON stated that while it is acceptable to raise one's voice to be heard by a resident with a hearing deficit, it is never acceptable to raise one's voice in a malicious manner. The DON stated that staff should never use profanity toward residents and that any such behavior must be reported immediately. The DON reported that the instructor notified management the morning after the incident. At that time, the instructor indicated a student CNA had informed the group that Staff #30 had been rude to a resident, but further details were not provided until the next day. The DON acknowledged that the instructor/Staff # 88, should have followed up to obtain additional information when initially revealed, but noted that once all details were known, the instructor did report the allegation per facility policy. The DON stated the facility conducted a full investigation into the allegation of abuse but was unable to determine if the allegation occurred. The DON reported that Staff #30 was released from employment for violations of professional conduct. Review of Staff #30's employment records revealed an Annual Performance Evaluation, dated September 18, 2025, revealed the facility encouraged the CNA to focus on the tone and delivery of her communication and stated sometimes it's not what you say, but how you say it makes the greatest impact. In addition, a Corrective Action Form, dated November 24, 2025, indicated that the CNA was terminated for violations of professional conduct. The corrective action documented two incidents involving Staff #30. The first incident occurred on November 17, 2025, when the employee was witnessed by a family member yelling at a co-worker about the removal of trays and a change in the scheduled feeding time. The second incident took place on November 18, 2025, when Staff #30 was observed on camera arguing with a resident at the nurse's station. The facility found both incidents to be in direct violation of the Professional Conduct and Workplace Violence Zero Tolerance policies.The facility's Caring Professional Handbook Workplace Violence Zero-Tolerance policy, states that intentional demeaning, intimidating, or harassing behavior of any kind, including but not limited to stalking, swearing, or shouting, is strictly prohibited. Violations of this policy will result in immediate disciplinary action, up to and including termination, and may be subject to civil prosecution.The facility's Caring Professional Handbook Harassment Zero-Tolerance policy, revealed that caring professionals hold the strict responsibility to avoid any action or conduct that could be viewed or construed as harassment of any kind. The policy further continues that unwelcomed jokes, language, and comments, or any act that causes the undue burden of harassment outside of the normal scope of social interaction and the expected differences that occur in a business setting are strictly prohibited. The facility's Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, effective January 1, 2024; dictates the facility to establish and maintain a culture of compassion and caring for all residents particularly those with behavioral, cognitive or emotional problems. In addition, the facility is directed to implement measures to address factors that may lead to abusive situations, for example: a. adequately prepare staff for caregiving responsibilities.The facility's Resident Rights/Dignity: Resident Rights policy, effective January 1, 2024, establishes that employees shall treat all residents with kindness, respect, and dignity. The facility's Personnel: Disciplinary Action policy, effective January 1, 2024, revealed anything less than professional behavior is not only inappropriate but is a hinderance to the wellbeing of all concerned. The facility's Personal Care: Hearing Impaired Resident-Care of policy, effective January 1, 2024, directs the staff when dealing with the hearing impaired, to enunciate clearly, slowly, and in a normal tone. The facility was to also provide pencil and paper or tablet to communicate in writing, if the resident is able. The facility's Personnel/Staffing: In-Service Training, All Staff policy, effective January 1, 2024, revealed that all staff are required to participate in regular in-service education. The facility's Personnel/Staffing: Staffing, Sufficient and Competent Nursing policy, effective January 1, 2024, revealed that competent staff must demonstrate the skills and techniques necessary to care for the resident needs including (but not limited to) the following areas: resident rights, behavioral health, person-centered care; and communication.

Based on clinical record review, staff and family interviews, and facility documents and policy, the facility failed to ensure a resident's privacy was maintained during medication administration for one resident (resident # 23). This deficient practice could result in further violations of resident privacy. Findings include: Resident #23 was initially admitted on [DATE] and readmitted on [DATE] with diagnosis including Non-St Elevation (Nstemi) Myocardial Infarction, Chronic Obstructive Pulmonary Disease, Muscle Weakness, Atherosclerotic Heart Disease, and Gastrointestinal Hemorrhage. A review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 12, indicating mild cognitive impairement. An interview was conducted on November 6, 2024 at 8:30 a.m. with a Registered Nurse and Unit Manager, (RN/Staff #26), where Staff #26 explained their expectations with respecting a resident's absolute privacy, that during patient care, doors should be closed, curtains should be drawn, that staff is expected to ask residents for their preferences, ensure resident's know their right to say no. Staff #26 also stated that staff has a learning management system that provides courses on Health Insurance Portability and Accountability Act (HIPAA) and resident rights. Staff #26 stated that the facility's expectations and professional standards apply to all staff when providing patient care. Staff #26 also stated that the expectation during medication administration is to ensure that any resident information is not viewable when staff is away from the medication cart, that the medication cart is locked when unattendance, that they introduce themselves to the resident and ensure the resident confirms their information, and that the resident is not being forced to take medications that they do not want to. However, during the interview with Staff #26 as stated above, an observation was made where Staff #26 provided a visual completion on how a nurse during medication administration is able to lock and unlock a resident's chart on their mobile devices. On November 6, 2024 at 10:12 a.m, a med cart located on the Long-Term Care (LTC) unit was observed unattended, and on the top of the medication cart, a device displayed Resident #23's name, date of birth, photo and the medications. A face bubble packet was also observed next to this device. An interview was conducted on November 6, 2024 at 10:12 a.m. with a Licensed Practical Nurse (LPN/Staff #88), where Staff #88 stated that the bubble packet does not have any medications in them and that they were left onto of the medication cart to remind her to re-order the medication. Staff #88 also stated that leaving the medication cart unattended with resident information being displayed and out in the open is not the facility's expectation and professional standards. Staff #88 acknowledged that she did leave Resident #23's information out in the open. An interview was conducted on November 6, 2024 at 2:43 p.m. with Director of Nursing (DON/Staff # 48), where Staff #48 stated that the facility's expectation is that staff honor the dignity and privacy of the residents, to ensure that they are closing the doors and closing curtains, and that residents have the right to take their medications in the hall if they wish to. Staff #84 also stated that during medication administration, staff is expected to knock upon entrance, introduce themselves and then close the curtain or close the door. Staff #84 also stated that staff is expected to lock the screen prior to administering any medication or covering any paper documents that may be viewable, as the risk for not ensuring resident confidentially is not within professional standards and that a visitor or an inappropriate party can view resident information. A review of an admission packet, on page 13, there is a section titled, Protected Health Information, revealed that the facility will not releaser any medical information to other parties without a properly signed Medical Release of Information from the resident or the responsible party. A policy titled Resident Rights, Dignity, revealed that the residents have their right to privacy and confidentiality to their medical records.

Based on clinical record reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to ensure that one resident (#128) was free from abuse from another resident (#66). This deficient practice could result in further instances of abuse. Findings include: -Resident #128 was admitted at the facility on December 4, 2023 with diagnoses that included dementia, chronic obstructive pulmonary disease, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated on June 11, 2024 revealed the resident had a BIMS score of 4, which indicated severe cognitive impairment. Review of care plan initially dated on February 26, 2024 and revised on August 1, 2024 revealed that resident #128 use antidepressant medication. The interventions included to monitor/document/report to provider as needed ongoing signs and symptoms of depression which included fear of being alone with others, attention seeking, concern with body functions, anxiety, and constant reassurance. -Resident #66 (alleged perpetrator) was admitted at the facility on March 28, 2024 with diagnoses that included unspecified dementia, type 2 diabetes mellitus, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6.0, which indicated severe cognitive impairment. The MDS also included that the resident mood includes feeling down, depressed, or hopeless, rarely feel lonely or isolated, and has verbal behavioral symptoms directed towards others. For every day activities, no impairment on the upper and lower extremities, uses a walker and wheelchair. Review of care plan initially dated on April 10, 2024 and revised on July 8, 2024 revealed that resident #66 has a verbal behavior problem, inappropriate sexual behaviors towards staff and residents, and exhibits personal sexual needs in his room. The interventions included anticipate and meet resident's needs, encourage as much participation/interaction as possible during care activities, identify behavior triggers, and refer to psychiatric provider for consultation as ordered. A a progress note for resident #128 dated on July 7, 2024 revealed resident #128 was yelling Quit touching me! get your hands off of me!, and further revealed the writer quickly turned around and saw resident #66 reaching for resident #128 and he also was looking like he was going to expose himself to her. The note continued that resident #128 thanked the writer several times for stepping in and ordered resident #66 to get away from resident #128. The note concluded that resident #66 is constantly going after our women here and scaring them A behavior progress note for resident #66 dated on July 7, 2024 revealed a resident identified as resident #128 yelling quit touching me get your hands off of me. A staff saw resident #66 reaching for resident #128 and resident #66 was looking like he was going to expose himself to resident #128. Furthermore, the progress note revealed that resident #66 is constantly going after our women here and scaring them. Furthermore, the progress note stated spends too much of my time keeping him from sexually harassing them by touching and groping their breasts against their wills. I just saw him going down the hall with his penis hanging out and then realized that he had it hanging out and touching his penis with one hand and trying to grope a Resident with his other hand. A health status note dated July 7, 2024 revealed the administrator was notified of resident #66's behavior. A behavior progress note dated July 8, 2024 revealed resident #66 was immediately removed from resident #128's location and administrative staff were aware of behaviors. A health status note progress note dated July 9, 2024 revealed a room changed for resident #66. A psych follow-up progress note dated on July 10, 2024 revealed provider was aware of resident #66 on change on condition monitoring for having a recent room change and resident #66 continuous to go into female rooms to try to touch them. A behavior progress note dated August 26, 2024 revealed resident #66 has been touching other females' residents on their private areas. The resident has been told multiple times to stop, but he would say I won't stop. The resident has been reported and the CNA's keeping a watch on him. Will continue to monitor. A behavior progress note dated August 28, 2024 revealed resident #66 grabbed another Resident's bottom and tried lifting her shirt. The female Resident swatted this Resident's hand away and said, No!. An interview was conducted on November 7, 2024 at 07:22 a.m. with licensed practical nurse (LPN)/Staff #88. Staff #88 stated that she recalls resident #66 who is very angry, sexually heightened, no impulse control. Resident #66 would grab resident's breasts, and that they moved him to the locked unit about 6 months ago. He scared the female residents. Staff #88 stated that she can recall two female residents that resident #66 targeted specifically in the locked unit. Staff #88 do not wish to share their names. Staff #88 stated that she had witnessed resident #66 touching female residents inappropriately and they have separated the residents and kept resident #66 away from the female resident. Staff #88 stated that she had notified her unit manager, the director of nursing (DON), and their executive director. An interview was conducted on November 7, 2024 at 07:43 a.m. with a certified nursing assistant (CNA/Staff #222). Staff #222 stated that she is familiar with the locked unit for residents with dementia. They observe residents and when residents argue they intervene by calming them down, separate them, and notify the nurse. As far as her training, she took acknowledgment test every month for dementia care and also, she went through abuse training. An interview was conducted on November 7, 2024 at 08:07 a.m. with a CNA (CNA/Staff #43). Staff #43 stated that his role includes scheduling CNAs and nurses. The CNAs schedule is based on their staff preference and skills and their shifts is 12-hour shift from 6 to 6. They also have a medication tech. An interview was conducted on November 7, 2024 at 08:16 a.m. with a Certified Medical Assistant (CMA/staff #61) Staff #61 identified resident #66 to this surveyor. Staff #61 stated that with resident #66, the resident does not keep still, wheels self in the hallway and in the dining room in the locked unit. Staff #61 stated that they do their best for caring their residents with dementia and when their residents become combative and in the dining room, they try to remove them in the dining room and take them to their room to their calm place. They distract them by for instance offering water. Furthermore, Staff #61 stated that resident #66 wheels himself back and forth, crashing into people and stuff, resident will run his wheelchair into them not intentionally, resident is very inappropriate to other female resident and all healthcare staff. For instance, such as with another resident, resident #66 went up to her and touch her breast and it happened about 1 -2 months ago. Resident#66 still does that. Also, when resident #66 was in the long-term care side, resident #66 went up and touch other resident's breast and verbally said inappropriate things to them and asking sexual favors. The residents over at the long-term side will tell the staff members because they are with it to say something. Staff #61 added that there was one instance that happened in the summer. Staff #61 stated that with Resident #66 when he first came in the facility was going to people's room and wandering. Resident #66 touched other female butt while walking with her walker, it happened like about 1-2 months ago, He also say things to few ladies, like the famous one is you can touch me like anywhere you want, and bribing them by holding a napkin to bribe and to see their breast. Staff #61 stated that she has reported the incident to Staff #55, staff #88 and the director of nursing (DON), they are aware. Staff #61 stated that their schedule sometime include one CNA in the unit and it is hard to constantly watch resident #66 and their nurse is out there in the opposite of their unit, pass the double doors. An interview was conducted on November 7, 2024 at 10:50 a.m. with a Registered Nurse (RN/Staff #55). Staff #55 stated that resident #66 has implosive behavior touching other people and grabbing other people and the last time this behavior happened was in the summer. Staff #55 stated that the process for reporting incident is to let his supervisor and executive director know. An interview was conducted on November 7, 2024 at 01:58 p.m. with the Director of Nursing (DON/Staff #103). The DON stated that she oversees residents' care and staffing to make sure it staffed properly. They make sure they are providing care and following policies and regulation. Regarding abuse it can be physical, financial, misappropriation of funds and neglect, and include sexual abuse. The process for any suspected abuse is to report to their abuse officer immediately, report to state immediately, if resident to resident make sure resident is safe and then report immediately. The DON stated that regarding resident #66, resident was admitted for skilled for fracture was in skilled unit then went to long-term in April and moved to another unit, resident has dementia then resident was moved in the locked unit in July because of exit seeking, has occasional behavior issue and they try to redirect as much as possible. Resident behavior issues exhibited such as displayed sexual behaviors to staff, mostly to the CNAs by grabbing their butt and breast. The DON recalled an incident who they did self -report where he grabbed a resident's breast. DON stated she does not know any other incident about inappropriate behavior towards other residents. DON stated that music therapy helped resident #66 like playing country music in his room, and more activities. The DON stated that for staff reporting abuse, their training is upon hire and as needed. She added that any abnormal behavior of resident, any change should be reported to the DON. The surveyor informed the DON of resident #66's behavior in his July's progress notes. DON is looking in Point Click Care (PCC) for resident #66 progress notes. DON stated that she is not aware of the July event. DON stated that she definitely needs to look into regarding the July incident with resident #128 and she would get with the administrator to review any documentation on this. DON stated intervention regarding resident #66 included a referral in show low and he was not accepted, resident has been seen by telepsych since May 2024. DON stated that he was started on Paroxetine in August. An interview was conducted on November 8, 2024 at 8:07 a.m. with CMA/Staff #74. Staff #74 stated that in the locked unit, they have 15-16 residents, and for staffing they have one CNA and one CMA and their nurse is in the skilled unit, or they have two CNAs and a nurse in the skilled unit, and today there is one CMA and one CNA. Staff #74 stated that regarding resident care plan, they check each resident's Kardex, it can be found in PCC in point of care (POC). In regards to training and in-services, they have in-services every month and have educational videos. The in-services every month tell them how to distract resident to switch their attention to an activity or how to deal with their behaviors. They use distraction when they are upset to get their mind or attention on something else. Regarding resident #66, Staff #74 stated that resident #66 needs help with activities of daily living (ADLs), activities, and rolls around, sometimes he does not have good behavior, he is not physical but can be nasty with the women with staff and residents, nasty as in he will just say can I see your boobs provocatively, intervention use is he will usually move him or tell him not to say those things, he has not seen any inappropriate touching by resident #66. Staff #74 stated that his role is make sure everyone is safe first then remove the person from situation and grab his radio and call for help. He will call the DON and the administrator to report incident such as physical and emotional abuse. An interview was conducted on November 8, 2024 at 10:12 a.m. with resident relation/Staff #113. Staff #113 stated that her role is she advocate for resident, help with non-clinical grievances such as with insurance, medical equipment, discharge planning. As a discharge planner she figures out their prior living, if need assistance, if live alone, and then come up with a goal and during their stay to make sure goal is still feasible if not have an alternate plan, referrals for home health and transfer to different facilities if needed. Regarding resident #66, she help locate his family out of state, she has sent referrals out of state in September 2024, and waiting to hear from them, and she made referral to a facility in July. Resident #66 has behaviors and she sent referrals to another facility in May 2024 and was denied. The denial reason was resident did not meet requirement. For the other facility referral , no bed was available. She stated that the behaviors such as sexual behaviors are inappropriate comment mostly to staff and to one resident incident which was reported to the state and that was grabbing resident's chest. She stated that the behavior seems to get better since he was moved to the locked unit which seems to help. Staff #113 recalled an incident that Resident #66 made a comment in September towards a female resident, the comment was show me your panties and he was talked to regarding that comment that was not appropriate, staff #113 saw this incident documented in the progress note by the DON. An interview was conducted on November 8, 2024 at 10:39 a.m. with the Administrator (Admin/Staff #106). Present during the interview are VP clinical Resource/Staff #225 and the DON. The administrator stated that regarding their abuse process, to report to the administrator as their abuse prevention coordinator and if not available to the DON. He stated that there are signs posted up in the building regarding abuse reporting. The administrator stated that they investigate the concern and determine if reportable or not, and a reportable abuse is physical abuse, sexual abuse, and neglect. The administrator stated that regarding sexual abuse, it is improper touching, not consenting to someone else or even uncomfortable situation like sexual advances. The administrator was prompted to review the progress note of resident #66/resident #128 in July 7, 2024. The administrator reading the progress notes, and stated that he agrees it's an abuse, 100 percent to be reported, and it was not reported to state agency and he was not aware of this. A review of facility's policy titled, Resident rights/Dignity: abuse, Neglect, Exploitation and Misappropriation Prevention program, in effect January 1, 2024 revealed residents have the right to be free from abuse, (2) develop and implement policies and protocols to prevent and identify (a.) abuse and mistreatment of residents; (8) identify and investigate all possible incidents of abuse of resident; (9) investigate and report any allegations within timeframes required by federal requirements.

Based on clinical record reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to follow their abuse policy for one resident. (#128) The deficient practice can result in further incidents of abuse. Findings include: -Resident #128 was admitted at the facility on December 4, 2023 with diagnoses that included dementia, chronic obstructive pulmonary disease, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated on June 11, 2024 revealed the resident had a BIMS score of 4.0, which indicated severe cognitive impairment. Review of care plan initially dated on February 26, 2024 and revised on August 1, 2024 revealed that resident #128 use antidepressant medication. The interventions included to monitor/document/report to provider as needed ongoing signs and symptoms of depression which included fear of being alone with others, attention seeking, concern with body functions, anxiety, and constant reassurance. -Resident #66 (alleged perpetrator) was admitted at the facility on March 28, 2024 with diagnoses that included unspecified dementia, type 2 diabetes mellitus, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. The MDS also included that the resident mood includes feeling down, depressed, or hopeless, rarely feel lonely or isolated, and has verbal behavioral symptoms directed towards others. For every day activities, no impairment on the upper and lower extremities, uses a walker and wheelchair. Review of care plan initially dated on April 10, 2024 and revised on July 8, 2024 revealed that resident #66 has a verbal behavior problem, inappropriate sexual behaviors towards staff and residents, and exhibits personal sexual needs in his room. The interventions included anticipate and meet resident's needs, encourage as much participation/interaction as possible during care activities, identify behavior triggers, and refer to psychiatric provider for consultation as ordered. A behavior progress note dated on July 7, 2024 revealed a resident identified as resident #128 yelling quit touching me get your hands off of me. A staff saw resident #66 reaching for resident #128 and resident #66 was looking like he was going to expose himself to resident #128. Furthermore, the progress note revealed that resident #66 is constantly going after our women here and scaring them. Furthermore, the progress note stated spends too much of my time keeping him from sexually harassing them by touching and groping their breasts against their wills. I just saw him going down the hall with his penis hanging out and then realized that he had it hanging out and touching his penis with one hand and trying to grope a Resident with his other hand. A health status note dated July 7, 2024 revealed the administrator was notified of resident #66's behavior. A behavior progress note dated July 8, 2024 revealed resident #66 was immediately removed from resident #128's location and administrative staff aware of behaviors. A health status progress note dated July 9, 2024 revealed a room changed for resident #66. A psych follow-up progress note dated on July 10, 2024 revealed provider aware of resident #66 on change on condition monitoring for having a recent room change and resident #66 continuous to go into female rooms to try to touch them. A behavior progress note dated August 26, 2024 revealed resident #66 has been touching other females' residents on their private areas. The resident has been told multiple times to stop, but he would say I won't stop. The resident has been reported and the CNA's keeping a watch on him. Will continue to monitor. A behavior progress note dated August 28, 2024 revealed resident #66 grabbed another Resident's bottom and tried lifting her shirt. The female Resident swatted this Resident's hand away and said, No!. An interview was conducted on November 7, 2024 at 07:22 a.m. with licensed practical nurse (LPN/Staff #88). Staff #88 stated that she recalls resident #66 who is very angry, sexually heightened, no impulse control. Resident #66 would grab resident's breasts, they moved him to the locked unit about 6 months ago. He scared the female residents. Staff #88 stated that she can recall two female residents that resident #66 targeted specifically in the locked unit. Staff #88 do not wish to share their names. Staff #88 stated that she had witnessed resident #66 touched female residents inappropriately and they have separated the residents and kept resident #66 away from the female resident. Staff #88 stated that she had notified her unit manager, the director of nursing, and their executive director. An interview was conducted on November 7, 2024 at 07:43 a.m. with a certified nursing assistant (CNA/Staff #222). Staff #222 stated that she is familiar with the locked unit for residents with dementia. They observe residents and when residents argue they intervene by calming them down, separate them, and notify the nurse. As far as her training, she took acknowledgment test every month for dementia care and also, she went through abuse training. An interview was conducted on November 7, 2024 at 08:07 a.m. with a CNA (CNA/Staff #43). Staff #43 stated that his role includes scheduling CNAs and nurses. The CNAs schedule is based on their staff preference and skills and their shifts is 12-hour shift from 6 to 6. They also have a medication tech. An interview was conducted on November 7, 2024 at 08:16 a.m. with a certified medical assistant (CMA/staff #61). Staff #61 identified resident #66 to this surveyor. Staff #61 stated that with resident #66, the resident does not keep still, wheels self in the hallway and in the dining room in the locked unit. Staff #61 stated that they do their best for caring their residents with dementia and when their residents become combative and in the dining room, they try to remove them in the dining room and take them to their room to their calm place. They distract them by for instance offering water. Furthermore, Staff #61 stated that resident #66 wheels himself back and forth, crashing into people and stuff, resident will run his wheelchair into them not intentionally, resident is very inappropriate to other female resident and all healthcare staff. For instance, such as with another resident, resident #66 went up to her and touch her breast and it happened about 1 -2 months ago. Resident#66 still does that. Also, when resident #66 was in the long-term care side, resident #66 went up and touch other resident's breast and verbally said inappropriate things to them and asking sexual favors. The residents over at the long-term side will tell the staff members because they are with it to say something. Staff #61 added that there was one instance that happened in the summer. Staff #61 stated that with Resident #66 when he first came in the facility was going to people's room and wandering. Resident #66 touched other female butt while walking with her walker, it happened like about 1-2 months ago, He also say things to few ladies, like the famous one is you can touch me like anywhere you want, and bribing them by holding a napkin to bribe and to see their breast. Staff #61 stated that she has reported the incident to registered nurse (RN)Staff #55, LPN/Staff #88 and the director of nursing (DON), they are aware. Staff #61 stated that their schedule sometime include one CNA in the unit and it is hard to constantly watch resident #66 and their nurse is out there in the opposite of their unit, pass the double doors. An interview was conducted on November 7, 2024 at 10:50 a.m. with a RN/Staff #55. Staff #55 stated that resident #66 has implosive behavior touching other people and grabbing other people and the last time this behavior happened was in the summer. Staff #55 stated that the process for reporting incident is to let his supervisor and executive director know. An interview was conducted on November 7, 2024 at 01:58 p.m. with the Director of Nursing, (DON/Staff #103). The DON stated that she oversees residents' care and staffing to make sure it staffed properly. They make sure they are providing care and following policies and regulation. Regarding abuse it can be physical, financial, misappropriation of funds and neglect, and include sexual abuse. The process for any suspected abuse is to report to their abuse officer immediately, report to state immediately, if resident to resident make sure resident is safe and then report immediately. The DON stated that regarding resident #66, resident was admitted for skilled for fracture was in skilled unit then went to long-term in April and moved to another unit, resident has dementia then resident was moved in the locked unit in July because of exit seeking, has occasional behavior issue and they try to redirect as much as possible. Resident behavior issues exhibited such as displayed sexual behaviors to staff, mostly to the CNAs by grabbing their butt and breast. The DON recalled an incident who they did self -report where he grabbed a resident's breast. DON stated she does not know any other incident about inappropriate behavior towards other residents. DON stated that music therapy helped resident #66 like playing country music in his room, and more activities. The DON stated that for staff reporting abuse, their training is upon hire and as needed. She added that any abnormal behavior of resident, any change should be reported to the DON. The surveyor informed the DON of resident #66's behavior in his July's progress notes. DON is looking in Point Click Care (PCC) for resident #66 progress notes. DON stated that she is not aware of the July event. DON stated that she definitely needs to look into regarding the July incident with resident #128 and she would get with the administrator to review any documentation on this. DON stated intervention regarding resident #66 included a referral in show low and he was not accepted, resident has been seen by telepsych since May 2024. DON stated that he was started on Paroxetine in August. An interview was conducted on November 8, 2024 at 8:07 a.m. with a CMA. (CMA/Staff #74). Staff #74 stated that in the locked unit, they have 15-16 residents, and for staffing they have one CNA and one CMA and their nurse is in the skilled unit, or they have two CNAs and a nurse in the skilled unit, and today there is one CMA and one CNA. Staff #74 stated that regarding resident care plan, they check each resident's Kardex, it can be found in PCC in point of care (POC). In regards to training and in-services, they have in-services every month and have educational videos. The in-services every month tell them how to distract resident to switch their attention to an activity or how to deal with their behaviors. They use distraction when they are upset to get their mind or attention on something else. Regarding resident #66, Staff #74 stated that resident #66 needs help with activities of daily living (ADLs), activities, and rolls around, sometimes he does not have good behavior, he is not physical but can be nasty with the women with staff and residents, nasty as in he will just say can I see your boobs provocatively, intervention use is he will usually move him or tell him not to say those things, he has not seen any inappropriate touching by resident #66. Staff #74 stated that his role is make sure everyone is safe first then remove the person from situation and grab his radio and call for help. He will call the DON and the administrator to report incident such as physical and emotional abuse. An interview was conducted on November 8, 2024 at 10:12 a.m. with a resident representative (rep/Staff #113). Staff #113 stated that her role is she advocate for resident, help with non-clinical grievances such as with insurance, medical equipment, discharge planning. As a discharge planner she figures out their prior living, if need assistance, if live alone, and then come up with a goal and during their stay to make sure goal is still feasible if not have an alternate plan, referrals for home health and transfer to different facilities if needed. Regarding resident #66, she help locate his family out of state, she has sent referrals out of state in September 2024, and waiting to hear from them, and she made referral to a facility in July. Resident #66 has behaviors and she sent referrals to another facility in May 2024 and was denied. The denial reason was resident did not meet requirement. For the other facility referral , no bed was available. She stated that the behaviors such as sexual behaviors are inappropriate comment mostly to staff and to one resident incident which was reported to the state and that was grabbing resident's chest. She stated that the behavior seems to get better since he was moved to the locked unit which seems to help. Staff #113 recalled an incident that Resident #66 made a comment in September towards a female resident, the comment was show me your panties and he was talked to regarding that comment that was not appropriate, staff #113 saw this incident documented in the progress note by the DON. An interview was conducted on November 8, 2024 at 10:39 a.m. with the Administrator (admin/Staff #106). Present during the interview was a clinical Resource (Admin/Staff #225) and the DON. The administrator stated that regarding their abuse process, to report to the administrator as their abuse prevention coordinator and if not available to the DON. He stated that there are signs posted up in the building regarding abuse reporting. The administrator stated that they investigate the concern and determine if reportable or not, and a reportable abuse is physical abuse, sexual abuse, and neglect. The administrator stated that regarding sexual abuse, it is improper touching, not consenting to someone else or even uncomfortable situation like sexual advances. The administrator was prompted to review the progress note of resident #66/resident #128 in July 7, 2024. The administrator reading the progress notes, and stated that he agrees it's an abuse, 100 percent to be reported, and it was not reported to state agency and he was not aware of this. A review of facility's policy titled, Resident rights/Dignity: abuse, Neglect, Exploitation and Misappropriation Prevention program, in effect January 1, 2024 revealed residents have the right to be free from abuse, (2) develop and implement policies and protocols to prevent and identify (a.) abuse and mistreatment of residents; (8) identify and investigate all possible incidents of abuse of resident; (9) investigate and report any allegations within timeframes required by federal requirements.

Based on clinical record reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to ensure an incident of abuse was reported to the state agency. This deficient practice can result in further incidents of abuse not being reported in accordance with professional standards. Findings include: -Resident #128 was admitted at the facility on December 4, 2023 with diagnoses that included dementia, chronic obstructive pulmonary disease, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated on June 11, 2024 revealed the resident had a BIMS score of 4.0, which indicated severe cognitive impairment. Review of care plan initially dated on February 26, 2024 and revised on August 1, 2024 revealed that resident #128 use antidepressant medication. The interventions included to monitor/document/report to provider as needed ongoing signs and symptoms of depression which included fear of being alone with others, attention seeking, concern with body functions, anxiety, and constant reassurance. -Resident #66 (alleged perpetrator) was admitted at the facility on March 28, 2024 with diagnoses that included unspecified dementia, type 2 diabetes mellitus, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. The MDS also included that the resident mood includes feeling down, depressed, or hopeless, rarely feel lonely or isolated, and has verbal behavioral symptoms directed towards others. For every day activities, no impairment on the upper and lower extremities, uses a walker and wheelchair. Review of care plan initially dated on April 10, 2024 and revised on July 8, 2024 revealed that resident #66 has a verbal behavior problem, inappropriate sexual behaviors towards staff and residents, and exhibits personal sexual needs in his room. The interventions included anticipate and meet resident's needs, encourage as much participation/interaction as possible during care activities, identify behavior triggers, and refer to psychiatric provider for consultation as ordered. A behavior progress note dated on July 7, 2024 revealed a resident identified as resident #128 yelling quit touching me get your hands off of me. A staff saw resident #66 reaching for resident #128 and resident #66 was looking like he was going to expose himself to resident #128. Furthermore, the progress note revealed that resident #66 is constantly going after our women here and scaring them. Furthermore, the progress note stated spends too much of my time keeping him from sexually harassing them by touching and groping their breasts against their wills. I just saw him going down the hall with his penis hanging out and then realized that he had it hanging out and touching his penis with one hand and trying to grope a Resident with his other hand. A health status note dated July 7, 2024 revealed the administrator was notified of resident #66's behavior. A behavior progress note dated July 8, 2024 revealed resident #66 was immediately removed from resident #128's location and administrative staff aware of behaviors. A health status progress note dated July 9, 2024 revealed a room changed for resident #66. A psych follow-up progress note dated on July 10, 2024 revealed provider aware of resident #66 on change on condition monitoring for having a recent room change and resident #66 continuous to go into female rooms to try to touch them. A behavior progress note dated August 26, 2024 revealed resident #66 has been touching other females' residents on their private areas. The resident has been told multiple times to stop, but he would say I won't stop. The resident has been reported and the CNA's keeping a watch on him. Will continue to monitor. A behavior progress note dated August 28, 2024 revealed resident #66 grabbed another Resident's bottom and tried lifting her shirt. The female Resident swatted this Resident's hand away and said, No!. An interview was conducted on November 7, 2024 at 07:22 a.m. with licensed practical nurse (LPN/Staff #88). Staff #88 stated that she recalls resident #66 who is very angry, sexually heightened, no impulse control. Resident #66 would grab resident's breasts, they moved him to the locked unit about 6 months ago. He scared the female residents. Staff #88 stated that she can recall two female residents that resident #66 targeted specifically in the locked unit. Staff #88 do not wish to share their names. Staff #88 stated that she had witnessed resident #66 touched female residents inappropriately and they have separated the residents and kept resident #66 away from the female resident. Staff #88 stated that she had notified her unit manager, the director of nursing, and their executive director. An interview was conducted on November 7, 2024 at 07:43 a.m. with a certified nursing assistant (CNA/Staff #222). Staff #222 stated that she is familiar with the locked unit for residents with dementia. They observe residents and when residents argue they intervene by calming them down, separate them, and notify the nurse. As far as her training, she took acknowledgment test every month for dementia care and also, she went through abuse training. An interview was conducted on November 7, 2024 at 08:07 a.m. with a CNA (CNA/Staff #43). Staff #43 stated that his role includes scheduling CNAs and nurses. The CNAs schedule is based on their staff preference and skills and their shifts is 12-hour shift from 6 to 6. They also have a medication tech. An interview was conducted on November 7, 2024 at 08:16 a.m. with a certified medical assistant (CMA/staff #61). Staff #61 identified resident #66 to this surveyor. Staff #61 stated that with resident #66, the resident does not keep still, wheels self in the hallway and in the dining room in the locked unit. Staff #61 stated that they do their best for caring their residents with dementia and when their residents become combative and in the dining room, they try to remove them in the dining room and take them to their room to their calm place. They distract them by for instance offering water. Furthermore, Staff #61 stated that resident #66 wheels himself back and forth, crashing into people and stuff, resident will run his wheelchair into them not intentionally, resident is very inappropriate to other female resident and all healthcare staff. For instance, such as with another resident, resident #66 went up to her and touch her breast and it happened about 1 -2 months ago. Resident#66 still does that. Also, when resident #66 was in the long-term care side, resident #66 went up and touch other resident's breast and verbally said inappropriate things to them and asking sexual favors. The residents over at the long-term side will tell the staff members because they are with it to say something. Staff #61 added that there was one instance that happened in the summer. Staff #61 stated that with Resident #66 when he first came in the facility was going to people's room and wandering. Resident #66 touched other female butt while walking with her walker, it happened like about 1-2 months ago, He also say things to few ladies, like the famous one is you can touch me like anywhere you want, and bribing them by holding a napkin to bribe and to see their breast. Staff #61 stated that she has reported the incident to registered nurse (RN)Staff #55, LPN/Staff #88 and the director of nursing (DON), they are aware. Staff #61 stated that their schedule sometime include one CNA in the unit and it is hard to constantly watch resident #66 and their nurse is out there in the opposite of their unit, pass the double doors. An interview was conducted on November 7, 2024 at 10:50 a.m. with a RN/Staff #55. Staff #55 stated that resident #66 has implosive behavior touching other people and grabbing other people and the last time this behavior happened was in the summer. Staff #55 stated that the process for reporting incident is to let his supervisor and executive director know. An interview was conducted on November 7, 2024 at 01:58 p.m. with the Director of Nursing, (DON/Staff #103). The DON stated that she oversees residents' care and staffing to make sure it staffed properly. They make sure they are providing care and following policies and regulation. Regarding abuse it can be physical, financial, misappropriation of funds and neglect, and include sexual abuse. The process for any suspected abuse is to report to their abuse officer immediately, report to state immediately, if resident to resident make sure resident is safe and then report immediately. The DON stated that regarding resident #66, resident was admitted for skilled for fracture was in skilled unit then went to long-term in April and moved to another unit, resident has dementia then resident was moved in the locked unit in July because of exit seeking, has occasional behavior issue and they try to redirect as much as possible. Resident behavior issues exhibited such as displayed sexual behaviors to staff, mostly to the CNAs by grabbing their butt and breast. The DON recalled an incident who they did self -report where he grabbed a resident's breast. DON stated she does not know any other incident about inappropriate behavior towards other residents. DON stated that music therapy helped resident #66 like playing country music in his room, and more activities. The DON stated that for staff reporting abuse, their training is upon hire and as needed. She added that any abnormal behavior of resident, any change should be reported to the DON. The surveyor informed the DON of resident #66's behavior in his July's progress notes. DON is looking in Point Click Care (PCC) for resident #66 progress notes. DON stated that she is not aware of the July event. DON stated that she definitely needs to look into regarding the July incident with resident #128 and she would get with the administrator to review any documentation on this. DON stated intervention regarding resident #66 included a referral in show low and he was not accepted, resident has been seen by telepsych since May 2024. DON stated that he was started on Paroxetine in August. An interview was conducted on November 8, 2024 at 8:07 a.m. with a CMA. (CMA/Staff #74). Staff #74 stated that in the locked unit, they have 15-16 residents, and for staffing they have one CNA and one CMA and their nurse is in the skilled unit, or they have two CNAs and a nurse in the skilled unit, and today there is one CMA and one CNA. Staff #74 stated that regarding resident care plan, they check each resident's Kardex, it can be found in PCC in point of care (POC). In regards to training and in-services, they have in-services every month and have educational videos. The in-services every month tell them how to distract resident to switch their attention to an activity or how to deal with their behaviors. They use distraction when they are upset to get their mind or attention on something else. Regarding resident #66, Staff #74 stated that resident #66 needs help with activities of daily living (ADLs), activities, and rolls around, sometimes he does not have good behavior, he is not physical but can be nasty with the women with staff and residents, nasty as in he will just say can I see your boobs provocatively, intervention use is he will usually move him or tell him not to say those things, he has not seen any inappropriate touching by resident #66. Staff #74 stated that his role is make sure everyone is safe first then remove the person from situation and grab his radio and call for help. He will call the DON and the administrator to report incident such as physical and emotional abuse. An interview was conducted on November 8, 2024 at 10:12 a.m. with a resident representative (rep/Staff #113). Staff #113 stated that her role is she advocate for resident, help with non-clinical grievances such as with insurance, medical equipment, discharge planning. As a discharge planner she figures out their prior living, if need assistance, if live alone, and then come up with a goal and during their stay to make sure goal is still feasible if not have an alternate plan, referrals for home health and transfer to different facilities if needed. Regarding resident #66, she help locate his family out of state, she has sent referrals out of state in September 2024, and waiting to hear from them, and she made referral to a facility in July. Resident #66 has behaviors and she sent referrals to another facility in May 2024 and was denied. The denial reason was resident did not meet requirement. For the other facility referral , no bed was available. She stated that the behaviors such as sexual behaviors are inappropriate comment mostly to staff and to one resident incident which was reported to the state and that was grabbing resident's chest. She stated that the behavior seems to get better since he was moved to the locked unit which seems to help. Staff #113 recalled an incident that Resident #66 made a comment in September towards a female resident, the comment was show me your panties and he was talked to regarding that comment that was not appropriate, staff #113 saw this incident documented in the progress note by the DON. An interview was conducted on November 8, 2024 at 10:39 a.m. with the Administrator (admin/Staff #106). Present during the interview was a clinical Resource (Admin/Staff #225) and the DON. The administrator stated that regarding their abuse process, to report to the administrator as their abuse prevention coordinator and if not available to the DON. He stated that there are signs posted up in the building regarding abuse reporting. The administrator stated that they investigate the concern and determine if reportable or not, and a reportable abuse is physical abuse, sexual abuse, and neglect. The administrator stated that regarding sexual abuse, it is improper touching, not consenting to someone else or even uncomfortable situation like sexual advances. The administrator was prompted to review the progress note of resident #66/resident #128 in July 7, 2024. The administrator reading the progress notes, and stated that he agrees it's an abuse, 100 percent to be reported, and it was not reported to state agency and he was not aware of this. A review of facility's policy titled, Resident rights/Dignity: abuse, Neglect, Exploitation and Misappropriation Prevention program, in effect January 1, 2024 revealed residents have the right to be free from abuse, (2) develop and implement policies and protocols to prevent and identify (a.) abuse and mistreatment of residents; (8) identify and investigate all possible incidents of abuse of resident; (9) investigate and report any allegations within timeframes required by federal requirements.

Based on clinical record reviews, staff and resident interviews, facility documentation and policy and procedures, the facility failed to investigate an allegation of abuse. This deficient practice could result in further incidents of resident abuse. Findings include: -Resident #128 was admitted at the facility on December 4, 2023 with diagnoses that included dementia, chronic obstructive pulmonary disease, and depression. Review of the quarterly Minimum Data Set (MDS) assessment dated on June 11, 2024 revealed the resident had a BIMS score of 4.0, which indicated severe cognitive impairment. Review of care plan initially dated on February 26, 2024 and revised on August 1, 2024 revealed that resident #128 use antidepressant medication. The interventions included to monitor/document/report to provider as needed ongoing signs and symptoms of depression which included fear of being alone with others, attention seeking, concern with body functions, anxiety, and constant reassurance. -Resident #66 (alleged perpetrator) was admitted at the facility on March 28, 2024 with diagnoses that included unspecified dementia, type 2 diabetes mellitus, and depression. Review of the admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 6, which indicated severe cognitive impairment. The MDS also included that the resident mood includes feeling down, depressed, or hopeless, rarely feel lonely or isolated, and has verbal behavioral symptoms directed towards others. For every day activities, no impairment on the upper and lower extremities, uses a walker and wheelchair. Review of care plan initially dated on April 10, 2024 and revised on July 8, 2024 revealed that resident #66 has a verbal behavior problem, inappropriate sexual behaviors towards staff and residents, and exhibits personal sexual needs in his room. The interventions included anticipate and meet resident's needs, encourage as much participation/interaction as possible during care activities, identify behavior triggers, and refer to psychiatric provider for consultation as ordered. A behavior progress note dated on July 7, 2024 revealed a resident identified as resident #128 yelling quit touching me get your hands off of me. A staff saw resident #66 reaching for resident #128 and resident #66 was looking like he was going to expose himself to resident #128. Furthermore, the progress note revealed that resident #66 is constantly going after our women here and scaring them. Furthermore, the progress note stated spends too much of my time keeping him from sexually harassing them by touching and groping their breasts against their wills. I just saw him going down the hall with his penis hanging out and then realized that he had it hanging out and touching his penis with one hand and trying to grope a Resident with his other hand. A health status note dated July 7, 2024 revealed the administrator was notified of resident #66's behavior. A behavior progress note dated July 8, 2024 revealed resident #66 was immediately removed from resident #128's location and administrative staff aware of behaviors. A health status progress note dated July 9, 2024 revealed a room changed for resident #66. A psych follow-up progress note dated on July 10, 2024 revealed provider aware of resident #66 on change on condition monitoring for having a recent room change and resident #66 continuous to go into female rooms to try to touch them. A behavior progress note dated August 26, 2024 revealed resident #66 has been touching other females' residents on their private areas. The resident has been told multiple times to stop, but he would say I won't stop. The resident has been reported and the CNA's keeping a watch on him. Will continue to monitor. A behavior progress note dated August 28, 2024 revealed resident #66 grabbed another Resident's bottom and tried lifting her shirt. The female Resident swatted this Resident's hand away and said, No!. An interview was conducted on November 7, 2024 at 07:22 a.m. with licensed practical nurse (LPN/Staff #88). Staff #88 stated that she recalls resident #66 who is very angry, sexually heightened, no impulse control. Resident #66 would grab resident's breasts, they moved him to the locked unit about 6 months ago. He scared the female residents. Staff #88 stated that she can recall two female residents that resident #66 targeted specifically in the locked unit. Staff #88 do not wish to share their names. Staff #88 stated that she had witnessed resident #66 touched female residents inappropriately and they have separated the residents and kept resident #66 away from the female resident. Staff #88 stated that she had notified her unit manager, the director of nursing, and their executive director. An interview was conducted on November 7, 2024 at 07:43 a.m. with a certified nursing assistant (CNA/Staff #222). Staff #222 stated that she is familiar with the locked unit for residents with dementia. They observe residents and when residents argue they intervene by calming them down, separate them, and notify the nurse. As far as her training, she took acknowledgment test every month for dementia care and also, she went through abuse training. An interview was conducted on November 7, 2024 at 08:07 a.m. with a CNA (CNA/Staff #43). Staff #43 stated that his role includes scheduling CNAs and nurses. The CNAs schedule is based on their staff preference and skills and their shifts is 12-hour shift from 6 to 6. They also have a medication tech. An interview was conducted on November 7, 2024 at 08:16 a.m. with a certified medical assistant (CMA/staff #61). Staff #61 identified resident #66 to this surveyor. Staff #61 stated that with resident #66, the resident does not keep still, wheels self in the hallway and in the dining room in the locked unit. Staff #61 stated that they do their best for caring their residents with dementia and when their residents become combative and in the dining room, they try to remove them in the dining room and take them to their room to their calm place. They distract them by for instance offering water. Furthermore, Staff #61 stated that resident #66 wheels himself back and forth, crashing into people and stuff, resident will run his wheelchair into them not intentionally, resident is very inappropriate to other female resident and all healthcare staff. For instance, such as with another resident, resident #66 went up to her and touch her breast and it happened about 1 -2 months ago. Resident#66 still does that. Also, when resident #66 was in the long-term care side, resident #66 went up and touch other resident's breast and verbally said inappropriate things to them and asking sexual favors. The residents over at the long-term side will tell the staff members because they are with it to say something. Staff #61 added that there was one instance that happened in the summer. Staff #61 stated that with Resident #66 when he first came in the facility was going to people's room and wandering. Resident #66 touched other female butt while walking with her walker, it happened like about 1-2 months ago, He also say things to few ladies, like the famous one is you can touch me like anywhere you want, and bribing them by holding a napkin to bribe and to see their breast. Staff #61 stated that she has reported the incident to registered nurse (RN)Staff #55, LPN/Staff #88 and the director of nursing (DON), they are aware. Staff #61 stated that their schedule sometime include one CNA in the unit and it is hard to constantly watch resident #66 and their nurse is out there in the opposite of their unit, pass the double doors. An interview was conducted on November 7, 2024 at 10:50 a.m. with a RN/Staff #55. Staff #55 stated that resident #66 has implosive behavior touching other people and grabbing other people and the last time this behavior happened was in the summer. Staff #55 stated that the process for reporting incident is to let his supervisor and executive director know. An interview was conducted on November 7, 2024 at 01:58 p.m. with the Director of Nursing, (DON/Staff #103). The DON stated that she oversees residents' care and staffing to make sure it staffed properly. They make sure they are providing care and following policies and regulation. Regarding abuse it can be physical, financial, misappropriation of funds and neglect, and include sexual abuse. The process for any suspected abuse is to report to their abuse officer immediately, report to state immediately, if resident to resident make sure resident is safe and then report immediately. The DON stated that regarding resident #66, resident was admitted for skilled for fracture was in skilled unit then went to long-term in April and moved to another unit, resident has dementia then resident was moved in the locked unit in July because of exit seeking, has occasional behavior issue and they try to redirect as much as possible. Resident behavior issues exhibited such as displayed sexual behaviors to staff, mostly to the CNAs by grabbing their butt and breast. The DON recalled an incident who they did self -report where he grabbed a resident's breast. DON stated she does not know any other incident about inappropriate behavior towards other residents. DON stated that music therapy helped resident #66 like playing country music in his room, and more activities. The DON stated that for staff reporting abuse, their training is upon hire and as needed. She added that any abnormal behavior of resident, any change should be reported to the DON. The surveyor informed the DON of resident #66's behavior in his July's progress notes. DON is looking in Point Click Care (PCC) for resident #66 progress notes. DON stated that she is not aware of the July event. DON stated that she definitely needs to look into regarding the July incident with resident #128 and she would get with the administrator to review any documentation on this. DON stated intervention regarding resident #66 included a referral in show low and he was not accepted, resident has been seen by telepsych since May 2024. DON stated that he was started on Paroxetine in August. An interview was conducted on November 8, 2024 at 8:07 a.m. with a CMA. (CMA/Staff #74). Staff #74 stated that in the locked unit, they have 15-16 residents, and for staffing they have one CNA and one CMA and their nurse is in the skilled unit, or they have two CNAs and a nurse in the skilled unit, and today there is one CMA and one CNA. Staff #74 stated that regarding resident care plan, they check each resident's Kardex, it can be found in PCC in point of care (POC). In regards to training and in-services, they have in-services every month and have educational videos. The in-services every month tell them how to distract resident to switch their attention to an activity or how to deal with their behaviors. They use distraction when they are upset to get their mind or attention on something else. Regarding resident #66, Staff #74 stated that resident #66 needs help with activities of daily living (ADLs), activities, and rolls around, sometimes he does not have good behavior, he is not physical but can be nasty with the women with staff and residents, nasty as in he will just say can I see your boobs provocatively, intervention use is he will usually move him or tell him not to say those things, he has not seen any inappropriate touching by resident #66. Staff #74 stated that his role is make sure everyone is safe first then remove the person from situation and grab his radio and call for help. He will call the DON and the administrator to report incident such as physical and emotional abuse. An interview was conducted on November 8, 2024 at 10:12 a.m. with a resident representative (rep/Staff #113). Staff #113 stated that her role is she advocate for resident, help with non-clinical grievances such as with insurance, medical equipment, discharge planning. As a discharge planner she figures out their prior living, if need assistance, if live alone, and then come up with a goal and during their stay to make sure goal is still feasible if not have an alternate plan, referrals for home health and transfer to different facilities if needed. Regarding resident #66, she help locate his family out of state, she has sent referrals out of state in September 2024, and waiting to hear from them, and she made referral to a facility in July. Resident #66 has behaviors and she sent referrals to another facility in May 2024 and was denied. The denial reason was resident did not meet requirement. For the other facility referral , no bed was available. She stated that the behaviors such as sexual behaviors are inappropriate comment mostly to staff and to one resident incident which was reported to the state and that was grabbing resident's chest. She stated that the behavior seems to get better since he was moved to the locked unit which seems to help. Staff #113 recalled an incident that Resident #66 made a comment in September towards a female resident, the comment was show me your panties and he was talked to regarding that comment that was not appropriate, staff #113 saw this incident documented in the progress note by the DON. An interview was conducted on November 8, 2024 at 10:39 a.m. with the Administrator (admin/Staff #106). Present during the interview was a clinical Resource (Admin/Staff #225) and the DON. The administrator stated that regarding their abuse process, to report to the administrator as their abuse prevention coordinator and if not available to the DON. He stated that there are signs posted up in the building regarding abuse reporting. The administrator stated that they investigate the concern and determine if reportable or not, and a reportable abuse is physical abuse, sexual abuse, and neglect. The administrator stated that regarding sexual abuse, it is improper touching, not consenting to someone else or even uncomfortable situation like sexual advances. The administrator was prompted to review the progress note of resident #66/resident #128 in July 7, 2024. The administrator reading the progress notes, and stated that he agrees it's an abuse, 100 percent to be reported, and it was not reported to state agency and he was not aware of this. A review of facility's policy titled, Resident rights/Dignity: abuse, Neglect, Exploitation and Misappropriation Prevention program, in effect January 1, 2024 revealed residents have the right to be free from abuse, (2) develop and implement policies and protocols to prevent and identify (a.) abuse and mistreatment of residents; (8) identify and investigate all possible incidents of abuse of resident; (9) investigate and report any allegations within timeframes required by federal requirements.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure that necessary pain medications were given according to provider instruction for one resident (resident's #18) This deficient practice could result in ineffective medication management resulting in negative outcomes. findings include: -Resident #18 was admitted on [DATE], with diagnoses that included surgical aftercare, surgery on the circulatory system, end stage renal disease, and sepsis. A physician's order dated October 3, 2024, revealed an order for Tramadol 50mg (milligrams) by mouth every 12 hours as needed for a pain scale of 6-10. An admission Minimum Data Set (MDS) assessment dated [DATE], revealed the resident had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident had no cognitive impairment. A care plan intervention with the initiated date of October 16, 2024, revealed that Resident #18 is at risk for pain and utilizes opioid medications per physician orders. Review of the Medication Administration Record (MAR) dated November 2024, revealed on November 3, 2024, Resident #18 was administered one tablet of Tramadol 50mg for a pain level of '4' at 3:50 a.m, and for a pain level of '4' at 7:06 p.m. An interview was conducted September 13, 2024 at 10:30 a.m. with a Registered Nurse (RN/Staff #55) to review Resident #18's physician orders and MAR. Staff #55 stated that the order of the Tramadol 50mg was given out of parameters on November 3, at 3:50 a.m. and 7:06 p.m. Staff #55 also stated that administering medications out of order parameters is not in professional standards as Resident #55 could have been offered an alternative medication or non-medicated intervention for the pain level of 4, rather than the Tramadol 50mg. An interview was conducted on November 6, 2024 at 2:43 p.m. with Director of Nursing (DON/Staff #48), where Staff #48 stated that the facility's expectation is medications are to be administered per physician orders, and that providing medication that is not within order parameters is not professional standards and does not properly treat the resident. The policy Administering Medications revealed that the administration of medications must be administered in accordance with the resident's order. 51103 Based on clinical record review, interviews, and review of facility policies and procedures, the facility failed to ensure necessary blood pressure medications were administered according to provider instruction for one resident. (#14) This deficient practice could result in side effects leading to negative resident outcomes. Findings Include: -Resident #14 was admitted to the facility on [DATE], with diagnoses that include hypotension, edema, bipolar disorder, and rheumatoid arthritis. The admission Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, which indicated resident was cognitively intact. A physician order dated August 7, 2024 revealed Midodrine 5mg (milligrams) to be given three times a day for hypotension (low blood pressure) unless the systolic blood pressure is greater than 130. Review of the Medication Administration Record (MAR) for October 2024 through November 2024 revealed multiple dates ([DATE], 5, 19, 25, 26, 28, [DATE], and 7) where Midodrine was administered with a systolic blood pressure greater than 130. An interview was conducted with a Pharmacist (Staff #125) on November 7, 2024 at 1:50 p.m. The pharmacist stated that the physician's orders should be followed unless otherwise ordered. Staff #125 further elaborated that sometimes there may be reasons why medications may be given out of parameters but it would still need to be justified and cleared with the physician. An interview was conducted with a Unit Manager (admin/Staff #26) and the Director of Nursing (DON/Staff #103) November 7, 2024 at 3:00 p.m. They both accessed the clinical record with this surveyor and reviewed the clinical documentation for Resident #14's Midodrine administrations. Both were able to identify episodes when midodrine was given outside of parameters and stated that the medication should have only been given within parameters, unless cleared by the provider. Both also agreed that this medication can cause the blood pressure to continue to rise which can also be problematic if it becomes too high. An interview with Licensed Practical Nurse (LPN/Staff #79) was conducted on November 8, 2024 at 10:57 a.m. The LPN stated that she will always check the blood pressure before giving the medication because it is part of the facility standards to follow physician orders. She further stated if she was to get the same blood pressure result three different times throughout the day she would reassess the resident and do interventions such as changing arms or changing the blood pressure cuff. She also stated the importance of giving midodrine within parameters because otherwise the resident can suffer consequences of hypertension. A policy titled Resident Examination and Assessment advises that the physician should be notified of any abnormal vital signs, and that vital signs for each resident should be obtained in accordance with the standard of care required, and based on the individual resident's condition. A policy titled Medication Administration advises that if the dosage is believed to be inappropriate or excessive, the administering person will contact the prescriber or the facility medical director to discuss the concerns.

Based on observations, clinical record reviews, interviews, and facility documents and policy, the facility failed to ensure one resident (#54), had call light accessibility. The deficient practice could result in residents not having the means to communicate with staff leading to negative outcomes. Findings include: -Resident #54 was admitted to the facility on [DATE], with diagnoses that included left sided paralysis, stroke, Type-2 Diabetes, repeated falls, and depression. The quarterly Minimum Data Set (MDS) dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 10, which indicated the resident had moderate cognitive impairment. The MDS also revealed that the resident experienced social isolation on rare occasion and is prescribed an antidepressant for mood support. A falls care plan initiated November 25, 2022 revealed resident #54 was at risk for falls related to deconditioning, with a noted intervention to assure the bed is against the wall, and the call light is within reach to ensure prompt response to all requests for assistance as needed. On November 6, 2024 at 12:10 p.m. the resident was observed in room sitting alone by bedside in a wheelchair. Upon closer inspection of resident, eyes appeared wet with tears, and resident was visibly shaking. The call light plug was securely inserted into the call light face plate. The call light cord extended straight down the wall, and was sandwiched between the mattress and the wall. The hand control for the call light system was not visible. On November 7, 2024 at 11:38 a.m. this surveyor returned to the resident's room and observed the call light system cord similar to the day prior, which extended down and was sandwiched between the wall and mattress. The call light hand control was not visible. This surveyor left the room with the resident who stated they were on the way to socialize in the hallway. This surveyor returned with a Unit Manager (admin/Staff #26) at 11:42 a.m. This surveyor observed staff #26 go to the head of the bed and follow the call light cord. staff #26 was able to use the cord and pull the call light from between the side of the wall and mattress. The Unit Manager then proceeded to affix the call light to the resident bedside to ensure control was reachable upon the resident return to room. An interview conducted on November 5, 2024 at 3:40 p.m. during initial pool screening with Resident #54. Resident #54 stated she does not have a call light, and needs one because she has already fallen out of bed three times already. She stated she wants the staff to keep her door open so when she falls, she can scream for help when in trouble. An interview conducted on November 7, 2024 at 11:38 a.m., with Resident #54 revealed she still never got a call light button. When surveyor pointed to the call light face plate and cord on the wall, the resident stated I can't get way over there to get that!. an interview was conducted with a unit manager (admin/staff #26) at approximately 11:42 a.m on November 7, 2024. Staff #26 stated that all residents are supposed to have easy access to their call lights. She further clarified that the position of Resident #54's call light was not easily accessible, especially with the resident's functional limitations. Staff #26 stated they will remind staff the importance of making sure call lights are easily accessible to all residents. An interview was conducted on November 7, 2024 at 3:00 p.m. with the unit manager (admin/staff #26) and the Director of nursing (DON/staff #103). During the interview the unit manager and the DON stated that it was important that call lights were within reach of the residents for routine and urgent matters. The policy titled Falls and Fall Risk, Managing, indicated the use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that two residents (#15) and (#50) were free from physical abuse resulting in injury by other residents (resident #50, and resident #75). The deficient practice could result in further incidents of resident to resident abuse. Findings include: Regarding resident #15 and resident #50 -Resident #15 was admitted to the facility on [DATE] with diagnoses that include Hemiplegia, sepsis, urinary tract infections, dysphagia, and hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment September 8, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. A behavioral care plan revised December 6, 2023 revealed the resident was at risk of impaired cognitive function related to dementia with a noted intervention of keeping the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. -Resident #50 was admitted to the facility on [DATE] with diagnoses that include Bipolar disorder, dysphagia, hypertension, depression, and post traumatic stress disorder. Review of the Admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10 which indicated the resident had moderate cognitive impairment. A behavioral care-plan initiated August 31, 2021 revealed the resident has the potential to demonstrate abusive behaviors related to dementia, mental illness, and poor impulse control, with noted interventions for staff to intervene before agitation escalates, and guide away from source of distress. A review of the clinical record progress notes for resident #15 dated October 5, 2024 at 3:53 a.m. revealed the resident was being monitored for a recent one on one incident with another resident, and that the resident #15 was hit in the head with a hairbrush. However, no progress notes detailing the incident in question were noted in resident #15's clinical record. An interview was conducted with resident #15 on October 21, 2024 at 12:55 p.m. The resident stated that resident #50 hit her on her face and pointed to her head. The resident stated there was a little bit of blood after, and that she didn't know what to do. The resident further stated resident #50 had a big bulky brush, an old one, and that was the brush that was used. An interview was conducted with a Certified Nursing Assistant (CNA/staff #5) on October 21, 2024 at 1:01 p.m. The CNA reported that resident #50 has lots of behaviors, and is not really a people person. The CNA stated that resident #50 can be mean to other residents at times and is very bossy. The CNA also stated resident #50 has been physical in the past. The CNA also confirmed the incident happened. An interview with a Registered Nurse (RN/staff #22) was conducted on October 21, 2024 at 1:16 p.m. The RN stated that resident #50 is needy, and doesn't realize she's not the only resident here. The RN stated that when she asked resident #50 why she hit resident #15 with the hair brush, resident #50 didn't want to talk about it. The RN stated resident #50 often gets mad with staff, has verbal outbursts and other behaviors. Regarding resident #50 and resident #75 -Resident #75 was admitted to the facility on [DATE], with diagnoses that include Dementia, heart disease, diabetes mellitus type II, epilepsy, and hypotension. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE]th, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 07 which indicated the resident had significant cognitive impairment. A behavior care-plan initiated April 10, 2024 revealed the resident has a behavior problem related to inappropriate sexual behaviors towards staff and residents, with noted interventions of identifying behavior triggers, and anticipate and meet the resident's needs. Review of information received from the SA complaint tracking system revealed that on May 20, 2024, the facility reported that resident #75 was seen grabbing resident #50's breasts, and that the incident was witnessed by staff. An interview was conducted with resident #50 on October 21, 2024 at 12:42 p.m. The resident stated that in the incident on May 20, 2024 that she was wandering down the hallway when resident #75 touched her. The resident stated she thinks resident #75 did it on purpose. The resident stated it had never happened before and that she did feel abused. An interview was conducted with a Certified Nursing Assistant (CNA/staff #5) on October 21, 2024 at 1:01 p.m. The CNA reported that they have witnessed abuse before, however not recently. The CNA stated that resident #75 has inappropriate behaviors, and that he's touchy feely with other residents. The CNA also stated that he has dementia, and may understand or not. The CNA also stated that he refuses and is resistant to care a lot. An interview with a Certified Nursing Assistant (CNA/staff #45) was conducted on October 21, 2024 at 12:50 p.m. The CNA stated that resident #90 is very spontaneous, and a few times was aggressive like if he wanted to leave, he would get mad. He further stated resident #60 got an abrasion on their face from resident #90, and that resident #90 gave resident #30 a big black eye. The CNA further stated that they try to redirect him if he's getting angry and if it causes yelling try to do a 1:1 for him. An interview with a Registered Nurse (RN/staff #22) was conducted on October 21, 2024 at 1:16 p.m. The RN stated they were aware of incidents involving resident #75. The RN stated that they were made aware of resident #75 inappropriately touching other residents; but had never witnessed it. The RN stated that they feel this wouldn't be an issue if they were not understaffed. An interview with the Director of Nursing (DON/staff #1) was conducted on August 20, 2024 at 1:53 p.m. The DON stated that resident #50 has been aggressive towards staff a few times. The DON confirmed the incident occurred and stated that after the incident with resident #15 they took her hair brush away, and that when she took it away resident #50 swung at her. The DON also stated that resident #75 has been here about a year and displays sexual behaviors, mostly towards staff. The DON stated the incident was witnessed by a CNA. However the DON stated that the incident occurred; that interventions are in place to prevent it from happening again, and that it was kind of an outlier incident. The DON concluded that the administrator is the abuse coordinator, and that her expectation is that staff report and act on abuse immediately. A review of facility policy titled ''Abuse Policy revealed that they strive to prevent the abuse of all residents. They recognize residents with the diagnosis of dementia and other mental illnesses whose behaviors are not always predictable. Further they recognize that due to the proximity of the residents to one another and an individual's freedom of choice, that situations may arise where it is not possible to completely prevent all incidents of abuse.

Based on observations, clinical record review, staff interviews, review of the Centers for Disease Control (CDC) guidelines and policies and procedures, the facility failed to maintain an effective infection control program, by failing to ensure that contact precautions were implemented for one resident (#105), with active Clostridium Difficile (C-diff). As a result, the Condition of Immediate Jeopardy (IJ) was identified. Findings include: On January 25, 2016 at 1:10 p. m., the Condition of Immediate Jeopardy was identified. The Administrator and the Director of Nursing were informed of the facility's failure to implement infection control procedures for one resident (#105), who was on contact precautions for[DIAGNOSES REDACTED]. An observation was conducted of a RN (Registered Nurse), who entered the resident's room, without donning a gown. The Administrator presented a plan of correction on January 25, 2016 at 3:15 p.m. The Administrator was informed that the plan of correction needed to include who would present the inservice education and the time frame for completing the inservice's, who would be responsible for re-stocking the isolation supply cart, and what monitoring processes would be implemented. The Administrator presented a second plan of correction on January 25, 2016 at 3:47 p.m. The Administrator was informed that the plan of correction needed to address all residents on contact precautions, and what monitoring would be implemented to ensure compliance. The Administrator presented a third plan of correction on January 25, 2016 at 4:16 p. m., and the plan of correction was accepted. Multiple observations were conducted on January 25, and 26, 2016, regarding the implementation of the facility's plan of correction. Multiple staff interviews were also conducted regarding their knowledge of infection control procedures, including contact precautions. The Condition of Immediate Jeopardy was abated on January 26, 2016 at 1:15 p.m. Resident #105 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of a laboratory report dated December 24, 2015, regarding a stool sample revealed the resident was positive for[DIAGNOSES REDACTED]. Review of the Physician's Recapitulation Report for January 2016, revealed the resident was receiving [MEDICATION NAME] HCI suspension every 6 hours for [MEDICATION NAME] due to[DIAGNOSES REDACTED]. A review of the clinical record revealed the resident continued to have loose stools and had a loose stool at 3:09 a.m. on January 25, 2016. Physician orders [REDACTED]. During a random observation conducted at 12:35 p.m. on January 25, 2016, a nurse was observed entering the resident's room wearing gloves, but no gown. A sign was observed on the door which read, Isolation Precautions Visitors Please Report To Nurses Station. The nurse was observed handing the resident a medication cup. The nurse then removed her gloves and washed her hands, prior to leaving the room. During this observation, it was also noted that there was an isolation cart outside of the resident's room. However, the cart did not contain any gowns. An interview was conducted with the nurse following the observation. The nurse stated that the resident was on contact precautions for[DIAGNOSES REDACTED]. She stated the precautions were for visitors and staff to wear gown and gloves, when in the room. She also stated that when she entered the room she did not anticipate coming into contact with the resident, therefore she only wore the gloves and had not donned a gown. When asked what the facility's policy was regarding contact precautions related to[DIAGNOSES REDACTED], the nurse stated that she was not sure. During an interview conducted at 12:45 p.m. on January 25, 2016, a certified nursing assistant exiting the resident's room stated that staff and visitors should don a gown and gloves before entering the room. She also stated the reason for the contact precautions was that the resident had[DIAGNOSES REDACTED]. During an interview conducted with the Assistant Director of Nursing (ADON) at 12:50 p.m. on January 25, 2016, the ADON stated that the resident was positive for[DIAGNOSES REDACTED]. She stated that the facility's policy was to retest the resident's stool when the resident has gone 48 hours without a loose stool. The ADON stated that the resident continues to have loose stools. Review of the facility's Infection Control policy for Clostridium Difficile revealed that the facility recognizes[DIAGNOSES REDACTED], due to the potential dangers to the residents and staff. The policy included that the development and teaching of infection control policies and procedures is critical in infection prevention. The policy also included that the facility will utilize .CDC recommendations in policy and procedure development and updating. Per the policy, understanding the transmission of[DIAGNOSES REDACTED] is vital to infection prevention. The organism is transferred via spores from contaminated environments, healthcare workers, and by infected persons. The stools of residents with[DIAGNOSES REDACTED] contain a large number of organisms. Therefore, residents with active diarrhea should be treated utilizing contact Precautions. The policy further included that gloves shoud be donned when entering the room of a resident with[DIAGNOSES REDACTED], however, the policy did not include that gowns needed to be applied prior to entering the room. The policy only stated that gowns should be worn if the staff anticipates that his/her clothing will have direct contact with the resident or the contaminated environment. Review of the 2007 CDC guidelines revealed that for the prevention of transmission of[DIAGNOSES REDACTED] in healthcare settings, use contact precautions for patients with known or suspected[DIAGNOSES REDACTED]. The guidelines included that[DIAGNOSES REDACTED] spores are transferred to patients mainly via the hands, who have touched a contaminated surface or item. The guidelines further included that for contact precautions, gloves and gowns should be applied when entering patient's rooms and during care and for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning personal protective equipment upon room entry and discarding before exiting the resident's room is done to contain pathogens, especially those that have been implicated in the transmission through environmental contamination (e.g.[DIAGNOSES REDACTED]). In addition, the State Operations Manual for Long Term Care under Infection Control(F441) includes that It is important that all infection prevention and control practices reflect current Centers for Disease Control (CDC) guidelines.

Based on clinical record review, observations, staff interviews, review of the National Pressure Ulcer Advisory Panel (NPUAP), review of hospital records, and review of facility policies and procedures, the facility failed to ensure that three residents (#s 140, 11, and 2), who entered the facility without pressure ulcers, were adequately monitored to prevent facility aquired pressure ulcers. One resident (#140) sustained actual harm. The survey sample was six. Findings include: -Resident #140 was admitted to the facility on [DATE], with hospital transfer [DIAGNOSES REDACTED]. Review of the hospital discharge summary dated March 8, 2010, documented that the resident underwent [REDACTED]. Review of the nursing admission assessment and nursing progress notes dated March 8, 2010, documented that the resident was assessed to be able to self-propel in a wheelchair, she was alert and oriented, was assessed to have [MEDICAL CONDITION] to all four extremities, had intact [MEDICATION NAME] to bilateral inner thighs due to sheering. Further notes documented she had been admitted for physical and occupational therapy due to her open reduction with internal fixation surgery of her left [MEDICAL CONDITION]. Review of the undated interim care plan, revealed that the plan was for the resident ' s skin to remain intact, staff were to observe for [MEDICAL CONDITION], tears, pressure areas, etc. Review of the admission Minimum Data Set (MDS) 2.0 dated March 15, 2010, revealed that the resident had no memory or cognitive impairments, she was able to make her needs know, she required extensive to total assistance with most of the activities of daily living skills, (i.e., bed mobility), and the support of two persons physical assist. She required a mechanical lift for transfers to and from the bed to wheelchair etc. The MDS further documented she had an indwelling catheter, was incontinent of bowel, had no pressure ulcers on admission. However, second to her mobility concerns she triggered for pressure ulcers. A care plan for "pressure ulcer prevention" was developed on March 16, 2010. The goal was that the resident was to show no signs or symptoms of skin breakdown thru the next review goal date of June 13, 2010. Interventions included turn and reposition as needed, weekly skin assessments, quarterly Braden Scale Scores, call light within reach, adequate hydration and nutrition, skin checks during dressing, bathing, pericare, and to notify nursing with any problems. A Braden Scale was completed on March 18, 2010 and documented that the resident scored a 19. It was documented on this form that a score of 17 or below required a weekly skin evaluation and documentation in the clinical record. Review of the "Unusual Skin Occurrence Investigation Report" and "Incident Report" both documents were dated March 21, 2010, at 8:30 a.m. These two reports documented that direct care staff left the resident on a bed pan for an extended length of time. The documents indicated that there were blisters and a dark purple area imprinted on the residents buttocks of a bed pan. The area was measured on the right buttocks as 2 centimeters (cm) by 22 cm and left buttock was 2 cm by 18 cm. The care plan was not updated to reflect the change in the condition of the resident's skin. Review of the clinical record revealed that the physician was notified on March 24, 2010, by a fax communication that the resident had sheering on her buttocks in the area where the bed pan imprint was located, staff asked for a treatment to be ordered with the suggestion of A and D ointment. The physician faxed his reply to the facility nurse with orders to clean the wound, apply [MEDICATION NAME], and change every five days or as needed. The week of March 29, 2010, documented that the resident had developed an open excoriation with redness on the resident's buttocks. There were no measurements documented. Further review documented the physician changed the treatment order on March 31, 2010, a telephone order at 2:17 p.m. "for stage II ulcer in crack of bottom:" cleanse with NS (normal saline), pat dry, wet to dry dressing, change BID (twice a day), until healed. Review of the "physician progress notes [REDACTED]. The physician documented that the resident was left on a bed pan. Barrier dressings were not sticking to the wound area due to the "large area." Stage II ulcer at coccyx, continue with barrier dressing, obtain an air mattress, and would add [MEDICATION NAME] cream. Review of the "Physician Orders" dated April 2, 2010, documented that the dressing to the resident's wounds had changed to [MEDICATION NAME] cream BID to be applied to open wounds topically. Again on April 5, 2010, a clarification order was written "to all open wounds on bottom apply [MEDICATION NAME] cream BID topically." Review of the care plan for pressure ulcers did not document the changes in the dressings for wound care. The nursing progress note dated April 16, 2010, documented that the resident was now on an air mattress to maintain skin integrity. Review of the April 18, 2010, nursing progress notes, documented that he resident had three stage II, one stage III pressure ulcers, and one necrotic cap on her left heel. These pressure ulcers were documented on the transfer sheet dated April 18, 2010, when the resident was transfer to the hospital at the request of the family. A review of the hospital records dated April 18, 2010, documented that the resident had multiple pressure ulcers that were stage II and III located on the coccyx. Also noted was a decubitus ulcer on the resident ' s left heel. The history and physical dictation from the hospital records, dated April 18, 2010, documented, "...Matters were complicated further when a couple of weeks ago she was left on a bed pan overnight and had significant ulcer formation on her buttocks, right and left, and now she has subsequently developed an ulceration on the presacral area just above the anus ...Also has been rubbing her left heel somewhat, trying to keep her legs moving, and apparently has developed an ulcer on the back of that heel..." Interview was conducted on April 13, 2011, with the LPN. The LPN stated that she had been on duty on March 21, 2010. She filled out the incident report that the resident had been left on a bed pan for an undetermined length of time. Staff further stated she had observed the resident's buttocks, and the image of the bed pan was imprinted on the resident's buttocks, the skin tissue was a dark purple color, and blisters were observed. During an interview on April 6, 2011, the director of nursing and corporate nurse stated that they were unable to locate any other medical record information for the resident such as, the pressure ulcers measurements, documentation of the wound care, and nursing progress notes. -Resident #2 was readmitted on [DATE], with [DIAGNOSES REDACTED]. A quarterly nursing assessment dated [DATE], included documentation that no pressure ulcers were present and that the resident was not at significant risk for the development of pressure ulcers. The resident's pressure ulcer score was a 15 and according to the pressure ulcer risk assessment guidelines, a score of 12 or less was a significant risk. A review of a weekly skin check record dated January 19, 2011, included documentation that the resident had an opened area on the coccyx. No additional information regarding this opened area was included on this skin record. A nursing note entry dated January 20, 2011, included documentation that an opened area on the resident's coccyx was present. However, again, evidence that a complete and thorough assessment of the opened area, including a description, size and stage of the open area, was not included in the nursing note entry. In addition, no further nursing note entries were documented until April 5, 2011, and did not include any documentation regarding the opened area on the resident's coccyx. A physician's order dated January 20, 2011, now included to cleanse the coccyx area with normal saline or wound cleaner, apply [MEDICATION NAME] to the open and change it every 3 days. However, a review of the January 2011, TAR (Treatment Administration Record) revealed that the prescribed treatment had not been administered until January 24, 2011, which was three days after the treatment order was obtained. A review of the February 2011, TAR also revealed documentation of the above treatment order but no documentation that the prescribed treatment had actually been administered on February 5, 8, or 26, 2011. Another quarterly nursing assessment dated [DATE], included documentation that the resident had a small ulcer on the coccyx area. However, a review of the weekly skin check records revealed only one entry dated February 3, 2011, which included that the resident had an, " Ulcer," on the coccyx area. Again, no documented evidence was able to be located in the resident's clinical record that included documentation that a complete and thorough assessment of the open area had been provided. In addition, a review of a facility form title, Wound Skin Detail Report, revealed that the opened area on the resident's coccyx had not been assessed, staged or measured until February 14, 2011, which was 26 days after the initial identification of the opened area on the resident's coccyx. On February 14, 2011, the opened area was identified to be a stage 2 pressure ulcer, which measured 1.7 by 1.4 cm. Per the documentation, no depth was present. Although a weekly skin check record dated March 2011, was located in the resident's clinical record, it was blank and contained no documentation that any weekly skin checks had been completed or any documentation of any skin integrity concerns. Furthermore, the March 2011, TAR included documentation that the physician ordered treatment had only been administered on March 3, and 8, 2011. In addition, an undated weekly skin check record was located in the current April MAR indicated [REDACTED]. A review of the April 2011, TAR again revealed documentation that the treatment had only been administered on April 11, and 12, and no documentation that the treatment had been administered every three days, from April 1, through 10, 2011. A pressure ulcer treatment observation was conducted on April 13, 2011. During this observation, the opened area on the resident's coccyx area was identified to be a stage II pressure ulcer, which measured 05. by 0.4 cm. An interview was conducted immediately following this observation with the RN/Wound Nurse. At this time, the RN stated that an assessment of the open area should have been conducted when the treatment order was obtained (January 20, 2011). The RN also stated that an RN was suppose to notified whenever a pressure ulcer developed, to ensure that a complete assessment was provided. He further stated that the weekly skin check records were suppose to be completed weekly by the nurse assigned to care for the resident on the day that it was due and that the weekly wound assessments/reports were completed by the RN/Wound Nurse. At this time, the RN/Wound Nurse acknowledged that the no additional wound assessments were able to be located prior to February 14, 2011. -Resident #11 was admitted on [DATE], with [DIAGNOSES REDACTED]. An admission nursing assessment dated [DATE], documented the the resident had an abrasion on the coccyx and physician orders included that a skin check was to be completed on a weekly basis. Per an Admission Minimum Data Set assessment dated [DATE], the resident was at risk for increased skin breakdown due to an existing stage II pressure ulcer on the coccyx and a care plan was developed. A review of the weekly skin care flowsheets documented the skin checks were completed during January, 2011, and again through February 20, 2011. There was no evidence the skin check was completed on the scheduled date of February 27, 2011. Per a nursing note entry dated February 28, 2011, the resident was found to have three small stage II pressure ulcers on the buttocks. Although the staff identified the pressure ulcers there was no evidence that care and treatment were provided despite facility standing orders to apply norma gel and [MEDICATION NAME] dressing every day until healed. Also in large captioned letters on the standing order form was, "...NOTIFY physician of any stage 2 ulcer..." There was no evidence of physician notification nor of a care plan that identified the problem, goals, or interventions. A review of the February and March, 2011, treatment administration records revealed no evidence that any treatment had been provided for the stage II pressure ulcers. Further, when the resident was discharged on [DATE]. The discharge instructions included that [MEDICATION NAME] was to be applied to the buttocks every three days and as necessary. There was also documented evidence that the resident had been discharged with a pressure ulcer on the coccyx and one on the right heel. Interviews were conducted on April 6, 7, and 12, 2011, with a RN and LPN who currently provide wound care to residents with pressure ulcers. Neither could state why there was a lack of documentation of physician notification and care and services that were to be administered. A facility policy titled, Pressure Ulcer Risk Assessment, included the following: " ...If pressure ulcers are not treated when discovered, they quickly get larger, become very painful for the resident, and often times become infected ...Pressure ulcers are a serious skin condition for the resident ... Routinely assess and document the condition of the resident's skin per facility wound and skin care program for any signs and symptoms of irritation or breakdown. Immediately report any signs of a developing pressure ulcer to the supervisor ...." The policy also included in the section titled " Assessment " stated the following: " ...Skin Assessment. Skin will be assessed for the presence of developing pressure ulcers on a weekly basis or more frequently if indicated. 3. Monitoring: a. Staff will maintain a "skin alert," performing routine skin inspections daily or every other day as needed. b. Nurses are to be notified to inspect the skin if skin changes are identified. c. Nurses will conduct skin assessments at least weekly to identify changes..." Review of the facility policy for "Pressure Ulcer Risk Assessment/Treatment" documented that the purpose of the procedure was to provide the care to existing pressure ulcers and the prevention of additional pressure ulcers. The licensed/professional nursing staff members were to review the resident ' s care plan, acquire the special needs of the resident, and assemble the equipment with any needed supplies. The policy indicated that staff members were to document in the resident's medical record the date, time, and type of skin care provided, any change in the resident's condition, the condition of the skin (i.e. the size, location, redness or tender areas). Per the NPUAP and the prevention of pressure ulcers stated, " Perform a head to toe skin assessment at least daily, especially checking pressure points such as...heels ...Use pillows or foam wedges to keep bony prominences, such as knees and ankles, from direct contact with each other ...Use devices that eliminate pressure on heels ...Implement pressure prevention educational programs ...include mechanisms to evaluate program effectiveness in preventing pressure ulcers ... "