Every finding on record at Haven of Sandpointe, LLC

Based on clinical record review, observations, interviews, and policy review, the facility failed to ensure that physicians' orders were followed for 3 of 3 sampled residents (Resident #36, #89, #60) regarding their suprapubic catheter care and treatment. The deficient practice could result in the residents developing an infection and not receiving the necessary treatment for their condition.Findings include:Regarding resident # 36-Resident #36 was admitted to the facility on [DATE], with a diagnosis that included the presence of urogenital implants, resistance to multiple antibiotics, retention of urine, urinary tract infection, benign prostatic hyperplasia, and neuromuscular dysfunction of the bladder. A physician's order dated October 12, 2023 revealed an active order to cleanse suprapubic catheter exit site with normal saline, pat dry. Apply split gauze dressing, secure with tape. Notify provider of any adverse signs and symptoms every day shift for suprapubic catheter care.Further review of the physician's orders revealed an active order dated September 2, 2025, to irrigate the suprapubic catheter with 60 milliliters of sterile normal saline every day, every day shift, to prevent clogging. A care plan revealed a focus area for suprapubic catheter due to neuromuscular dysfunction of the bladder. Interventions included providing suprapubic catheter care every shift by the nurse. Date initiated January 21, 2026. Further review of the care plan revealed a focus for urinary tract infections. Interventions included checking the resident at least every two hours for incontinence and to wash, rinse, and dry soiled areas. A quarterly minimum data set assessment (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 4, indicating the resident was cognitively impaired further review revealed the resident had no indicators for behaviors, required substantial maximal assistance with toileting hygiene, had an indwelling catheter, a diagnosis for neurogenic bladder, was at risk for developing pressure ulcers or injuries and was receiving applications of ointments/medications other than to the feet. A review of the treatment administration record (TAR) for August 2026 revealed no documentation on August 1, 2026, for the irrigation of the suprapubic catheter with 60 milliliters of sterile normal saline every day.Further review of the TAR revealed no documentation on August 1, 2026, for cleansing of the suprapubic catheter exit site with normal saline, pat dry, application of split gauze dressing, and securing with tape. There was no evidence that the physician was notified regarding the irrigation of the suprapubic catheter with 60 milliliters of sterile normal saline every day, or that the cleansing of the suprapubic catheter exit site with normal saline, pat dry, application of split gauze dressing, and secure with tape was not administered as ordered.An interview was conducted on August 4, 2026, at approximately 2:00 pm with resident # 36. The resident was lying on his bed with his catheter bag and tubing attached to the bottom frame of his walker. Resident indicated he wanted his walker where it was currently placed. There were no visible kinks or residue observed in the tubing. An interview was conducted on August 4, 2026, at 2:21 p.m. with Registered Nurse (RN/Staff # 307). Staff #307 stated the resident has a suprapubic catheter and that, so far there have been no issues with the catheter. Staff #307 reviewed the resident's clinical orders, stating the orders are to flush the resident's catheter daily with 60 milliliters every day shift to prevent clogging and to change the dressing daily. Staff #307 reviewed the electronic health record and stated the 12hr on the TAR means staff have 12 hours to complete the treatment. She further stated that a check mark on the TAR means that the treatment was completed and that no check mark meant that the treatment was not done. She confirmed that no treatments for irrigation or changing of the resident's catheter were completed on August 1, 2026. She stated that if a treatment is not completed for whatever reason, the expectation is that it is documented in the progress notes why it was not done. Staff #307 reviewed the progress notes for any documentation revealing that there were no notes indicating why the treatment was not completed or that the provider was notified. -Regarding resident #89Resident #89 was initially admitted to the facility on [DATE], and re-admitted to the facility on [DATE], with diagnoses including disorders of urethra, recurrent and persistent hematuria with unspecified morphologic changes, encounter for attention to other artificial openings of urinary tract, neuromuscular dysfunction of bladder, presence of urogenital implants.A physician's order dated June 29, 2026 revealed an active order to cleanse suprapubic catheter exit site with normal saline, pat dry, apply split gauze dressing, secure with tape. Notify provider of any adverse signs or symptoms, every day shift. A review of the TAR record for July 2026 revealed no documentation on July 24, 2026, for cleansing of the suprapubic catheter exit site with normal saline, pat dry, application of split gauze dressing, and secure with tape. There was no evidence that the physician was notified of the cleansing of the suprapubic catheter exit site with normal saline, pat dry, application of split gauze dressing, and secure with tape was not administered as ordered.-Regarding resident #60Resident #60 was admitted to the facility on [DATE] with a diagnosis that included neuromuscular dysfunction of the bladder, retention of urine, and presence of urogenital implants.A physician's order dated May 18, 2026 revealed an active order for suprapubic catheter care per nurse. CNA may empty drainage bag. Every shift for other. Further review of the order summary revealed an active wound care order dated May 15, 2026, to cleanse suprapubic catheter exit site with normal saline, pat dry. Apply split gauze dressing, secure with tape. Notify provider of any adverse signs or symptoms. Every day shift.A care plan revealed a focus area for suprapubic catheter due to neuromuscular dysfunction of bladder with a revision date of May 18, 2026. Interventions included providing suprapubic catheter care every shift by a nurse; date initiated May 18, 2026.A quarterly minimum data set assessment (MDS) assessment dated [DATE] revealed the resident had a brief interview for mental status (BIMS) score of 13, indicating the resident's cognition was intact. Further review revealed the resident had no indicators for behaviors, required substantial maximal assist with toileting hygiene, and had an Indwelling catheter, including a suprapubic catheter and nephrostomy tube.A review of the treatment administration record (TAR) for July 1, 2026 through July 31, 2026 revealed no documentation for Wound Care- Cleanse suprapubic catheter exit site with normal saline, pat dry. Apply split gauze dressing, secure with tape. Notify provider of any adverse signs or symptoms every day shift for the following dates: July 3, 4, 5, 11, 18, 25, 2026. Further review of the TAR revealed no documentation for suprapubic catheter care per nurse. CNA may empty drainage bag. Every shift for other on the following dates: July 3, 4, 5, 2026. A review of TAR for August 1, 2026 through August 31, 2026 revealed no documentation for Wound Care: Cleanse suprapubic catheter exit site with normal saline, pat dry. Apply split gauze dressing, secure with tape, every day shift for the following dates: August 1, 2026.Further review of the TAR revealed no documentation for suprapubic catheter care per nurse. CNA may empty drainage bag. Every shift for other. Notify provider of any adverse signs or symptoms. Every shift for the following dates: August 1, 2026.There was no evidence that the physician was notified that the cleansing of the suprapubic catheter exit site with normal saline, pat dry. Apply split gauze dressing, secure with tape or that suprapubic catheter care per nurse was not administered as ordered.An interview was conducted on August 4, 2026, at 3:12 p.m. with Certified Nursing Assistant (CNA/Staff #133). Staff #133 stated catheter care is completed every 2 hours and Foleys are emptied every shift and documented in the resident's plan of care. She stated that she reports any changes or concerns related to catheter use, including potential symptoms of a urinary tract infection (UTI), to the nurse immediately. She further stated that she is aware that the resident's catheter dressings should be changed daily and will let the nurse know if the gauze needs changing for any suprapubic catheters.An interview was conducted on August 4, 2026, at 3:22 p.m. with Certified Nursing Assistant (CNA/Staff #347). She stated the catheters are drained every hour when she does brief changes to make sure they are not too full and at the end of her shift. She stated if she sees any signs or symptoms of a UTI, such as blood in the urine or if the residents report any pain, she will notify the nurse of any signs of an infection. An interview was conducted on August 4, 2026, at 3:40 p.m. with the Director of Nursing (DON/ Staff # 829). The DON stated that she expects staff to follow the orders as written. The DON stated that if there is a check mark on the MAR or TAR, that means the task was marked as completed and followed as written. She further stated that if there is no check mark on the MAR or TAR for the order, it means that the order was not done, and that the 12 HR on the TAR means that nursing staff has 12 hours to complete the treatment or medication order. The DON stated if the order is not completed, clinical staff must document in the progress note the reason why the order was not completed and notify the physician that it was not completed. The DON reviewed the orders, and August 2026 MAR and TAR for resident #36 and stated the TAR for August 2026 revealed no irrigation of suprapubic catheter with 60ml's of sterile normal saline every day did not occur on August 1, 2026 and that there was no documentation on August 1, 2026 of the order to cleanse the suprapubic catheter exit site with normal saline, pat dry, apply split gauze dressing, secure with tape. The DON reviewed the orders for resident #89 and stated there was an active order to cleanse the suprapubic catheter exit site with normal saline, pat dry, apply split gauze dressing, secure with tape, notify provider of any adverse signs or symptoms, every day shift. She further reviewed the TAR for July 2026, revealing no documentation on July 24, 2026, and no documentation that the physician had been notified that the order had not been completed. The DON reviewed the orders for resident #60 and stated there was an active order for suprapubic catheter care per nurse. CNA may empty drainage bag. Every shift for other and an active order to cleanse suprapubic catheter exit site with normal saline, pat dry. Apply split gauze dressing, secure with tape. Notify provider of any adverse signs or symptoms. Every day shift. The DON reviewed the TAR for July 1, 2026 through July 31, 2026, confirming no documentation for Wound Care: Cleanse suprapubic catheter exit site with normal saline, pat dry. Apply split gauze dressing, secure with tape. Notify provider of any adverse signs or symptoms. Every day shift for the following dates: July 3, 4, 5, 11, 18, 25, 2026. Further review of the TAR by the DON confirmed no documentation for suprapubic catheter care per nurse. CNA may empty drainage bag. Every shift for other on the following dates: July 3, 4, 5, 2026. The DON reviewed the progress notes and stated there was no documentation that the physician had been notified that the orders for resident #89's suprapubic catheter care had not been completed. The DON stated that not completing the orders for catheter care places the residents at risk for urinary tract infections or catheter-related infections. Review of the facility policy titled Urinary/Renal Conditions: Catheter Care, Urinary states the purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Review of the facility policy titled Quality of Care: Medication and Treatment Orders states that medications and treatment will be consistent with principles of safe and effective order writing.

Based on clinical record review, staff interviews, and review of facility policy, the facility failed to ensure that the comprehensive person-centered care plan was reviewed and revised by the interdisciplinary team after each assessment to address ongoing wound care and treatment interventions for one of three sampled residents (Resident #41). This deficient practice could place the resident at risk for infection, skin integrity decline, and missed medical services. The universe was 103.Findings include:Resident #41 was initially admitted on [DATE], with diagnoses including metabolic encephalopathy, generalized muscle weakness, essential primary hypertension, epilepsy, and bipolar disorder.A baseline Care Plan, dated July 7, 2022, revealed a focus area initiated for potential impairment to skin integrity related to generalized weakness, which was resolved on February 21, 2024. However, further review of the comprehensive person-centered care plan failed to reveal any focus area or interventions addressing the resident's chronic malignant upper back wound.A Quarterly Minimum Data Set (MDS) assessment, dated August 8, 2024, revealed that the resident had a Brief Interview of Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The MDS further revealed the resident had physical impairments following a history of cerebral infarction with left hemiparesis.A physician progress note, dated October 22, 2024, revealed that the resident developed an open skin lesion to his upper back described by staff as a dry, raised, rough spot, which occurred alongside a stated history of melanoma to his right heel. A physician order, dated October 22, 2024, revealed an order to cleanse the upper back with normal saline, apply calcium alginate, and apply a dry dressing daily.A physician order, dated October 22, 2024, revealed an order to consult dermatology for atypical upper back lesions for 7 days. A physician progress note, dated July 1, 2025 at 10:32 AM, revealed that the back wound was stable but remained unhealed. A physician progress note, dated July 8, 2025 at 10:45 AM, revealed that the back wound was friable with a small amount of bleeding.A physician progress note, dated July 22, 2025 at 10:54 AM, revealed that the back wound had enlarged, measuring 3.2 cm in length by 2.2 cm in width x 0.1 cm in depth. A physician progress note, dated August 5, 2025 at 1:29 PM, revealed that the back wound was continuing to enlarge, measuring 3.4 cm in length by 2.2 cm in width x 0.1 cm in depth. A physician progress note, dated August 26, 2025 at 12:19 PM, revealed that the back wound was enlarging and had not healed.A physician progress note, dated September 23, 2025 at 12:45 PM, revealed that the back wound measured 4 cm in length by 3.2 cm in width x 0.1 cm in depth, and the peri wound skin was friable with yellow drainage.A physician progress note, dated September 30, 2025 at 12:05 PM, revealed that the back wound was continuing to enlarge. A physician progress note, dated October 14, 2025 at 12:52 PM, revealed that the back wound was without improvement and measured 4.5 cm in length by 3.2 cm in width x 0.1 cm in depth.A physician progress note, dated October 21, 2025 at 12:36 PM, revealed that the back wound continued to increase in size.A physician progress note, dated October 28, 2025 at 11:15 AM, revealed that there was evidence of a Pseudomonas burden in the back wound, and the treatment order was changed to cleanse the upper back with 0.25% acetic acid solution, apply hydrofera blue sponge, and cover with a dry dressing every other day.A physician progress note, dated November 25, 2025 at 1:18 PM, revealed that the back wound showed increased hypertrophy and friability. A physician progress note, dated December 30, 2025, revealed that the facility was awaiting Power of Attorney (POA) transfer for a skin resection consultation.A progress note, dated January 13, 2026 at 2:33 PM, revealed that the resident's daughter noticed that the back wound was draining and bleeding, resulting in a 911 call and transport to the emergency department, though the resident was not experiencing a medical emergency.A Health Status progress note, dated January 13, 2026 at 10:30 PM, revealed that the resident returned via stretcher with a new physician order for Cephalexin 500mg by mouth four times a day for 5 days for a back skin lesion infection.A Care Plan focus, initiated January 14, 2026, revealed a temporary focus for treatment of the acute skin infection. However, it did not address the resident's chronic malignant upper back wound, ongoing wound management, monitoring, drainage, odor, pain, or need for specialty follow-up. The temporary focus was resolved on January 22, 2026, while the wound itself remained active.A Weekly Skin Check and Wound Assessment, dated January 20, 2026 at 11:10 PM, revealed a raised open area to the upper midback. A physician progress note, dated January 27, 2026 at 11:47 AM, revealed that the malignant back wound was not healed, measuring 6 cm in length by 5 cm in width x 0.1 cm in depth, with a moderate amount of yellow drainage, a strong odor, and periwound erythema.A physician progress note, dated February 24, 2026 at 11:33 AM, revealed that the resident had a trauma wound from skin picking on his right forearm measuring 1 cm in length by 1 cm in width, and a new physician order, dated February 24, 2026, was put in place to cleanse with wound wash, apply bacitracin ointment, and cover with a dry dressing daily.A Weekly Skin Check and Wound Assessment, dated March 19, 2026 at 12:04 PM, revealed that the upper back cancer lesion plateaued, measuring 8 cm in length by 6.5 cm in width, with a moderate odor after cleansing. A quarterly MDS assessment, dated March 21, 2026, revealed that the resident had a Brief Interview for Mental Status (BIMS) score of 3, indicating severe cognitive impairment. The resident was totally dependent on staff for bed mobility, transfers, toilet hygiene, and personal hygiene, was confined to a manual wheelchair, and reported experiencing frequent pain with an intensity rating of 8 out of 10 on the numeric rating scale.A Weekly Skin Check and Wound Assessment, dated April 30, 2026 at 1:21 PM, revealed that the upper back cancer lesion measured 8.5 cm in length by 7.5 cm in width, with a light amount of serosanguineous drainage and a faint odor.A physician progress note, dated May 19, 2026 at 10:31 AM, revealed that the treatment order was changed to cleanse with wound wash, apply 500mg crushed flagyl (antibiotic), and cover with silver gelling fiber and a dry dressing daily for 4 weeks.A Weekly Skin Check and Wound Assessment, dated May 21, 2026 at 2:20 PM, revealed that the upper back cancer lesion measured 6.5 cm in length by 6.5 cm in width, with light sanguineous drainage and a faint odor.A Weekly Skin Check and Wound Assessment, dated June 9, 2026 at 11:30 AM, revealed that the malignant back wound was not healed, measuring 5 cm in length by 5.5 cm in width.A Care Plan, dated June 22, 2026, revealed that the care plan was closed due to the resident's discharge.A Weekly Skin Check and Wound Assessment, dated July 9, 2026, revealed a large raised open mass area (cancer lesion) to the upper midback, as well as a small flaky area to the mid chest and flaky skin on the right forearm.In an interview conducted on August 4, 2026, at 2:39 PM, Certified Nursing Assistant (CNA/Staff #137) stated that he checks on incontinent residents regularly, changes briefs and provides pericare, and reports any new rashes, cuts, or wounds to the nurse immediately. An interview was conducted on August 4, 2026, at 2:49 PM with a registered nurse (RN/Staff #160) who stated that the facility conducts weekly skin assessments and Braden assessments, and if there is anything new they document it and document any care provided. She stated that Staff #267 was the wound care nurse and that staff round every two hours. She stated that they coordinate with therapy and communicate with the interdisciplinary team if they notice improvement or decline. During a review of the clinical record, she stated that the resident received wound care and was getting metronidazole for an open upper back wound. She stated that, according to physician progress notes dated June 16, 2026, the resident's back wounds dated back to October 2024. She stated that, to her understanding, there was never a dermatology visit for the resident despite scheduled appointments. She stated that there was no care plan for his wounds between 2024 and 2026 regarding interventions to improve or better his wound care. She stated that infection is the biggest risk, as an open wound exposure to bacteria and pathogens can make the wound worsen. She stated that miscommunication is a risk, as it could be a possibility that the nurses miss the wound care for residents if it is not care-planned. An interview was conducted on August 4, 2026, at 3:17 PM with a licensed practical nurse who served as the wound care nurse (LPN/Staff #267) who stated that he has worked at the facility for three years and goes throughout all the halls throughout the day. He stated that he remembered Resident #41 and covers all types of wounds. He stated that the resident had a mass growing on his back that the wound nurse practitioner said was a type of cancer, which was very small at first and grew more and more. He stated that there were issues with the resident's money and insurance not aligning with what the doctor was approving. During a review of the resident's clinical record, he stated that an order was written on March 20, 2026, for a dermatology consult, but the resident never went to see dermatology because there was an issue with the daughter. He stated that the risk is that the wound could have gotten worse and that they should have seen dermatology. He stated that infection is the biggest risk and that an open wound exposes the resident to bacteria and pathogens, which can make the wound worsen. He stated that miscommunication is the risk where nurses could miss the wound care for residents if it is not care planned.An interview was conducted on August 4, 2026, at 3:55 PM with the director of nursing (DON/Staff #562), who stated that she expects staff to assist residents with any of their needs, perform rounding every two hours, and perform weekly skin checks. She stated that if the certified nursing assistants notice anything, they notify the nurse, who then notifies the doctor. She stated that the nurses take the orders and enter them into the electronic record, and the transportation department makes the appointments. During a review of the resident's clinical record, she stated that the resident did not go to his dermatology appointments because his daughter was the Power of Attorney and would cancel the appointments after agreeing to go. She stated that Adult Protective Services eventually informed the facility that the daughter had no rights to the resident and was stealing from him, and the state appointed a public fiduciary in June 2026. She stated that the resident's back wound, which developed in October 2024, and its interventions were not care-planned. She stated that the risk of not care-planning this issue is that other members of the care team or the interdisciplinary team may not know about it, which could lead to the wound getting worse.Review of the facility policy titled Assessments/Care Planning: Care Plans, Comprehensive Person-Centered, revised January 1, 2024, revealed 11. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. 12. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met; d. at least quarterly, in conjunction with the required quarterly MDS assessment.

Based on interviews, review of clinical record, and facility policy, the facility failed to protect the residents' (#3, and #2) right to be free from physical abuse. The deficient practice could result in physical and psychosocial harm. -Regarding Resident #3: Resident #3 was admitted to the facility on [DATE], and re-admitted [DATE], with diagnoses that included Alzheimer's disease, dementia with agitation, history of falling, anxiety disorder, mental disorder not otherwise specified, and spinal stenosis.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) assessment score of 5, indicating severe cognitive impairment.A care plan for behaviors revised September 3, 2025, revealed that Resident #3 had a resident to resident altercation, and an additional intervention was initiated on September 3, 2025, which indicated for a medication review.A Behavior Note dated July 24, 2025, revealed that Resident #3 was verbally inappropriate with staff and other residents. Resident #3 attempted to touch a female resident inappropriately, and the staff redirected the resident and spoke to him regarding his behavior.A Behavior Note dated July 28, 2025, revealed Resident #3 continues with sexual comments toward female staff.A Late Entry Incident Note dated September 2, 2025, revealed that Resident #3 was walking to the dining room for lunch pushing his wheelchair, as Resident #3 passed by another resident, the other resident said hi to Resident #3 who did not acknowledge the other resident. The other resident punched Resident #3 on his upper back, and Resident #3 reacted with punching the other resident on the left upper chest. The residents were separated by staff, vitals were taken, assessment completed, and no injuries were noted.Regarding Resident #2:Resident #2 was admitted to the facility April 12, 2024, with diagnoses that included unspecified dementia, anxiety disorder, unspecified hearing loss, and chronic obstructive pulmonary disease.A quarterly MDS assessment dated [DATE], revealed Resident #2 had a BIMS assessment score of 4, indicating severe cognitive impairment.A care plan initiated June 24, 2024, revealed Resident #2 had behaviors of attempting to hit and kick staff, yelling toward other residents, and a resident to resident altercation. An additional intervention was initiated on September 3, 2025 to place Resident #2 close to staff when awake.A Behavior Note dated July 24, 2025, revealed Resident #2 hit a staff on the arm as the staff passed by the resident, and the resident was redirected and asked not to be hitting others. Resident #2 was unable to verbalize understanding due to expressive aphasia.A Behavior Note dated July 30, 2025, revealed a staff opened Resident #2's room door for her, and Resident #2 hit the staff on the left arm, and that later in the day, Resident #2 walked toward her room and stopped in the hallway, pulled her pants and brief down, and squatted and urinated on the floor. Staff helped her dress herself, and took Resident #2 to the restroom to assist with care.A Behavior Note dated August 2, 2025, revealed that after lunch, a Certified Nursing Assistant (CNA) removed Resident #2's lunch plate from in front of her. Resident #2 stood up quickly and started yelling at the CNA and grabbed the CNA's arm tightly. The resident's arm had to be pried off of the CNA. Additionally, the note revealed that Resident #2 was known to be very obsessive and territorial to anything she thinks is hers.A Behavior Note dated August 11, 2025, revealed that Resident #2 was observed to be very agitated throughout the shift. Scheduled medication was administered as ordered; however, it was not effective in reducing agitation. Resident #3 displayed exit-seeking behaviors and became physically aggressive when staff attempted redirection, including attempts to strike staff.A Psych Follow-Up Note dated September 2, 2025, revealed that staff reports that Resident #2 has been aggressive. Resident #2 did hit another resident and has a history of hitting staff as well. Today she is refusing to talk to us, is very flat and guarded, and has isolating behavior.A Late Entry Incident Note dated September 2, 2025, revealed that Resident #2 was sitting in the dining room when another resident walked by. Resident #2 said hi and the other resident did not stop to acknowledge her, and as the other resident continued to walk by, Resident #2 got upset and punched the other resident on his back. The other resident turned around and punched Resident #2 on her chest. The residents were separated by staff, vitals were taken, assessment completed, and no injuries were noted.A facility investigation report submitted to the state agency on September 8, 2025, revealed that following the initial report of the incident on September 2, 2025, Resident #3 and Resident #2 were separated and checked to ensure safety. An investigation was initiated and two staff members were interviewed who were present during the interaction, a CNA and a nurse. According to staff accounts, around lunch time, Resident #3 was walking past Resident #2. Some form of verbal interaction occurred between the two residents. Resident #3 acknowledged that Resident #2 had said something, but was unable to discern what Resident #2 was communicating. Resident #3 felt Resident #2 make contact with his back and turned and pushed her away as it surprised him. The investigation report further revealed that the CNA's statement indicated that Resident #2 reached out with a semi open hand and made a swinging motion before intervening. The nurse also responded to the interaction and assisted in the separation of the two residents. Assessments were conducted with no injuries noted.An interview was conducted with a CMA (Staff #45) on September 16, 2025, at 9:49 A.M. who stated that he was present during the incident between Resident #3 and Resident #2 on September 2, 2025. Staff #45 stated that the incident occurred just before lunch in the dining area, and Staff #45 was sitting with his back facing Resident #3 and Resident #2. He stated that he heard a noise that sounded like physical contact, and then he heard Resident #3 yell out. Staff #45 stated that then he saw the nurse (Staff #50) intervene and separate Resident #2 and Resident #3. Staff #45 stated that right after the incident, Resident #3 was complaining that the back side of his shoulder was hurting, but then later in the day, Resident #3 was saying that his shoulder was fine.An interview was conducted with a CNA (Staff #9) on September 16, 2025, at 10:06 A.M. Staff #9 stated that in the case of an abuse allegation, that staff are expected to report it to their immediate supervisor immediately, the residents are separated, and then afterward an investigation is conducted by the Administrator. Staff #9 stated that she was present for the incident between Resident #3 and Resident #2 on September 2, 2025. Staff #9 stated that it was around 11:00 A.M., and Resident #3 was walking into the dining room. Resident #2 was sitting in the dining room already, and Staff #9 was positioned about 15 feet away in the dining room. Staff #9 stated that she heard Resident #2 say something that couldn't be understood to Resident #3, and then she heard what sounded like a punch, and then heard the nurse call out Resident #2's name. Staff #9 stated she did not see any physical contact made, but then she heard Resident #3 say that Resident #2 had just hit him. A telephonic interview was conducted with a Registered Nurse (RN / Staff #50) on September 16, 2025, at 12:06 P.M. Staff #50 stated that she was present for the incident between Resident #3 and Resident #2 on September 2, 2025. Staff #50 stated that Resident #3 was pushing his wheelchair into the dining room and walked past Resident #2 who was already sitting in the dining room. Resident #2 said something to Resident #3 that did not make sense, and Resident #3 acknowledged Resident #2, but then Staff #50 stated that she saw that Resident #2 got up and punched Resident #3 in the upper back between the shoulder blades. Staff #50 stated that then, she saw that Resident #3 reacted and punched Resident #2 in the upper chest region toward the front of the resident's shoulder area. Staff #50 stated that she intervened and separated the residents, and then Resident #3 apologized and stated that his punch was just a reaction. Staff #50 stated that when she saw Resident #2 punch Resident #3, that Resident #2 looked angry and that the punch was aggressive in nature. Staff #50 stated that after the incident, she assessed the residents for injury and did not see any, and then notified the Director of Nursing (DON) and Administrator, and that she wrote a progress note in the medical record that accurately described the incident. Staff #50 stated that this is not the first time Resident #2 has been physically aggressive toward other residents.An interview was conducted with the Director of Nursing (DON / Staff #1) on September 16, 2025, at 12:27 P.M. The DON stated that her expectation for staff to prevent resident to resident altercations would be to know the residents well enough to identify changes in behavior and triggers. Regarding the incident between Resident #3 and Resident #2 on September 2, 2025, the DON stated that her understanding of the incident was that Resident #2 had tried to talk to Resident #3 and when he did not respond, Resident #2 became agitated and struck Resident #3, and then Resident #3 struck Resident #2 back. The DON stated that she did not know the location on the body where Resident #3 or Resident #2 were struck. The DON stated that in the case where one resident hits another resident, that would be considered abuse.An interview was conducted with the Administrator (Staff #66) on September 16, 2025, at 12:24 A.M. Staff #66 stated that physical abuse is when a person is intentionally trying to cause harm to a resident, and examples of physical abuse included hitting or pinching. Staff #66 stated that his understanding of the incident was that Resident #3 was walking down the hallway pushing his wheelchair and Resident #2 may have said something to Resident #3. Staff #66 stated that then, Resident #3 felt something on his back and turned around and pushed Resident #2. Then, Staff #66 stated that the nurse intervened and separated the residents. Regarding the question if Staff #66 believed that physical abuse occurred in the incident, Staff #66 did not answer the question directly, but Staff #66 did state that he did not believe that Resident #2 was trying to hurt Resident #3.A telephonic interview was conducted with a family member of Resident #3 on September 16, 2025, at 2:14 P.M. Resident #3's family stated that after the incident occurred on September 2, 2025, that the nurse (Staff #50) called the family to notify the family of the incident. Resident #3's family stated that the nurse stated that a resident went up to Resident #3 and hit him as hard as she could and then Resident #3 turned around and punched the other resident in the chest.Review of the policy titled Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated January 1, 2024, revealed that 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.

Number of residents sampled:16Number of residents cited:13The facility failed to ensure the protection/management of resident funds for 13 of 16 residentsBased on interviews, review of clinical records, facility 5 day report to the state agency (SA) and review of facility policy and procedures, the facility failed to ensure the protection/management of resident trust funds for 13 residents out of 16 (#3, #5, #18, #31, #32, #58, #63, #75, #76, #77, #86, #95, #96, #108, #109, #110). The deficient practice could result in continued misappropriation/exploitation of other residents.Findings Include:Resident #108 was admitted to the facility on [DATE], with diagnoses that included hypertension, dementia, muscle weakness and history of falling.A review of the minimum data set (MDS) dated [DATE] for Resident #108 revealed a brief interview mental status (BIMS) score of 09, which shows moderate cognitive impairment.Resident #75 was admitted to the facility on [DATE], with diagnoses that included dementia without behavioral disturbance, major depressive disorder, myocardial infarction and anxiety disorder.A review of the minimum data set (MDS) dated [DATE], for Resident #75 revealed a brief interview mental status (BIMS) score of 03, which shows severe cognitive impairment.An interview was conducted on August 6, 2025 at 1016 am with Public Fiduciary Lead (PFL), who works under the court appointed Adult Public Fiduciary (APF). On July 27, 2022, the court appointed APF to be the fiduciary over Resident #108. The new administrator, executive director Staff #147 contacted us and informed the office of a situation. He became aware of some inconsistencies, looked and found theft. The police, adult protective services (APS), department of health services (DHS) were contacted and business office manager Staff #148 was terminated.An interview was conducted on August 6, 2025 at 1029 a.m. with APF for Resident #108. Based on a short time, Staff #148 was putting transactions as spending money due to dementia. Some expenses included: digital expense $498.29, flowers at $72, food snack shop Instacart $289.71, coloring books and pencils 1542.45, miscellaneous items- basketball hoop, description not for figurines, cushion covers $1254.38, $810.76 and $4067.69. For Resident #75, expenses included a grill, cupcakes, macaroons, Apple TV, Prime Video, remote control monster trucks, miniature figurines, basketball hoop items, gumball machine, decorations. Restitution total $20,565.93. Food, Amazon, pictures, flowers $1157.82. That was from June 7, 2022 through June 30, 2024. He did not have any clothing or any items. Radio, clothing and a lot of purchases on Amazon totaling $9483.90. Purchases titled as shopping. Shopping sprees on bedding and clothing, $570. Resident #75 did not have a lot. There was a lot of Amazon, door dash, Sunny Skin-tanning place, Instacart, Target shopping for clocks, thermal water bottles, bedding items. Resident #75's purchases were going straight to Staff #148's use. Resident #75 did not have any of those items and we had to purchase bedding and clothing for him after going to his room at the facility to see the purchased items on his account.Review of the facility's 5 day report to the SA, showed that Resident #75's account had multiple purchases from Audible, Amazon and recurring purchases. Resident #75 was unable to be interviewed and a visual review was conducted of his room with none of items charged to his account being found.Resident #5 was admitted to the facility on [DATE], with an original admission date of October 12, 2020, with diagnoses that include respiratory failure, kidney failure, chronic obstructive pulmonary disease (COPD), muscle weakness, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side.A review of the minimum data set (MDS) dated [DATE] for Resident #5 revealed a brief interview mental status (BIMS) score of 15, which shows cognitive intact.An interview was conducted on August 8, 2025 at 907 a.m. with Resident #5 and revealed that Resident #5 was informed by the office of a $500 stay at a hotel. Resident #5 did not stay at a hotel and did not have a receipt for a hotel stay. The office did not have the receipt either. The court said that they will have to pay back the money and Staff #148 took other residents' money too.Review of the facility's 5 day report to the SA, showed that a receipt was procured in relation to a hotel stay on April 25, 2024 to April 28, 2024 at the Delta Phoenix Mesa Hotel. It was confirmed that the purchase was made using the resident trust fund debit card and an identical charge was matched to Resident #5's resident account in April. The dates correlated to Staff #148's daughters dance competition that was posted on social media. The dance competition website confirms that the hotel was used for participants that week as well.Resident #63 was admitted to the facility on [DATE], with diagnoses that include type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, anxiety.A review of the minimum data set (MDS) dated [DATE] for Resident #63 revealed a brief interview mental status (BIMS) score of 14, which shows cognitive intact.An interview was conducted on August 8, 2025 at 9:03 a.m. with Resident #63 and revealed that a month ago, was notified that someone had purchased a ring at Dillard's and things from Fast Eddy's. Resident #63 does not know the total amount used from the account, but it was someone who worked in the business office.Review of the facility's 5 day report submitted to the SA revealed that Dillard's was able to provide the exact item purchased based on the submitted receipt, a silver sized 11, men's ring with a cross. A post on social media was found of Staff #148's family member with a ring identical to the picture provided by Dillard's. A review showed that this purchase was applied to Resident #63's resident account. The resident was questioned regarding purchasing any new jewelry in the last couple months and stated she had not received anything and does not shop at Dillard's.Resident #77 was admitted to the facility on [DATE] with an original admission date of May 6, 2023, with diagnoses that include Alzheimer's disease, dementia, anxiety, type 2 diabetes mellitus, depression and a history of falling.A review of the minimum data set (MDS) dated [DATE] for Resident #77 revealed a brief interview mental status (BIMS) score of 03, which shows severe cognitive impairmentAn interview was conducted on August 6, 2025 at 1:19 p.m. with a family member of Resident #77 and revealed that the family members were notified of Resident #77 having $260 to $280 dollars taken from his account from Staff #148. The case is going to court because this was that person's second offense. 19 other people are involved.Resident #110 was originally admitted to the facility on [DATE] with diagnoses that include cerebral infarction with speech and language deficits, chronic kidney disease, major depressive disorder and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #110 revealed a brief interview mental status (BIMS) score of 11, which shows moderate cognitive impairment.An interview was conducted on August 6, 2025 at 2:11 p.m. with a family member of Resident #110 and revealed that the family member was notified after Resident #110 passed away that he had an outstanding bill of $18. Then was notified that Staff #148 took money from Resident #110. The family member stated that they could not understand how money was taken since Resident #110 had nothing and they let the $18 go. No amount was given as to how much was taken from Resident #110.Resident #18 was originally admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, dementia and legal blindness.A review of the minimum data set (MDS) dated [DATE] for Resident #18 revealed a brief interview mental status (BIMS) score of 11, which shows moderate cognitive impairment.An interview was conducted on August 6, 2025 at 12:36 p.m. with a financial power of attorney (FPOA) to resident #18 and revealed that the FPOA was notified of some discrepancies of Resident #18's account and it was reported right away. No clue as to how much was taken, but to ask Resident #18 because some days Resident #18 is sharp as a tac.An interview was conducted on August 12, 2025 at 10:02 a.m. with Resident #18 and revealed that someone stole money and does not know the amount. Three different figures were given and does not know which is right. The police came and told Resident #18 that someone from the facility took money from Resident #18's account.Resident #109 was originally admitted to the facility on [DATE] with diagnoses that include dementia, Alzheimer's disease, anxiety, major depressive disorder and repeated falls.A review of the minimum data set (MDS) dated [DATE] for Resident #109 revealed a brief interview mental status (BIMS) score of 00, which shows severe cognitive impairment.An interview was conducted on August 6, 2025 at 11:36 a.m. with a family member of Resident #109 and revealed that $1200 of Resident #109's share cost was put into the trust account and not the share account. Resident #109's family member never signed to have a trust account at the facility. Staff member #147 has been on top of this and is communicating as much as he can. This was also reported to the police, because if you do not report it, nobody else will and it can happen to someone else. Staff #148 did this at another facility and it went unreported.Resident #31 was originally admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, COPD, major depressive disorder, anxiety and obstructive sleep apnea.A review of the minimum data set (MDS) dated [DATE] for Resident #31 revealed a brief interview mental status (BIMS) score of 13, which shows cognitive intact.An interview was conducted on August 7, 2025 at 10:23 a.m. with Resident #31 and revealed that someone in the office stole $2000 from Resident #31 and that the person who stole the money does not work at the facility anymore. Money was taken from other residents. Staff #147 informed Resident #31 of the money being taken from his account.Resident #86 was originally admitted to the facility on [DATE] with diagnoses that include cerebral palsy, hypothyroidism, type 2 diabetes mellitus and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #86 revealed a brief interview mental status (BIMS) score of 15, which shows cognitive intact.An interview was conducted on August 7, 2025 at 1028 a.m. with Resident #86 and revealed that a lady some time ago a lady was taking money from the trust and $190 was taken from Resident #86. The case is ongoing and there are court dates. Around $40,000 has been taken from all the residents involved and another facility.Resident #95 was originally admitted to the facility on [DATE] with diagnoses that include anoxic brain damage, type 2 diabetes mellitus, anxiety disorder, major depressive disorder and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #95 revealed a brief interview mental status (BIMS) score of 08, which shows cognitive impairment.An interview was conducted on August 8, 2025 with Resident #95 and revealed that $100 had been taken from the trust account and has not been returned or replaced. Resident #95 had tried to purchase something from the store and the money was not there. Resident #95 now wears a lanyard to keep track of the card to the account.An interview was conducted on August 7, 2025 at 3:38 p.m. with business office manager Staff #130 and revealed that about 1.5 years into the job as the assistant in the business office, Staff #130 noticed that things were not okay with the trust account. Staff #130 did not report because the previous executive director would have fired Staff #130 before getting everything straightened out, due to the friendship between the former executive director and staff #148. Staff #130 stated that it was a personal opinion because that type of thing only happens in the movies. Staff #130 also revealed that if you do not report any suspicion of misappropriation, you can get in trouble, it will affect the residents, and will continue to happen if you do not speak up.Review of documents received by the SA on August 8, 2025 about 08:05 a.m. revealed copies of resident trust accounts that were compromised by Staff #148. The documents included Residents #3, #5, #31, #58, #63, #75, #76, #77 and #95.Review of a document received by the SA on August 8, 2025 about 0805 a.m. titled Unofficial Report Staff #148 Misappropriation 08/08/2025, from Staff #147. The document included information of audits being conducted. Staff #147 interviewed Staff #130 which revealed that Staff #130 was fairly positive that Staff #148 was using resident funds inappropriately for personal use and was terrified to bring it the previous administrator due to the close relationship that Staff #148 had with him. Staff #130 was scared that any accusation or report would result in retaliation and/or termination as Staff #130 had witnessed favoritism towards Staff #148 in past conflicts. Staff #130 felt that Staff #148 was utilizing funds for personal use and gain. Receipts were not being produced for all charges during reconciliation. Staff #130 saw alleged purchases for items on resident accounts that align with personal purchases that Staff #148 had made. Examples included food purchases, gift items and beauty products that Staff #130 did not see given to the residents. Staff #130 expressed that she did not have all the pieces of the puzzle but had bank statements and resident trust transactions that would potentially prove that misappropriation was occurring.Staff #147 began comparing partial bank statements against resident trust transaction reports. Three resident accounts were found that had incomplete documentation and there was a need to verify the purchases for the residents. The residents were Resident #5, Resident #75 and Resident #63. On June 4, 2024 Staff #148 was suspended while an investigation for the suspicious charges continued which included: Resident #75 - multiple amazon purchases for audio books. Resident #5 - Hotel stay in Phoenix, AZ. Resident #63 - Jewelry purchase at Dillard's. Resident #75's account was chosen for review based on his cognitive deficit and the increased number of amazon purchases being assigned to his trust account without proper documentation or receipts. Many of the amazon books were not purchased through the facility amazon account. Resident #75 does not possess any device to utilize for listening and does not hold the cognitive capacity to confirm any of the purchases. Resident #63 had a purchase from Dillard's on her account. One receipt with out a resident signature (indicating that the resident signed for reception of the item) was taken to Dillard's to confirm the purchase. The store associate scanned the receipt and provided a picture of the item. It was a silver sized 11 men's ring with a cross on it. Resident #63 was questioned about receiving or requested any men's jewelry and had not. Staff member #148 remembered running into Staff member #147 and her family while shopping at Dillard's and Staff #148 informed they were shopping for a family member's graduation. A search on Staff #148's Instagram account showed a photo of a family member wearing a ring that appears to be the same ring from Dillard's. Resident #5 had a suspicious charge on his resident trust account. A large specific sum that was labelled as a correction with no details to support the transaction. An amount matching the charge on Resident #5's resident trust account was found as a line item listed was a hotel room. Staff #147 drove to Phoenix to confirm with hotel staff that Staff #148 was the only person associated with the room, that Staff #148 would need to provide photo ID to be able to check in, and the card was used for the stay. Another search on Instagram revealed that Staff #148's family had a dance competition held at that hotel the days of the booked room. Staff #148 also posted pictures with correlating dates to the stay. In conclusion it was found that Staff #148 failed to follow proper policies and procedures according to Haven Health's company standards. Staff #148 employment was terminated on 6/7/24. The Yuma Police Department (YPD) was notified on 6/4/24 and the facility has provided all evidence requested and is cooperating in the active investigation and case against Staff #148. A forensic accountant was used by YPD to investigate transactions and impact. Specific amounts for potential resident loss have not been provided or shared at this time. No resident has experienced a loss of care due to this incident. An interview was conducted on August 8, 2025 at 9:46 a.m. with Executive Director Staff #147 and revealed that when misappropriation occurs in the facility you report, start the investigation with all parties including the family/resident. Reporting to the four main which are the SA, police, ombudsman and APS. The POA and or guardian are also notified. The state would be notified of each resident and three residents were listed on the 5 day. The police started asking for more documents, more residents were involved. The misappropriation policy states we should be reporting those. Staff #147 met with Staff #130 regarding the trust accounts and showed proof. No resident had ever had that many charges on the resident account and Staff #130 showed Staff #147 how to read the bank statements and it took some time to read. Staff #147 did not know there was a resident debit card and started to look at Staff #147's purchasing card and business card and trying to match them up to the resident debit card and they were both in Staff #148's name and Staff #148 could not find any charges that were connected to her. Her business card and what charges were being made and the resident card statements and they were not matching. Then Staff #147 realized there was another card being used. Found a receipt and Staff #130 was right that receipts were not being turned in, the 4 digits did not match the pea card. Then the resident trust to the resident debit card then there were a couple charges that were erroneous and suspicious. I acknowledged it and reported right from the get go. After that did the investigation, and she was suspended. There were multiple people that said she was solid and I did not have to worry, then I was scared that I had to, then that she was misappropriating funds. I thought I was going to get in trouble. I reported it and reported to my supervisor. Then we met with Staff #148 and said that we have suspicion, and we have an investigation to follow, do you have any receipts. We were able to see a hotel stay. Resident #75 did not have an [NAME], no device and nothing to use to listen on (for the audio books) then the police did the investigation and when they asked for a lot more evidence then requested more records for other people so it was provided. Staff #148 was terminated for not following policy/procedure. During the investigation, Staff #148 found out I was calling former jobs and friends of Staff #148 still worked there and then tipped Staff #148 off. I do not know if they were in on it. Can only prove there was misappropriation through Staff #148. The detective was working with me and asked for more records. A forensic account was brought in, there were some dead ends and some rabbit holes. I have not been privy to all of the information. There was an interview and the detective tried to present some evidence but was told not to by the defense attorney. The total amount is not known.Review of the policy titled, Resident Rights/Dignity: Resident Rights, Version 051123 (Policies and Procedures in effect on January 1, 2024), revealed that 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect, misappropriation of resident property and exploitation.

Number of residents sampled:16Number of residents cited:13The facility failed to ensure the accounting and records of resident funds for 13 of 16 residentsBased on interviews, review of clinical records, facility 5 day report to the state agency (SA) and review of facility policy and procedures, the facility failed to ensure the accounting and records of resident trust funds for 13 residents out of 16 (#3, #5, #18, #31, #32, #58, #63, #75, #76, #77, #86, #95, #96, #108, #109, #110). The deficient practice could result in continued misappropriation/exploitation of other residents.Findings Include:Resident #108 was admitted to the facility on [DATE], with diagnoses that included hypertension, dementia, muscle weakness and history of falling.A review of the minimum data set (MDS) dated [DATE] for Resident #108 revealed a brief interview mental status (BIMS) score of 09, which shows moderate cognitive impairment.Resident #75 was admitted to the facility on [DATE], with diagnoses that included dementia without behavioral disturbance, major depressive disorder, myocardial infarction and anxiety disorder.A review of the minimum data set (MDS) dated [DATE], for Resident #75 revealed a brief interview mental status (BIMS) score of 03, which shows severe cognitive impairment.An interview was conducted on August 6, 2025 at 1016 am with Public Fiduciary Lead (PFL), who works under the court appointed Adult Public Fiduciary (APF). On July 27, 2022, the court appointed APF to be the fiduciary over Resident #108. The new administrator, executive director Staff #147 contacted us and informed the office of a situation. He became aware of some inconsistencies, looked and found theft. The police, adult protective services (APS), department of health services (DHS) were contacted and business office manager Staff #148 was terminated.An interview was conducted on August 6, 2025 at 1029 a.m. with APF for Resident #108. Based on a short time, Staff #148 was putting transactions as spending money due to dementia. Some expenses included: digital expense $498.29, flowers at $72, food snack shop Instacart $289.71, coloring books and pencils 1542.45, miscellaneous items- basketball hoop, description not for figurines, cushion covers $1254.38, $810.76 and $4067.69. For Resident #75, expenses included a grill, cupcakes, macaroons, Apple TV, Prime Video, remote control monster trucks, miniature figurines, basketball hoop items, gumball machine, decorations. Restitution total $20,565.93. Food, Amazon, pictures, flowers $1157.82. That was from June 7, 2022 through June 30, 2024. He did not have any clothing or any items. Radio, clothing and a lot of purchases on Amazon totaling $9483.90. Purchases titled as shopping. Shopping sprees on bedding and clothing, $570. Resident #75 did not have a lot. There was a lot of Amazon, door dash, Sunny Skin-tanning place, Instacart, Target shopping for clocks, thermal water bottles, bedding items. Resident #75's purchases were going straight to Staff #148's use. Resident #75 did not have any of those items and we had to purchase bedding and clothing for him after going to his room at the facility to see the purchased items on his account.Review of the facility's 5 day report to the SA, showed that Resident #75's account had multiple purchases from Audible, Amazon and recurring purchases. Resident #75 was unable to be interviewed and a visual review was conducted of his room with none of items charged to his account being found.Resident #5 was admitted to the facility on [DATE], with an original admission date of October 12, 2020, with diagnoses that include respiratory failure, kidney failure, chronic obstructive pulmonary disease (COPD), muscle weakness, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side.A review of the minimum data set (MDS) dated [DATE] for Resident #5 revealed a brief interview mental status (BIMS) score of 15, which shows cognitive intact.An interview was conducted on August 8, 2025 at 907 a.m. with Resident #5 and revealed that Resident #5 was informed by the office of a $500 stay at a hotel. Resident #5 did not stay at a hotel and did not have a receipt for a hotel stay. The office did not have the receipt either. The court said that they will have to pay back the money and Staff #148 took other residents' money too.Review of the facility's 5 day report to the SA, showed that a receipt was procured in relation to a hotel stay on April 25, 2024 to April 28, 2024 at the Delta Phoenix Mesa Hotel. It was confirmed that the purchase was made using the resident trust fund debit card and an identical charge was matched to Resident #5's resident account in April. The dates correlated to Staff #148's daughters dance competition that was posted on social media. The dance competition website confirms that the hotel was used for participants that week as well.Resident #63 was admitted to the facility on [DATE], with diagnoses that include type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, anxiety.A review of the minimum data set (MDS) dated [DATE] for Resident #63 revealed a brief interview mental status (BIMS) score of 14, which shows cognitive intact.An interview was conducted on August 8, 2025 at 9:03 a.m. with Resident #63 and revealed that a month ago, was notified that someone had purchased a ring at Dillard's and things from Fast Eddy's. Resident #63 does not know the total amount used from the account, but it was someone who worked in the business office.Review of the facility's 5 day report submitted to the SA revealed that Dillard's was able to provide the exact item purchased based on the submitted receipt, a silver sized 11, men's ring with a cross. A post on social media was found of Staff #148's family member with a ring identical to the picture provided by Dillard's. A review showed that this purchase was applied to Resident #63's resident account. The resident was questioned regarding purchasing any new jewelry in the last couple months and stated she had not received anything and does not shop at Dillard's.Resident #77 was admitted to the facility on [DATE] with an original admission date of May 6, 2023, with diagnoses that include Alzheimer's disease, dementia, anxiety, type 2 diabetes mellitus, depression and a history of falling.A review of the minimum data set (MDS) dated [DATE] for Resident #77 revealed a brief interview mental status (BIMS) score of 03, which shows severe cognitive impairmentAn interview was conducted on August 6, 2025 at 1:19 p.m. with a family member of Resident #77 and revealed that the family members were notified of Resident #77 having $260 to $280 dollars taken from his account from Staff #148. The case is going to court because this was that person's second offense. 19 other people are involved.Resident #110 was originally admitted to the facility on [DATE] with diagnoses that include cerebral infarction with speech and language deficits, chronic kidney disease, major depressive disorder and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #110 revealed a brief interview mental status (BIMS) score of 11, which shows moderate cognitive impairment.An interview was conducted on August 6, 2025 at 2:11 p.m. with a family member of Resident #110 and revealed that the family member was notified after Resident #110 passed away that he had an outstanding bill of $18. Then was notified that Staff #148 took money from Resident #110. The family member stated that they could not understand how money was taken since Resident #110 had nothing and they let the $18 go. No amount was given as to how much was taken from Resident #110.Resident #18 was originally admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, dementia and legal blindness.A review of the minimum data set (MDS) dated [DATE] for Resident #18 revealed a brief interview mental status (BIMS) score of 11, which shows moderate cognitive impairment.An interview was conducted on August 6, 2025 at 12:36 p.m. with a financial power of attorney (FPOA) to resident #18 and revealed that the FPOA was notified of some discrepancies of Resident #18's account and it was reported right away. No clue as to how much was taken, but to ask Resident #18 because some days Resident #18 is sharp as a tac.An interview was conducted on August 12, 2025 at 10:02 a.m. with Resident #18 and revealed that someone stole money and does not know the amount. Three different figures were given and does not know which is right. The police came and told Resident #18 that someone from the facility took money from Resident #18's account.Resident #109 was originally admitted to the facility on [DATE] with diagnoses that include dementia, Alzheimer's disease, anxiety, major depressive disorder and repeated falls.A review of the minimum data set (MDS) dated [DATE] for Resident #109 revealed a brief interview mental status (BIMS) score of 00, which shows severe cognitive impairment.An interview was conducted on August 6, 2025 at 11:36 a.m. with a family member of Resident #109 and revealed that $1200 of Resident #109's share cost was put into the trust account and not the share account. Resident #109's family member never signed to have a trust account at the facility. Staff member #147 has been on top of this and is communicating as much as he can. This was also reported to the police, because if you do not report it, nobody else will and it can happen to someone else. Staff #148 did this at another facility and it went unreported.Resident #31 was originally admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, COPD, major depressive disorder, anxiety and obstructive sleep apnea.A review of the minimum data set (MDS) dated [DATE] for Resident #31 revealed a brief interview mental status (BIMS) score of 13, which shows cognitive intact.An interview was conducted on August 7, 2025 at 10:23 a.m. with Resident #31 and revealed that someone in the office stole $2000 from Resident #31 and that the person who stole the money does not work at the facility anymore. Money was taken from other residents. Staff #147 informed Resident #31 of the money being taken from his account.Resident #86 was originally admitted to the facility on [DATE] with diagnoses that include cerebral palsy, hypothyroidism, type 2 diabetes mellitus and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #86 revealed a brief interview mental status (BIMS) score of 15, which shows cognitive intact.An interview was conducted on August 7, 2025 at 1028 a.m. with Resident #86 and revealed that a lady some time ago a lady was taking money from the trust and $190 was taken from Resident #86. The case is ongoing and there are court dates. Around $40,000 has been taken from all the residents involved and another facility.Resident #95 was originally admitted to the facility on [DATE] with diagnoses that include anoxic brain damage, type 2 diabetes mellitus, anxiety disorder, major depressive disorder and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #95 revealed a brief interview mental status (BIMS) score of 08, which shows cognitive impairment.An interview was conducted on August 8, 2025 with Resident #95 and revealed that $100 had been taken from the trust account and has not been returned or replaced. Resident #95 had tried to purchase something from the store and the money was not there. Resident #95 now wears a lanyard to keep track of the card to the account.Review of documents received by the SA on August 8, 2025 about 08:05 a.m. revealed copies of resident trust accounts that were compromised by Staff #148. The documents included Residents #3, #5, #31, #58, #63, #75, #76, #77 and #95.Review of a document received by the SA on August 8, 2025 about 0805 a.m. titled Unofficial Report Staff #148 Misappropriation 08/08/2025, from Staff #147. The document included information of audits being conducted. Staff #147 interviewed Staff #130 which revealed that Staff #130 was fairly positive that Staff #148 was using resident funds inappropriately for personal use and was terrified to bring it the previous administrator due to the close relationship that Staff #148 had with him. Staff #130 was scared that any accusation or report would result in retaliation and/or termination as Staff #130 had witnessed favoritism towards Staff #148 in past conflicts. Staff #130 felt that Staff #148 was utilizing funds for personal use and gain. Receipts were not being produced for all charges during reconciliation. Staff #130 saw alleged purchases for items on resident accounts that align with personal purchases that Staff #148 had made. Examples included food purchases, gift items and beauty products that Staff #130 did not see given to the residents. Staff #130 expressed that she did not have all the pieces of the puzzle but had bank statements and resident trust transactions that would potentially prove that misappropriation was occurring.Staff #147 began comparing partial bank statements against resident trust transaction reports. Three resident accounts were found that had incomplete documentation and there was a need to verify the purchases for the residents. The residents were Resident #5, Resident #75 and Resident #63. On June 4, 2024 Staff #148 was suspended while an investigation for the suspicious charges continued which included: Resident #75 - multiple amazon purchases for audio books. Resident #5 - Hotel stay in Phoenix, AZ. Resident #63 - Jewelry purchase at Dillard's. Resident #75's account was chosen for review based on his cognitive deficit and the increased number of amazon purchases being assigned to his trust account without proper documentation or receipts. Many of the amazon books were not purchased through the facility amazon account. Resident #75 does not possess any device to utilize for listening and does not hold the cognitive capacity to confirm any of the purchases. Resident #63 had a purchase from Dillard's on her account. One receipt with out a resident signature (indicating that the resident signed for reception of the item) was taken to Dillard's to confirm the purchase. The store associate scanned the receipt and provided a picture of the item. It was a silver sized 11 men's ring with a cross on it. Resident #63 was questioned about receiving or requested any men's jewelry and had not. Staff member #148 remembered running into Staff member #147 and her family while shopping at Dillard's and Staff #148 informed they were shopping for a family member's graduation. A search on Staff #148's Instagram account showed a photo of a family member wearing a ring that appears to be the same ring from Dillard's. Resident #5 had a suspicious charge on his resident trust account. A large specific sum that was labelled as a correction with no details to support the transaction. An amount matching the charge on Resident #5's resident trust account was found as a line item listed was a hotel room. Staff #147 drove to Phoenix to confirm with hotel staff that Staff #148 was the only person associated with the room, that Staff #148 would need to provide photo ID to be able to check in, and the card was used for the stay. Another search on Instagram revealed that Staff #148's family had a dance competition held at that hotel the days of the booked room. Staff #148 also posted pictures with correlating dates to the stay. In conclusion it was found that Staff #148 failed to follow proper policies and procedures according to Haven Health's company standards. Staff #148 employment was terminated on 6/7/24. The Yuma Police Department (YPD) was notified on 6/4/24 and the facility has provided all evidence requested and is cooperating in the active investigation and case against Staff #148. A forensic accountant was used by YPD to investigate transactions and impact. Specific amounts for potential resident loss have not been provided or shared at this time. No resident has experienced a loss of care due to this incident. An interview was conducted on August 8, 2025 at 9:46 a.m. with Executive Director Staff #147 and revealed that when misappropriation occurs in the facility you report, start the investigation with all parties including the family/resident. Reporting to the four main which are the SA, police, ombudsman and APS. The POA and or guardian are also notified. The state would be notified of each resident and three residents were listed on the 5 day. The police started asking for more documents, more residents were involved. The misappropriation policy states we should be reporting those. Staff #147 met with Staff #130 regarding the trust accounts and showed proof. No resident had ever had that many charges on the resident account and Staff #130 showed Staff #147 how to read the bank statements and it took some time to read. Staff #147 did not know there was a resident debit card and started to look at Staff #147's purchasing card and business card and trying to match them up to the resident debit card and they were both in Staff #148's name and Staff #148 could not find any charges that were connected to her. Her business card and what charges were being made and the resident card statements and they were not matching. Then Staff #147 realized there was another card being used. Found a receipt and Staff #130 was right that receipts were not being turned in, the 4 digits did not match the pea card. Then the resident trust to the resident debit card then there were a couple charges that were erroneous and suspicious. I acknowledged it and reported right from the get go. After that did the investigation, and she was suspended. There were multiple people that said she was solid and I did not have to worry, then I was scared that I had to, then that she was misappropriating funds. I thought I was going to get in trouble. I reported it and reported to my supervisor. Then we met with Staff #148 and said that we have suspicion, and we have an investigation to follow, do you have any receipts. We were able to see a hotel stay. Resident #75 did not have an [NAME], no device and nothing to use to listen on (for the audio books) then the police did the investigation and when they asked for a lot more evidence then requested more records for other people so it was provided. Staff #148 was terminated for not following policy/procedure. During the investigation, Staff #148 found out I was calling former jobs and friends of Staff #148 still worked there and then tipped Staff #148 off. I do not know if they were in on it. Can only prove there was misappropriation through Staff #148. The detective was working with me and asked for more records. A forensic account was brought in, there were some dead ends and some rabbit holes. I have not been privy to all of the information. There was an interview and the detective tried to present some evidence but was told not to by the defense attorney. The total amount is not known.An interview was conducted on August 13, 2025 at 10:31 a.m. with ED Staff #147 and revealed that to make sure this does not happen again, they have implemented a system with two business office managers. One of the managers will do the resident trust, then signs off. Then the other manager will review and then sign off. Training on abuse and misappropriation continues, following the policy. If you don't report it, it can continue if abuse and misappropriation is not reported. Review of the policy titled, Resident Rights/Dignity: Resident Rights, Version 051123 (Policies and Procedures in effect on January 1, 2024), revealed that 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect, misappropriation of resident property and exploitation and r. have the facility manage his or her funds (if he or she wishes).

Number of residents sampled:14Number of residents cited:97The facility failed to ensure residents are free from misappropriation for 14 of 97 residents.Based on interviews, review of clinical records, facility 5 day report to the state agency (SA) and review of facility policy and procedures, the facility failed to ensure 14 residents out of 16 (#3, #5, #18, #31, #63, #75, #76, #77, #86, #95, #96, #108, #109, #110) were free from misappropriation by a staff member (#148). The deficient practice could lead to misappropriation of resident money and belongings by other staff members.-Findings include:Resident #108 was admitted to the facility on [DATE], with diagnoses that included hypertension, dementia, muscle weakness and history of falling.A review of the minimum data set (MDS) dated [DATE] for Resident #108 revealed a brief interview mental status (BIMS) score of 09, which shows moderate cognitive impairment.Resident #75 was admitted to the facility on [DATE], with diagnoses that included dementia without behavioral disturbance, major depressive disorder, myocardial infarction and anxiety disorder.A review of the minimum data set (MDS) dated [DATE], for Resident #75 revealed a brief interview mental status (BIMS) score of 03, which shows severe cognitive impairment.An interview was conducted on August 6, 2025 at 1016 am with Public Fiduciary Lead (PFL), who works under the court appointed Adult Public Fiduciary (APF). On July 27, 2022, the court appointed APF to be the fiduciary over Resident #108. The new administrator, executive director Staff #147 contacted us and informed the office of a situation. He became aware of some inconsistencies, looked and found theft. The police, adult protective services (APS), department of health services (DHS) were contacted and business office manager Staff #148 was terminated.An interview was conducted on August 6, 2025 at 1029 a.m. with APF for Resident #108. Based on a short time, Staff #148 was putting transactions as spending money due to dementia. Some expenses included: digital expense $498.29, flowers at $72, food snack shop Instacart $289.71, coloring books and pencils 1542.45, miscellaneous items- basketball hoop, description not for figurines, cushion covers $1254.38, $810.76 and $4067.69. For Resident #75, expenses included a grill, cupcakes, macaroons, Apple TV, Prime Video, remote control monster trucks, miniature figurines, basketball hoop items, gumball machine, decorations. Restitution total $20,565.93. Food, Amazon, pictures, flowers $1157.82. That was from June 7, 2022 through June 30, 2024. He did not have any clothing or any items. Radio, clothing and a lot of purchases on Amazon totaling $9483.90. Purchases titled as shopping. Shopping sprees on bedding and clothing, $570. Resident #75 did not have a lot. There was a lot of Amazon, door dash, Sunny Skin-tanning place, Instacart, Target shopping for clocks, thermal water bottles, bedding items. Resident #75's purchases were going straight to Staff #148's use. Resident #75 did not have any of those items and we had to purchase bedding and clothing for him after going to his room at the facility to see the purchased items on his account.Review of the facility's 5 day report to the SA, showed that Resident #75's account had multiple purchases from Audible, Amazon and recurring purchases. Resident #75 was unable to be interviewed and a visual review was conducted of his room with none of items charged to his account being found.Resident #5 was admitted to the facility on [DATE], with an original admission date of October 12, 2020, with diagnoses that include respiratory failure, kidney failure, chronic obstructive pulmonary disease (COPD), muscle weakness, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side.A review of the minimum data set (MDS) dated [DATE] for Resident #5 revealed a brief interview mental status (BIMS) score of 15, which shows cognitive intact.An interview was conducted on August 8, 2025 at 907 a.m. with Resident #5 and revealed that Resident #5 was informed by the office of a $500 stay at a hotel. Resident #5 did not stay at a hotel and did not have a receipt for a hotel stay. The office did not have the receipt either. The court said that they will have to pay back the money and Staff #148 took other residents' money too.Review of the facility's 5 day report to the SA, showed that a receipt was procured in relation to a hotel stay on April 25, 2024 to April 28, 2024 at the Delta Phoenix Mesa Hotel. It was confirmed that the purchase was made using the resident trust fund debit card and an identical charge was matched to Resident #5's resident account in April. The dates correlated to Staff #148's daughters dance competition that was posted on social media. The dance competition website confirms that the hotel was used for participants that week as well.Resident #63 was admitted to the facility on [DATE], with diagnoses that include type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, anxiety.A review of the minimum data set (MDS) dated [DATE] for Resident #63 revealed a brief interview mental status (BIMS) score of 14, which shows cognitive intact.An interview was conducted on August 8, 2025 at 9:03 a.m. with Resident #63 and revealed that a month ago, was notified that someone had purchased a ring at Dillard's and things from Fast Eddy's. Resident #63 does not know the total amount used from the account, but it was someone who worked in the business office.Review of the facility's 5 day report submitted to the SA revealed that Dillard's was able to provide the exact item purchased based on the submitted receipt, a silver sized 11, men's ring with a cross. A post on social media was found of Staff #148's family member with a ring identical to the picture provided by Dillard's. A review showed that this purchase was applied to Resident #63's resident account. The resident was questioned regarding purchasing any new jewelry in the last couple months and stated she had not received anything and does not shop at Dillard's.Resident #77 was admitted to the facility on [DATE] with an original admission date of May 6, 2023, with diagnoses that include Alzheimer's disease, dementia, anxiety, type 2 diabetes mellitus, depression and a history of falling.A review of the minimum data set (MDS) dated [DATE] for Resident #77 revealed a brief interview mental status (BIMS) score of 03, which shows severe cognitive impairmentAn interview was conducted on August 6, 2025 at 1:19 p.m. with a family member of Resident #77 and revealed that the family members were notified of Resident #77 having $260 to $280 dollars taken from his account from Staff #148. The case is going to court because this was that person's second offense. 19 other people are involved.Resident #110 was originally admitted to the facility on [DATE] with diagnoses that include cerebral infarction with speech and language deficits, chronic kidney disease, major depressive disorder and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #110 revealed a brief interview mental status (BIMS) score of 11, which shows moderate cognitive impairment.An interview was conducted on August 6, 2025 at 2:11 p.m. with a family member of Resident #110 and revealed that the family member was notified after Resident #110 passed away that he had an outstanding bill of $18. Then was notified that Staff #148 took money from Resident #110. The family member stated that they could not understand how money was taken since Resident #110 had nothing and they let the $18 go. No amount was given as to how much was taken from Resident #110.Resident #18 was originally admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, dementia and legal blindness.A review of the minimum data set (MDS) dated [DATE] for Resident #18 revealed a brief interview mental status (BIMS) score of 11, which shows moderate cognitive impairment.An interview was conducted on August 6, 2025 at 12:36 p.m. with a financial power of attorney (FPOA) to resident #18 and revealed that the FPOA was notified of some discrepancies of Resident #18's account and it was reported right away. No clue as to how much was taken, but to ask Resident #18 because some days Resident #18 is sharp as a tac.An interview was conducted on August 12, 2025 at 10:02 a.m. with Resident #18 and revealed that someone stole money and does not know the amount. Three different figures were given and does not know which is right. The police came and told Resident #18 that someone from the facility took money from Resident #18's account.Resident #109 was originally admitted to the facility on [DATE] with diagnoses that include dementia, Alzheimer's disease, anxiety, major depressive disorder and repeated falls.A review of the minimum data set (MDS) dated [DATE] for Resident #109 revealed a brief interview mental status (BIMS) score of 00, which shows severe cognitive impairment.An interview was conducted on August 6, 2025 at 11:36 a.m. with a family member of Resident #109 and revealed that $1200 of Resident #109's share cost was put into the trust account and not the share account. Resident #109's family member never signed to have a trust account at the facility. Staff member #147 has been on top of this and is communicating as much as he can. This was also reported to the police, because if you do not report it, nobody else will and it can happen to someone else. Staff #148 did this at another facility and it went unreported.Resident #31 was originally admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, COPD, major depressive disorder, anxiety and obstructive sleep apnea.A review of the minimum data set (MDS) dated [DATE] for Resident #31 revealed a brief interview mental status (BIMS) score of 13, which shows cognitive intact.An interview was conducted on August 7, 2025 at 10:23 a.m. with Resident #31 and revealed that someone in the office stole $2000 from Resident #31 and that the person who stole the money does not work at the facility anymore. Money was taken from other residents. Staff #147 informed Resident #31 of the money being taken from his account.Resident #86 was originally admitted to the facility on [DATE] with diagnoses that include cerebral palsy, hypothyroidism, type 2 diabetes mellitus and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #86 revealed a brief interview mental status (BIMS) score of 15, which shows cognitive intact.An interview was conducted on August 7, 2025 at 1028 a.m. with Resident #86 and revealed that a lady some time ago a lady was taking money from the trust and $190 was taken from Resident #86. The case is ongoing and there are court dates. Around $40,000 has been taken from all the residents involved and another facility.Resident #95 was originally admitted to the facility on [DATE] with diagnoses that include anoxic brain damage, type 2 diabetes mellitus, anxiety disorder, major depressive disorder and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #95 revealed a brief interview mental status (BIMS) score of 08, which shows cognitive impairment.An interview was conducted on August 8, 2025 with Resident #95 and revealed that $100 had been taken from the trust account and has not been returned or replaced. Resident #95 had tried to purchase something from the store and the money was not there. Resident #95 now wears a lanyard to keep track of the card to the account.An interview was conducted on August 7, 2025 at 3:38 p.m. with business office manager Staff #130 and revealed that about 1.5 years into the job as the assistant in the business office, Staff #130 noticed that things were not okay with the trust account. Staff #130 did not report because the previous executive director would have fired Staff #130 before getting everything straightened out, due to the friendship between the former executive director and staff #148. Staff #130 stated that it was a personal opinion because that type of thing only happens in the movies. Staff #130 also revealed that if you do not report any suspicion of misappropriation, you can get in trouble, it will affect the residents, and will continue to happen if you do not speak up.Review of documents received by the SA on August 8, 2025 about 08:05 a.m. revealed copies of resident trust accounts that were compromised by Staff #148. The documents included Residents #3, #5, #31, #58, #63, #75, #76, #77 and #95.Review of a document received by the SA on August 8, 2025 about 0805 a.m. titled Unofficial Report Staff #148 Misappropriation 08/08/2025, from Staff #147. The document included information of audits being conducted. Staff #147 interviewed Staff #130 which revealed that Staff #130 was fairly positive that Staff #148 was using resident funds inappropriately for personal use and was terrified to bring it the previous administrator due to the close relationship that Staff #148 had with him. Staff #130 was scared that any accusation or report would result in retaliation and/or termination as Staff #130 had witnessed favoritism towards Staff #148 in past conflicts. Staff #130 felt that Staff #148 was utilizing funds for personal use and gain. Receipts were not being produced for all charges during reconciliation. Staff #130 saw alleged purchases for items on resident accounts that align with personal purchases that Staff #148 had made. Examples included food purchases, gift items and beauty products that Staff #130 did not see given to the residents. Staff #130 expressed that she did not have all the pieces of the puzzle but had bank statements and resident trust transactions that would potentially prove that misappropriation was occurring.Staff #147 began comparing partial bank statements against resident trust transaction reports. Three resident accounts were found that had incomplete documentation and there was a need to verify the purchases for the residents. The residents were Resident #5, Resident #75 and Resident #63. On June 4, 2024 Staff #148 was suspended while an investigation for the suspicious charges continued which included: Resident #75 - multiple amazon purchases for audio books. Resident #5 - Hotel stay in Phoenix, AZ. Resident #63 - Jewelry purchase at Dillard's. Resident #75's account was chosen for review based on his cognitive deficit and the increased number of amazon purchases being assigned to his trust account without proper documentation or receipts. Many of the amazon books were not purchased through the facility amazon account. Resident #75 does not possess any device to utilize for listening and does not hold the cognitive capacity to confirm any of the purchases. Resident #63 had a purchase from Dillard's on her account. One receipt with out a resident signature (indicating that the resident signed for reception of the item) was taken to Dillard's to confirm the purchase. The store associate scanned the receipt and provided a picture of the item. It was a silver sized 11 men's ring with a cross on it. Resident #63 was questioned about receiving or requested any men's jewelry and had not. Staff member #148 remembered running into Staff member #147 and her family while shopping at Dillard's and Staff #148 informed they were shopping for a family member's graduation. A search on Staff #148's Instagram account showed a photo of a family member wearing a ring that appears to be the same ring from Dillard's. Resident #5 had a suspicious charge on his resident trust account. A large specific sum that was labelled as a correction with no details to support the transaction. An amount matching the charge on Resident #5's resident trust account was found as a line item listed was a hotel room. Staff #147 drove to Phoenix to confirm with hotel staff that Staff #148 was the only person associated with the room, that Staff #148 would need to provide photo ID to be able to check in, and the card was used for the stay. Another search on Instagram revealed that Staff #148's family had a dance competition held at that hotel the days of the booked room. Staff #148 also posted pictures with correlating dates to the stay. In conclusion it was found that Staff #148 failed to follow proper policies and procedures according to Haven Health's company standards. Staff #148 employment was terminated on 6/7/24. The Yuma Police Department (YPD) was notified on 6/4/24 and the facility has provided all evidence requested and is cooperating in the active investigation and case against Staff #148. A forensic accountant was used by YPD to investigate transactions and impact. Specific amounts for potential resident loss have not been provided or shared at this time. No resident has experienced a loss of care due to this incident. An interview was conducted on August 8, 2025 at 9:46 a.m. with Executive Director Staff #147 and revealed that when misappropriation occurs in the facility you report, start the investigation with all parties including the family/resident. Reporting to the four main which are the SA, police, ombudsman and APS. The POA and or guardian are also notified. The state would be notified of each resident and three residents were listed on the 5 day. The police started asking for more documents, more residents were involved. The misappropriation policy states we should be reporting those. Staff #147 met with Staff #130 regarding the trust accounts and showed proof. No resident had ever had that many charges on the resident account and Staff #130 showed Staff #147 how to read the bank statements and it took some time to read. Staff #147 did not know there was a resident debit card and started to look at Staff #147's purchasing card and business card and trying to match them up to the resident debit card and they were both in Staff #148's name and Staff #148 could not find any charges that were connected to her. Her business card and what charges were being made and the resident card statements and they were not matching. Then Staff #147 realized there was another card being used. Found a receipt and Staff #130 was right that receipts were not being turned in, the 4 digits did not match the pea card. Then the resident trust to the resident debit card then there were a couple charges that were erroneous and suspicious. I acknowledged it and reported right from the get go. After that did the investigation, and she was suspended. There were multiple people that said she was solid and I did not have to worry, then I was scared that I had to, then that she was misappropriating funds. I thought I was going to get in trouble. I reported it and reported to my supervisor. Then we met with Staff #148 and said that we have suspicion, and we have an investigation to follow, do you have any receipts. We were able to see a hotel stay. Resident #75 did not have an [NAME], no device and nothing to use to listen on (for the audio books) then the police did the investigation and when they asked for a lot more evidence then requested more records for other people so it was provided. Staff #148 was terminated for not following policy/procedure. During the investigation, Staff #148 found out I was calling former jobs and friends of Staff #148 still worked there and then tipped Staff #148 off. I do not know if they were in on it. Can only prove there was misappropriation through Staff #148. The detective was working with me and asked for more records. A forensic account was brought in, there were some dead ends and some rabbit holes. I have not been privy to all of the information. There was an interview and the detective tried to present some evidence but was told not to by the defense attorney. The total amount is not known.Review of the policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Version 051123 (Policies and Procedures in effect on January 1, 2024), revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

Number of residents sampled:16Number of residents cited:13The facility failed to ensure the implementation of abuse misappropriation policy for 13 of 16 residentsBased on interviews, review of clinical records, facility 5 day report to the state agency (SA) and review of facility policy and procedures, the facility failed to ensure the implementation of their abuse/misappropriation policy for 13 residents out of 16 (#3, #5, #18, #31, #32, #58, #63, #75, #76, #77, #86, #95, #96, #108, #109, #110). The deficient practice could result in continued misappropriation/exploitation of other residents.Findings Include:An interview was conducted on August 7, 2025 at 3:12 p.m. with Certified Nursing Assistant (CNA) Staff #63 and revealed that when a resident has concerns over missing money or items, the staff will check with the business office, look in the resident room, then if can not find it, report it to the group.An interview was conducted on August 7, 2025 at 3:22 p.m. with Licensed Practical Nurse (LPN) Staff #5 and revealed that when a resident says they are missing money or items, you go with the resident to their room, ask when they last had it. Then go to the manager, business office or ask the CNAs. Investigate what happened, notify the administrator, Director of Nursing (DON), report to the state and ombudsman.An interview was conducted on August 7, 2025 at 3:38 p.m. with business office manager Staff #130 and revealed that about 1.5 years into the job as the assistant in the business office, Staff #130 noticed that things were not okay with the trust account. Staff #130 did not report because the previous executive director would have fired Staff #130 before getting everything straightened out, due to the friendship between the former executive director and staff #148. Staff #130 stated that it was a personal opinion because that type of thing only happens in the movies. Staff #130 also revealed that if you do not report any suspicion of misappropriation, you can get in trouble, it will affect the residents, and will continue to happen if you do not speak up.An interview was conducted on August 8, 2025 at 09:46 a.m. with Executive Director (ED) Staff #147 and revealed that when there is an allegation of misappropriation in the facility, you notify the four main parties. State Agency (SA), police, Adult Protective Services (APS) and the Ombudsman. Also, the Power of Attorney (POA) and guardian. Three residents were listed on the 5 day report to the SA (Residents #5, #63 and #75). The following day the police started their investigation. The police started asking for more documents. The policy states we should be reporting those (misappropriation). The findings were reported to the supervisor of Staff #147. An interview was conducted on August 13, 2025 at 10:17 a.m. with Director of Nursing (DON) Staff #126 and revealed that when an allegation of abuse/misappropriation occurs, you make sure the resident is safe, then notify the appropriate entities and start investigating. Abuse, neglect and misappropriation training is done at least annually and any time there is a concern or allegation.An interview was conducted on August 13, 2025 at 10:31 a.m. with ED Staff #147 and revealed that to make sure this does not happen again, they have implemented a system with two business office managers. One of the managers will do the resident trust, then signs off. Then the other manager will review and then sign off. Training on abuse and misappropriation continues, following the policy. If you don't report it, it can continue if abuse and misappropriation is not reported.Review of the facility policy Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Version 051123 (Policies and Procedures in effect on January 1, 2024), revealed that section 2 reads: Develop and implement policies and protocols to prevent and identify: theft, exploitation or misappropriation of resident property. Section 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Section 9. Investigate and report any allegations with timeframes required by federal requirements.

Number of residents sampled:16Number of residents cited:13The facility failed to ensure the reporting of alleged violations for 13 of 16 residents.Based on interviews, review of clinical records, facility 5 day report to the state agency (SA) and review of facility policy and procedures, the facility failed to ensure the reporting of misappropriation/exploitation for 13 residents out of 16 (#3, #5, #18, #31, #32, #58, #63, #75, #76, #77, #86, #95, #96, #108, #109, #110). The deficient practice could result in continued misappropriation/exploitation of other residents.Findings Include:An interview was conducted on August 7, 2025 at 3:38 p.m. with business office manager Staff #130 and revealed that about 1.5 years into the job as the assistant in the business office, Staff #130 noticed that things were not okay with the trust account. Staff #130 did not report because the previous executive director would have fired Staff #130 before getting everything straightened out, due to the friendship between the former executive director and staff #148. Staff #130 stated that it was a personal opinion because that type of thing only happens in the movies. Staff #130 also revealed that if you do not report any suspicion of misappropriation, you can get in trouble, it will affect the residents, and will continue to happen if you do not speak up.An interview was conducted on August 8, 2025 at 09:46 a.m. with Executive Director (ED) Staff #147 and revealed that when there is an allegation of misappropriation in the facility, you notify the four main parties. State Agency (SA), police, Adult Protective Services (APS) and the Ombudsman. Also the Power of Attorney (POA) and guardian. Three residents were listed on the 5 day report to the SA (Residents #5, #63 and #75). The following day the police started their investigation. The police started asking for more documents. The policy states we should be reporting those (misappropriation).An interview was conducted on August 13, 2025 at 10:31 a.m. with ED Staff #147 and revealed that to make sure this does not happen again, they have implemented a system with two business office managers. One of the managers will do the resident trust, then signs off. Then the other manager will review and then sign off. Training on abuse and misappropriation continues, following the policy. If you don't report it, it can continue if abuse and misappropriation is not reported.An interview was conducted on August 13, 2025 at 10:17 a.m. with Director of Nursing (DON) Staff #126 and revealed that when an allegation of abuse/misappropriation occurs, you make sure the resident is safe, then notify the appropriate entities and start investigating. Abuse, neglect and misappropriation training is done at least annually and any time there is a concern or allegation.Review of the facility policy Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Version 051123 (Policies and Procedures in effect on January 1, 2024), revealed that section 2 reads: Develop and implement policies and protocols to prevent and identify: theft, exploitation or misappropriation of resident property. Section 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Section 9. Investigate and report any allegations with timeframes required by federal requirements.

Based on observations, staff interviews and policy review, the facility failed to ensure that medications were not left at the bedside for three residents (#86 and #93). The deficient practice could result in harm to the residents, and/or visitors who have access to medications. Findings include: -Resident #93 was admitted on [DATE] diagnosis included pneumonia, acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, chronic combined systolic (congestive) and diastolic (congestive) heart failure, and type 2 diabetes mellitus. The quarterly Admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that resident is cognitively intact. Resident #93 care plan did not address that resident is able to self-administer medication Review of the physician’s orders revealed no orders to self-administer medications. Review of progress note revealed no interdisciplinary meeting for self-administer medication. Review physician’s orders had start order of July 08, 2025 at 11:15AM for Wound care, abdomen, cleanse with Bath Wipes, pat dry, apply a liberal amount of miconazole nitrate 2% powder topical every shift as needed. Review of the assessments revealed not assessed to self-administer medications. An observation was conducted on August 05, 2025 at 10:37AM in Resident #190’s room and revealed that the resident was lying in his bed, table on the side of resident 93’s bed there was red tube laying with cap closed. Resident #93 stated that it is tube for rash and itchiness. He stated that sometimes staff members the tube very close to him or on the table. Immediately staff member was called. An interview was conducted on August 05, 2025 at 12:38 PM with Certified Nurse Assistance (CNA/staff #111), who identified the red tube as 3 oz of antifungal powder. Staff #111 stated this is not supposed to be left at the bedside. She stated that risk would having antifungal powder left on bedside would be that other resident could grab the powder and not being applied properly. An interview was conducted on August 05, 2025 at 12:42 AM with the Licensed Practical Nurse (LPN/staff #146), who identified the tube as antifungal powder. She stated that it is not supposed be left at the bedside. The risk of having antifungal powder left at the beside would that resident could misuse it and resident can administer incorrectly. An interview was conducted on August 13, 2025 at 11:43AM with Director of Nursing (DON/ Staff #126), who stated that their facility process is not have any medication left at the bedside. DON stated that if resident wants to self-administer, they would first require assessment, safe box will be given to resident to store medication, then resident will be educated to let the nurse know when they took the medication so they put on the chart. She stated that resident #93 does not have self-administer orders to use antifungal cream and no assessment is done for him. DON stated that antifungal cream should not been left at the bedside. She stated that there will risk pose to having antifungal powder left at the bedside such as another resident getting hold of it and intended resident can use it inappropriately. Staff #126 stated that having medication left at the bedside does not meet their facility policy. Reviewed the policy titled “Administering Medication” Revised date January 1, 2024 revealed Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. A review of the Clinical and Med-Pass Policies: Medications effective January 1, 2024, revealed that topical medications used in treatments are recorded on the resident’s treatment record (TAR). The policy further revealed that residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. -Resident # 86 was admitted on [DATE], discharged on September 16, 2022 and readmitted on [DATE] with diagnosis including: cerebral palsy, hypothyroidism, abnormal results of lever function studies, hyperlipidemia, essential hypertension, allergic rhinitis, Type II Diabetes with hyperglycemia, diabetic retinopathy and polyneuropathy, obstructive sleep apnea, pancytopenia, iron deficiency anemia, non-alcoholic steatohepatitis, unspecified cirrhosis of the liver, diverticulosis of intestine, limitation of activities due to disability, other reduced mobility, abnormal posture, muscle weakness, personal history of COVID-19 and chronic superficial gastritis without bleeding. The resident remains at the facility. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive deficits. The Patient Health Questionnaire (PHQ-2) revealed a score of 00, indicating no need for further mood assessment. Section E of the MDS revealed that the resident exhibited no delusions, hallucinations, physical or verbal behaviors, and no wandering or rejection of care. The MDS revealed no deficits in functional abilities of the upper or lower extremities; however, due to the diagnosis of Cerebral Palsy, the resident used an electric wheelchair for mobility purposes. The MDS revealed that the resident required set-up assistance for eating, substantial assistance with oral hygiene and upper body dressing, and dependence in lower body dressing and footwear application. A review of physician orders revealed use of mobility bars for bed mobility, full code status, incentive spirometry, chest percussion using percussion cup to assist in breaking up secretions and wound care to buttocks that specified: apply stoma powder, wipe away excess, cover with triad paste every shift and after incontinent episodes to prevent moisture-associated skin damage (MASD), and shearing every shift. There were no observed changes in medication orders. A review of physician orders revealed no orders for self-administered medications. A review of the comprehensive care plan dated June 27, 2025, revealed that the resident had bowel and bladder incontinence and was at risk for skin breakdown. The care plan further revealed that the resident had potential for functional decline due to the diagnosis of Cerebral Palsy, and goals that included that the resident would be free of complications related to hypertension, diabetes mellitus, and anemia. Further, the care plan revealed no evidence that the resident was authorized to self-administer medications. A review of the resident’s skin care assessment dated [DATE] revealed a new skin abrasion to the right buttocks area with no pressure injury. A review of the resident’s Treatment Administration Record revealed no deficits in incontinence or skin care treatments. A review of the resident’s Medication Administration Record revealed no deficits in medication administration. An observation was conducted on August 5, 2025 at 12:05 PM that revealed an unlabeled medication cup approximately 1/2 full of thick, white ointment located on an overbed table holding a number of the resident’s personal items at the resident’s bedside. The resident stated that she believed it contained triad cream that was used following the changing of incontinent briefs to treat a “shear” injury. Also observed on the bedside was a bottle of ketoconazole shampoo that was labeled with an illegible prescription label. An interview was conducted with Certified Nursing Assistant (CNA), Staff # 42, on August 5, 2025 at 12:10 PM. The CNA stated that residents cannot have medications at the bedside and that if they were seen, they would be removed from the room and taken to the nurse or a medication technician in the hall. Staff # 42 stated that it is the practice of staff to check for medications at bedside during tray checks, and defined medication as tablets, inhalants, or topicals. The CNA stated that the risk of finding medications at the bedside is that someone else may take them. An interview was conducted with Licensed Practical Nurse (LPN), Staff #146, on 8/5/2025 at 1215 PM. The LPN stated that medications at bedside could be anything that the doctor ordered that has an intervention and outcome. However, the LPN stated that no over-the-counter medicines are allowed at bedside. Staff # 146 stated that medications at the bedside that are unlabeled do not meet her expectations as the risk could lead to the medication not being taken for the intended purpose, drug interactions, or other residents taking the medication. Upon return to the room on August 5, 2025 at 12:38 PM, the medication cup containing the medication was observed to be in the resident’s wastebasket below the overbed table where it was previously located. Staff #87, Certified Medication Assistant (CMA), was asked to accompany the surveyor to identify the medication in the waste basket. An interview was conducted with the CMA, who stated that in her role, she checks medication, removes it from the medication cart, and carries it to the resident to administer it. Staff #87 stated that if she found unlabeled medication at the bedside, she would ask the nurse or ‘toss it’ but would not discard the medication in the resident’s room. When asked to identify the substance in the medication cup, the CMS stated that it appeared only to be zinc used as a skin barrier, as it “looks like bottom cream, but I cannot be certain.” The CMA stated that because she was not sure what the medication was, she could not identify the potential risk to the resident, but stated that she did not believe that it would cause harm. An interview was conducted on August 6, 2025 at 09:20 AM with Registered Nurse (RN), Staff # 108 who stated that medication administration is guided by the six rights of medication administration. The RN stated that she checks three times before administering medications; first checking the medication order, then checking the medication when removing it from the cart, and finally checking again when leaving the cart before taking it to the resident. Staff # 108 stated that if the medication is for oral administration, she would assess the resident’s ability to swallow and position them or crush the medication if needed and indicated. The RN stated that when using topical medications, she obtains the medication from the designated medication in the medication cart, and if a large tube or tub, places a small amount into a medication cup to take with her into the room. If the medication is in a small tube or container and the resident is in a private room, the medication may be taken into the room. The RN stated that following administration of the topical medication, she would throw the medication cup and gloves into the resident’s trash can and then bag the trash and remove it by carrying it to place in the trash in the dirty utility room. Staff # 108 stated that finding medication in a resident’s room would not meet her expectations, as the risk to residents would be that the resident may apply the medication to an area that didn’t need it, or someone could remove it and use it when it was not ordered. An interview was conducted with the Director of Nursing (DON), Staff # 32, on August 7, 2025 at 11:21 AM, who stated that the resident must be assessed for their ability to self-administer medications correctly. If they pass the assessment, orders are obtained and the item is care planned and reviewed quarterly, or sooner if there is a change in condition. Medications need to be secured at all times, and residents are not allowed to administer narcotics or any medications that could pose a danger to themselves or others. Having unlabeled medications at the bedside would not meet her expectations. The DON stated that the risk of this would be that someone else could find and use them when they were not prescribed.

Based on observations, staff interviews, and policy review, the facility failed to ensure food items were labeled and dated, and food was prepared under sanitary conditions. The deficient practice could increase the risk of foodborne illness.Findings include:Regarding food labeling and dating:During the initial kitchen observation conducted on August 5, 2025, at 10:52 a.m., a small, light-colored round cake was found in the walk-in freezer. Upon inspection of the cake, it was noted that the cake was past its expiration date of 7/24. Additionally, a clear, plastic bag containing French toast sticks and another clear, plastic bag containing cinnamon rolls were found not marked with use-by or expiration dates. Upon verification that the cake had expired and the bags containing the French toast sticks and cinnamon rolls were undated, the three items were immediately removed from the freezer and disposed of in the trash.An interview with the Dietary Aide (staff #100) was conducted on August 5, 2025, at 10:58 a.m. He was asked about the policy regarding dates listed on food items. He responded that everything should be labeled and should have a use-by date. He was then asked what the concern is if an item is not used by the expiration date. He responded that the food could go bad. He was then asked what risk that was to the resident. He responded that the resident could get sick.An interview with Dietary Manager (staff #26) was conducted on August 7, 2025, at 1:16 p.m. She was asked what the expectation is for food storage. She replied that all food must be dated. They get it, put it up, mark it, date it, first in, first out. If it is taken out of the box, it has to be dated. She was then asked if there is a risk if the food is not dated. She replied yes. When asked what the risk is, she said that whoever eats it could get sick. She was then asked what if there was something past the expiration date. She said that it would get thrown out. When asked if there was a risk if the expired food was eaten, she responded that someone could get sick. The Executive Director (Staff #147) was interviewed on August 7, 2025, at 1:29 PM. The Executive Director was asked what his expectations were for food storage. His response was making sure that things were dated or labeled, items defrosting are on the bottom shelf, making sure things that could drip are on the bottom shelf, making sure things aren't mixed, and making sure containers are closed completely. He was then asked what the risk is if items aren't properly dated in the fridge or freezer, to which he replied foodborne illness and adverse reactions. When asked what should be done if a food item was discovered that had expired in 2024, he responded that it should be discarded. The facility's policy titled Food Storage and Date Marking states that dates for items will be checked prior to use, and expired items discarded. Furthermore, the policy indicated that all foods will be checked to ensure that they are consumed by their use-by dates or discarded. Regarding kitchen sanitation and conditions:During a puree observation on August 7, 2025, at 11:05 AM, a cook (Staff #54) was observed to use a bare hand to remove the blades of a Ninja brand blender after it was used to puree noodles. When the incident was noted, the kitchen staff immediately disposed of the contaminated food and took the Ninja blender and blades to be washed and sanitized. She then stated that she usually wears gloves. She then attempted to make a puree a second time using the Robot Coup. Upon completion of the puree cycle on the Robot Coup, the food was then transferred to a container. She then removed the blades from the Robot Coup with a bare hand. When the second incident was noted, the kitchen staff immediately disposed of the contaminated food and took the Robot Coup blender and blades to be washed and sanitized. The dry Ninja brand blender was then used, and the puree was completed without incident. An interview with Dietary Manager (staff #26) was conducted on August 7, 2025, at 1:16 p.m. [NAME] was asked what the expectations are for the puree process. She responded that her expectations are that they do exactly as trained. She was then asked what that entails, to which she said, always wear gloves. The equipment has to be clean and dry. When she was asked what the risk is of putting your hand in a turned-off food processor, she answered cross-contamination.The Executive Director (Staff #147) was interviewed on August 7, 2025, at 1:29 PM. The Executive Director was asked what his expectations were for food safety. He responded that food should be prepped properly and at a safe temperature. He was then asked if he would have concerns if someone reached their bare hands into a processor. He replied with yes. When asked what risk that would pose, he replied with risk-safety and infection control, cleanliness, and maintaining a sanitary environment.The facility's policy titled Bare Hand Contact with Food and Use of Plastic Gloves states that single-use gloves will be worn when handling food directly with hands to ensure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. The policy also says that staff will use clean barriers such as single-use gloves, tongs, deli paper, and spatulas when handling food. Furthermore, the policy states that clean barriers such as single-use gloves are to be used anytime hands would otherwise touch food directly.

Number of residents sampled:26Number of residents cited:1The facility failed to ensure that the medical record for 1 resident (#107) out of 26 was complete and accurate.Based on resident and staff interviews, review of the clinical record, facility documentation, and policy, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete, accurately documented, and readily accessible for one resident (#107). The deficient practice could result in miscommunication between health care providers, leading to delayed or incorrect care and inappropriate treatment planning.Findings Include:Resident # 107 was initially admitted to the facility on [DATE] and discharged on 2/18/2025 with diagnoses that included: chronic obstructive pulmonary disease, age-related osteoporosis with current pathological fracture of the vertebrae, bipolar disorder, atherosclerotic heart disease, chronic diastolic heart failure, morbid obesity, hypertensive heart disease, difficulty in walking, retention of urine, due to obstructive and reflux uropathy, depression, anxiety disorder and non-ST elevation myocardial infarction (NSTEMI).A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Mental Status Interview (BIMS) score of 14, indicating no cognitive impairment. The MDS revealed that the resident had no hallucinations, delusions, verbal behaviors directed towards others, and no behavioral symptoms not directed toward others, such as hitting or scratching of self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds. The MDS further stated that the resident exhibited physical behavioral symptoms directed toward others, such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually on 1-3 days, and revealed that the resident demonstrated no rejection of care or exit-seeking behaviors. The MDS further revealed that the resident used a manual wheelchair and indicated no functional impairment of upper or lower extremities. The MDS revealed that resident #107 had an indwelling urinary catheter, smoked, and used oxygen through a nasal canula.A review of the resident's Comprehensive Care Plan dated 9/8/2023 revealed that the resident had an actual or potential problem with psychosocial well-being due to anxiety, with a related goal of verbalization of feelings related to emotional state by review date. Interventions related to this goal included: allowing the resident time to answer questions and verbalize feelings, perceptions, and fears, assisting, encouraging, and supporting the resident to set realistic goals, and to encouraging participation from resident who depends on others to make their own decisions. The Care Plan further revealed that the resident had a mood problem related to anxiety and depression with a related intervention to observe/monitor/record/report to MD the risk for harming others, increased anger, labile mood or agitation, or if the resident feels threatened by others of has thoughts of harming someone, possession of weapons or objects that could be used as weapons. The Care Plan revealed that the resident was at risk for resident-to-resident altercation due to lack of awareness when driving the chair backwards despite staff education. The Care Plan further revealed additional risks for resident-to- resident altercations due to impulsiveness despite staff redirection, including hitting staff when redirected.A review of physician orders dated 2/3/2025 revealed that the resident was placed on Buspar and duloxetine related to increased agitation and behaviors. A review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no omissions or inconsistencies. A review of the progress note dated 6/3/2025 revealed that a staff member was called to respond to an incident that occurred during the resident's scheduled activities, in which another resident was involved. The physician's progress note dated 5/14/2025 revealed that staff reported that the resident got into an argument about the weather that escalated to physical aggression with another resident; however, the resident's record revealed no prior incident describing the event that occurred on 5/12/2025. A review of the Weekly Skin Check and Wound assessment dated [DATE] revealed a skin assessment notation marked as ‘yes' for Does resident have skin impairments -new and/or ongoing? The remainder of the document contained no additional information. No progress note was identified for the resident- to-resident abuse allegation that occurred on 5/12/2024.An interview was conducted with Licensed Practical Nurse (LPN), Staff # 147, on 8/13/2025 at 09:18 AM. The LPN stated that if a resident had a possible change in status following a fall or following an altercation between residents, staff would separate the residents and assess them for injury. Staff # 147 stated that the assessment would include taking vital signs, conducting a check of their skin to ensure they did not get hurt. The LPN stated that when the resident assessment was completed, she would follow the facility chain of command to first notify the unit manager and then the Assistant Director of Nursing, followed by the Director of Nursing and the facility Administrator. The LPN described the process of skin assessment as wheeling the resident to their room or an available open room, changing the resident into a gown, and completing a full-body observation while looking for any bruising or skin tears. The LPN stated that the observation would be comprehensive because while looking for bumps and bruising, even a scratch to the cornea could happen, so we check head to toe, because you just never know. When asked how the skin assessment is documented in the resident's electronic health record, the LPN stated that it would be entered in a form following completion of the assessment. The LPN was asked to pull up the record for resident #107 and stated that H on the form represented history. The LPN stated that the skin assessment showed positive entry, noting yes, but revealed no further information on what was reported. The LPN then demonstrated the correct process for entering a new skin assessment. The LPN stated that if a skin assessment had new findings or if there was an incident of resident-to-resident abuse resulting in injury, there would be a progress note entered describing the incident. Staff # 147 searched for a progress note in resident #107's electronic health record, but found no entry for the event that was reported during the week of 5/20/25 through 5/27/2025. The LPN stated that not finding these documents would not meet her expectations, as it would contain additional information. The LPN further stated, that the progress note should be in there.An interview was conducted on 8/13/2025 at 09:59 AM with the Director of Nursing (DON), Staff # 126. The DON stated that a skin assessment is not always required as long as there is documentation in the notes or in incident reports. The DON stated that if a skin assessment was started and a skin issue was identified, the skin assessment form in the electronic health record should be filled out. Staff # 126 stated that not filling out the document would not meet her expectations, as the resident may not receive appropriate care, and you would not know what the skin issue is. The DON searched for a progress note during the time period of the alleged abuse allegation, but no notes were identified in the electronic health record. The DON stated that it should have been documented in a progress note or an incident report. The DON reported that all incident reports are maintained in Point Click Care, the facility's documentation platform. A review of the Haven Health Policy, B001 Documentation: Charting and Documentation, Version 051123, effective January 1, 2024, revealed that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Number of residents sampled:26Number of residents cited:2The facility failed to protect the resident's right to be free from verbal and physical abuse in 2 of 26 residents.Based on closed record review, resident and staff interviews, as well as review of facility documentation and policy, and through observation of current practice, the facility failed to protect the resident's right to be free from verbal and physical abuse in 2 of 26 residents.Findings include:- Regarding Resident #26:Resident #26 was initially admitted to the facility on [DATE] and remains in the facility with medical diagnoses that included: end-stage renal disease, dementia, muscle weakness, glaucoma, lack of coordination, and anxiety disorder.The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS revealed that the resident demonstrated no hallucinations, delusions, physical or verbal behaviors toward others or other behaviors not directed to others including physical symptoms such as hitting or scratching of self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds. The MDS revealed that the resident demonstrated rejection of care 1-3 days and demonstrated no exit-seeking behaviors. The MDS further revealed that the resident used a manual wheelchair and documented no functional impairment of upper or lower extremities.However, a review of the resident's comprehensive care plan dated 5/12/2025 revealed that resident #26 had impaired functional mobility with an associated goal to remain free from complications of impaired range of motion through the next review date and an intervention to report and document any decline in function and refer to therapy as needed.The care plan further revealed that the resident had a visual impairment requiring glasses to improve visual acuity. The care plan revealed that the resident exhibited a behavior of touching another resident's arm that was perceived to be inappropriate and was redirected. The resident also reportedly refused to go to bed on time, refused to be changed, and refused to be toileted despite staff encouragement and assistance. The care plan revealed that the resident had impaired thought processing due to dementia with an associated goal of communicating basic needs on a daily basis and interventions for the care team to communicate with the resident, family, and caregivers regarding the resident's capabilities and needs. Additional related interventions included discussion of concerns about confusion, engage resident in simple, structured activities that avoid overly demanding tasks, keep routine consistent, report changes in cognitive function specifically, changes in decision making ability, memory, recall and general awareness, difficult expressing self, difficulty understanding others or changes in mental status or level of consciousness to MD and to use task segmentation to support short-term memory deficits.A review of progress notes dated 5/14/2024 revealed that the resident was involved in a small altercation with another resident; however, the resident had no memory of the event and had no complaints or concerns reported to staff.A review of physician orders revealed no issues or concerns specific to this allegation.A review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no omissions or inconsistencies. - Regarding Resident #107:Resident # 107 was initially admitted to the facility on [DATE] and discharged on 2/18/2025 with diagnoses that included: chronic obstructive pulmonary disease, age-related osteoporosis with current pathological fracture of the vertebrae, bipolar disorder, atherosclerotic heart disease, chronic diastolic heart failure, morbid obesity, hypertensive heart disease, difficulty in walking, retention of urine, due to obstructive and reflux uropathy, depression, anxiety disorder and non-ST elevation myocardial infarction (NSTEMI).A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Mental Status Interview (BIMS) score of 14, indicating no cognitive impairment. The MDS revealed that the resident had no hallucinations, delusions, verbal behaviors directed towards others, and no behavioral symptoms not directed toward others, such as hitting or scratching of self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds. The MDS further stated that the resident exhibited physical behavioral symptoms directed toward others, such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually on 1-3 days, and revealed that the resident demonstrated no rejection of care or exit-seeking behaviors. The MDS further revealed that the resident used a manual wheelchair and indicated no functional impairment of upper or lower extremities. The MDS revealed that resident #107 had an indwelling urinary catheter, smoked, and used oxygen through a nasal canula.A review of the resident's Comprehensive Care Plan dated 9/8/2023 revealed that the resident had an actual or potential problem with psychosocial well-being due to anxiety, with a related goal of verbalization of feelings related to emotional state by review date. Interventions related to this goal included: allowing the resident time to answer questions and verbalize feelings, perceptions and fears, assist, encouraging and supporting the resident to set realistic goals, and encouraging participation from resident who depends on others to make own decisions. The Care Plan further revealed that the resident had a mood problem related to anxiety and depression with a related intervention to observe/monitor/record/report to MD the risk for harming others, increased anger, labile mood or agitation, or if the resident feels threatened by others of has [NAME] of harming someone, possession of weapons or objects that could be used as weapons. The Care Plan revealed that the resident was at risk for a resident to resident altercation due to lack of awareness when driving the chair backwards, despite staff education. The Care Plan further revealed additional risks for resident to resident altercations due to impulsiveness despite staff redirection, including hitting staff when redirected.A review of physician orders dated 2/3/2025 revealed that the resident was placed on Buspar and duloxetine related to increased agitation and behaviors.A review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no omissions or inconsistencies. A review of the progress note dated 6/3/2025 revealed that a staff member was called to respond to an incident that occurred during the resident's scheduled activities, in which another resident was involved. The physician's progress note dated 5/14/2025 revealed that staff reported that the resident got into an argument about the weather that escalated to physical aggression with another resident; however, the resident's record revealed no prior incident describing the event that occurred on 5/12/2025.A review of the Weekly Skin Check and Wound assessment dated [DATE] revealed a skin assessment notation marked as ‘yes' for Does resident have skin impairments -new and/or ongoing? The remainder of the document contained no information. No progress note was identified for the resident to resident abuse allegation that occurred on 5/12/2024.An interview was held with resident #26 on 8/8/2025 at 08:52 AM, who stated that he feels happy and safe at the facility. The resident denied any memory of arguing or having an altercation with another resident. When asked specifically about an issue with resident #107, resident #26 stated that he had no memory of the event in question. Resident #26 stated that he had no memory of any disagreements or altercations with other residents. The resident stated that his needs are being met and that he would go to any staff member if he had additional concerns.An interview was conducted with Registered Nurse, (RN) Staff #108, on 8/12/2025 at 09:06 AM. The RN stated that abuse can be verbal, physical, emotional, financial, or sexual, and stated that any abuse requires prevention, observation, and notification to the facility Director of Nursing or Executive Director. Staff # 108 stated that abuse can occur between staff and residents or residents to residents and between residents who have dementia. The RN stated that preventative measures for residents with dementia include low beds, frequent monitoring, floor mats, non-slip footwear, and care planning to communicate resident needs to staff, baseline fall risk and skin assessments and ongoing discussions among the teams about their status and behaviors. If residents did not have dementia, but were at risk for abusing each other, the RN stated that prevention would be largely the same, but staff would also work to educate residents about coping strategies, reminding them to use call lights for assistance and to ensure they know how to report any issues or concerns. Staff #108 stated that resident- to- resident abuse is rare but would not meet expectations as the risk could be injury or harm to the residents. An interview was conducted with Staff #52, Certified Nursing Assistant (CNA), on 8/12/2025 at 11:59 AM. The CNA stated that abuse can be verbal, physical, emotional as well as others. Staff #52 stated that if abuse is witnessed, she would make sure that residents are safe and report the event immediately to the supervisor as it is her understanding that they have a timeline to report the event. The CNA stated that she would notify the nurse, obtain vital signs of the involved residents, complete a skin assessment, and make sure that blood pressure was not too high, as blood pressure can go up with adrenaline, and check the resident for any injuries. The CNA stated that she recalled the specific event as it was the first resident-to-resident abuse incident she witnessed in her career. Staff #52 stated that the residents didn't have a great relationship, and they didn't get along and tended to avoid each other. She stated that the event occurred when one resident was wheeling down the hallway and the other one came up behind him in the wheelchair (facing the same direction and bumped into him from behind, explaining it occurred like a rear-end collision between cars. The CNA stated that she was alerted when the residents started fighting. Staff # 52 stated that when she got to them, they were both in their wheelchairs, facing each other, yelling and throwing punches. The CNA reported that she separated the residents with the help of a co-worker and got the nurse who talked to the Executive Director, as she did after the residents were assessed and the situation had settled down. The CNA stated that she had no memory that either resident was injured in the event. The CNA stated that one of the residents still resides in the facility, and the other one moved to an assisted living facility approximately two months after the altercation. The CNA stated that prevention efforts before the event were based on the observation that the two individuals did not get along with staff giving them verbal cues to de-escalate by saying, Stop, it's okay, don't look at him, let's go over here, and so on. The CNA stated that staff received training on abuse through video trainings that occur monthly and the topics include abuse, infection control, and others that relate to being a CNA. The CNA stated that having residents fight would not meet her expectation. The CNA stated that the risk to the residents could be that they would feel uncomfortable, unwelcome, not want to be here, and could, go to another facility. Staff # 52 stated that, in retrospect, possible prevention measures could have included moving residents so that they were not on the same hallway or discharging the more independent of the two residents sooner. An interview was conducted with resident #83 on 8/12/2025 at 12:10 PM. The resident stated that she has been in the facility for two weeks and denied any concerns. Resident #83 stated that she feels safe in the facility and has not witnessed or experienced any abuse between residents, but if she did, she would tell a nurse.An interview was conducted with resident #10 on 8/12/2025 at 12:15 PM. The resident stated that she had been in the facility for three months and feels safe. The resident stated that when she had a concern, she addressed it with staff, and it was resolved to her satisfaction. Resident #10 stated that she had no issue with staff or other residents, stating, everyone loves me. The resident stated that if she witnessed or experienced abuse, she stated that she would notify the social work staff.An interview was conducted with resident #67 on 8/12/2025 at 12:20 PM. The resident stated that she is not sure how long she has been at the facility, having come from the hospital after having a minor heart attack. The resident stated that she has not experienced abuse and feels safe in the facility. The resident stated that if she witnessed or experienced abuse, she would report it to the head nurse, or take it further if needed.An interview was conducted with Housekeeping Aide, Staff #75, with translation assistance from Environmental Services Supervisor, Staff #71, on 8/12/2025 at 2:15 PM. Staff #75 stated that she works in all areas of the facility and occasionally speaks with residents, but if care needs are identified, she would find a CNA to help them. The housekeeping aide stated that she has only witnessed resident-to- resident abuse once, that was a long time ago when she saw two residents fighting in the 100 hallway.When asked to describe the event, Staff #75 stated that the two residents were in in their wheelchairs, moving them in the same direction, one behind the other. The one in the rear bumped into the one in front, and the one in front became angry, and the two started yelling at each other. Their yelling got the housekeeping aide's attention, and she ran to get a CNA, and both responded to the resident #26 and resident #107 to help. Staff # 75 further stated that by then, the residents were facing each other, yelling, Get out of my way, and other loud statements, and hitting each other. The Housekeeping Aide stated that she was unsure if either one was hit. Staff #75 stated that lots of staff responded because of the yelling and separated the residents and got them settled down. Staff #75 stated that when others responded, she went back to work. She has no memory of damage or injury to either resident, and because she works the night shift and her supervisor works on the day shift, she reported the event to her supervisor the next day. An interview was conducted with Licensed Practical Nurse (LPN), Staff #147, on 8/13/2025 at 0918 AM. The LPN stated that abuse can be physical, sexual, verbal, or financial, and further stated that the facility has zero tolerance for any abuse. Staff #147 stated that we don't want abuse here, but are aware that it can happen, and we do all that we can to prevent it.The LPN stated that she would identify residents who are at risk for resident-to-resident abuse by their behaviors, such as responding in anger, being irritable, as we work with them and observe them. Staff #147 stated that another factor identifying residents who are at risk for resident-to-resident abuse because they may have complaints or they may not be satisfied with care. The LPN stated that staff try to match residents who are compatible with each other and with staff so everyone can be happy and not have any arguments. Staff #147 stated that this is true on their dementia unit because residents get agitated and do not understand when we try to redirect them, but their way of thinking is not like ours.An interview was conducted with staff #126, Director of Nursing (DON), on 8/13/2025 at 0959 AM who defined abuse as physical, emotional, verbal, or misappropriation. The DON stated that when resident-to-resident abuse occurs, the residents are separated and made safe, and the event is immediately reported. When resident-to-resident abuse occurs, the staff look for any bruising, skin tears, and assesses for injuries. Staff #126 stated that following resident-to-resident abuse, an incident report is generated, as is a note in the resident's electronic health record. The DON stated that resident-to- resident to abuse does not meet her expectations and that she doesn't like it, but sometimes it is difficult to avoid and stated that the risk to the resident is injury or emotional distress.A review of the Haven Health Policy # 003: Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, effective January 1, 2024 revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy further states that the facility employs a facility-wide commitment and resource allocation to protect residents from abuse from facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and/or any other individual.

Based on clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #1 was free from abuse from resident #2. The deficient practice could result in residents experiencing emotional and mental trauma from abuse. Findings include: Related to resident #1- Resident #1 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, major depressive disorder, and partial paralysis on the left side following a stroke. Review of a quarterly Minimum Data Set (MDS), dated [DATE] revealed resident #1 completed a Brief Interview for Mental Status (BIMS) and scored a 15 which indicated the resident was cognitively intact. A review resident #1's progress note in her Electronic Health Record (EHR), a progress note dated November 26, 2024 at 4:32 PM indicated that resident #1 had made an inappropriate comment about her roommate's, at the time, mother. The roommate (resident #2) then grabbed resident #1's hair. Related to resident #2- Resident #2 was admitted to the facility on [DATE] with diagnoses of partial paralysis on the left side following a stroke, type 2 diabetes, schizoaffective disorder and major depressive disorder. Review of the admission MDS, dated [DATE] revealed resident #2's BIMS score was 12 which indicated the resident was moderately cognitively intact. The MDS also noted the resident had not exhibited any behaviors during the look-back period. The care plan for Resident #2 did not indicate the resident had a behavior problem towards others. Review of resident #2's progress notes in her EHR (Electronic Health Record) revealed a progress note dated November 26, 2024 at 4:47 PM. The note shared that resident #2 was witnessed pulling her roommate's pony tail because the roommate made an inappropriate comment about resident #2's mother. An interview was conducted on December 9, 2024 at 4:44 p.m. with resident #1 in her room. Resident #1 indicated that she currently felt safe in the facility. She also shared that the girl next door attacked me. Resident #1 continued to explain that the girl used to be her roommate but she had pulled resident #1's hair which was witnessed by a Certified Nursing Assistant (CNA/Staff #46). An interview was conducted on December 10, 2024 at 8:26 a.m. with resident #2 in her room. She explained that she has changed rooms many times at the facility during her stay because she can't get along with people. She also shared that she pulled the hair of her former roommate because she had called her mom a bitch. An interview was conducted on December 10, 2024 at 4:52 p.m. with a Certified Nursing assistant (CNA/staff #46). She confirmed that she was working on November 26, 2024 and had witnessed the altercation between residents #1 and #2. Staff #46 explained that both residents had returned to their room from an afternoon outing and she had walked into the room to assist resident #2. Both residents were relaxed, in their wheelchairs, and out of the blue, both residents started exchanging words and resident #1 had insulted resident #2's mother. Then resident #2 reached out to grab resident #1's hair bun and staff #46 had grabbed resident #2's hand and the resident released the hair. Staff #46 also added that she then wheeled resident #2 out of the room into the lobby to separate the two residents. Social services staff then pulled resident #2 aside to talk to her. Staff #46 indicated that there had been no other altercations between the two residents in the past and they had gotten along well with each other. An interview was conducted with the Resident Relations Manager (RRM/Staff #50) on December 10, 2024 at 5:08 p.m. When asked to explain what transpired between resident #1 and resident #2, staff #50 explained that resident #2 and grabbed resident #1's hair because resident #1 had made a comment about resident #2's mom who had passed away. Resident #2 had gotten upset and said that no one talks about her mom that way. After the altercation, the residents were put into different rooms. When asked what would the risks to the residents be if they were abused in the facility, staff #50 indicated that residents would be in an unsafe environment and it would cause issues such as behaviors. Staff #50 also added that the facility wants residents to feel safe and they knew if they did not feel safe, they could talk to social services. An interview was conducted with Licensed Practical Nurse (LPN/Staff #49) on December 10, 2024 at 5:26 p.m. Staff #49 shared that she did not witness the altercation between both residents but she was informed about it by staff #46. Once she was notified, she did an assessment with both residents and there were no injuries noted. Staff #49 also reported the incident and the police came to investigate and then social services investigated as well. An interview was conducted on December 10, 2024 at 5:39 p.m. with the Director of Nursing (DON/Staff #54). Staff #54 indicated that there was a verbal incident between resident #1 and #2 due to resident #1 saying something about resident #2's mother. This had caused resident #2 to become upset and grabbed resident #1's hair. She also indicated that a CNA was present during the altercation and was able to respond quickly and separate the two residents. Staff #54 was not aware of any other altercations that involved resident #2 but did note that resident #2 could be mean at times but it usually wasn't directed towards anyone. Review of a policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation, and Misappropriation Prevention Program indicated that residents had a right to be free from abuse. The policy also noted that there was a facility-wide commitment to protect residents from abuse . from other residents.

Based on staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure a resident was free from abuse. This deficient practice could result in further incidents of physical abuse. Findings include: Resident #21 was admitted on [DATE] with diagnoses of anxiety disorder, and depression. A quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a BIMS (Brief interview for mental status) of 2, indicating that this resident was severely cognitively impaired and included inattention and disorganized thinking continuously present. A care plan dated April 15, 2024 included this resident had a behavior problem including impaired cognitive function, impaired safety awareness, wandering/exit-seeking, threatening, throwing water cups to staff despite staff reorientation/education and resident to resident altercation despite staff redirection with interventions. Interventions including intervene as necessary to protect the rights and safety of others. These interventions note a revision on November 25, 2024, however the revisions noted to the care plan do not include any changes or new interventions. No new interventions were added to this focus since April 15, 2024 A progress note dated July 13, 2024 at 6:01 p.m. included that the nurse writer witnessed an altercation between resident and another patient. This note included that a male resident sat down at a dining table and this resident started cursing at the other resident and lunged towards him. This note included that a CNA stopped resident this from making contact and that the male resident was escorted to another table . However, no new interventions were added to the care plan for this interaction and review of the tracking system did not find that this incident was reported. A progress note dated July 27, 2024 included Resident is aggressive towards other residents and staff; throw objects across table; difficulty redirecting. Will continue to monitor However, no new interventions were added to the care plan for this interaction and review of the tracking system did not find that this incident was reported. A progress note dated September 4, 2024 included at 3:30 p.m. (resident #21) was choking (resident #6) and that a CNA noticed and stopped her. This note included that (resident #21) said she was just playing and that no injuries noted on (resident #6). (Resident #6) stayed in the dining area and (resident #21) went to her room right after. A progress note dated November 18, 2024 at 7:50 p.m. included that Resident was upset due to another resident letting staff know that resident spit her pills out when staff turned away and that this resident got upset and threw plastic cup at the other resident. This note included that this resident attempted to kick resident and that she was redirected. However, no new interventions were added to the care plan for this interaction and review of the tracking system did not find that this incident was reported. -Resident #6 was admitted on [DATE] with diagnoses of dementia and anxiety. A quarterly MDS dated [DATE] revealed the resident had a BIMS of 3, indicating the resident was severely cognitively impaired with inattention and disorganized thinking continuously present. A care plan dated April 19, 2024 included that the resident has a behavior problem related to verbal behavior, wandering and unaware of safety precautions. This focus has an intervention to intervene as necessary to protect the rights and safety of others, and to remove from situation and take to alternate location as needed. This focus has no new interventions after May 10, 2024. A progress note dated November 24, 2024 included, Around 1930 nurse hear CNAs assisting resident and trying to get resident out of her room. At arrival (resident #21) was very agitated and screaming at CNAs. CNAs were trying to get (resident #6) out of room, CNA and nurse stayed with (resident #21) while other CNA help (resident #6) get out of room through the next room's shared bathroom, because (resident #21) was blocking the door. CNAs and nurse were able to separate residents and keep both safe. CNAs reported they witnessed resident walking and (resident #21) getting up from her bed. When resident was going back to her bed, resident pulled on her roommate's oxygen tubing, then (resident #21) grabbed resident's hair and pushing her away. CNA told roommate to let her go and roommate did. Both residents were separated for their safety. A full skin assessment was done to both residents. No injuries or open areas noted on either resident . An interview conducted on November 26, 2024 with a Registered Nurse (RN/staff #54) who said that she is the regular nurse for this hall. She said that resident #21 and resident #6 are sisters and that resident #21 can get aggressive at times and that she is upset by others in the chair she likes to sit in in the common area and that there was a male resident that she did not like. She said that resident #21 tried to kick a male resident when he was in her chair and also when he told a nurse that resident #21 did not take her medication. She said that she was informed that resident #21 had pulled someone's hair but that she had not yet reviewed the notes. She said that resident can't be in with her sister but can't be without her. She said that resident #21 tries to defend resident #6 from other residents and that resident #21 had tried to smack resident #6 before. She said that if no staff intervenes she could see resident #21 hurting another resident. She said that they had tried to move resident #21 and 6 to different rooms in the past but that the resident's guardian did not agree. She said that staff have to alternate on their jobs because they cannot take their eyes off of the residents or an incident would occur. This nurse said that the if it is needed that staff #32 and #71 will make changes to the care plan if it's needed and that it might be needed for resident #21. An interview was conducted on November 26, 2024 at 12:44 p.m. with a Certified Medication Assistant (CMA/staff# 37) who said that resident #21 is quiet but when we don't understand what she wants she gets mad, doesn't want anyone in her chair. This staff said that if a resident sits in her chair she gets mad and kicks and throws water. This staff said that resident #21 does not want resident #6 to get up and down. This staff said that they were told that over the weekend that resident #21 and resident #6 had fought and that the resident's representative wanted them in the same room. This staff said that this was not the first time that these two residents had fought. This CMA said that resident #21 had gotten angry at another resident who had said that resident #21 had not taken her medcation so when that staff asked her to open her hand, she got mad at the resident and threw the cup of water. This staff said that the staff asked resident #21 to go and apologize after she had calmed down, and that resident #21 came back and kicked the resident. An interview was conducted on November 26, 2024 at 12:28 p.m. with a Certified Nursing Assistant (CNA/staff #17) who said that this is the primary hall they work on. This staff said that resident #21 and resident #6 get along at times and that resident #21 wants to have control over #6's wandering. This staff said that resident #6 is unaware and just wanders. This staff said that resident #21 had tried to strangle resident #6 in the past and that usually if they go after another we try to separate them or stop that from getting out of hand. This staff said that there are interventions that the staff usually uses such as placing them at different tables and currently separating these residents but that they do not think that there are interventions on the care plan. An interview was conducted on December 5, 2024 at 12:31 p.m. with a CMA (staff #14) who said that they are a Medication Technician and that they work CNA shifts as well. This staff said that resident #21's triggers are if she sees residents arguing or if they are loud or if someone being mean to her sister, or if she goes to sleep and resident #6 is up and wandering it bothers her. This staff stated that was there when resident #21 pulled resident #6's hair. She said that she was finishing up care in the room and resident #21 was at the door and resident #6 was behind her trying to get out. She said that resident #21 was mad and just wanted her (#6) to get out. This staff said that she called the other CNA and that resident #21 was wearing her oxygen and that the tubing was going around the bed, so she told resident #21 that resident #6 would trip and then resident #6 wandered back to bed and got tangled with the oxygen tubing and pulled on it. Resident #21 turned around and grabbed resident #6 and was shaking her and shoved her to the foot of the bed and she bounced off of it and got scared. This staff said that she and the CNAs were telling resident #21 to be nice don't do that and the nurse got in front of her and told her to stop hurting her sister. This CNA said that resident #21 got upset that she was trying to get resident #6 out and that the nurse was distracting and calming her down, so she opened the bathroom where resident #6 was trying to hide and she helped her out the bathroom door to the adjoining room and kept her with us in the dining room through the ending of the shift. This CNA said that she was not on shift for the strangling though she had heard about it. She said that the staff do follow the care plan but also they try to ask the other CNAs to see what will help and tell each other that they have doing this to help that situation out. This CNA said that they get abuse training every month, mostly online and sometime in person. She said that she reports it to the nurse so that the nurse can take action and report it. An interview was conducted on December 23, 2024 at 2:04 p.m. with the Director of Nursing (DON/staff #43) who said that abuse is anything that can harm the residents and that abuse could be physical, or emotional. This DON said that someone who is not cognitively intact can abuse another person and that they care plan abuse. This staff said that usually the staff would care plan under the initiator and include any trigger that may have caused that, anything that would help the staff to recognize coming behaviors. This DON stated that the care plan was revised on November 25th but did not provide an answer as to why there was not a new intervention. She stated that any care plan revisions would be on the care plan and not documented elsewhere. This DON stated that that the staff report abuse immediately within the 2 hour window. She said that she did not know about the other issues of abuse that were noted in resident #21's clinical record. A policy titled Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated January 1, 2024 revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation and that 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. This document includes that this facility will investigate and report any allegations within timeframes required by federal requirements. A policy titled Assessments/Care Planning: Care Plans, Comprehensive Person-Centered revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. This document included that services provided for or arranged by the facility and outlined in the comprehensive care plan are trauma-informed and that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#247) was provided services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for the resident. Findings include: Resident #247 was admitted on [DATE] with diagnosis including surgical aftercare, bacteremia, sepsis, acute osteomyelitis, type 2 diabetes mellitus, peripheral vascular disease and right foot transmetatarsal amputation. Review of the electronic health record revealed that the BIMS (brief interview of mental status) had not yet been completed. A review of the physician's orders on September 14, 2023 revealed an order for pain evaluation each shift utilizing a 0 to 10 pain scale. A further review of the physician orders revealed an order to administer oxycodone-acetaminophen 5-325mg 1 tablet, by mouth, every 6 hours as needed for pain ranging 6 to 10. A review of the MAR (medication administration record) revealed the following administration history: 09/14/2023 Pain not assessed second and third shift 09/15/2023 Pain not assessed third shift 09/16/2023 Second shift-oxycodone-acetaminophen administered at a pain level 5 and no pain assessment for third shift 09/17/2023 First and third shift-oxycodone-acetaminophen administered at a pain level 5. 09/18/2023 First shift-oxycodone-acetaminophen administered at a pain level 4. Pain not assessed for second and third shift. An interview was conducted with Staff # 31 (CNA) on September 19, 2023 at 9:32 a.m. Staff #31 stated that resident's will either let her know verbally if they are in pain or via body language, include facial grimaces. She stated that is she is notifies or observes a resident in pain she would let the nurse know. She stated that the nurses assess how much pain the resident is in, but she would attempt non-pharmacological measures to include repositioning the resident or distracting them. An interview was conducted with staff # (145) on September 19, 2023 at 9:53 a.m. Staff #145 stated that she automatically introduces her self to each resident and asks if they are experiencing pain. She stated that she also watches for signs to include: restlessness and facial expressions. She stated that you become familiar with and get to know your patients. She stated that once it has been established that a resident is in pain, she would check on an order for pain medications. If the order was noted to be in the resident's file, she would administer the medication as prescribed and in accordance with the pain level expressed by the resident. She stated that there would never be a time that the pain medication would be administered outside of the prescribed parameters. She stated that the pain level, as expressed by the resident, would always be charted. However, the MAR did not reveal evidence of consistent pain level charting. A follow-up interview was conducted on September 21, 2023 at 11:50 a.m. with staff #145. Staff #145 stated that if a resident requested pain medications outside of the prescribed parameters, she would also check to see if there was another order for pain medication available that would fall inside of the designated parameters. She stated that if there were no other pain medications ordered, she would contact the doctor for other options. Staff #145 pulled up the MAR for resident #247 and stated that the oxycodone-acetaminophen appeared to have been administered outside of the designated parameters for September 16, 17 and 18. She stated that the risk of administering medications outside of parameters could include the resident being more drowsy and potential fall. An interview was conducted on September 21, 2023 at 12:19 a.m with staff #38 (DON). Staff #38 stated that her expectation for pain management is that each resident is assessed at least once per shift and that pain is managed or outreach to the physician is conducted for alternatives. She stated that her expectation is for staff to assess the pain, consult the chart for current orders and follow the orders as written. Staff #38 pulled up the MAR for resident #247 and stated that the facility had already identified this occurrence of administering medications outside of ordered parameters and that it was being reviewed. She stated that the risk for not following physician orders could include over-medication. A review of the facility's pain management protocol policy, with a review date of June 2023, revealed that staff will observe the resident for evidence of pain using a consistent approach and a standardized pain assessment instrument to identify the severity of the pain. The policy further revealed that during monitoring, staff is to reassess the individual's pain at least each shift.

Based on staff interviews, and review of facility documentation and policies, the facility failed to ensure that the QAA (quality assessment and assurance) committee collected data and monitored it's performance regarding adverse events for performance improvement. Findings include: An interview was conducted on September 21, 2023 at 2:32 p.m. with staff #8 (Administrator) and staff #38 (DON). Staff #8 stated that meetings are held every 3rd Wednesday of the month. Staff #8 shared that information as related to any PIP (performance improvement plans) is shared forward to the departments involved in the PIP. The administrator stated that the QAA committee is currently working on a PIP for falls, which had been implemented on September 20, 2023. The team is also working on a PIP for medications administered outside of ordered parameters. Staff #8 stated that a previous PIP that had been on resident showers, which had been resolved. He stated that as a result of QAA committee, a shower team had been integrated but stated that the results showed that the previous method had been more effective with ensuring timely resident showers; however, there was no evidence of data supporting how the performance measure was being tracked and monitored. The administrator stated that he was unable to locate any tracking data in support of the previous PIP. Staff #8 stated that the risk of not effectively tracking data as related to PIP's could impact the outcome of an effective performance improvement plan. A review of the facilities quality performance improvement program version 1017, copyright date 2017, revealed that the primary purpose of the quality assurance and performance improvement program is to establish data-driven, facility-wide processes that improve quality of care, quality of life and clinical outcomes for residents; however, there was no evidence of data utilized to track performance outcomes.

Based on clinical record review, staff interviews and the RAI (Resident Assessment Instrument) Manual, the facility failed to ensure a significant change MDS (Minimum Data Set) assessment was completed for one resident (#3) within the required timeframe. The deficient practice could result in the resident not having continuity of care. Findings include: Resident #3 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The IDT (interdisciplinary team) care plan conference note dated June 8, 2021 included the resident's progress was discussed with the family; and that, the physician recommended hospice consult and the family had accepted this recommendation. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The health status note dated June 8, 2021 included that hospice was at the facility for evaluation of the resident. A physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . The hospice care plan dated June 8, 2021 included the resident was on hospice due to [CONDITION(S)] disease. Intervention included hospice service to follow protocol and document hospice visits. Another care plan dated June 8, 2021 included the resident had terminal prognosis related to [CONDITION(S)] disease and was under hospice care. On June 9, 2021, the resident's facesheet was revised to include a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] In the quarterly MDS assessment dated [DATE], hospice care was not coded. A modification of the quarterly MDS assessment dated [DATE] was done to include that the resident was on hospice care. However, this modification was still on an export ready status and there was no documentation that it was transmitted. Further review of the clinical record revealed that a significant change MDS assessment was not completed until September 9, 2021. An interview was conducted with the MDS coordinators (staff #19 and #97) on August 4, 2022 at 2:21 p.m. Both staffs stated that when a resident enrolls to hospice, has orders for hospice, dis-enrolls from hospice or change hospice providers, a significant change MDS assessment is completed within 14 days from the order or transfer/admitted to hospice. Staff #19 stated that residents who has orders for hospice, is enrolling or dis-enrolling from hospice are discussed in the daily stand-up meeting attended by them, social service and the IDT team. A review of the clinical record was conducted with staffs #19 and #97 during the interview. Staff #97 said she and staff #19 did not know that resident #3 enrolled or had orders for hospice at the time they completed the scheduled quarterly MDS assessment on July 11, 2021. Staff #97 said that as soon as they realized the resident was on hospice, they made modifications to the quarterly MDS and called their corporate office. Staff #97 said that corporate office instructed them to complete the significant change MDS on the next assessment which was scheduled on September 2021. Regarding the modification of the quarterly MDS assessment dated [DATE], staff #97 stated that she did not know why the modified assessment was not included in a batch transmitted; and why it was not transmitted at all. Staff #97 said in the past, corporate was responsible in ensuring all completed MDS assessment are exported; and that, it was only recently that she and staff #19 were taught and instructed to export/transmit/submit completed assessments. The RAI manual instructed that the nursing home is required to complete the MDS Significant Change in Status Assessment (SCSA) if a nursing home resident elects the hospice benefit and when the resident comes off the hospice benefit (revoke). The ARD (assessment reference date) must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident. The ARD must be within 14 days from one of the following: 1) the effective date of the hospice election revocation (which can be the same or later than the date of the hospice election revocation statement, but not earlier than); 2) the expiration date of the certification of terminal illness; or 3) the date of the physician's or medical director's order stating the resident is no longer terminally ill.

Based on staff interviews, clinical record review, and policy and procedures, the facility failed to ensure appropriate infection control guidelines were followed related to droplet precautions and catheter care for one resident (#86). The deficient practice increases the risk for transmission of infection. Findings include: Regarding Personal Protective Equipment (PPE) During an observation conducted on 08/01/22 at 12:33 p.m., a housekeeper was observed mopping the floor in a resident's room that had a droplet precaution sign on the door. A PPE cart was observed outside the room in the hallway. The housekeeper was observed wearing a gown, gloves, and a KN95 mask. She had not donned the protective eyewear or N95 mask as directed by the sign on the door. On 08/01/22 at 12:35 p.m. an interview was conducted with the housekeeper (staff #31). She stated that the resident in the room was on special precautions. She stated that the sign was on the door yesterday as well. Staff #31 said that sometimes she asks what the resident has, but that this time she had not asked. She stated that she was supposed to wear a gown, gloves, and mask into the room. The housekeeper stated that the KN95 was ok to wear in the room, but that she could not wear goggles or a face shield because she could not see. Staff #31 stated that she stopped wearing eye protection because of that. At 12:55 p.m. on 08/01/22, a Certified Nursing Assistant (CNA) was observed to exit the same resident's room, approach the PPE cart, then turn and quickly return into the resident's room without donning PPE. She was observed to be wearing a KN95 mask only, (no gown, gloves, or eye protection.) Upon looking further into the room, a nurse was observed at the resident's bedside. She was observed to have donned a KN95 face mask and gloves. She was observed attempting to assist the resident to drink a liquid supplement. On 08/01/22 at 1:04 p.m., an interview was conducted with the Registered Nurse (RN/staff #144) and the CNA (staff #145). Staff #144 stated that she did not work at the facility. She stated that the set-up for PPE requirements was different from the last time she was in the facility, and that the location of the PPE was different the last time she was there. She looked over at the PPE cart that was outside the resident's door and stated that she had missed it, My bad. Staff #145 stated that she had a gown with her in the resident's room, but she did not put it on because she did not transfer the resident. She reviewed the sign on the resident's door and stated that she understood the expectation was for staff to don eye protection, mask, gown, and gloves upon entering the resident's room. She stated that she had received in-service training regarding the requirements. An interview was conducted on 08/01/22 at 1:21 p.m. with the Director of Nursing (DON/staff #137). She stated that the expectation is that staff will don a gown, N95 mask, eye protection, and gloves upon entering the room whether they touch the resident or not. She stated that all the PPE supplies should be available in the PPE cart. She stated that the associated risks of not donning the appropriate PPE included transferring infection to other residents and staff. Review of the facility Infection Control Program dated 2013 included it is the policy of the facility to maintain an active infection control program with the focus of providing a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. The infection control program encompasses prevention, surveillance, containment, education, and reporting. Regarding catheter care An observation of suprapubic catheter care was conducted on 08/04/22 at 10:04 AM with an RN (staff #116). The RN was observed to perform hand hygiene, don gloves, and set up the equipment on a round table without disinfecting/sanitizing the table. The table where the treatment equipment was placed had dirty clothes, blue printed gowns, a white bed sheet, plastic bowls, and a large plastic graduate with a green lid on it. Staff #116 placed the unopened split 4x4 dressing and a stack of bulk gauze on top of the table, poured normal saline into an 8 oz plastic cup, and placed the bulk gauze inside the plastic cup. The RN explained to the resident what she was going to do. She removed the old dressing, doffed gloves and donned a pair of clean gloves without performing hand hygiene. She took a few clean gauzes from the plastic cup and cleansed the site. The RN then cleaned the site using a QTIP with NS, cleaning away from the stoma away from the tube. Staff #116 then pat dry the area going from the stoma away from the tube. Staff #116 removed the gloves and donned clean gloves without performing hand hygiene. She then opened a package of splint sponge 4x4 dressing, took the right glove off, took a pair of scissors from her pocket, and cleaned them with an alcohol pad. Staff #116 donned a glove to the right hand without performing hand hygiene. She then secured the dressing with [MEDICATION(S)] tape, removed the gloves and dated the dressing. Staff #116 washed hands in the bathroom. The RN used a cleaning Sani cloth and wiped the saline wound wash and placed the item into the cart immediately after. Following the observation, an interview was conducted with the RN at 10:23 AM. The RN stated when she cleaned the sterile saline spray, she should have let it set for 3 minutes and let it air dry per manufacturing instructions of the disinfectant wipes that she used. Staff #116 stated she washed her hands prior to the treatment, and that she should have washed her hands in between dirty to clean glove changes. An interview was conducted with the DON (staff #137) on 08/04/22 at 2:28 PM. The DON stated staff attend a skills training to demonstrate proper catheter care. The DON stated there is no process in place related to monitoring residents receiving catheter care as ordered as well as following infection protocol while providing catheter care. Review of the facility policy Suprapubic Catheter Care Policy revised October 2010 stated the purpose of the procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. Review the resident's care plan to assess for any special needs of the resident.

Based on staff interviews, clinical record reviews, and review of policy and procedure, the facility failed to ensure 3 residents (#69, #12, and #291) received care and services to promote the prevention, healing, and prevent the development of additional pressure ulcers/injury consistent with professional standards of practice. The sample size was 4 residents. The deficient practice increases the risk of pain, infection, and rehospitalization . Findings include: -Resident #69 admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. The resident required limited to extensive 1-person physical assistance for most Activities of Daily Living (ADLs), and had no pressure ulcers/injury to skin. Review of the discharged with return not anticipated MDS assessment dated [DATE] revealed the resident did not have a pressure ulcer or injury. The resident subsequently readmitted to the facility on [DATE]. A health status progress note dated 02/24/22 at 9:08 p.m. included the resident had arrived at the facility at approximately 5:45 p.m. with bilateral heels described as boggy. A pressure injury care plan initiated on 02/25/22 related to an unstageable pressure injury on the left heel had a goal for intact skin, free of redness, blisters or discoloration. Interventions included weekly skin assessments. The admission MDS assessment dated [DATE] revealed one stage 2 pressure ulcer. The resident's care plan was revised on 03/02/22 to include pressure-relieving boots. A physician order dated 03/03/22 revealed instructions to cleanse the left heel with wound wash spray, pat dry and apply [MEDICATION(S)] (absorbent foam dressing), every day for wound care. However, further review of the physician orders did not indicate that an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . In addition, review of the clinical record did not indicate the pressure ulcer to the resident's left heel was evaluated until 03/10/22. A Wound Note dated 03/10/22 at 2:58 pm included a full thickness injury. The wound bed was described as about 25% pink granulation tissue with 50-75% yellow/light brown dry slough. Measurements were 3.5 centimeters (cm) x 3.6 cm x 0.1 cm. The note did not include a description of the peri wound, the wound edges, whether or not there was exudate and/or how much, a description of the exudate, and whether or not the wound was producing an odor. The note stated that the wound was cleansed with normal saline (NS), dressings were applied per orders, and that the nurse practitioner had been notified of the wounds and was asked to please see them at the next visit. A physician order dated 03/15/22 revealed to cleanse the left heel with NS, apply [MEDICATION(S)] (enzyme), and to cover with a dry dressing every day. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Measurements were noted as 2.7 cm x 2.7 cm, with no drainage noted. The wound bed was described as having 26-50% eschar, 1-25% slough, and 1-25% pink granulation. The Pressure Ulcer Documentation and assessment dated [DATE] revealed a facility acquired, unstageable pressure ulcer to the left heel which measured 3.0 cm x 3.2 cm x 0.1 cm with scant yellow drainage, no odor, and the resident reported pain of 9 out of 10 on a pain scale. The wound bed was described as about 50-75% soft black eschar, 1-25% pink granulation tissue. The current treatment remained in place. Pressure Ulcer Documentation and Assessment was completed on 03/30/22. A physician order dated 04/06/22 revealed instructions to cleanse the left heel with wound wash, pat dry, apply santyl (callangenaze), cover with Dakin's (antiseptic) soaked gauze, apply an occlusive dressing and wrap with kerlix. Notify the provider of any adverse signs or symptoms; one time a day for wound care. The Pressure Ulcer Documentation and assessment dated [DATE] was completed and Glucerna (nutritional supplement) was added as a nutritional intervention. The physician order dated 04/12/22 stated to discontinue the Dakin's soaked gauze after cleansing, cover with an occlusive dressing, wrap with kerlix, and to cover the area with spandage one time a day for wound care. The Pressure Ulcer Documentation and assessment dated [DATE] revealed the wound was classified as a stage 3 pressure ulcer. The April 2022 Treatment Administration Record (TAR) revealed treatments were provided as ordered, with the exception of 04/18 and 04/19. The Pressure Ulcer Documentation and Assessment for 04/22/22 was blank and did not reveal evidence to indicate whether or not the wound had been evaluated. The physician order dated 05/04/22 stated to cleanse the wound with normal saline (NS) in lieu of wound cleanser. Review of the May 2022 TAR did not reveal evidence the wound treatment was provided 05/08 and 05/14. Per the clinical record, the resident was sent out to the hospital on 05/18/22 and returned on 05/22/22. Review of the May 2022 TAR did not reveal evidence the treatment was provided on 05/23/22. In addition, on 05/24/22, the code 9 was documented in the space provided to indicate instruction to see the nurse's note. However, review of the nursing progress notes did not include documentation to provide a rationale for why the resident did not receive treatment that day. The Pressure Ulcer Documentation and assessment dated [DATE] revealed the pressure ulcer to the left heel was unstageable due to slough and eschar. The wound measured 1.2 cm x 1.3 cm x 0.1 cm, with no tunneling. Drainage was described as a small amount of serous fluid, the wound bed was 25% epithelialization, 25% eschar, 25% slough, and 25% pink granulation. The resident reported pain during treatment. However, the severity of the pain according to a pain scale was not documented. Juven (supplement) was added as an additional nutritional intervention. The June 2022 TAR revealed the treatment orders for the pressure ulcer to the left heel remained in place. Treatments were completed as ordered with the exception of 06/03, 06/25, and 06/26. On 06/07 and 06/11 the code 9 had been documented in the space provided for treatment completion. However, review of the nursing progress notes did not include a rationale as to why the treatments had not been completed. Pressure Ulcer Documentation and Assessments were completed on 06/05, 06/13, 06/18, and 06/26/22. Review of the Pressure Ulcer Documentation and Assessments included wound evaluations on 07/03/22, and 07/09/22. The Pressure Ulcer Documentation and assessment dated [DATE] revealed the stage 3 pressure ulcer measured 0.9 cm x 1.0 cm x 0.2 cm, no tunneling was noted, and the drainage was described as a small amount of serous fluid. The wound bed was described as 25% slough 75% granulation. The July 2022 TAR revealed that treatments were administered as ordered with the exception of 07/20. The physician order dated 07/20/22 stated to cleanse the left heel with NS, pat dry, apply santyl, cover with Dakin's 0.25 soaked gauze, wrap with kerlix, and cover with spandage every other day for wound care. Review of the July 2022 TAR did not reveal evidence the treatment was provided on 07/21, 07/23, 07/26, and 07/28. Review of the Pressure Ulcer Documentation and assessment dated [DATE] revealed a stage 3 pressure ulcer to the left heel. The wound measured 0.8 cm x 0.8 cm x 0.2 cm, no tunneling, and a small amount of serous exudate with no odor. The wound bed was described as pink granulation and slough. The resident reported pain during the treatment. An observation of wound care was conducted on 08/03/22 at 1:34 p.m. with a Licensed Practical Nurse (LPN/staff #26) and LPN (staff #67). Staff #26 removed the soiled dressing and described the exudate as a moderate amount of serosanguinous drainage. He described the periwound as macerated, radiating approximately 2.0 cm around the wound edges. 6 additional open areas were noted to be surrounding the wound, measuring approximately 0.1 - 0.2 cm. The wound was cleansed with NS and patted dry with gauze. Staff #26 described the wound bed as 90-95% slough and 10% granulation tissue. The wound measured 1.5 cm x 1.7 cm x 0.3 cm with an undermining of 0.6 cm from 10 to 12 o'clock. Staff #26 applied santyl and 0.25 soaked Dakin's gauze to the wound bed. The area was covered with an occlusive dressing, wrapped with kerlix, and a pressure-relieving boot was applied. The resident grimaced throughout the dressing change and reported experiencing pain. On 08/04/22 at 12:55 p.m., an interview was conducted with an LPN (staff #67). She stated that she was certified in wound care, but that she was not the wound nurse at this facility. She stated that in her experience, she would anticipate improvement in a wound within 2-3 weeks. She stated that she would contact the provider if there was no improvement, and ask for/suggest a different treatment. She stated that the treatment needs to meet the wound and said that she would not anticipate that santyl would be placed on new granulation tissue. She stated that she would expect an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated it would not meet her expectation for the treatment order not to change because the goal would be to see improvement and/or healing of the pressure ulcer. An interview was conducted on 08/04/22 at 1:14 p.m. with the Director of Nursing (DON/staff #137). She stated that once a wound is identified, the wound nurse will be notified and complete an assessment and call the provider for wound orders. She stated that general practice is for the wound assessment to be completed weekly. The DON stated visual assessment shall be completed daily during dressing changes. She stated that after 3 weeks with no change, she would expect the wound nurse to reach out to the provider to let him know the treatments have not been effective. She stated she would expect the wound nurse to ask for a different wound treatment and/or intervention, reach out to the wound Nurse Practitioner, and/or obtain a referral to the wound care center. She stated that she would anticipate that a different treatment would have been put into place. The DON stated that it did not meet her expectation that the peri-wound had not been protected with skin prep. She stated that the risks associated with the resident's pressure ulcer included pain, infection, and rehospitalization . -Resident #12 readmitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A further potential impairment to skin integrity care plan dated 06/22/21 related to incontinence and limited mobility had a goal to be free from injury. Interventions stated to encourage food nutrition and hydration in order to promote healthier skin. A physician order dated 06/30/22 revealed to cleanse the sacral Moisture Associated Skin Damage (MASD) with NS, pat dry, apply Triad (sterile coating) and cover with a foam dressing one time a day for wound care. Review of the Weekly Skin Check and Wound assessment dated [DATE] revealed an open area had been identified on the resident's coccyx. The risk for nutritional problems care plan was updated to reflect a pressure injury to the resident's sacrum on 07/02/22. Review of the July 2022 TAR revealed treatments were administered 07/01 through 07/05 as ordered. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound bed was described as 26-50% epithelialization, 1-25% slough, and 1-25% pink granulation. Wound orders included to cleanse with NS, apply medical grade honey, and cover with a dry protective dressing daily. Review of the July 2022 TAR revealed treatments were administered per orders from 07/06 through 07/11. The physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . The wound bed was described as 1-25% epithelialization, and 51-75% slough. The note stated that the wound was deteriorating. Dressings/recommendations included to clean the wound with NS, apply medical grade honey, and cover with a dry protective dressing daily. In addition, the note called for repositioning per facility protocol. However, the order was not added to the July 2022 TAR until 07/14/22. Further review of the TAR revealed that no evidence was provided to indicate whether or not treatments had been provided on 07/15 and 07/18. A physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . Measurements of the sacral wound were 2 cm x 0.6 cm. No depth to the wound was identified. There was a small amount of serous drainage noted. The wound bed had 1-25% epithelialization, 1-25% slough, 26-50% pink granulation. The treatment remained the same. Further review of the July 2022 TAR revealed no evidence the treatment was provided on 07/21 or 07/23. The Pressure Ulcer Documentation and assessment dated [DATE] revealed a stage 2 pressure ulcer to the sacrum which measured 2.2 cm x 0.7 cm x 0.1 cm, with no tunneling noted. No drainage was identified, and the wound bed was described as epithelialization and slough. The treatment remained the same. Review of the July 2022 TAR revealed no evidence treatment was provided on 07/25, 07/26 and 07/27. The 07/29/22 Pressure Ulcer Documentation and Assessment revealed a stage 2 pressure ulcer which measured 2.0 cm x 0.6 cm x 0.1 cm, no tunneling, and a small amount of serous drainage noted. The wound bed was described as pink granulation, slough, and epithelialization. An observation of wound care was conducted on 08/03/22 at 10:06 AM with an LPN (staff #26) who was assisted by a second LPN (staff #67). Staff #26 stated that the wound on the resident's sacrum was a stage 2 pressure ulcer, according to his knowledge. Staff #26 performed hand hygiene and applied clean gloves to remove the resident's soiled dressing. Staff #26 stated that he did not know when the dressing had been changed prior to this because there was no date on the dressing. Staff #26 stated there was a small amount of serosanguinous drainage on the dressing. He described the wound edges as attached with scarring at the peri wound area. Hand hygiene was performed and the wound was cleansed. He identified the wound bed with 30-40% slough and 60-70% granulation tissue. Wound measurements were 4.0 cm x 3.0 cm x 0.1 cm. Medical grade honey and a dry foam dressing were applied. An interview was conducted with the DON (staff #137) on 08/04/22 at 3:23 PM. She stated that she would expect that upon identification of a pressure ulcer, the wound would be assessed with [MEDICAL RECORD OR PHYSICIAN ORDER] . She stated her expectations included providing treatments according to the physician orders. -Resident #291 was admitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the admission skin assessment dated [DATE] at 7:36 p.m. stated pressure ulcers were present on admission to the right buttock and right heel. A baseline care plan initiated on July 22, 2022 included skin problems to the right buttock pressure ulcer, right heel pressure ulcer, sacrum pressure ulcer related to decreased mobility. The goal stated the pressure ulcer will show signs of healing and remain free from infection. The interventions stated to administer treatments as ordered, and avoid positioning the resident on the right buttock, sacrum, and right heel. A Weekly Skin Check and Wound Assessment - V 2 dated July 28, 2022 at 9:00 p.m., stated skin issues to sacrum, pressure ulcer and left trochanter (hip) pressure ulcer were being treated. Review of a physician order dated July 22 through July 31, 2022 stated to apply Santyl ointment 250 unit/gram topically every day shift for wound care for 30 days. Apply to wound on right gluteus and right heel as directed once daily (or more frequently if dressing becomes soiled). Review of the TAR dated July 2022 revealed no evidence the treatment was not provided on 7/22, 7/23, 7/24, and 7/26/2022. A physician order dated July 22 through July 31, 2022, stated to apply [MEDICATION(S)] Cream 2% to pressure ulcers topically two times a day for wound care. Review of TAR dated July 2022 revealed no evidence treatments were not provided on July 23, 24, and 26, 2022 at 8:00 a.m. An interview was conducted on August 4, 2022 at 4:04 p.m. with the DON (staff #137). Staff #137 stated her expectation for pressure ulcer management is that the physician order is followed, including the frequency as ordered. Review of facility policy, Wound Management Program, stated the facility's program structure is to provide a comprehensive wound management program with a goal to promote the highest level of functioning and well-being of the residents and to minimize the number of residents that develop in house acquired pressure ulcers. The treatment goals revealed for all residents with wounds to receive treatment and services consistent with the resident's goals of treatment. The wound management program is structured and implemented using processes founded on acceptable standards of practice, research driven clinical guidelines and interdisciplinary involvement. Residents with wounds are to be assessed weekly and reviewed in the skin and weight meeting while the wound is active and for two weeks after complete wound healing.

Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure one resident (#13) was treated with dignity by failing to knock and requesting permission before entering the resident's room. The sample size was 18. The deficient practice could result in residents not being treated in a dignified manner. Findings include: Resident #13 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. An interview was conducted with the resident on 08/01/22 at 1:28 PM. The resident stated that often, the staff do not knock on the door before entering. During the interview, a CNA (Certified Nursing Assistant) was observed entering the resident's room without knocking. Further observations of residents' rooms revealed the following: Observation - 08/03/22 at 9:48 AM - Housekeeper entering without knocking on the resident's door. Observation - 08/03/22 at 11:11 AM - CNA entering without knocking on the resident's door. Observation - 08/03/22 at 12:07 PM - Housekeeper entering without knocking on the resident's door. An interview was conducted with a CNA (staff #96) on 08/03/22 at 11:12 AM. The CNA stated that she knows the policy is that they always knock on residents' doors before entering. She stated that she sometimes forgets and admits she has walked into residents' rooms without knocking, An interview was conducted with a housekeeper (staff #118) on 08/03/22 at 11:35 AM. Staff #118 stated that she knows the policy is to knock before entering a resident's room and that this should include residents who are sleeping. She admitted that she has become busy and entered a resident's room without knocking and asking permission to enter. An interview was conducted with the Director of Nursing (DON/staff #137) on 08/04/22 at 8:52 AM. The DON stated the facility policy is that staff knock on a resident's door before entering the room and that all staff should follow the policy. The DON stated it is her expectation that a resident's right to privacy be maintained by asking permission to enter a resident's room. The facility policy titled Quality of Life - Dignity stated each resident is to be cared for in a manner that promotes quality of life, dignity and respect. The policy further stated that staff will knock and request permission before entering residents' rooms.

Based on observations, clinical record reviews, staff interviews and policy and procedures, the facility failed to ensure that two residents (#27 and #83) received care consistent with professional standards of practice to prevent pressure ulcer/injury development, and/or to promote the healing of existing pressure ulcers. The deficient practice resulted in a lack of timely and thorough pressure ulcer assessments being done and/or identifying wound deterioration timely and/or treatments being missed. Findings include: -Resident #27 was admitted on [DATE], with [DIAGNOSES REDACTED]. A Braden Skin assessment dated [DATE] revealed the resident was considered to be at high risk for the development of pressure sores. A care plan for pressure ulcer risk included a goal to minimize risk for pressure ulcers. Interventions were to encourage the resident to turn and reposition frequently and incontinence care as promptly as possible to keep the resident clean and dry. A nursing progress note dated February 4, 2019 included the resident had redness to bilateral medial balls of her feet. The note stated that it looked like the resident's shoes may be too tight, causing irritation and that the family was notified. Regarding the left metatarsal: On February 5, 2019, a nursing progress note included that the wound nurse had been notified that the resident had redness/abrasions to bilateral feet. Upon assessment, the resident was noted with a protruding lateral metatarsal head with blanchable redness, consistent with characteristics of a bunion. Left metatarsal had an old, dry scabbed abrasion that measured 0.3 cm x 0.5 cm x depth (unable to determine/UTD) and no signs or symptoms of infection noted. The physician was notified, an order was obtained and the new treatment was carried out. A physician's orders [REDACTED]. The orders also included to monitor for adverse changes and notify medical doctor (MD) of any adverse changes. Review of February 2019 through April 2019 TAR's revealed that treatments were carried out per physician's orders [REDACTED]. However, review of the clinical record revealed there were no further wound assessments of the left lateral metatarsal head from February 6, 2019 through May 5, 2019, nor documentation if or when the wound had healed. A nursing progress note dated May 6, 2019 included that the wound care nurse had been notified that the resident had a popped blister to the left metatarsal head, which measured 2.5 cm x 2.0 cm x 0.1 cm. The wound bed was described as pink and moist, partially covered by a skin flap, wound edge defined, peri wound with mild [DIAGNOSES REDACTED] extending 1.0 cm from wound edge, scant serous exudate, no odor and no signs or symptoms of infection. The note stated the resident had chronic bunions to bilateral medial metatarsal heads. The physician was in the facility and was notified, and an order was obtained and carried out. A physician's orders [REDACTED]. The order included to monitor for adverse changes and notify MD. A weekly skin assessment dated [DATE] included that the resident had a popped blister to the left medial metatarsal. A care plan for at risk for development of additional pressure ulcers was developed on May 20, 2019. The care plan included that the resident's shoes were too tight. A goal was for the pressure ulcer to resolve with no complications. Interventions included to remove shoes that do not fit well and provide shoes that fit appropriately, pressure reducing mattress, skin assessment as needed, treatment as ordered, and to turn and reposition as often as needed. Further review of the clinical record revealed there was no evidence that the left medial metatarsal was thoroughly assessed to include measurements, a description of the wound bed, surrounding tissue and if any drainage was present from May 7 through May 20, 2019. A nursing progress note dated May 21, 2019 by the wound care nurse included the left medial metatarsal head which had a popped blister was now a stage III pressure injury, due to location. The wound measured 3.5 cm x 3.5 cm x 0.1 cm., wound bed was pink and moist, previously noted to be covered with a skin flap however, no flap was currently present, wound edge was defined, peri wound with mild [DIAGNOSES REDACTED] now extending 2.2 cm from wound edge, warm to touch, scant serous exudate and no odor. The note stated the physician had been notified, an order was obtained and carried out. A physician's orders [REDACTED]. Another physician's orders [REDACTED]. Review of the May 2019 Medication Administration Record [REDACTED]. Review of the May TAR revealed that treatments were administered per physician's orders [REDACTED]. Continued review of the clinical record revealed no evidence that the left medical metatarsal stage III pressure ulcer was thoroughly assessed from May 22 through June 1, 2019. A wound rounds progress note dated June 2, 2019 included that the stage III pressure injury to the left medial metatarsal head had slightly increased in size from the previous assessment. The wound measured 3.8 cm x 3.5 cm x 0.1 cm. The wound bed was described as pink and moist, the wound edge was defined, peri wound with mild [DIAGNOSES REDACTED] which now extended 2.6 cm from wound edge, scant exudate and no odor. The note included the MD was updated on wound status. Preventative measures in place included weekly skin assessments, offloading with Prevalon (heel protection) boots when in bed as tolerated, and to administer treatment per MD order. The note stated that the resident's family had provided new shoes to the resident. A nursing note three days later dated June 5, 2019, revealed that the wound nurse had notified the Family Nurse Practitioner (FNP) that the stage III pressure ulcer to the left medial metatarsal head had 20% moist black eschar and 80% pink moist tissue. The note stated the wound was now classified as an unstageable pressure injury and a new order was received and carried out. A physician's orders [REDACTED]. Review of June 2019 TAR revealed that treatments were administered daily as ordered. A wound rounds progress note dated June 8, 2019 included that the unstageable pressure injury to the left medial metatarsal head had slightly increased in size from the last assessment and measured 3.8 cm x 3.5 cm x depth (unable to determine/UTD). The wound bed continues with 20% moist black eschar, 80% moist pink tissue, wound edge defined, periwound with increased [DIAGNOSES REDACTED], now extending 3.0 from wound edge, scant serous exudate and MD updated on status. The note indicated that preventative measures in place included off-loading with Prevalon boots when in bed as tolerated, to ensure proper fitting footwear is worn and to administer treatment per MD order. A nursing progress note dated June 11, 2019 included the wound nurse had notified the NP of increased [DIAGNOSES REDACTED] to the periwound and left medial metatarsal head unstageable pressure injury. The note stated the site remained at 3.8 cm x 3.5 cm x UTD, wound bed continued with 20% moist black eschar, 80% moist pink tissue, wound edge defined, peri wound with increased [DIAGNOSES REDACTED], now extending 4.0 cm from wound edge, scant serous exudate, no odor and was warm to touch. The note included that a new order had been obtained and carried out. Review of a physician's orders [REDACTED]. A wound rounds progress note dated June 15, 2019 revealed the unstageable pressure injury to the left medial metatarsal head remained at 3.8 cm x 3.5 cm x UTD. The wound bed continues with 20% moist black eschar, 80% moist pink tissue, wound edge defined, peri wound with increased [DIAGNOSES REDACTED], now extending 4.0 cm from wound edge, scant serous exudate, no odor and warm to touch. MD updated on wound status. A physician's orders [REDACTED]. The wound rounds progress note on June 22, 2019 indicated the wound status remained the same. A nursing progress note dated June 26, 2019 included that the resident returned from a podiatrist appointment with orders to wash the foot with soap and water, apply Santyl collagenous in 1/8 thickness to wound. Cover with [MEDICATION NAME] 4 x 4 and 4, Kerlix to be done every day until healed. A MD progress note dated June 27, 2019 included that the resident had been referred to the podiatrist and that debridement had been done, with instructions for local wound care. A wound rounds progress note dated June 28, 2019 included that the unstageable pressure injury to the left medial metatarsal head was now classified as a stage III pressure injury, with increased size due to a debridement procedure on June 26, at the physician's office. The wound measurements were 6.0 cm x 3.0 cm x 0.2 cm and the wound bed was described as 100% pink moist tissue, wound edge defined, peri wound with decreased [DIAGNOSES REDACTED], now extending 1.2 cm from wound edge, continues with scant serous exudate, no odor and no signs or symptoms of infection. MD updated on wound status. Review of the June 2019 TAR revealed that wound care was provided daily in accordance with physician's orders [REDACTED]. However, review of the clinical record revealed that the left medial metatarsal head pressure ulcer was not thoroughly assessed again until July 7, 2019. A wound rounds progress note dated July 7, 2019 revealed the resident had a stage III pressure injury that remained at 6.0 cm x 3.0 cm x 0.2 cm. The wound bed was described with 100% pink moist tissue, wound edge defined, peri wound with decreased [DIAGNOSES REDACTED] now extending 1.0 cm from wound edge, continues with scant serous exudate, no odor, and no signs or symptoms of infection. Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance with activities of daily living. Per the MDS, the resident was at risk for pressure ulcer development and had two stage 2 pressure ulcers and one stage 3. Review of July 2019 wound round progress notes revealed that thorough wound assessments were provided on July 14, 20, and 27. Review of the July 2019 TAR revealed that treatments were provided per physician's orders [REDACTED]. Review of August 2019 wound round progress notes revealed that thorough wound assessments were provided on August 3, 10, and 17. A wound rounds progress note dated August 24, 2019 included for a stage III pressure injury to the left great metatarsal, which measured 1.7 cm x 1.6 cm x 0.1 cm. The wound bed was described with 100% pink moist granulation tissue, wound edge defined and continues with merging [MEDICATION NAME] tissue, peri wound within normal limits, decrease in exudate, now with scant serosanguineous exudate, no odor, and no signs or symptoms of infection. However, review of the clinical record revealed the wound to the resident's left metatarsal was not thoroughly reassessed, including wound measurements, a description of wound bed and peri wound, any exudate, odor, and signs and symptoms of infection until September 7, 2019. A wound rounds progress note dated September 7, 2019 included the left metatarsal wound measured 1.3 cm x 1.4 cm x 0.1 cm. The wound bed was described as 100% pink moist granulation tissue, wound edge defined and continues with merging [MEDICATION NAME] tissue, peri wound within normal limits, scant serous exudate, no odor and no signs or symptoms of infection. A wound rounds progress note dated September 12, 2019 included the stage III pressure injury to the left great metatarsal head had a slight decrease in size from the previous assessment dated [DATE], and measured 1.2 cm x 1.1 cm x 0.1 cm. The wound bed was described with 100% pink moist granulation tissue, wound edge defined and continued with merging [MEDICATION NAME] tissue, peri wound within normal limits, scant serous exudate, no odor, and no signs or symptoms of infection noted. MD notified of wound status. Further review of the clinical record revealed the wound was not thoroughly assessed again until September 28, 2019, which included measurements, a description of the wound bed, peri wound, any exudate, odor, and signs and symptoms of infection. A wound rounds progress note dated September 28, 2019 revealed the left metatarsal head wound measured 0.8 cm x 0.6 cm x 0.1 cm. The wound bed was described with 100% pink moist granulation tissue, wound edge defined and continued with merging [MEDICATION NAME] tissue, peri wound within normal limits, scant serous exudate, no odor, and no signs or symptoms of infection noted. MD notified of wound status. A nursing progress note dated October 4, 2019 stated the wound care nurse had informed the MD that the stage III pressure injury to the left great metatarsal head was now resolved, and treatments were discontinued. However, a wound rounds progress note the following day dated October 5, 2019, revealed the stage III pressure injury to the left metatarsal head had significantly decreased in size from the assessment dated [DATE], and measured 0.2 cm x 0.1 cm x 0.1 cm. The wound bed was described with 100% pink moist granulation tissue, wound edge defined and continued with merging [MEDICATION NAME] tissue, peri wound within normal limits, scant serous exudate, no odor, and no signs or symptoms of infection noted. Review of a Minimum Data Set (MDS) progress note dated October 5, 2019 by the wound care nurse, revealed the stage III pressure injury to the resident's left metatarsal head was resolved. A late entry nursing progress note dated October 7, 2019 included that per the wound care nurse, the stage III pressure ulcer/injury to left metatarsal head had resolved. Regarding the right lateral/medial metatarsal head: A nursing progress note dated July 1, 2019 stated the wound nurse had notified the MD that the resident had a suspected deep tissue injury (SDTI) to the right lateral metatarsal head, which measured 1.3 cm x 2.0 cm x depth (UTD). The area was described as dark maroon in color; skin intact, no exudate, and no signs or symptoms of infection. The note included the resident had a chronic, large, protruding bunion to the area. An order was obtained and carried out; will continue to offload with Prevalon boots and monitor for adverse changes. A physician's orders [REDACTED]. Monitor for adverse changes and notify MD. Review of the wound rounds progress notes dated July 7, 14, 20, and 27, 2019 revealed that the right lateral metatarsal head wound (SDTI) had decreased in size slightly and skin had remained intact. Review of July 2019 TAR revealed that treatments were administered per physician's orders [REDACTED]. Review of the wound rounds progress notes dated August 3, 2019 revealed a SDTI to the right medial metatarsal head which measured 1.0 cm x 1.5 cm x UTD. The area was described as dark maroon, skin intact, no exudate, and no signs or symptoms of infection noted. Wound rounds progress notes for August 10 and 18, 2019 revealed that the wound to the right metatarsal head was thoroughly assessed, with a slight decrease in size. A weekly wound rounds progress note dated August 24, 2019 revealed the SDTI to the right medial metatarsal head measured 0.5 cm x 0.5 cm x UTD, and the wound remained intact, with no changes in wound status. Review of the August 2019 TAR revealed treatments were administered according to physician's orders [REDACTED]. However, further review of the clinical record revealed the wound to the right medial metatarsal was not assessed again until September 7, 2019. Review of the wound rounds progress note dated September 7, 2019 revealed the SDTI to the right medial metatarsal head had slightly decreased in size to 0.4 cm x 0.4 cm x UTD. Area remained stable with dark maroon intact skin, no exudate, and no signs or symptoms of infection noted. Review of the wound rounds progress note dated September 12, 2019 revealed no change in wound status. Review of the September 2019 TAR revealed that treatments were administered per physician's orders [REDACTED]. However, further review of the clinical record revealed the wound to the right medial metatarsal was not assessed from September 13 through 27, 2020, which included wound measurements, a description of the wound bed, exudate or signs or symptoms of infection. A physician's orders [REDACTED]. Monitor for adverse changes and notify MD, every day for bunion. A wound rounds progress note dated September 28, 2019 included that the right medial metatarsal head was initially a SDTI and was now a stage III pressure ulcer. The wound measured 0.3 cm x 0.3 cm x UTD. The wound bed was described as 100% pink moist tissue, no exudate, and no signs or symptoms of infection noted. The note stated that the resident had been seen by the podiatrist on September 26, 2019 and that the area had been debrided, and a new order had been put into place. Further review of the September 2019 TAR revealed that treatments were provided according to physician's orders [REDACTED]. Review of the wound rounds progress note dated October 5, 2019 included a stage III pressure ulcer to the right medial metatarsal head, with measurements at 0.3 cm x 0.3 cm x 0.1 cm. The wound bed was described as 100% pink moist tissue, wound edge defined, peri wound with mild [DIAGNOSES REDACTED] extending 0.3 cm from wound edge, no exudate, and no signs or symptoms of infection noted. However, further review of the clinical record revealed the stage III pressure injury to the right medial metatarsal was not thoroughly assessed from October 6 through October 18, 2019. A wound rounds progress note dated October 19, 2019 included that the stage III pressure ulcer continued to measure 0.3 cm x 0.3 cm x 0.1 cm, with the wound bed described as 100% pink moist tissue. The wound edge was defined as having dry peeling skin, peri wound continues with mild [DIAGNOSES REDACTED] extending 0.3 cm from wound edge, had scant serous exudate, and no signs or symptoms of infection. MD updated on wound status. Review of the October 2019 TAR revealed that treatments were per provided per physician's orders [REDACTED]. Further review of the clinical record revealed the stage III pressure injury to the right medial metatarsal head was not thoroughly assessed from October 20 through November 1, 2019. A wound rounds progress note dated November 2, 2019 revealed there was a slight decrease in the wound to 0.3 cm x 0.2 cm x 0.1 cm. The wound bed was described as 100% pink moist tissue, wound edge defined, peri wound continues with mild [DIAGNOSES REDACTED] extending 0.2 cm from wound edge, with scant serous exudate, and no signs or symptoms of infection noted. Wound rounds progress notes dated November 8, 2019 revealed there was no change in wound measurements and had a decrease in [DIAGNOSES REDACTED] to 0.1 cm from wound edge. A wound rounds progress note dated November 16, 2019 included a decrease in size to the right medial metatarsal head wound which measured 0.3 cm x 0.1 cm x 0.1 cm. The wound bed was described with 100% pink moist tissue, wound edge defined, peri wound within normal limits, continues with scant serous exudate, and no signs or symptoms of infection noted. Review of the clinical record revealed thorough wound assessments were provided on November 23 and 30, 2019, with a slight decrease in size. Review of the November 2019 TAR revealed that treatments were administered per physician's orders [REDACTED]. Wound rounds progress notes dated December 7 and 14, 2019 revealed thorough assessments were completed. The annual MDS assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive 2+ person physical assistance with activities of daily living. Per the MDS, the resident was at risk for pressure ulcer development and had one stage III pressure ulcer. Interventions included for pressure-relieving devices for her chair and bed, nutrition and hydration interventions to manage skin problems, pressure ulcer care, and application of ointment. A physician's orders [REDACTED]. A wound rounds progress note dated December 21, 2019 revealed for a stage III pressure injury to the right medial metatarsal head, which continued to measure at 0.2 cm x 0.1 cm x 0.1 cm. The wound bed was described as 100% moist pink tissue, wound edge defined, peri wound within normal limits, continues with scant exudate, no odor noted, and no signs or symptoms of infection. A wound rounds progress note dated December 28, 2019 included that a thorough wound assessment was completed, with slight decrease in size of wound and no change in status. Review of December 2019 TAR revealed that treatments were administered as ordered by the physician. A wound round assessment dated [DATE] included a stage III pressure injury to the right medial metatarsal head, which measured at 0.2 cm x 0.1 cm x 0.1 cm. Wound bed was described as 100% pink moist tissue, wound edge defined, peri wound within normal limits, continues with scant exudate, and no signs or symptoms of infection noted. Review of a wound rounds progress note dated January 11, 2020 revealed that a thorough wound assessment of the right medial metatarsal head had a slight decrease in size and no change in wound status. Continued review of the clinical record revealed the wound to the right medial metatarsal head was not thoroughly assessed from January 5 through January 24, 2020. A wound rounds progress note dated January 25, 2020 revealed the stage III pressure injury to the right medial metatarsal head measured 0.1 cm x 0.1 cm x 0.1 cm. The wound bed was described as 100% pink moist tissue, wound edge defined, peri wound within normal limits, continues with scant exudate, and no signs or symptoms of infection noted. Review of the January 2020 TAR revealed that treatments were administered per physician's orders [REDACTED]. Further review of the clinical record revealed there was no nursing documentation to indicate if the right medial metatarsal head pressure ulcer had healed from January 26 through 31, 2020. Review of the physician orders [REDACTED]. During the survey from March 2 through 5, 2020, a wound care observation was unable to be performed, as per the resident's family preference. An interview was conducted with a Certified Nursing Assistant (CNA/staff #42) on March 5, 2020 at 9:44 a.m. She stated that she didn't remember anything about the resident wearing shoes that were too tight. She stated if a resident's foot was red or had open areas, she would tell the nurse. On March 5, 2020 at 10:45 a.m., an interview was conducted with the wound nurse/Assistant Director of Nursing (staff #57). She said that she did not know whether or not the pressure injuries to the resident's feet were caused by the shoes that were too tight. She stated she could not speak for the wound nurse prior to her, but that her process is to provide wound assessments on a weekly basis and to document the wound assessments in the resident's progress notes. She said the wound assessments include wound measurements, description of the wound bed, wound edge, peri wound area, amount of exudate, odor, and signs or symptoms of infection. -Resident #83 was readmitted to the facility on [DATE] and readmitted on [DATE], with [DIAGNOSES REDACTED]. Regarding the sacrum/coccyx pressure ulcer: Review of the clinical record revealed the resident had developed a stage 2 coccyx pressure ulcer, which had resolved by December 2, 2019. A nursing progress note dated December 17, 2019 included the resident had been sent to the hospital for an evaluation. The discharge Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 8 on the Brief Interview for Mental Status (BIMS) assessment, indicating moderate cognitive impairment. The resident required extensive 2+ person physical assistance with most activities of daily living (ADLs), and was at risk for pressure ulcer development. Pressure ulcer interventions in place included a pressure-reducing device for chair and bed, and pressure ulcer care. Another nursing note dated December 18, 2019 at 4:09 a.m. revealed the resident had been admitted to the hospital. A nursing progress note dated December 22, 2019 included the resident had returned to the facility at 1:32 p.m. Per the report from the hospital, the resident was dependent on all ADLs, required assistance with feedings, and was incontinent of bowel. A Braden scale for predicting pressure sore risk dated December 22, 2019 revealed the resident scored a 13.0, indicating she was at moderate risk for the development of pressure sores. The nursing admission skin assessment dated [DATE] did not include documentation of any skin breakdown or pressure ulcers to the coccyx/sacrum. Review of the weekly skin assessment dated [DATE] revealed no documentation that the resident had any skin breakdown to the coccyx/sacrum. A nursing progress note dated January 3, 2020 included that during a weekly skin check, an open area was noted to the resident's sacrum. The note stated that the MD was notified and an order was obtained. There was no further description of the open area to the sacrum. A physician's orders [REDACTED]. Review of the clinical record revealed there was no documentation of a thorough assessment of the open area to the sacrum from January 3 through 6, 2020, which included measurements, a description of the wound bed, if any exudate was present, any odor or the stage of the pressure ulcer. A nursing progress note dated January 7, 2020 revealed the wound care nurse had been notified that the resident had an open area to the coccyx. Upon assessment, the resident was noted with a reopened stage II pressure ulcer measuring 1.8 cm x 2.0 cm x 0.1 cm. The wound bed was described as pink moist tissue, with wound edge defined, peri wound within normal limits, scant exudate, no odor and no signs or symptoms of infection. MD was notified and an order was obtained and treatment carried out. A physician's orders [REDACTED]. The order included to notify MD of any changes. Review of a wound rounds progress note dated January 11, 2020 revealed the coccyx wound measured 1.8 cm x 2.0 cm x 0.1 cm. The wound bed was described as pink moist tissue, wound edge defined, peri wound within normal limits, scant exudate, no odor and no signs or symptoms of infection. Preventative measures in place included weekly skin assessments, re-positioning every 2 hours as tolerated while in bed and pressure reducing mattress. Review of a wound rounds progress note dated January 18, 2020 revealed a stage II pressure ulcer to the resident's coccyx. The wound measured 1.5 cm x 1.8 cm x 0.1 cm and had pink moist tissue, wound edge defined, peri wound within normal limits, scant exudate, no odor and no signs or symptoms of infection. A wound rounds progress note dated January 25, 2020 included a stage II pressure ulcer to the coccyx, which measured 1.0 cm x 1.8 cm x 0.1 cm. The wound bed was described as pink moist tissue, wound edge defined, peri wound within normal limits, scant exudate, no odor and no signs or symptoms of infection. A registered dietitian progress note dated January 30, 2020 revealed the resident's meal intake was approximately 68% for the last 20 meals. A recommendation was to discontinue Nepro one can daily, and begin Nepro 8 ounces twice daily to meet increased needs. Review of the physician's orders [REDACTED]. Review of the January 2020 TAR revealed that wound treatments were administered in accordance with the physician's orders [REDACTED]. A wound rounds progress note dated February 1, 2020 revealed the coccyx wound measured 1.0 cm x 1.5 cm x 0.1 cm. The wound bed was described as pink moist tissue, wound edge defined, peri wound within normal limits, scant exudate, no odor and no signs or symptoms of infection. A Braden scale for predicting pressure sore risk dated February 7, 2020 revealed the resident scored a 13.0, indicating at moderate risk for the development of pressure sores. A physician's orders [REDACTED]. A wound rounds progress note dated February 8, 2020 revealed the stage II pressure ulcer on the coccyx measured 1.0 cm x 1.5 cm x 0.1 cm. The wound bed was described as pink moist tissue, wound edge defined, peri wound within normal limits, scant exudate, no odor and no signs or symptoms of infection. MD notified of wound status. A nutrition assessment dated [DATE] included the resident had a stage II pressure ulcer to the coccyx. The note stated the resident was receiving Nepro 8 oz daily, with 100% consumed. The recommendation again was to increase Nepro 8 oz to twice daily. Review of an annual MDS assessment dated [DATE] revealed the resident had moderate cognitive impairment with daily decision making skills. The resident required extensive assistance with bed mobility, transfers and eating. Per the MDS, the resident was at risk for developing pressure ulcers and had one stage 2 pressu

Based on clinical record reviews, staff interviews, hospital documentation and review of policies and procedures, the facility failed to provide the necessary care and services to maintain the highest practicable well-being for one resident (#163) with a change of condition. Findings include: Resident #163 was admitted to the facility on [DATE], and discharged to the hospital on January 11, 2015, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance with activities of daily living. Review of the altered nutritional status care plan revealed the resident was at risk, due to fluctuating food intake. The goal was to provide adequate calories, protein and fluids to meet the resident's needs. Interventions included to monitor intake and record every meal, obtain and monitor lab/diagnostic work as ordered and to report results to physician and follow up as indicated, and provide substitute/alternate if intake is less than 75%. The physician's telephone orders dated January 2, 2015 included for blood cultures times two, complete blood count (CBC), urinalysis (UA), and a chest x-ray for an elevated temperature. A physician's order dated January 3, 2015 included for Tylenol 650 mg by mouth every 4 hours as needed for an elevated temperature. A nurse's note dated January 3, 2015 at 1:49 a.m., included the resident's temperature was 100.4 and Tylenol was administered. A nurse's note for January 4, 2015 at 2:19 a.m., documented the resident was running a temperature of 102 degrees and Tylenol was given. There was no documentation if the blood work, UA and chest x-ray were completed as ordered, and there was no documentation if the physician had been notified that the resident continued to have a temperature. According to the clinical record documentation, the chest x-ray which was ordered on January 2, was not done until January 5, 2015. The results were unremarkable and were faxed to the physician, with no further orders. A nurse's note dated January 7, 2015 at 7:44 p.m., included the resident had right eye drainage, the physician was notified and orders were obtained to culture the drainage. A nurse's note dated January 8, 2015 at 1:33 a.m., documented the resident had an elevated temperature of 102.2 degrees and was given Tylenol and the temperature increased to 103 degrees. Ice packs were applied and the temperature decreased to 101 degrees. The note also included that the resident refused to drink water or take Tylenol by mouth, so an order for [REDACTED].>A nurse's note dated January 8, 2015 at 3:17 a.m., revealed the resident was found on the floor laying on his right side next to the bathroom door. The resident was noted to have discolorations to the right knee, right side of chest, right elbow and right hip area and the physician was notified. According to a Fall Screening Tool dated January 8, which was completed by a physical therapist aide, the resident typically ambulates by himself to the bathroom and does well, however; the resident has been sick with a temperature and this is why they think he fell . The note included that the nursing notes indicated the resident had a fever for five days. Further review of the clinical record revealed the CBC, the blood cultures and the UA were not collected until January 8, which was more than 5 days after the tests were ordered. The eye culture was also done on January 8. Nurse's notes from January 8, 2015 at 2:53 p.m., revealed that the preliminary results were back and information was passed on to the evening shift and that the resident ate poorly this shift. A note at 9:31 p. m., revealed the lab report was faxed and she attempted to contact the physician, and was waiting for a response from the physician. Review of the laboratory results dated [DATE] revealed the following: white blood count was 17.6 (normal is 4.8-10.8) with [DIAGNOSES REDACTED]s 87.0 (normal 50-70) and Lymphocytes 6.0 (normal 25-40). The urinalysis report included the urine was amber and hazy, and the culture was pending. A nurse's note dated January 9, 2015 included the resident's temperature was 99.6. A nurse's note dated January 10 at 8:00 p.m., revealed the resident had refused dinner and refused to swallow crushed medications. Per the Medication Administration Record, [REDACTED]. A nurse's note dated January 11, 2015 at 5:35 a.m., documented the resident was running a temperature of 102.4 degrees, was given Tylenol and the temperature decreased to 98 degrees. Review of the Certified Nursing Assistant (CNA) documentation for January 2015 revealed the resident had decreased meal intakes as follows: January 1 and 2 = no intake for one meal January 3 = no intake for two meals January 7 = no intake for one meal January 8 = no intake for two meals January 9 = no intake for one meal January 10 = no intake for two meals January 11 = no intake for breakfast Continued review of the clinical record revealed there was no documentation that the physician was notified of the resident refusing multiple medications on June 10, nor of the resident's poor oral intake. In addition, there was no documentation of any interventions that were implemented to address the resident's decreased oral intake, nor was the resident reassessed by dietary for any increased oral intake needs. A nurse's note dated January 11, 2015 at 4:45 p.m., revealed the resident was sent to the hospital, due to being lethargic and running temperatures greater that 100 degrees and that the resident had not eaten for a couple of days. Upon transport, the resident's temperature was 101.6, pulse was 106, respirations were 22 and oxygen saturation was 91%. Review of the hospital records dated January 11, 2015 revealed the resident came from the nursing home and was very lethargic, confused and had severe dehydration. Hospital [DIAGNOSES REDACTED]. The resident's admission condition was noted as poor. The hospital documentation further included that the resident was discharged on [DATE] and was placed on hospice care. An interview with the Director of Nursing (DON) was conducted on May 14, 2015 at 9 a.m. The DON stated that the nurses should notify the physician of any changes in condition and document the information in the resident's chart. The DON did not know why the blood work that was ordered on January 2, was not completed until January 8, or why the chest x-ray that was ordered at the same time was not completed until January 5. She further stated the nurses should be aware of the residents fluids and dietary intake and when there is a decline they should be notifying the physician. A interview was conducted on May 14, 2015 with a Registered Nurse, who stated that if one of her residents were running a temperature, she would do a full assessment with vital signs and contact the physician. She said she would try and get the x-ray and labs right away. A review of the facility's policy and procedure regarding the role of the nurse revealed to deliver quality nursing care to assigned residents in compliance with current applicable federal, state, and local standards, guidelines, and established policies and procedures, which encourages each resident to maintain or attain the highest practical physical, mental, and psychological well-being. The policy also included to document accurate and ongoing assessments of the residents status, document resident care which reflects nursing interventions, resident response to care provided, residents needs, problems, capabilities, limitations and progress towards goals. The nurses are to communicate with physicians regarding residents needs, the nursing assessments and recommendations as needed and assist in developing a written plan of care that identifies the nursing needs of the resident and the goals to be accomplished. -Resident #330 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed admission orders [REDACTED]. According to the History and Physical dated April 26, 2015, the resident was receiving [MEDICAL TREATMENT] treatments and had a right-side AV (ateriovenous) fistula. Review of the admission MDS (Minimum Data Set) assessment dated [DATE], revealed the resident was receiving [MEDICAL TREATMENT] services. Review of the clinical record documentation including the TARs (Treatment Administration Records) and nurses notes from admission through May 14, revealed there was inconsistent documentation of pre and post assessments (i.e. monitoring of the AV fistula site, vital signs, assessment for bruit and thrill) that were completed on the days when the resident had gone to [MEDICAL TREATMENT]. An interview was conducted on May 14, 2015, with the nurse where the resident resided. The nurse stated she isn't on the unit when the resident leaves for [MEDICAL TREATMENT] at 6:00 a.m., but stated when the resident returns from [MEDICAL TREATMENT], the nurse should document assessment of vital signs, bruit and thrill, condition of the shunt site and document it in the nursing notes. The nurse stated that the bruit and thrill would be documented on the TAR. A review of the facility policy for [MEDICAL TREATMENT] revealed documentation that nurses are to asses the presence of a bruit and thrill at the fistula site every shift and after [MEDICAL TREATMENT] to ensure that the access was in proper working condition and to document the bruit and thrill on the TAR. The policy further documented that the resident would be assessed pre/post [MEDICAL TREATMENT] to include status of vascular access and document the resident's condition, vital signs, and response to [MEDICAL TREATMENT] treatment.

Based on active and closed clinical record reviews, hospital documentation, staff interviews, and policy review, the facility failed to adequately supervise one resident (#329) resulting in a fall with fractures, failed to accurately assess one resident's (#71) fall risk, and failed to ensure three residents (#'s 73, 103 and 326) were provided increased supervision following resident to resident altercations. Findings include: -Resident #329 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of an admission nursing assessment dated [DATE], revealed the resident was oriented times one (to person) and required extensive assistance of at least one person for transfers on/off the toilet. A review of a certified nursing assistant (CNA) work sheet for November 2, 2014, revealed the resident was totally dependent for toilet use and required the assistance of at least one person. A Fall Risk assessment dated [DATE], identified that the resident was at medium risk for falls. A care plan for Activities of Daily Living dated November 2, 2014 included an intervention of two person assist for toileting. A nursing progress note dated November 3, 2014, included that while a CNA was assisting the resident in the bathroom, one of her gloves tore. The CNA advised the resident to stay seated on the toilet and she would return as soon as she obtained another glove. The resident nodded in understanding. When the CNA walked from the bathroom to the resident's room to retrieve a glove, she heard a thud. The CNA quickly returned to find the resident had fallen off the toilet, with her chin and right shoulder pressed against the wall. The physician was notified and orders were obtained to transfer the resident to the emergency room for further evaluation. According to the facility's investigation, the resident was left alone in the bathroom and attempted to self transfer and fell . Review of the hospital emergency room chest x-ray dated November 3, 2014, revealed the resident had sustained undisplaced fractures of the fourth and fifth ribs. During an interview conducted with a CNA on May 13, 2015 at 1:35 p.m., she stated that if a resident needed assistance with toileting and transfers on and off the toilet, she would not leave the resident unattended. She stated it would be safer for the CNA to trigger the bathroom call light and wait for help. A registered nurse was interviewed on May 13, 2015 at 2:00 p.m., and stated that if a resident was assessed to need extensive assistance for using the toilet, she would not leave the resident alone in the bathroom. She stated she would instruct the CNA's working on the unit to always assist the resident, especially when the resident has right sided weakness. The CNA involved in the incident was unable to be reached for an interview. An interview was conducted with the Director of Nursing (DON) on May 13, 2015 at 2:30 p.m., who confirmed that residents requiring assistance of at least one person should not be left alone in the bathroom. Review of a facility policy titled, Fall Prevention Program included that this facility will be proactive in reducing the number of resident falls and injuries. The objectives included to promote proactive health care practices for patient care planning which minimize the risk for falls. For the resident at moderate or high risk for fall, the staff should implement interventions as for all residents. -Resident #71 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the Nurses Notes dated April 20, 2015, revealed the resident was found on the floor. The note also included the resident was trying to find and get into her wheelchair. A review of the Nurses Notes dated May 7, 2015, revealed the resident was found on the floor by the bed. The note further included the resident stated she slipped out of bed. Despite the two falls, a Fall Risk assessment dated [DATE], assessed the resident as being at low risk for falls. The assessment also noted the resident had no falls in the past three months. In addition, the investigation regarding the fall on May 7, also included that the resident had no other recent falls. Review of a fall risk care plan revealed the following interventions: call light within reach, door alarm on bathroom door and remind the resident to request assistance for transfers. During an observation conducted with the Director of Nursing at 2:15 p.m. on May 13, 2015, the alarm on the resident's bathroom door was observed to not be functioning, because the part of the alarm that should have been attached to the door frame was missing. During the observation the resident stated that her call light was suppose to be above her head on the left side of her pillow. The call light was observed on her right side next to her purse on her bed. During an interview conducted on May 13, 2015, the Director of Nursing reviewed the Fall Assessment and the Fall Investigation and stated that the two assessments were not accurate. The DON stated that it was the DON and ADON's (Assistant Director of Nursing) responsibility to assure that the nurses complete the Fall Risk Assessment and the Fall Investigation accurately. She further stated that it was the nurses responsibility to ensure that care plan approaches are implemented and that the alarms function properly. Review of a facility policy titled, Fall Prevention Program included that this facility will be proactive in reducing the number of resident falls and injuries. The objectives included to promote proactive health care practices for patient care planning which minimize the risk for falls. For the resident at moderate or high risk for fall, the staff should implement interventions as for all residents. -Resident #326 was readmitted on [DATE], with [DIAGNOSES REDACTED]. Review of an admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status score of six, which indicated the resident had severe cognitive impairment. Further review of this MDS revealed that the resident exhibited physical behavioral symptoms directed toward others, such as hitting, kicking, and grabbing on a daily basis and had verbal behavioral symptoms directed toward others (for example: threatening others, screaming at others) which occurred four to six days of the observation period. In Section V. Care Area Assessment, behavioral symptoms and psychotropic drug use triggered, with a decision to care plan. A behavioral care plan included the resident was verbally and physically abusive towards others. The interventions included for the Alzheimer's unit, intervene as necessary to protect the rights and safety of others, monitor location at all times, document wandering behavior and attempt diversional interventions in behavior log. A Nursing Note dated September 6, 2014 at 9:50 a.m., documented the resident was very agitated, screaming at another resident and staff. The resident then hit another resident and threw an entire bucket of water with cleaning solution off the housekeeping cart onto the resident. This writer and 2 CNAs (Certified Nursing Assistants) tried to redirect res (resident) away from scenario. Res would not walk away, she would not stop hitting, screaming and trying to bite anyone close to her. This writer with the assistance from another Nurse administered PRN (as needed) Haldol (antipsychotic medication) IM (intramuscularly). The note further included that the CNA and nurse then applied a gait belt for safety reasons and transferred the resident to the bed. As the nurse leaned in to remove the gait belt, the resident kicked the nurse in the chest, and the nurse flew backwards and hit the wheelchair and the wall. The CNA tried to calm the resident down but was unable and they left the room, as the resident was again hitting, biting and scratching them. Review of the facility's investigative report revealed that staff had witnessed resident #326 pour a bucket diluted cleaning solution over another resident and staff intervened. The documented that the resident will be placed on 15 minute checks for 72 hrs. Another Nursing Note dated September 7 at 9:55 a.m., reflected that the resident continued on 15 minute checks for safety precautions and that there was no agitation, aggressive or hitting behavior thus far. Nursing Notes on September 7 at 11:33 p.m., and September 8 at 5:59 a.m., revealed that the resident continued on 15 minute checks for aggressive/combative behaviors. A Nursing Note dated September 9 at 2:40 p.m., reflected that monitoring for aggressive and combative behavior toward staff and peers continued and that the resident showed no aggression or combativeness thus far this shift. Despite documentation in the Nursing Notes that 15 minute checks were continued, the clinical record did not reflect any documentation that the 15 minute checks were done every 15 minutes for 72 hrs. In addition, the behavior and psychotropic medication use care plans were not updated to reflect the need for the 15 minute checks that were to be completed. During an interview with a Licensed Practical Nurse (LPN) on May 13, 2015 at 12:56 p.m., the LPN explained that when there is a resident to resident altercation, the nurses not the CNAs document the 15 minute checks in the computer, if the resident was to be monitored for more than 24 hours. With regards to care plan updating, the LPN stated that the 15 minute checks would be included as part of the care plan for the resident's behavior and that this would be completed by nursing staff. During interviews with the DON on May 13 and May 14, 2015, the DON stated 15 minute checks were to be documented on a form that would be kept in the resident's clinical record. The DON explained that medical records staff could not locate documentation that the 15 minute checks were performed on resident #326, after the resident to resident altercation on September 6. The DON further stated that since there was no documentation, she could not prove the resident was being monitored and supervised following the incident. -Resident #73 was admitted to the facility December 1, 2009, with [DIAGNOSES REDACTED]. Review of a High Risk Meeting note dated November 3, 2014 documented that on October 31, 2014, this resident bit another resident on the arm causing a break in the skin. The new interventions that were to be implemented were to place the resident on 15 minute checks for 72 hours and monitor for aggressive behaviors when agitated. Review of the resident's care plans included the resident was on 15 minute checks for 72 hours for safety. However, there was no clinical record documentation that the 15 minute checks were done to show that the resident was provided increased supervision and monitoring following this incident. A interview was conducted with the DON on May 13, 2015 at 2:30 p.m., who was unable to locate documentation of the 15 minute checks for this resident and stated that if they were not documented they probably were not done. -Resident #103 was admitted to the facility April 26, 2014, with the [DIAGNOSES REDACTED]. Review of a High Risk Meeting note dated November 3, 2014 revealed that this resident was bit on the arm by resident #73. Resident #103 had taken resident #73's stuff animal and was teasing her. The only new intervention that was to be implemented was to monitor for signs and symptoms of infection every shift until healed. Review of the clinical record revealed there was no documentation regarding any increased supervision which was provided to resident #103, despite the behavior of teasing resident #73. An interview was conducted with a licensed nurse who stated that when a behavioral disturbance occurs, they separate the residents and do 15 minute checks. A interview was conducted with the DON on May 13, 2015 at 2:30 p.m., who was unable to locate documentation of any increased supervision, including 15 minute checks that were provided to resident #73 following the altercation. The DON stated that if it is not documented then it probably was not done. Review of the facility's policy and procedures revealed that it is the responsibility of the DON or the evening or Night Supervisor to take immediate and appropriate actions to intervene in situations and to ensure sufficient supervision and monitoring is provided to limit the probability of reoccurrence. Residents who are abusive to other residents must be monitored, must have care plans that address the behavior and other residents must be protected. A policy for Supervision and/or 15 minute check monitoring was requested. However, administration stated that there was no policy.

Based on clinical record review, staff interviews, hospital documentation and policy review, the facility failed to ensure that one resident (#163) received sufficient fluids to maintain proper hydration and failed to ensure a fluid restriction was followed as ordered for one resident (#330). Findings include: -Resident #163 was admitted to the facility on [DATE] and discharged to the hospital on January 11, 2015, with [DIAGNOSES REDACTED]. Review of the Minimum Data Set assessment dated [DATE] revealed the resident had severe cognitive impairment and required extensive assistance with activities of daily living. A review of the Nutritional assessment dated [DATE], revealed the resident required 1500 cc of fluids per day. A goal included for adequate hydration. According to the altered nutritional status care plan, the resident was at risk due to fluctuating food intake. The goal included the resident would be provided adequate fluids to meet his needs. Interventions included to monitor intake and for the registered dietician to evaluate and make recommendations as needed. A physician's orders [REDACTED]. A physician's orders [REDACTED]. A nurse's note dated January 3, 2015 at 1:49 a.m., included the resident's temperature was 100.4. A nurse's note for January 4, 2015 at 2:19 a.m., documented the resident was running a temperature of 102 degrees and Tylenol was given. There was no documentation if the physician had been notified that the resident continued to have a temperature. A nurse's note dated January 8, 2015 at 1:33 a.m., documented the resident had an elevated temperature of 102.2 degrees and was given Tylenol and the temperature increased to 103 degrees. Ice packs were applied and the temperature decreased to 101 degrees. The note also included that the resident refused to drink water or take Tylenol by mouth, so an order for [REDACTED].>According to a Fall Screening Tool dated January 8, 2015 which was completed by a physical therapist aide included that the nursing notes indicated the resident had a fever for five days. A nurse's note dated January 9, 2015 included the resident's temperature was 99.6. A nurse's note dated January 10 at 8:00 p.m., revealed the resident had refused dinner. A nurse's note dated January 11, 2015 at 5:35 a.m., documented the resident was running a temperature of 102.4 degrees, was given Tylenol and the temperature decreased to 98 degrees. A review of the Certified Nursing Assistant charting for fluid percentages revealed the following amounts of fluid consumed per day: January 3 was 120cc, January 4 was 1440 cc, January 5 was 1320cc, January 6 was 1200cc, January 7 was 720cc, January 8 was 360cc, January 9 was 360cc, January 10 was 480cc and January 11 was 240cc. Continued review of the clinical record revealed there was no documentation that the physician was notified of the resident's poor fluid intake. In addition, there was no documentation of any interventions that were implemented to address the resident's decreased fluid intake, nor was the resident reassessed by dietary for any increased fluid needs, due to running a temperature off and on from January 2 through 11, and having poor fluid intake. A nurse's note dated January 11, 2015 at 4:45 p.m., revealed the resident was sent to the hospital, due to being lethargic and running temperatures greater that 100 degrees and that the resident had not eaten for a couple of days. Review of the hospital records dated January 11, 2015 revealed the resident came from the nursing home and was very lethargic, confused and had severe dehydration. Hospital [DIAGNOSES REDACTED]. The resident's admission condition was noted as poor. The hospital documentation further included that the resident was discharged on [DATE] and was placed on hospice care. An interview with the DON (Director of Nursing) was conducted on May 14, 2015 at 9 a.m. The DON stated that the nurses should be monitoring the resident's fluid intake and when there is a decline, the physician should be notified of a change in condition and to monitor for dehydration. An interview with the Director of Food Services was conducted on May 14, 2015 at 10:30 a.m. She stated that she does the initial assessment of the residents nutritional needs and then the dietician will check them when she comes in every two weeks. She stated that the CNA's keep track of the residents fluids at meals and if a resident becomes ill, the nurses will let her know and she will meet with the resident and provide broth or whatever the resident feels like eating/drinking. Review of the nurses job description revealed that the nurse needs to assess residents and analyze information to develop appropriate interventions to prevent decline. Notify appropriate staff to evaluate for weight loss and dehydration. Maintain current knowledge of patients condition/information through the maintenance of accurate lists.This knowledge includes diet, hydration. Review of a policy for the Best Practice for Nutrition Intervention Protocol revealed that when a resident is at nutritional or dehydration risk, appropriate interventions should be implemented. Interventions must be in place for residents with poor oral intake. The following recommended dietary interventions should be implemented within 72 hours of being identified as at risk, unless interventions are contraindicated by disease/Diagnosis: [REDACTED]. 2. Encourage fluids sent from dietary to equal 8 oz servings per day. These fluids are in addition to bedside water. 3. Add to hydration cart. -Resident #330 was admitted on [DATE], with [DIAGNOSES REDACTED]. A review of the resident's clinical record revealed physician's admission orders [REDACTED]. Continued review of the clinical record revealed a care plan, dated April 29, 2015, for altered nutritional status, that documented fluid restrictions per physician order [REDACTED]. A review of the admission MDS (minimum data set) assessment dated [DATE], documented that the area of dehyration was triggered and was to be care planned. Further review of the clinical record for April 23, 2015 - May 14, 2015, revealed documentation of the resident's fluid consumption at each meal with no documentation found regarding fluids consumed between meals, such as, with medication pass or snacks. An interview was conducted on May 14, 2015. with the RN (registered nurse) who was providing cares and medications to the resident. The RN stated that fluids would be documented on the flow sheet or MAR (medication administration sheet.) The RN was able to provide a copy of the documentation by the CNA (certified nursing assistant) of fluids consumed with meals, but there was no flow sheet found with documentation of fluid intakes by the resident at other than meal times. During an interview conducted with the DON (Director of Nursing) on May 14, 2015, the DON stated that there should be an intake and output record on the resident's chart, but none was found. A policy regarding documentation of fluid intake documentation was requested however the DON stated there was no formal policy and a copy of the intake and output record was provided and the DON stated the nurses were to fill that out for resident's with fluid restrictions.

Based on closed clinical record review, staff interviews, review of the Lippincott Manual of Nursing Practice, facility documentation and policy review, the facility failed to ensure that adequate supervision was provided to one resident (#253) who fell while unattended and sustained a fracture to the right tibia/fibula, resulting in actual harm. Findings include: Resident #253 was admitted to the facility May 5, 2005, and has had multiple readmissions. [DIAGNOSES REDACTED]. Review of a fall care plan updated on January 31, 2012, documented a fall was sustained when the resident was being assisted by another resident to stand up. The care plan identified the resident was at risk for falls characterized by a history of falls and injury, poor safety awareness, impaired balance, poor coordination and the use of psychotropic medications. Approaches included call light within reach, commonly used items within easy reach, and to explain and remind the resident regarding the risks of non-compliance with ambulation and transfer recommendations and devices. Review of a fall risk assessment dated [DATE], revealed the resident was intermittently confused and required assistance with elimination. On this assessment, it did not determine any specific level of fall risk (i.e. low risk, moderate risk or high risk). Review of the Quarterly Minimum Data Set assessment dated [DATE], section G functional status, included that the resident was not steady when moving from a seated to a standing position and was only able to stabilize with assistance. A nurse's note dated August 8, 2012, documented the resident was confused and combative. According to the high risk meeting progress notes dated August 19, 2012, the resident was very hard of hearing and could become very confused related to advanced dementia. The Activities of Daily Living (ADL) care plan for self care performance deficit, related to dementia and impaired decision making included to provide extensive assistance with dressing and to position resident so that ADLs can occur in a secure/balance position. Review of the behavior care plan included that behaviors would not result in injury to the resident or others, and would cooperate with care and that needs would be anticipated and assessed. A nurse's note entry dated September 24, 2012, included the resident came out of the shower room with a CNA and had fallen. The resident was found on her left side in front of the shower chair. When asked what happened the resident stated "can you help me." The resident was assessed at which time it was found that the resident had a misalignment of the right knee and was subsequently transferred to the hospital for treatment. According to the documentation, an x-ray was obtained and was positive for a fracture to her right tibia and fibula. Review of the fall investigation report, revealed the resident had been left alone in her room sitting on a shower chair, while the CNA left the room to obtain an incontinence brief. When the CNA returned, the resident was in the process of falling from the shower chair. She was subsequently sent to the hospital related to a misalignment to her lower extremity. Additionally, the report included that the resident had dementia with a history of confusion, had impaired mobility, was non ambulatory, required assistance with all transfers, and that due to her impaired hearing, she feared being left alone. Per the report, factors that may have contributed to the fall included the following; wet floor, not dressed properly, and call light not within reach. The report also included that the resident had not had other falls recently. During an interview conducted on January 17, 2013, the CNA stated that she had worked frequently with the resident. She stated that at the time of the event, the resident was seated in a shower chair in her room, after having had a shower. The CNA stated that she needed a brief (incontinence brief) and she went out into the hall a short distance to obtain a brief from the linen cart outside the resident's door. She said when she came back, the resident was on the floor. She added that she did not see the resident fall and that the resident had never attempted to get up on her own before. During this interview, the CNA stated that she should not have left the resident alone. During an interview conducted on January 17, 2013, the assistant director of nursing stated that the resident was very hard of hearing and was afraid of falling. She was unaware that the resident had a history of [REDACTED]. In a follow up interview, the assistant director of nursing stated that she had no policy regarding supervision of residents with cognitive deficits. Review of a facility policy titled "Giving a Bath or Shower" included to review the care plan for information regarding the amount of assistance needed, limitation in positions or activity, and any other special considerations. A review of the Lippincott Manual of Nursing Practice eighth edition, page 1749, regarding dementia included expected outcomes: "Safety precautions and close surveillance maintained; no injury."

Based on closed clinical record reviews, hospital documentation, staff interviews, and facility policy review, the facility failed to provide blood sugar testing for four residents (#254, 259, 258, and 129). Resident #254 sustained actual harm as a result. The facility failed to adequately and consistently assess the respiratory status of one resident (#200). Findings include: -Resident #254 was admitted to the facility on [DATE], and readmitted on [DATE], with [DIAGNOSES REDACTED]. A physician's orders [REDACTED].= 2 units, ,[DATE]= 3 units, ,[DATE]= 4 units, ,[DATE]= 5 units, ,[DATE]= 7 units, ,[DATE]=8 units, ,[DATE]=10 units, ,[DATE]=11 units, and for blood sugar results greater than 350 to call the physician. The orders also included for [MEDICATION NAME] green scale at bedtime to be given subcutaneous using the following scale: for blood sugar less than 70 call physician, ,[DATE]=2 units, ,[DATE]=3 units, ,[DATE]=4 units, ,[DATE]=5 units, ,[DATE]=6 units, ,[DATE]= 7 units, and for blood sugar results greater than 350 to call the physician. According to a fax transmittal sent to the physician dated [DATE], the resident had a blood sugar of 45 and was given instant glucose and juice. The resident's blood sugar was rechecked 30 minutes later with a result of 197. Review of the care plans revealed that the resident was at risk for hypo/hyperglycemic reactions due to diabetes. Interventions included to provide diabetic medications as ordered and to monitor and document side effects and to monitor and report signs and symptoms of hypo/[MEDICAL CONDITION]. Review of the February 2012 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Despite these low blood sugars, there was no documented evidence in the clinical record that the physician was notified per the physician orders. Further review of the clinical record revealed physician telephone orders dated February 15, 2012, for 15 units of [MEDICATION NAME]to be given now. However, there were no nurses notes or other documentation regarding the condition of the resident or what the resident's blood sugar was at the time of this order. A nurse's note dated February 16, 2012, documented that at 11:00 a.m., the resident was unresponsive and clammy. The resident's blood sugar was checked with the last test strip in the facility due to "...not having any in central supply or any where else in the building. Central supply and management aware. Pt. blood sugar was 22..." The note further documented that glucose gel and [MEDICATION NAME] was given including oxygen and that orange juice with sugar and med pass slowly through a straw was also attempted but resident "continued to be unresponsive so 911 was called and pt. was sent to the ER." Review of the emergency room records revealed the resident was brought to the emergency due to a blood sugar of 22. The facility gave [MEDICATION NAME] and oral glucose and the EMS gave IV fluids (D50), and his blood sugar increased to 165. The note documented the resident was dizzy and was an ill-appearing man in respiratory distress. Diagnostic impressions included the [DIAGNOSES REDACTED], pneumonia,[MEDICAL CONDITIONS] and [MEDICAL CONDITION]. According to the hospital documentation, the resident arrived at the hospital at 12:37 p.m. However, the nurse's notes documented the concern with the the resident being unresponsive and clammy with a blood sugar of 22 at 11 a.m. Further review of the facility documentation including nurse's notes revealed there was no explanation as to the delay and there was no documentation of any ongoing assessments of the resident's condition that were done, nor that the resident's blood sugar was rechecked or of any additional interventions that were done during this time frame. -Resident #258 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the MAR for February 16, 2012, at 6:00 a.m., revealed that the resident did not receive his blood sugar testing or insulin. His blood glucose was tested at 11:30 a.m. and was 314, which was higher than normal. -Resident #259 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the MAR for February 16, 2012 at 7:00 a.m., revealed that the resident did not receive his blood sugar testing or his insulin at this time. His blood glucose was tested at 11:00 a.m. and was 300, which was higher than normal. -Resident #129 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. Review of the MAR for February 16, 2012 at 5 a.m., revealed that the resident did not receive his blood sugar testing or his insulin at this time. An interview was conducted with a registered nurse (RN) on [DATE]. The RN stated that the facility did run out of test strips for the glucometer machines and that some of her residents did not get their blood sugar tested on that day (February, 16, 2012). She also stated that these same residents did not get their insulin on that day and it was documented on their MAR. An interview was conducted with the activities director on [DATE]. The activities director stated that she went to another facility to borrow some glucometer test strips until they could get some. She stated that it was the responsibility of nursing/central supply to make sure that there are enough test strips in the facility. An interview was conducted on [DATE], with the assistant director of nursing (ADON), who was the director of nursing at the time of the incident. She stated that central supply told her there were twenty packets and that each packet had fifty test strips. She also stated that she was not notified when the facility ran out of test strips, as another nurse was being trained to be the director of nursing (DON) and she was helping to train the new DON. She further stated that the order came in a few days after the incident, so she stated that she did not think this was a problem. Review of the facility's policy on [DIAGNOSES REDACTED] revealed "Insulin Shock is a condition that occurs in diabetic residents when they receive too much insulin; miss a meal, or when they have too much physical activity, the onset is sudden...signs and symptoms: appears to be in a coma, unconscious, or partially unconscious...low blood glucose levels should be reported to the charge nurse and physician, hold insulin until capillary blood glucose levels have normalized. Capillary blood glucose levels should be repeated frequently, until they normalize..." -Resident #200 was admitted to the facility on [DATE], with a [DIAGNOSES REDACTED]. The resident expired on [DATE]. A review of the physician orders [REDACTED]. For chronic [MEDICAL CONDITION] obstruction disease the resident was ordered, [MEDICATION NAME] nebulizer to be administered routinely and as needed, [MEDICATION NAME] nebulizer to be administered routinely and as needed, [MEDICATION NAME] 10 mg, singular 10 mg. The physician ordered to maintain the resident's oxygen level greater that 90% (percent) at 2 liters of oxygen as needed. A review of the initial nursing assessment dated [DATE], revealed documentation that the resident had abnormal lung sounds and a productive cough. A review of the Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. A review of the MAR for [DATE] through 10, 2012, lacked documented evidence that the resident's oxygen level had been monitored. Further review of the September MAR indicated [REDACTED]. A review of the nursing notes dated [DATE], revealed that the resident complained of shortness of breath and was administered an SVN treatment. The notes lacked documented evidence that her breath sounds were auscultated and her oxygen level was assessed. The nursing notes dated [DATE], documented that the resident having "labored" breathing and oxygen was administered at 2 liters. The notes lacked documented evidence that lung sounds were auscultated and oxygen level was assessed. The notes lacked documentation as to how long the resident required the oxygen The nursing notes dated [DATE], documented that the resident was sent to the hospital and admitted with a [DIAGNOSES REDACTED]. An interview with a licensed practical nurse conducted on [DATE], revealed that the assessments were to be documented in the nursing notes or on the treatment record. The nurse further stated that a complete assessment would include the residents vitals, breath sounds and their response to any given treatment and if they do not respond to the treatment then the doctor should be notified and documented.

Based on clinical record review, observations, staff interviews, facility documentation review, the facility failed to ensure that one resident (#17), was transferred appropriately and as a result sustained actual harm. The facility also failed to have the resident environment was free from accident hazards. The sample size was four. Findings include: Resident #17 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident care plan, dated July 8, 2010, and September 26, 2010, revealed that the resident required the assistance of two or a Hoyer lift with transfers. The annual minimum data set (MDS) assessment dated [DATE], documented that the resident was totally dependent for transfers, required the physical assistance of two persons for transfers, and required a mechanical lift for transfers. On November 14, the clinical record documented that the resident was transferred by a certified nursing assistant (#8). According to the nurse's notes, staff #8 stated that she heard a "popping" sound from the resident's left hip or knee area. The resident was assessed and the range of motion was within normal limits. Review of the resident's clinical record revealed that the resident had an x-ray to the left hip on November 15, 2010, related to complaints of pain. Findings on the final report included that there was a probable nondisplaced fracture of the acetabulum of the left hip. The facility's investigation was reviewed and dated November 18, 2010. The report documented that staff #8 transferred the resident without the assistance of a second staff member and without the use of the Hoyer lift. During an interview conducted October 7, 2011, with the director of nursing, he stated he was aware of the events of November 14, 2010, the resident sustained [REDACTED]. -During observations conducted on October 3, 2011 at 11:40 a.m., and 1:15 p.m., and October 4, 2011, at 9:50 a.m., and 2:30 p.m., physical therapy parallel bars were observed to be located immediately outside the entrance to the physical therapy department, and were located against the wall of the corridor, extending over and obstructing the handrail. During an interview conducted October 3, 2011 at 11:58 a.m., the administrator stated a new structure for rehabilitation, physical therapy, and medical records was currently being built. She further stated that there were no active renovations being conducted to the current physical therapy department room, and that the current physical therapy department room was to be entirely relocated to the new structure when construction has been completed. During an interview conducted October 4, 2011, at 2:40 p.m., the physical therapist stated the parallel bars were in the corridor daily, from 8:00 a.m., to 12:00 noon and are moved back into the physical therapy room in the afternoon. She further stated that there was not enough room in the physical therapy room for the parallel bars. Observations conducted October 4, 2011, of the corridor outside the physical therapy room, included the physical therapist instructing a resident in a wheelchair how to propel the wheelchair. The therapist was observed behind the resident, with the resident maneuvering the wheelchair between the parallel bars in the corridor, and the opposing wall. Further observation revealed a lack of space on either side of the resident, to safely accommodate an individual's passage in the corridor. The corridor was observed and measured, with the maintenance supervisor, and found to be eight feet in width from wall to wall. A facility policy titled "Resident Rights", page 14, included, that the facility must provide a safe environment. Another facility policy titled "Kissito Healthcare Operational Policy Manual", 27.1, regarding general safety, included "The purpose of the the safety management program is to provide a physical environment free of hazards and to manage staff activities to reduce the risk of human injury."