Every finding on record at Haven of Scottsdale

Number of residents sampled: 46Number of residents cited: 1Based on observation, interview, review of clinical record, staff interviews, review of facility's video footage, policy and procedure, the facility failed to ensure adequate supervision was provided to one resident (#27). The deficient practice resulted in the resident sustaining injury from accidental foley catheter dislodgement and a transfer to the hospital.Findings include:-Resident #27 was re-admitted on [DATE], with diagnoses of acute on chronic congestive heart failure, cardiomyopathy, pneumonia, unspecified dementia, anxiety disorder, and retention of urine.A care plan dated December 5, 2025, revealed Resident #27 was at risk for functional self-care deficits and/or functional mobility limitations related to subdural hemorrhage; and, had a catheter. Goals were to safely perform functional self-care and mobility tasks; and, that the resident will be and will remain free from catheter-related trauma. Interventions included that the resident required assistance with transferring and toileting; required an assistive device to reposition and turn in bed to encourage resident to participate to the fullest extent possible with each interaction; and, to encourage resident to use call light to call for assistance.A Fall Risk Evaluation dated December 5, 2025, revealed Resident #27 had a fall risk score of 18 indicating the resident was high risk for fall.The health status note dated December 6, 2025 included that Resident #27 continued to be disoriented and at times reminded of his surroundings. According to the documentation, resident was noted pulling on his foley catheter, forgets that he has a foley catheter and required reminders.The eMAR (electronic medication administration record) note dated December 6, 2025 revealed the resident was alert and oriented x 1-2, very forgetful, was forgetting that he had a foley catheter in place and was yelling.A History and Physical physician note dated December 6, 2025, revealed the resident was agitated, confused, alert and oriented only to self; and, was pulling on his foley catheter. The documentation included that the resident needed more supervision; and that, the provider discussed with staff that resident #27 may not be appropriate for the facility because of agitation reasons.A Health Status Note dated December 7, 2025 included Resident #27 was alert, confused, forgetful, and needed reminders throughout the night. Per the documentation, the resident liked to sit with someone so the resident sat at the nurse station with a staff part of the morning. The note revealed the resident's urine was noted to be bloody due to the resident pulling on his foley catheter yesterday; and that, family visited and sat with the resident all evening and the resident was calmer.The eMAR note dated December 7, 2025 revealed resident was alert and oriented x3, able to make needs known to staff, required frequent redirection and frequently yelled out asking where his family was.Another eMAR note dated December 7, 2025 included that the resident did not want to move or adjust his body in the bed. The documentation included that the resident thought he could stand up by himself or move himself to the edge of the bed.An eMAR note dated December 8, 2025, revealed a change of condition for the resident's behaviors of yelling out and pulling on foley catheter.The physician progress note dated December 8, 2025 included that the resident had advanced vascular dementia with behaviors, was agitated, confused, alert and oriented only to self; was pulling on his foley catheter and needed more supervision. Further, the documentation included that the resident was very encephalopathic at this time; and that, the provider discussed with staff that resident #27 may not be appropriate for the facility because of agitation reasons.A physician order dated December 8, 2025 included to target symptoms/behaviors tracking for anxiety as evidenced by restlessness every shift.An encounter note dated December 9, 2025 included that when the resident initially arrived to the facility, he was more agitated, anxious and disoriented; and that, the resident was started on an anticonvulsant for mood lability and 1st generation antihistamine for anxiety/restlessness. Per the documentation, family reported that the resident appeared calmer since the medications were introduced. The documentation also included that staff reported resident had agitation. Assessments included dementia with behavioral disturbances and recent behavioral concerns of agitation and restlessness with difficulties adjusting to facility. Recommended nonpharmacologic strategies included environmental modifications to ensure safety, structured activities to reduce triggers for wandering and agitation and consistent sleep routine.The physician progress note dated December 9, 2025 included that the resident was agitated, confused, alert and oriented only to self; was pulling on his foley catheter and needed more supervision. Further, the documentation included that the resident was very encephalopathic at this time; and that, the provider discussed with staff that resident #27 may not be appropriate for the facility because of agitation reasons.The eMAR note dated December 10, 2025 included the resident was yelling throughout the night.The skilled needs review dated December 10, 2025 revealed that following comprehensive review, the IDT (interdisciplinary team) attested that resident met all criteria for skilled services.The daily skilled evaluation dated December 10, 2025 included that the resident was disoriented x 4.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #27 had a brief interview for mental status (BIMS) assessment score of 9, indicating the resident had moderate cognitive impairment. The assessment also included the resident had no evidence of acute change in mental status, had no potential indicators of psychosis such as hallucinations and delusions, and the resident's current behavior status, care rejection of wandering was worse in comparison to prior assessment. Active diagnoses included CVA (cerebrovascular accident), non-Alzheimer's dementia, anxiety, depression, and altered mental status. An eMAR note dated December 11, 2025, revealed the resident was yelling and screaming throughout the night, and that as needed (PRN) anxiety medication was not effective.The psychiatry progress note dated December 11, 2025, revealed Resident #27 was seen near the nursing station resting in wheelchair. The note revealed that according to the chart, the resident had been yelling and screaming throughout the night, did not sleep, and had been given PRN (as needed) anti-anxiety medication with no effect.A physician order dated December 11, 2025 included for change of condition monitoring for yelling out every shift for 6 days. The documentation included that physician was notified.A care plan initiated on December 11, 2025 revealed the resident had a behavior problem related to impaired cognitive function, impaired safety awareness and verbal behavior (yelling out and banging on table instead of using call light). The goal was that resident safety will be maintained. Interventions included anticipating and meeting the resident's needs; for caregivers to provide opportunity for positive interaction, attention and to stop and talk with the resident as passing by; explaining all procedures to the resident before starting and allow the resident time to adjust to changes; identifying behavior triggers; intervening as necessary to protect the rights and safety of others, and approach/speak in a calm manner, diverting attention, and removing from situation and taking to alternate location as needed; and, administering medications as ordered, monitoring/documenting for side effects and effectiveness.An eMAR note dated December 12, 2025 included the resident woke up intermittently, called out for his family, and was redirected as needed.Another eMAR note dated December 12, 2025 revealed the resident called out for his family 4 times; and that, the resident stopped calling out when he was informed that his family was at home.The physician progress note dated December 12, 2025 revealed the resident was agitated, confused, alert and oriented only to self; was pulling on his foley catheter, needed more supervision; and, the provider discussed with staff that Resident #27 may not be appropriate for the facility because of agitation reasons.The eMAR notes dated December 13, 2025 included the resident continued to yell out even after needs had been met. Per the documentation, the resident was confused, was redirected as needed, and still continued to yell out.A daily skilled evaluation dated December 14, 2025 revealed the resident was oriented x1 and had Foley catheter in place.The eMAR notes dated December 14, 2025 included that resident was yelling and screaming, and that anti-anxiety medication was administered. It also included that after administration, the resident was calm and rested for short periods of time, and continued to yell out and scream at intervals.An eMAR note dated December 16, 2025 revealed Resident #27 continued to yell out at intervals throughout the night; and that, episodes of yelling and screaming had decreased.A psychiatry progress note dated December 16, 2025 included Resident #27 remained confused and continued with intermittent moments of yelling out at night. The documentation included that it seemed to lessen when PRN anti-anxiety medication was administered.The physician progress note dated December 17, 2025 revealed the resident was agitated, confused, alert and oriented only to self; was pulling on his foley catheter, needed more supervision; and, the provider discussed with staff that resident #27 may not be appropriate for the facility because of agitation reasons.Another eMAR note dated December 16, 2025 revealed the resident was yelling and agitated.A psychiatry progress note dated December 18, 2025 included resident was still having moments of yelling and calling out for his family. The documentation included that staff reported the resident had agitation; and, review of systems included resident had poor insight, limited judgment, and slow processing, tangential thought process. Assessment included Dementia with behavioral disturbance. Recommendations included for nonpharmacological strategies such as environmental modifications to ensure safety, structured activities to reduce triggers for wandering and agitation, and consistent sleep routine, to consider pharmacologic intervention if there was concern for safety of the resident / others, and to continue to monitor for mood, anxiety, or behavioral concerns.A care plan initiated December 18, 2025 revealed Resident #27 had impaired cognitive function/dementia or impaired thought processes related to impaired decision making. Goal was that the resident will be able to communicate needs on a daily basis. Interventions included to administer medications as ordered; to keep routine consistent and try to provide consistent caregivers as much as possible to decrease confusion; and, to monitor, document, and report to the physician any changes in cognitive function, and to use task segmentation to support short term memory deficits.The physical therapy (PT) progress note dated December 22, 2025, revealed Resident #27 had poor sequencing of tasks during walking, had poor execution of walking technique that resulted in decreased safety with walking, and was a fall risk. Per the documentation, the resident required minimum assistance for chair to/from bed transfers and for walking, and required cues for safe sequencing of tasks.A psychiatry progress note dated December 22, 2025 included Resident #27 was yelling out when needing assistance and often required frequent reorientation. It also included that the resident became restless and yelled out at times.The daily skilled evaluation December 23, 2025 revealed the resident had a foley catheter in place, had verbal behavior directed at others, required frequent redirection, and frequently yelled out and asking [NAME] occupational therapy (OT) daily note dated December 24, 2025 included the resident required frequent redirection throughout the session due to poor cognition.The daily evaluation note dated December 24, 2025 revealed the resident had a foley catheter in place, had verbal behavior directed at others requiring frequent redirection, and frequently yelled out instead of using the call light.The pulmonary progress note dated December 24, 2025 included the resident was confused and thought that his family was not aware of his location.The physician progress note dated December 24, 2025 revealed the resident was agitated, confused, alert and oriented only to self; was pulling on his foley catheter and needed more supervision; and, the provider discussed with staff that resident #27 may not be appropriate for the facility because of agitation reasons.A speech therapy (ST) daily note dated December 26, 2025 included the resident was able to answer orientation questions with 0% accuracy despite max cueing from the therapist. Per the documentation, the resident had continued confusion and stated that this was his home, questioned why was the therapist was there, and asked where his family was. The documentation also included that the therapist attempted to orient the resident to place and situation, but the resident started to yell out for help.The psychiatry progress note dated December 26, 2025 revealed Resident #27 yelled for help or for his family; and that the resident settled down when talked to but then began yelling out intermittently. The note included that staff reported that resident was more anxious recently and continued with intermittent yelling out. According to the documentation, the resident was later moved out of his room and into common area where he seemed to settle down more and have less moments of yelling out. It also included that the resident remained fairly confused, requiring frequent reorientation, was provided with the call light but continued to yell out. Recommendations included nonpharmacologic strategies such as environmental modifications to ensure safety, structured activities to reduce triggers for wandering and agitation, and consistent sleep routine, to consider pharmacologic intervention if there was concern for safety of the resident / others, and to continue to monitor for mood, anxiety, or behavioral concerns.The daily skilled evaluation notes dated December 26 and 27, 2025 revealed the resident had a foley catheter in place, had verbal behavior directed at others, required frequent redirection, and frequently yelled out instead of using the call light.The ST daily note dated December 28, 2025 included the resident consistently yelled out that he had to pee. Per the documentation, the resident had poor immediate recall, and began to yell out again as therapist walked away; and that, resident made comments that he did not know where he was.A physician progress note dated December 28, 2025 revealed the resident constantly and repeatedly yelled that he needed help. The plan included for mobilization with staff assistance, and safety/fall precautions per facility protocols.An OT daily note dated December 29, 2025 included the resident was easily confused, upset, and not easily redirected. It also included that multiple attempts were made but resident continued to perseverate on going home, and was unable to participate in therapy session.The physician progress note dated December 29, 2025 revealed the resident was agitated, confused, alert and oriented only to self; was pulling on his foley catheter and needed more supervision. It also continued to document that the provider discussed with staff that Resident #27 may not be appropriate for the facility because of agitation reasons.A PT Daily Note dated December 30, 2025, revealed that the resident was discharged from PT services due to resident transitioning to hospice services at home. The note also included the resident required minimum to moderate assistance for transfers, and was significantly limited by confusion and fear due to pain in bilateral lower extremities and penis.The psychiatry progress note dated December 30, 2025 included the resident was sleeping in bed, intermittently waking up and yelling out for help to sit up; and that resident continued with ongoing behaviors of yelling out for help at family. It also included that resident frequently required redirection and reorientation, was provided with call light but continued to yell out, becomes anxious de to disorientation and forgetfulness. The documentation also included that staff reported similar behavioral observations and that resident had some ongoing sleep disturbance with resident intermittently sleeping but having moments of yelling during the night as well. Recommendations included nonpharmacologic strategies such as environmental modifications to ensure safety, structured activities to reduce triggers for wandering and agitation, and consistent sleep routine; to consider pharmacologic intervention if there was concern for safety of patient/others; and, to continue to monitor for mood, anxiety, or behavioral concerns.The neurology progress note dated December 30, 2025 revealed Resident #27 was lying in bed while yelling for help and was unable to verbalize needs when asked about what he needs. The note revealed the resident cannot be redirected, and was intermittently yelling; and that, staff reported that the resident was constantly yelling and shouting all night as well.A Pulmonary Progress Note dated December 30, 2025, revealed the resident was sitting edge of bed, remained confused, alert and oriented to self only, and was yelling out for his family.An eMAR note dated December 30, 2025, revealed the resident continued to yell out and refused medication.The daily skilled evaluation notes dated December 30 and 31, 2025 revealed the resident had a foley catheter in place, had verbal behavior directed at others, required frequent redirection, and frequently asking for his family and frequently yelled out instead of using the call light.Review of the clinical record revealed that the resident was admitted to hospice on December 31, 2025.The care plan dated December 31, 2025 included that Resident #27 was admitted to hospice with diagnosis of senile degeneration of brain, effective January 1, 2026. Interventions included to provide activities to meet needs, routine position changes and exercise to comfort and relieve pressure, 1 to 1 visits and provide support to family as needed, and to document one to one support, activities of daily living (ADL) needs per facility protocol and existing plan of care, and, medication as ordered to ensure comfort.A psychiatry progress note dated January 1, 2026, revealed the resident was in a chair intermittently yelling for help and assistance to use the bathroom, and was calmed down with redirection. The note included that revealed that staff reported continuation of the behaviors of yelling out despite frequent reminders to use the call light, agitation and, had started to refuse medications. Per the documentation, staff reported difficulties in medication administration; and that, the resident remained forgetful and confused. The documentation also included that the resident presented with limited attention and ability to maintain logical/linear thought. Mental status examination included poor short- and long-term memory were poor, tangential concentration, poor insight, and limited judgment. It also included that resident was confused and required frequent re-orientation. Recommendations included for nonpharmacological strategies such as environmental modifications to ensure safety, structured activities to reduce triggers for wandering and agitation, and consistent sleep routine, and to consider pharmacologic intervention if there was concern for safety of patient/others.The pulmonary progress note dated January 1, 2026 included the resident remained confused and was yelling out.The daily skilled evaluation dated January 1, 2026 revealed resident was oriented x 1, had verbal behavior directed at others, required frequent redirection, and frequently asking for his family and frequently yelled out instead of using the call light.A BIMS assessment dated [DATE], revealed Resident #27 had a score of 6 indicating severe cognitive impairment.The behavior notes dated January 2, 2026 included that Resident #27 was alert and oriented to self, was refusing medications, continued to have behaviors of yelling throughout the day, and had multiple attempts to self-ambulate to leave the facility, and was assisted back to his chair before he could exit the building. Continued re-assurance was offered and redirection were not effective. The note included that the resident was administered with an antianxiety medication and a narcotic opioid in his cheek. The documentation also included that hospice was notified to have nurse come to the facility for assessment and assistance.The physician progress note dated January 2, 2026 continued to document that the resident was agitated, confused, alert and oriented only to self; was pulling on his foley catheter and needed more supervision. It also continued to document that the provider discussed with staff that resident #27 may not be appropriate for the facility because of agitation reasons.A physician order dated January 2, 2026, included for Lorazepam (antianxiety) oral concentrate 2 mg (milligram)/ml (milliliters), to give 1 ml by mouth every 2 hours as needed for anxiety as evidenced by restlessness and agitation, related to anxiety disorder.The eMAR note dated January 3, 2026 revealed that Foley catheter was re-inserted on previous shift and that the resident was voiding clear yellow urine into the foley bag.A behavior note dated January 3, 2026 included the resident was yelling for his family, asked for water and when he was given fresh water, the resident threw a cup at a certified nursing assistant (CNA).The daily skilled evaluation dated January 3, 2026 revealed resident was oriented x 1, had foley catheter in place, had verbal behavior directed at others, required frequent redirection, and frequently asking for his family and frequently yelled out instead of using the call light.Despite documentation continued documentation that Resident #27 needed more supervision, may not be appropriate for the facility, behaviors of yelling out and pulling foley catheter, attempts to self-ambulate there was no evidence found that the facility placed and implemented new interventions to increase supervision for Resident #27.There was also no evidence that nonpharmacological strategies such as structured activities, environmental modifications, consistent sleep routine were put in place as recommended by the psychiatric provider.Review of the Medication and Treatment Administration Record (MAR/TAR) for January 2026, revealed that Lorazepam was not documented as administered; and, there were no episodes of anxiety as target behaviors recorded from January 2 through 4, 2026.An observation was conducted on January 4, 2026, at 7:03 a.m. Resident #27 was sitting in a reclining wheelchair (gerichair) in the hallway directly across the nurses' station; and was the only resident sitting in this area. The resident's catheter bag was attached to his gerichair. There was no call light or call bell present for the resident to use; and, the television was not turned on nor was there an activity that the resident could do while on his gerichair. The resident was continuously yelling out loud and was frequently asking for help; however, there were no staff at the nurses' station or in the area where the resident was.At 7:42 a.m. on January 4, 2026, at 7:42 a.m., Resident #27 continued to be sitting in the gerichair in the hallway directly across the nurses' station, and, was the only resident sitting in this area. The resident's catheter bag was attached to his gerichair. There were no staff at the nurses' station or in the area where the resident was. The resident stood up from the gerichair and took small unsteady steps forward toward the nurses' station and was yelling out very loudly. There were no staff who was near the resident who continued walked towards the nurses' station which resulted in his foley catheter tube pulled taught from the bag hung on his gerichair. The resident yelled out loudly and repeatedly in pain; and, the resident's foley catheter tube and balloon were then observed on the floor. The resident continued to yell out loudly that he was in pain, and a CNA (Staff #17) then approached the resident, and attempted to pull the resident by his arm back toward his gerichair. The resident told the CNA that that he had a bowel movement on himself. The licensed practical nurse (LPN /Staff #9) approached and instructed the CNA (staff #17) to assist the resident in the bathroom to get him cleaned up, and that, the nurse would re-insert the catheter. The resident then sat in the gerichair, and the CNA pushed the resident in the gerichair back to his room.At approximately 8:13 a.m. on January 4, 2026, the LPN (Staff # 9) and the emergency medical services (EMS) were in the resident's room. The LPN reported to EMS that Resident #27 stood up from his chair and pulled his catheter out; and that, the resident was covered with blood with some large clots. An observation of the resident's bathroom revealed some blood on the toilet seat and on the front of the toilet bowl.At 8:35 a.m. on January 4, 2026, EMS assisted Resident #27 onto a gurney by EMS staff. The resident asked EMS where they were taking him, and the EMS told that resident that he will be taken to the hospital as he accidentally pulled out his foley catheter. A progress note dated January 4, 2026 revealed Resident #27 was walking toward the nurses' station while yelling, the resident's foley catheter was found lying on the floor under his chair; and that, a CNA was trying to assist the resident back to the chair. The documentation included that the resident was taken to his room, where he was placed on the toilet; and that, the provider was notified. It also included that the nurse instructed a CNA to place the resident in bed after toileting so the catheter could be replaced; and that, upon entering the resident's room, the resident was standing by his bed, wearing a brief with large amount of bright red blood and large clots present. The documentation revealed the provider was updated of the resident's bleeding and clots, and the provider gave an order for the resident to be sent to the emergency department.A progress note dated January 4, 2025 included that Resident #27 was sent to the hospital earlier in the morning due to foley catheter being pulled out by the resident with balloon still inflated. It also included that the nurse spoke with the hospital emergency room (ER) nurse and was told that the Foley catheter was re-inserted. According to the documentation, the resident was agitated in the ER, screaming for help and yelling murder! which was the resident's baseline behavior at the facility.Another progress note dated January 4, 2026 revealed Resident #27's return to the facility was paused due to the resident having to be put in restraints at the hospital.A review of the facility's video camera footage of the nurses' station, where Resident #27 was located on January 4, 2026, was conducted with the Administrator (Staff #55) on January 6, 2026, at 1:02 p.m. The video footage from January 4, 2026, beginning at 6:00 a.m., revealed the following:At 6:00 a.m., Resident #27 was seated in a gerichair with the leg rest elevated and the backrest reclined. A Foley catheter bag was observed hanging beneath the leg rest portion of the chair.At 6:45 a.m., Resident #27 called out that he needed to use the bathroom. A staff member responded and informed the resident that he had a catheter. The resident stated that he needed assistance to use the men's restroom.At 6:47 a.m., staff left the resident alone at the nurses' station area. The resident began yelling for help. No staff responded. A nurse was observed standing at a medication cart approximately 30 feet away but did not respond. The resident continued yelling and requested water.At 6:49 a.m., a staff member responded. The resident requested to be positioned upright so he could drink water. Staff stated they wanted him to remain reclined until breakfast. The resident stated he could not drink water while reclined.At 6:50 a.m., staff adjusted the chair to a more upright position and provided the resident with water. Staff told the resident there was no reason for yelling and that he was waking others. The resident requested to speak with someone in authority. Staff told him his family was sleeping and then left him alone.At 6:53 a.m., the resident continued yelling for help and requested assistance to use the bathroom. A male staff member walked past without responding. A nurse was observed at a medication cart approximately 30 feet away. No staff assisted the resident with toileting.At 6:55 a.m., the resident told a nurse he had a bowel movement. The nurse instructed him to wait until assistance could be found.At 6:57 a.m., a nurse walked past the resident, who again stated he needed to use the bathroom. The nurse did not respond.At 6:58 a.m., the resident continued yelling loudly for help and bathroom assistance.At 7:05 a.m., a nurse told the resident that his family had been contacted and would arrive later, and instructed him to stop yelling. The nurse then left. The resident was not assisted with toileting and continued yelling repeatedly, stating he might attempt to walk and could hurt himself.At 7:22 a.m., the resident yelled that he would start breaking things and attempted to stand. A voice was heard telling him to sit down. A nurse approached and stated it was too early to call his family.At 7:24 a.m., after the nurse walked away, the resident again attempted to stand. Two nurses were at the nurses' station facing away. As the resident partially stood, the gerichair wheels were not locked securely and rolled backward until hitting the wall. The resident landed back in the chair, and the foley catheter bag fell to the floor. A nurse then approached, rehung the catheter bag on the gerichair, and instructed the resident to remain seated.At 7:27 a.m., the nurse told the resident she would retrieve his family's phone number and return, then left the area.At 7:32 a.m., the resident yelled loudly for help approximately 35 times. No staff responded.At 7:37 a.m., a therapy staff member spoke briefly with the resident, told him his family would arrive later, and stated she would return to assist with breakfast, then left.At 7:40 a.m., the resident repeatedly yelled for help and requested the police. A staff member told him it was early and that his family lived far away, then walked away while the resident continued speaking. No staff remained in the area.At 7:42 a.m., the resident stood up from the gerichair and took several unsteady steps away while yelling. The foley catheter tubing became taut as he moved away from the chair. The catheter and balloon were then pulled out and fell onto the floor. The resident yelled loudly in pain. A staff member approached and grabbed the resident's right arm, attempting to pull him back toward the gerichair.An interview with a random alert and oriented male on hallway A was conducted on January 4, 2026, at 7:33 a.m. He stated that the facility was usually quiet until that man (referring to Resident #27) was admitted to the facility sometime before December 25, 2025. He said that resident #27 had been yelling out loudly for help often; and that, the yelling had affected his sleep.An interview was conducted with a CNA (Staff #17) on January 4, 2026, at approximately 7:48 a.m. The CNA stated that caring for residents with behaviors was very hard because the facility was so understaffed. The CNA said that Resident #27 screamed all the time, and had gotten up from his chair before in the past; however, the CNA stated that this was the first time Resident #27 had accidentally pulled his foley catheter out.An interview with a random alert and oriented female resident on hallway B was conducted on January 4, 2026 at 8:12 a.m. The female resident stated that she hears the poor man (referring to R

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to implement their policy on abuse reporting and investigation for allegations of abuse for 2 of 9 sampled residents (#77 and #72). The deficient practice could result in allegations of abuse not reported, not investigated and residents not protected from continued abuse.Findings include: -Resident #77 was admitted on [DATE] with diagnoses of displaced intertrochanteric fracture of the left femur, osteoporosis and chronic pain. The ADL (activities of Daily Living) care plan dated August 1, 2023 included the resident was at risk for ADL self-care performance deficit. Intervention included to encourage resident to participate to the fullest extent possible with each interaction. The progress note dated August 1, 2023 revealed the resident was admitted after a GLF (ground level fall) at home and presented with left hip fracture. The IDT (interdisciplinary team) fall review dated August 7, 2023 included that the resident sustained a fall on August 7, 2023 at 5:00 a.m. The documentation included that resident was found on the floor by the toilet sit facing sideways on the right side; and that, resident reported that he fell. According to the documentation, the resident was alert and oriented x 3 and able to verbalize what happened, was assisted to the wheelchair with a gait belt and 3 person assist assist x3. The alert note dated August 7, 2023 revealed the resident was found on the floor by the toilet sit facing sideways on the right side; and the resident reported that he fell. According to the documentation, the resident was alert and oriented x 3 and able to verbalize what happened, was assisted to the wheelchair with a gait belt and 3 person assist assist x3. A progress note dated August 7, 2023 included that while the resident was observed during smoking break, the resident stated that he was unhappy with facility; and that, the resident did not go into detail about the reasons why he was unhappy,. A late entry incident note dated August 7, 2023 revealed the resident reported that he was treated roughly, and does not want further care from a CNA (certified nurse assistant) that worked for the morning shift on this day. According to the documentation, skin assessment was completed and there were no new findings. It also included that the ED (executive director), DON (director of nursing), physician and the family were notified. The initial facility report submitted to the SA (State Agency) on August 7, 2023 revealed that the resident reported to the unnamed therapist that he did not want care from a CNA assigned to him on August 7, 2023; and that, he had at least 3 broken bones from the CNA who was going to kill him and was out to get him. The report included that the resident was able to describe the CNA as a younger female about 24-[AGE] years old, had a lighter brown hair with glasses, had tattoos and was wearing blue and black; but the resident did not know the CNA's name. The documentation included that later, the resident reported that the CNA wore dark grey clothes and had tattoos on the left arm; and that, there was a CNA that best fits this description. According to the report, the resident reported that the CNA wheeled him around too fast, bumped his feet on walls and he felt like a horse while being showered; and, while being turned during cares by the CNA, he hit his face on the wall. The report included that the CNA was immediately suspended and at the time of the report submission, the facility was contacting other agencies. However, review of the clinical record and facility documentation, there was no evidence found that this allegation was reported to law enforcement and APS (Adult Protective Services); and that, the results of the investigation of the alleged abuse was submitted to the SA within 5 working days of the incident. There was also no evidence that this allegation was thoroughly investigated by the facility. -Resident #72 was admitted on [DATE] with diagnoses of chronic embolism, hemiplegia and hemiparesis, restless leg syndrome and other specified disorders of the brain. The ADL care plan dated July 26, 2023 included the resident was at risk for ADL self-care performance deficit. Interventions included to praise efforts at self care and to encourage resident to participate to the fullest extent possible with each interaction. The health status note dated August 12, 2023 revealed the resident was alert and oriented x 3-4. The late entry NP (nurse practitioner) progress note dated August 30, 2023 included that the resident had been smoking since she was [AGE] years old; and that the resident smokes every day. The psychology progress notes dated September 13, 2023 revealed that observations of and conversations with resident revealed no evidence of psychological harm related to incident last week. The documentation did not include details of the incident. Per the documentation that after speaking with resident, there were no concerns or changes noted since the occurrence; and that, the resident has had no other incidents of conflicts. The psychology progress notes dated September 14, 2023 revealed that observations of and conversations with resident revealed no evidence of psychological harm related to incident last week. The documentation did not include details of the incident. Per the documentation that after speaking with resident, there were no concerns or changes noted since the occurrence. The initial facility report submitted to the SA on September 14, 2023 included that resident #72 reported to the ED (staff #54) that on September 11, 2023 at 2:00 p.m., another resident made sexual comments towards resident #72 while she was sitting on the smoking patio last week. However, review of the clinical record and facility documentation, there was no evidence found that this allegation was reported to law enforcement; and that, the results of the investigation of the alleged abuse was submitted to the SA within 5 working days of the incident. There was also no evidence that this allegation was thoroughly investigated by the facility. The email correspondence from the Director of Nursing (DON/staff #19) dated January 5, 2026 revealed that the investigation/incidents and/or complaints requested for resident #77 and #72 were not available because they were outside the guidelines. An interview with the DON (staff #19) was conducted on January 6, 2026 at 1:47 p.m. The DON stated she does not know where the investigations for the incident related to residents #77 and #72 because both residents as in her email were outside the guideline. She said that outside the guideline was their policy which dictates what and for how long documents including incidents/investigations were maintained for X number of years. An interview with a registered nurse (RN/staff #25) was conducted on January 6, 2026 at 3:17 p.m. The RN stated that different types of abuse included financial, physical, sexual, verbal and emotional abuse; and, when there is an allegation of abuse and/or neglect, staff ensures the resident was safe, the alleged aggressor is separated from the resident/victim. The RN stated that if the allegation involved a staff member, the staff is sent home so there is no access to the resident/victim or anyone else that may be put in danger. The RN also said that allegations of abuse and/or neglect is reported to the administrator immediately; and the Ombudsman, police, physician, family were also notified. In an interview with another RN (staff #32) conducted on January 6, 2026 at 3:28 p.m., the RN stated that if an allegation of abuse was to reported to her, she would ensure that the resident was secured, safe and would separate the resident from the perpetrator. She stated that she would also notify the ED, DON or the assistant DON so they could work together to resolve the situation. The RN said that if the perpetrator was a staff member, that staff member would be sent home and she would call the ED. An interview was conducted on January 6, 2026 at 3:40 p.m. with the social services director (SSD/staff #56) who stated that different types of abuse included sexual, physical, emotional and financial abuse; and if there were allegations of abuse, it would immediately be reported directly to the ED. He stated that if the ED was not available, the incident will be reported either to the DON or the ADON. The SSD stated that when there was an allegation of abuse, the first thing to do was to ensure the resident was safe; and if the perpetrator was a staff member, they were immediately suspended until the investigation was concluded. The SSD further stated that his role in abuse investigation was to help with the facility's self-report and assist the ED with investigation. During an interview with the administrator (staff #55) conducted on January 7, 2026 at 8:30 a.m., he stated that he could not any evidence of the investigation the facility conducted regarding resident #77 and #72. The administrator further stated that he follows the facility policy on record retention which stated that incident reports and self-reports must only be retained for a period of 12 months after the date of report or posting; and, grievances must only be retained for a period of 3 years. In another interview with the DON (staff #19) conducted on January 7, 2026 at 12:13 p.m., the DON stated that staff will follow their policy on abuse, when there was an allegation of abuse. She stated that when there was an allegations of abuse, staff would ensure that residents were safe; and if it involved a staff, the staff would be suspended until the facility's investigation was over. She stated that the allegation of abuse is reported to the abuse coordinator; and, investigation will be conducted by the abuse coordinator who will then send a preliminary report to the SA, APS, Ombudsman, police and family. She stated the allegation of abuse will be reported to the SA, APS, Ombudsman and police within the 2 hour window for suspected abuse. The DON also said that investigation of the allegation of abuse conducted by the abuse coordinator involved conducting interviews with the victim, the alleged perpetrator and possible witnesses; and, the abuse coordinator would then submit the 5-day report of the investigation to the SA. The policy on Abuse, Neglect, Exploitation and Misappropriation Prevention Program with effective date of January 1, 2024 included 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 resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives:-Develop and implement policies and protocols to prevent and identify: a. abuse or mistreatment of residents; b. neglect of residents; and/or c. theft, exploitation or misappropriation of resident property;-Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property;-Investigate and report any allegations within timeframes required by federal requirements; and, -Protect residents from any further harm during investigations.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure an allegations of abuse were reported to APS and law enforcement; and failed to ensure that the results of the investigations of the alleged violation for 2 of 9 sampled residents (#77 and #72) were submitted to the SA within 5 working days of the incident. The deficient practice could result in allegations of abuse not investigated and residents not protected from continued abuse.Findings include: -Resident #77 was admitted on [DATE] with diagnoses of displaced intertrochanteric fracture of the left femur, osteoporosis and chronic pain. The ADL (activities of Daily Living) care plan dated August 1, 2023 included the resident was at risk for ADL self-care performance deficit. Intervention included to encourage resident to participate to the fullest extent possible with each interaction. The progress note dated August 1, 2023 revealed the resident was admitted after a GLF (ground level fall) at home and presented with left hip fracture. The IDT (interdisciplinary team) fall review dated August 7, 2023 included that the resident sustained a fall on August 7, 2023 at 5:00 a.m. The documentation included that resident was found on the floor by the toilet sit facing sideways on the right side; and that, resident reported that he fell. According to the documentation, the resident was alert and oriented x 3 and able to verbalize what happened, was assisted to the wheelchair with a gait belt and 3 person assist assist x3. The alert note dated August 7, 2023 revealed the resident was found on the floor by the toilet sit facing sideways on the right side; and the resident reported that he fell. According to the documentation, the resident was alert and oriented x 3 and able to verbalize what happened, was assisted to the wheelchair with a gait belt and 3 person assist assist x3. A progress note dated August 7, 2023 included that while the resident was observed during smoking break, the resident stated that he was unhappy with facility; and that, the resident did not go into detail about the reasons why he was unhappy,. A late entry incident note dated August 7, 2023 revealed the resident reported that he was treated roughly, and does not want further care from a CNA (certified nurse assistant) that worked for the morning shift on this day. According to the documentation, skin assessment was completed and there were no new findings. It also included that the ED (executive director), DON (director of nursing), physician and the family were notified. The initial facility report submitted to the SA (State Agency) on August 7, 2023 revealed that the resident reported to the unnamed therapist that he did not want care from a CNA assigned to him on August 7, 2023; and that, he had at least 3 broken bones from the CNA who was going to kill him and was out to get him. The report included that the resident was able to describe the CNA as a younger female about 24-[AGE] years old, had a lighter brown hair with glasses, had tattoos and was wearing blue and black; but the resident did not know the CNA's name. The documentation included that later, the resident reported that the CNA wore dark grey clothes and had tattoos on the left arm; and that, there was a CNA that best fits this description. According to the report, the resident reported that the CNA wheeled him around too fast, bumped his feet on walls and he felt like a horse while being showered; and, while being turned during cares by the CNA, he hit his face on the wall. The report included that the CNA was immediately suspended and at the time of the report submission, the facility was contacting other agencies. However, review of the clinical record and facility documentation, there was no evidence found that this allegation was reported to law enforcement and APS (Adult Protective Services); and that, the results of the investigation of the alleged abuse was submitted to the SA within 5 working days of the incident. -Resident #72 was admitted on [DATE] with diagnoses of chronic embolism, hemiplegia and hemiparesis, restless leg syndrome and other specified disorders of the brain. The ADL care plan dated July 26, 2023 included the resident was at risk for ADL self-care performance deficit. Interventions included to praise efforts at self care and to encourage resident to participate to the fullest extent possible with each interaction. The health status note dated August 12, 2023 revealed the resident was alert and oriented x 3-4. The late entry NP (nurse practitioner) progress note dated August 30, 2023 included that the resident had been smoking since she was [AGE] years old; and that the resident smokes every day. The psychology progress notes dated September 13, 2023 revealed that observations of and conversations with resident revealed no evidence of psychological harm related to incident last week. The documentation did not include details of the incident. Per the documentation that after speaking with resident, there were no concerns or changes noted since the occurrence; and that, the resident has had no other incidents of conflicts. The psychology progress notes dated September 14, 2023 revealed that observations of and conversations with resident revealed no evidence of psychological harm related to incident last week. The documentation did not include details of the incident. Per the documentation that after speaking with resident, there were no concerns or changes noted since the occurrence. The initial facility report submitted to the SA on September 14, 2023 included that resident #72 reported to the ED (staff #54) that on September 11, 2023 at 2:00 p.m., another resident made sexual comments towards resident #72 while she was sitting on the smoking patio last week. However, review of the clinical record and facility documentation, there was no evidence found that this allegation was reported to law enforcement; and that, the results of the investigation of the alleged abuse was submitted to the SA within 5 working days of the incident. An interview with a registered nurse (RN/staff #25) was conducted on January 6, 2026 at 3:17 p.m. The RN stated that allegations of abuse and/or neglect is reported to the administrator immediately; and the Ombudsman, police, physician, family were also notified. In an interview with another RN (staff #32) conducted on January 6, 2026 at 3:28 p.m., the RN stated that if an allegation of abuse was to reported to her, she would ensure that the resident was secured, safe and would separate the resident from the perpetrator. She stated that she would also notify the ED, DON or the assistant DON so they could work together to resolve the situation. An interview was conducted on January 6, 2026 at 3:40 p.m. with the social services director (SSD/staff #56) who stated that different types of abuse included sexual, physical, emotional and financial abuse; and if there were allegations of abuse, it would immediately be reported directly to the ED. He stated that if the ED was not available, the incident will be reported either to the DON or the ADON. The SSD further stated that his role in abuse investigation was to help with the facility's self-report and assist the ED with investigation. During an interview with the administrator (staff #55) conducted on January 7, 2026 at 8:30 a.m., he stated that he could not any evidence of the investigation the facility conducted regarding resident #77 and #72. The administrator further stated that he follows the facility policy on record retention which stated that incident reports and self-reports must only be retained for a period of 12 months after the date of report or posting; and, grievances must only be retained for a period of 3 years. In another interview with the DON (staff #19) conducted on January 7, 2026 at 12:13 p.m., the DON stated that staff will follow their policy on abuse, when there was an allegation of abuse. She stated that allegation of abuse is reported to the abuse coordinator; and, investigation will be conducted by the abuse coordinator who will then send a preliminary report to the SA, APS, Ombudsman, police and family. She stated the allegation of abuse will be reported to the SA, APS, Ombudsman and police within the 2 hour window for suspected abuse. The DON also said that investigation of the allegation of abuse conducted by the abuse coordinator involved conducting interviews with the victim, the alleged perpetrator and possible witnesses; and, the abuse coordinator would then submit the 5-day report of the investigation to the SA. The policy on Abuse, Neglect, Exploitation and Misappropriation Prevention Program with effective date of January 1, 2024 included 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 resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: -Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property; and, investigate and report any allegations within timeframes required by federal requirements.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure allegations of abuse for 2 of 9 sampled residents (#77 and #72) were thoroughly investigated. The deficient practice could result in residents not protected from continued abuse and appropriate corrective action not taken.Findings include: -Resident #77 was admitted on [DATE] with diagnoses of displaced intertrochanteric fracture of the left femur, osteoporosis and chronic pain. The ADL (activities of Daily Living) care plan dated August 1, 2023 included the resident was at risk for ADL self-care performance deficit. Intervention included to encourage resident to participate to the fullest extent possible with each interaction. The progress note dated August 1, 2023 revealed the resident was admitted after a GLF (ground level fall) at home and presented with left hip fracture. The IDT (interdisciplinary team) fall review dated August 7, 2023 included that the resident sustained a fall on August 7, 2023 at 5:00 a.m. The documentation included that resident was found on the floor by the toilet sit facing sideways on the right side; and that, resident reported that he fell. According to the documentation, the resident was alert and oriented x 3 and able to verbalize what happened, was assisted to the wheelchair with a gait belt and 3 person assist assist x3. The alert note dated August 7, 2023 revealed the resident was found on the floor by the toilet sit facing sideways on the right side; and the resident reported that he fell. According to the documentation, the resident was alert and oriented x 3 and able to verbalize what happened, was assisted to the wheelchair with a gait belt and 3 person assist assist x3. A progress note dated August 7, 2023 included that while the resident was observed during smoking break, the resident stated that he was unhappy with facility; and that, the resident did not go into detail about the reasons why he was unhappy,. A late entry incident note dated August 7, 2023 revealed the resident reported that he was treated roughly, and does not want further care from a CNA (certified nurse assistant) that worked for the morning shift on this day. According to the documentation, skin assessment was completed and there were no new findings. It also included that the ED (executive director), DON (director of nursing), physician and the family were notified. The initial facility report submitted to the SA (State Agency) on August 7, 2023 revealed that the resident reported to the unnamed therapist that he did not want care from a CNA assigned to him on August 7, 2023; and that, he had at least 3 broken bones from the CNA who was going to kill him and was out to get him. The report included that the resident was able to describe the CNA as a younger female about 24-[AGE] years old, had a lighter brown hair with glasses, had tattoos and was wearing blue and black; but the resident did not know the CNA's name. The documentation included that later, the resident reported that the CNA wore dark grey clothes and had tattoos on the left arm; and that, there was a CNA that best fits this description. According to the report, the resident reported that the CNA wheeled him around too fast, bumped his feet on walls and he felt like a horse while being showered; and, while being turned during cares by the CNA, he hit his face on the wall. The report included that the CNA was immediately suspended and at the time of the report submission, the facility was contacting other agencies. However, review of the clinical record and facility documentation, there was no evidence found that the allegation of abuse for resident #77 was thoroughly investigated by the facility. -Resident #72 was admitted on [DATE] with diagnoses of chronic embolism, hemiplegia and hemiparesis, restless leg syndrome and other specified disorders of the brain. The ADL care plan dated July 26, 2023 included the resident was at risk for ADL self-care performance deficit. Interventions included to praise efforts at self care and to encourage resident to participate to the fullest extent possible with each interaction. The health status note dated August 12, 2023 revealed the resident was alert and oriented x 3-4. The late entry NP (nurse practitioner) progress note dated August 30, 2023 included that the resident had been smoking since she was [AGE] years old; and that the resident smokes every day. The psychology progress notes dated September 13, 2023 revealed that observations of and conversations with resident revealed no evidence of psychological harm related to incident last week. The documentation did not include details of the incident. Per the documentation that after speaking with resident, there were no concerns or changes noted since the occurrence; and that, the resident has had no other incidents of conflicts. The psychology progress notes dated September 14, 2023 revealed that observations of and conversations with resident revealed no evidence of psychological harm related to incident last week. The documentation did not include details of the incident. Per the documentation that after speaking with resident, there were no concerns or changes noted since the occurrence. The initial facility report submitted to the SA on September 14, 2023 included that resident #72 reported to the ED (staff #54) that on September 11, 2023 at 2:00 p.m., another resident made sexual comments towards resident #72 while she was sitting on the smoking patio last week. However, review of the clinical record and facility documentation, there was no evidence found that the allegation of abuse for resident #72 was thoroughly investigated by the facility. The email correspondence from the Director of Nursing (DON/staff #19) dated January 5, 2026 revealed that the investigation/incidents and/or complaints requested for resident #77 and #72 were not available because they were outside the guidelines. An interview with the DON (staff #19) was conducted on January 6, 2026 at 1:47 p.m. The DON stated she does not know where the investigations for the incident related to residents #77 and #72 because both residents as in her email were outside the guideline. She said that outside the guideline was their policy which dictates what and for how long documents including incidents/investigations were maintained for X number of years. An interview was conducted on January 6, 2026 at 3:40 p.m. with the social services director (SSD/staff #56) who stated that different types of abuse included sexual, physical, emotional and financial abuse; and if there were allegations of abuse, it would immediately be reported directly to the ED. He stated that if the ED was not available, the incident will be reported either to the DON or the ADON. The SSD further stated that his role in abuse investigation was to help with the facility's self-report and assist the ED with investigation. During an interview with the administrator (staff #55) conducted on January 7, 2026 at 8:30 a.m., he stated that he could not any evidence of the investigation the facility conducted regarding resident #77 and #72. The administrator further stated that he follows the facility policy on record retention which stated that incident reports and self-reports must only be retained for a period of 12 months after the date of report or posting; and, grievances must only be retained for a period of 3 years. In another interview with the DON (staff #19) conducted on January 7, 2026 at 12:13 p.m., the DON stated that staff will follow their policy on abuse, when there was an allegation of abuse. She stated that when there was an allegations of abuse, staff would ensure that residents were safe; and if it involved a staff, the staff would be suspended until the facility's investigation was over. She stated that the allegation of abuse is reported to the abuse coordinator; and, investigation will be conducted by the abuse coordinator who will then send a preliminary report to the SA, APS, Ombudsman, police and family. She stated the allegation of abuse will be reported to the SA, APS, Ombudsman and police within the 2 hour window for suspected abuse. The DON also said that investigation of the allegation of abuse conducted by the abuse coordinator involved conducting interviews with the victim, the alleged perpetrator and possible witnesses; and, the abuse coordinator would then submit the 5-day report of the investigation to the SA. The policy on Abuse, Neglect, Exploitation and Misappropriation Prevention Program with effective date of January 1, 2024 included 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 resident abuse, neglect and exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives: identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property; and, investigate and report any allegations within timeframes required by federal requirements. The facility memo on Retention of Records dated November 1, 2025 revealed that pursuant to the Federal [(2 CFR S483.70 and 42 CFR S483.35(i)(4)] and State (A.A.C. R9-10-404 and A.R.S. 12-2297) regulations, a skilled nursing facility in the State of Arizona is only required to keep or retain records, staffing records, personnel records and quality manager and incident records for the period indicated in the regulation. The greatest period of retention required is 6 years after the date of discharge and that is the period of which pertains only to retention of resident medical records. Incident reports and self-reports must only be retained for a period of 12 months after the date of report or posting. grievances of the facility must only be retained for a period of 3 years after the grievance decision is issued. As a federally and state regulated skilled nursing facility, it follows the retention requirements mentioned above and therefore, requests for documents spanning time periods prior to said retention requirements are outside of the scope and ask for the production of records is not required to meaintain due to time passed.

-Regarding Resident #82: Resident #82 was admitted on [DATE], with diagnoses that included end stage renal disease and type 2 diabetes mellitus. An admission Evaluation note dated January 2, 2026, revealed Resident #82 admitted from short-term general hospital for intravenous (IV) infusions with contact isolation. A physician order dated January 3, 2026, included contact isolation due to Extended-Spectrum Beta-Lactamases (ESBL) for 5 days or until treatment has been completed on January 6. A care plan focus dated January 4, 2026, revealed the resident had an active infection including ESBL with interventions that included contact/droplet isolation precautions, educate resident and staff regarding preventative measures to contain infection, use as much disposable equipment as possible or use dedicated equipment (i.e. BP cuff, thermometer), non-disposable resident care equipment to be appropriately cleaned and disinfected per facility protocol, provide independent activities or 1:1 activities as tolerated by resident and as able, and administer antibiotic as per physician orders. An Occupational Therapy (OT) Daily Note dated January 5, 2026, revealed the resident was seen in room on isolation precautions. A Nurse Practitioner (NP) progress note dated January 5, 2026, revealed Resident #82 was diagnosed with ESBL E. coli urinary tract infection, and the resident was admitted to the facility for completion of treatment from the hospital, therapy, and rehab. An observation was conducted on January 4, 2026, at 3:46 p.m. of a certified nursing assistant (CNA / Staff #47), who entered Resident #82's room, pushing a vitals cart inside the room. On the right side of the resident's room doorway was a sign that revealed that the resident was on contact isolation precautions. Outside of the resident's room was a clear plastic isolation cart that contained personal protective equipment (PPE). No sanitizing wipes were observed in the room, in the isolation cart, or anywhere in the vicinity of the hallway. As Staff #47 entered Resident #82's room, Staff #47 did not perform hand hygiene with hand washing or hand sanitizer, and did not put on a gown or gloves. Staff #47 stated to Resident #82 that she was going to assess the resident's vital signs, and then proceeded to apply a blood pressure cuff around the resident's ankle as he was lying in bed. The staff then closed the resident's door. The staff then exited the room and did not sanitize the vitals cart, and pushed the vitals cart down the hall to the therapy gym and left the machine in the therapy gym. An interview was conducted on January 4, 2026, at 3:56 p.m. with Staff #47 directly after she left the vitals cart in the therapy gym. Staff #47 stated that if a resident was on isolation precautions, then staff would know because there would be a sign on the resident's door indicating the type of precautions, and what PPE would be worn. For contact precautions, Staff #47 stated staff would be required to wear a gown and gloves when entering the room. Staff #47 stated that when equipment such as a vitals cart is brought in an isolation room for use and brought out of the room to use with other residents, then that equipment is sanitized with sanitizing wipes. Staff #47 stated that she had never heard of disposable equipment such as a disposable or single-use blood pressure cuff or stethoscope for taking vital signs, and that she did not believe the facility had those items. Staff #47 stated that she was not sure if any of the rooms she was assigned to had isolation precautions because she did not receive verbal report at shift change. Staff #47 stated she did not know if the room she was just in for Resident #82 was an isolation room, and Staff #47 stated that she did not wear a gown and gloves when providing care then. Resident #82's room was observed together, and Staff #47 read the sign beside the resident's door and stated that yes, this was a contact isolation room. Staff #47 stated that normally the sign is hung on the center of the door, and this sign was hung to the side of the door, and that was why she missed it. Regarding sanitizing the vitals cart, Staff #47 stated that she did not know where sanitizing wipes were located, because usually they were located in the isolation cart outside the resident's door, and that currently there were none there. Staff #47 stated that she believed there were some sanitizing wipes in the wound nurse's cart, but that was locked and the wound nurse was not in the facility, so she was not sure where the sanitizing wipes could be found. Another observation was conducted on January 4, 2026, directly after the interview with Staff #47 ended, and Staff #47 was observed asking another staff member where sanitizing wipes were, and at 4:06 p.m., Staff #47 obtained sanitizing wipes and cleaned the vitals machine in the therapy gym. An interview was conducted on January 6, 2026, at 9:39 a.m. with a registered nurse / unit manager (RN / Staff #7) who stated that if a resident was on contact precautions, then there would be a sign on the door indicating the type of precautions, and that a gown and gloves were required to be worn when entering the resident's room to provide care. Staff #7 stated that when exiting the resident's room, the PPE would be taken off before leaving the room, and any equipment would be sanitized prior to leaving the room with sanitizing wipes. Staff #7 stated that additionally, hand washing was required before leaving a room on contact precautions. Staff #7 stated that if a staff did not put on PPE or wash hands or clean equipment when required to do so, then the risk could be spread of infection. An interview was conducted on January 6, 2026, with a licensed practical nurse (LPN /Staff #9) at 11:36 a.m. who stated that if a resident was on contact isolation precautions that there would be a sign by the resident's door that would indicate what PPE was required for staff to wear when providing care to the resident. Staff #9 stated that equipment that was used for a resident on isolation precautions either remains in the room with the resident while on isolation precautions, or the equipment was sanitized when leaving the room, with sanitizing wipes. Staff #9 stated that staff are required to wash hands or perform hand hygiene before and after providing resident care. Staff #9 also stated that if staff did not wear PPE or wash hands or sanitize equipment when indicated, then the risk could be spread of infection to other residents or staff. An interview was conducted on January 6, 2026, at 3:10 p.m. with the Director of Nursing (DON / Staff #19) who stated she expected staff who were caring for a resident on contact isolation precautions to observe the sign on the resident's door and put on the required PPE prior to entering the resident's room, wash their hands before leaving the room, and to sanitize any equipment leaving the room with sanitizing wipes that should be located in the isolation carts outside the resident's room. Staff #19 stated that there would be a risk of spread of infection if staff did not follow the infection control practices. Review of the facility policy titled Managing Infections: Isolation - Categories of Transmission-Based Precautions, dated January 1, 2024, revealed transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-based precautions are additional measures that protect staff, visitors and other residents from becoming infected. These measures are determined by the specific pathogen and how it is spread from person to person. The three types of transmission-based precautions are contact, droplet and airborne. Transmission-based precautions are used only when the spread of infection cannot be reasonably prevented by less restrictive measures. When a resident is placed on transmission-based precautions, appropriate notification is placed on the room entrance door and on the front of the chart so that personnel and visitors are aware of the need for and the type of precaution. The signage informs the staff of the type of CDC precaution(s), instructions for use of PPE, and/or instructions to see a nurse before entering the room. When transmission-based precautions are in effect, non-critical resident-care equipment items such as a stethoscope, sphygmomanometer, or digital thermometer will be dedicated to a single resident (or cohort of residents) when possible. If re-use of items is necessary, then the items will be cleaned and disinfected according to current guidelines before use with another resident. Contact precautions are implemented for residents known or suspected to be infected with microorganisms that can be transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. The decision on whether contact precautions are necessary are evaluated on a case by case basis. Staff and visitors wear gloves (clean, non-sterile) when entering the room. While caring for a resident, staff will change gloves after having contact with infective material (for example, fecal material and wound drainage). Gloves are removed and hand hygiene performed before leaving the room. Staff avoid touching potentially contaminated environmental surfaces or items in the resident's room after gloves are removed. Staff and visitors wear a disposable gown upon entering the room and remove before leaving the room and avoid touching potentially contaminated surfaces with clothing after gown is removed. Review of the facility policy titled Managing Infections: Isolation - Initiating Transmission - Based Precautions, dated January 1, 2024, revealed transmission-based precautions are initiated when a resident develops signs and symptoms of a transmissible infection; arrives for admission with symptoms of an infection; or has a laboratory confirmed infection; and is at risk of transmitting the infection to other residents. Transmission-based precautions may include contact precautions, droplet precautions, or airborne precautions. When transmission-based precautions are implemented, the infection preventionist (or designee): ensures that protective equipment (i.e., gloves, gowns, masks, etc.) is maintained outside the resident's room so that anyone entering the room can apply the appropriate equipment, ensures that protective equipment and supplies needed to maintain precautions during care are in the resident's room; and ensures that an appropriate linen barrel/hamper and waste container, with appropriate liner, are placed in or near the resident's room.

Based on observation, interview, review of clinical record, and review of facility policy and procedure, the facility failed to ensure a resident (#27) was treated with dignity and respect. The deficient practice could lead to psychosocial harm of a resident.-Findings include:Resident #27 was re-admitted on [DATE], with diagnoses of acute on chronic congestive heart failure, cardiomyopathy, pneumonia, unspecified dementia, anxiety disorder, and retention of urine.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #27 had a brief interview for mental status (BIMS) assessment score of 9, indicating moderate cognitive impairment.A care plan focus dated December 5, 2025, revealed Resident #27 was at risk for functional self care deficits and / or functional mobility limitations, with a goal to safely perform functional self care and mobility tasks. Interventions included: -The resident required assistance with transferring-Encourage resident to participate to the fullest extent possible with each interaction -Encourage resident to use call light to call for assistance.A Health Status Note dated December 6, 2026, revealed Resident #27 continued to be disoriented at times and needed reminded of his surroundings, and that the resident was noted to pulling on his foley catheter, and that the resident forgot he had a foley catheter, requiring reminders.A Health Status Note dated December 7, 2025, revealed Resident #27 had confusion and was forgetful, and liked to sit with someone, so the resident sat at the nurse station with a staff part of the morning. The note revealed the resident's urine was noted to be bloody due to the resident pulling on his foley catheter yesterday.An eMAR Medication Administration Note dated December 8, 2025, revealed a change of condition for the resident's behaviors of yelling out and pulling on foley catheter.A Physician Progress Note dated December 9, 2025, revealed the resident had advanced dementia with behaviors.An Activity Progress Note dated December 9, 2025, revealed the resident enjoyed teaching people how to do new things, playing games, sports, attending social gatherings, watching movies, photography, playing bingo, dominos, and being with his family.A physician order dated December 11, 2025, included for change of condition monitoring every shift for 6 days, due to resident yelling out, and that the physician was notified.A care plan focus initiated on December 11, 2025, revealed Resident #27 had a behavior problem related to impaired cognitive function, impaired safety awareness, verbal behavior (yelling out and banging on table instead of using call light), with a goal that safety would be maintained. Interventions included:-Administer medications as ordered, and monitor / document for side effects and effectiveness-Allow resident to make decisions about plan of care-Anticipate and meet the resident's needs -Caregivers to provide opportunity for positive interaction, attention. Stop and talkwith the resident as passing by.-Encourage as much participation / interaction as possible during care activities-Encourage me to follow the plan of care, but respect the resident's choices.-Explain all procedures to the resident before starting and allow the resident time to adjust to changes-Give a clear explanation of all care activities prior to and as they occur duringeach contact-Identify behavior triggers-If the resident resists with ADLs, reassure the resident, leave, return and try again-If issues arise, remove from situation-If reasonable, discuss the resident's behavior, and explain / reinforce why the behavior isinappropriate and/or unacceptable-Intervene as necessary to protect the rights and safety of others, and approach / speakin a calm manner, divert attention, and remove from situation and take to alternatelocation as needed-Refer to psychiatric provider for consultation as orderedThere was no evidence of updates, additions, or revisions to the care plan focus' interventions since December 11, 2025.A psychiatry provider encounter note dated December 18, 2025, revealed the resident was still having moments of yelling and calling out for his wife.A care plan focus initiated December 18, 2025, revealed Resident #27 had impaired cognitive function / dementia or impaired thought processes due to impaired decision making. Interventions initiated on December 18, 2025, included:-Administer medications as ordered-Keep routine consistent and try to provide consistent caregivers as much as possible to decrease confusion-Monitor, document, and report to the physician any changes in cognitive function, and to use task segmentation to support short term memory deficits.There was no evidence of updates, additions, or revisions to the care plan focus' interventions since December 18, 2025.A Physical Therapy (PT) Progress Note dated December 22, 2025, revealed Resident #27 presented with poor sequencing of tasks during walking, and that poor execution of walking technique resulted in decreased safety with walking, and that fall risk was noted. Resident #27 required minimum assistance for chair to / from bed transfers and for walking, and required cues for safe sequencing of tasks.An Occupational Therapy (OT) daily note dated December 24, 2025, revealed the resident required frequent redirection throughout the session due to poor cognition.A Speech Therapy (ST) Daily Note dated December 26, 2025, revealed Resident #27 was able to answer orientation questions with 0% accuracy despite max cueing from the therapist. The resident had continued confusion, stating this is my home, why are you here? where is my wife?. The note revealed the therapist attempted to orient the resident to place and situation, but the resident started to yell out for help.A psychiatry provider encounter note dated December 26, 2025, revealed Resident #27 yelled for help or for his wife, and settled down when talked to but then began yelling out intermittently. The note revealed that per staff, the resident appeared more anxious recently and continued with intermittent yelling out.An ST Daily Note dated December 28, 2025, revealed Resident #27 constantly yelled out and with poor immediate recall, and that the resident began to yell out again as therapist walked away.A Physician Progress Note dated December 28, 2025, revealed the resident constantly yelled I need help repeatedly, and appeared to be about the same. The plan included for mobilization with staff assistance, and safety / fall precautions per facility protocols.A PT Daily Note dated December 30, 2025, revealed that the resident required minimum to moderate assistance for transfers.A neurology provider encounter note dated December 30, 2025, revealed Resident #27 was seen lying in bed while yelling for help and unable to verbalize needs when asked about what he needs. The note revealed the resident could not be redirected, and was intermittently yelling, and that per staff, the resident was constantly yelling and shouting all night as well.A Pulmonary Progress Note dated December 30, 2025, revealed the resident remained confused, alert and oriented to self only, and was yelling out for his wife.An eMar Medication Administration Note dated December 30, 2025, revealed the resident continued to yell out and refused medication.A Daily Skilled Evaluation note dated December 31, 2025, revealed the resident had verbal behavior directed at others requiring frequent redirection, and frequently yelled out instead of using call light.A care plan focus dated December 31, 2025, revealed Resident #27 was admitted to hospice with diagnosis of senile degeneration of brain, effective January 1, 2026. Interventions included:-Nutrition and hydration to maintain comfort-Provide activities to meet needs-Routine position changes and exercise to comfort and relieve pressure-1 to 1 visits and provide support to family as needed, and to document one to one support-Activities of daily living (ADL) needs per facility protocol and existing plan of care-Medication as ordered to ensure comfortA psychiatry provider encounter note dated January 1, 2026, revealed the resident was seen intermittently yelling for help, and calmed down with redirection. The note revealed that staff reported continuation of the resident's same behaviors of yelling out despite frequent reminders to use the call light, and that the resident presented with limited attention and ability to maintain logical / linear thought. The note revealed the resident's speech was yelling out, short- and long-term memory were poor, concentration was tangential, insight was poor, and judgment was limited, and the resident was confused and required frequent re-orientation. Recommendations included for nonpharmacological strategies such as environmental modifications to ensure safety, structured activities to reduce triggers for wandering and agitation, and consistent sleep routine, and to consider pharmacologic intervention if there was concern for safety of patient/others.A BIMS assessment dated [DATE], revealed Resident #27 had a score of 6, indicating severe cognitive impairment.A Behavior Note dated January 2, 2026, revealed Resident #27 continued to have behaviors of yelling throughout the day, and that redirection had no effect.A Progress Note dated January 4, 2026, revealed Resident #27 was noted walking toward nurses' station while yelling, and that the resident's foley catheter was lying on the floor under his chair. The note revealed a certified nursing assistant (CNA) was trying to assist the resident back to the chair. The provider was notified the resident had pulled his catheter out, and the resident was taken to his room, where he was placed on the toilet. The note revealed the nurse instructed a CNA to place the resident in bed after toileting so the catheter could be replaced. Upon entering the room, the resident was standing by his bed, with brief noted with large amount of bright red blood and large clots present. The documentation revealed the provider was updated of the resident's bleeding and clots, and gave an order for the resident to be sent to the emergency department.An observation was conducted on January 4, 2026, at 7:03 a.m. by a team of state surveyors who observed Resident #27 sitting in a reclining wheelchair (gerichair) in the hallway in front of the nurses' station. There was no call light or call bell present for the resident. There was no staff visible nearby the resident. There was no evidence that the resident was set up with any sort of activity or TV show for the resident to watch. The resident was yelling out loudly and frequently for help.Another observation was conducted on January 4, 2026, at 7:42 a.m. of Resident #27 sitting in the gerichair in the hallway in front of the nurses' station. The resident stood up from the gerichair and started to take small unsteady steps forward toward the nurses' station and was yelling out very loudly. No staff were observed near the resident. The resident continued to take small steps forward, which pulled his foley catheter tube taught, and the catheter bag was attached to the gerichair. The resident then was observed to yell out loudly and repeatedly in pain, and the foley catheter tube and balloon were then observed on the floor. The resident continued to yell out loudly in pain, and a CNA (Staff #17) then approached the resident quickly and called out Resident #27's first name. Without re-assuring the resident or explaining what she was doing, Staff #17 grabbed the resident's right arm with both of the staff's hands and arms, and attempted to pull the resident by his arm toward the gerichair. At the same time, Resident #27 stated No and was trying to walk in the opposite direction that Staff #17 was pulling him by the arm. The floor nurse (Staff #9) who was down the hall, called out don't pull on him, and Staff #17 let go of the resident and walked over to the gerichair and brought it over to Resident #27. The resident stated that he had a bowel movement on himself, and Staff #9 approached the resident and instructed Staff #17 to assist the resident in the bathroom to get him cleaned up, and then Staff #9 would re-insert the catheter. The CNA positioned the gerichair directly in front of Resident #27 and said in a rude tone of voice, sit down here. The CNA did not explain further, and stated again in a rude tone of voice for the resident to sit. The resident was still standing in front of the gerichair, and Staff #17 stated again firmly and rudely sit in there. The resident was taken to the bathroom in the gerichair, and Staff #17 assisted the resident with the toileting task. The observation was continued from outside the door of the resident's bathroom, and the resident's and Staff #17's voices could be overheard from outside the bathroom door. Staff #27 continued to speak to Resident #27 in a firm and rude tone of voice. Resident #27's voice was overheard to say to Staff #17 please don't be rude.A follow-up observation was conducted with the Administrator (Staff #55) on January 6, 2026, at 1:02 p.m. of the facility's video camera footage from January 4, 2026, at 6:00 a.m. of the nurses' station area, revealing the following: -6:00 a.m.: Resident #27 was sitting in a gerichair with the legrest of the chair in the elevated position and the chair back reclined. A foley catheter bag was observed hanging under the legrest portion of the chair. -6:45 a.m.: Resident #27 called out that he needed to use the bathroom. A staff responded to the resident and stated that the resident had a catheter in. The resident replied to the staff and stated that he needed to use the men's room and needed help to use it. The staff did not assist the resident. -6:47 a.m.: The staff was observed leaving the nurses' station area. The resident yelled out for help. No staff responded. The resident called out again why won't you help me, and please help me repeatedly. A nurse was observed standing at a medication cart in the hallway approximately 30 feet away. The resident continued to yell please water and give me water, and no staff responded. -6:49 a.m.: The resident continued to yell out for help and for water. A staff responded and the resident asked the staff to sit him upright so that he could drink water. The staff stated I want you to sit like this for a little longer until breakfast is served. The resident stated he could not drink water reclined like that. -6:50 a.m.: The staff adjusted the resident's gerichair backrest to a more upright position and poured the resident a cup of water. The staff stated to the resident there's no reason for that and you are waking everybody up. The resident stated to the staff, I need to talk to someone who is in authority. The staff stated to the resident that his family was in bed. The staff left the nurse's station area. -6:53 a.m.: Resident #27 continued to yell for help. A male staff walked past the resident, did not attend to the resident, and left the area. No staff was observed nearby the resident, and a nurse was passing medications at a medication cart approximately 30 feet away. No staff had assisted the resident with going to the bathroom as requested. -6:55 a.m.: The resident stated to the nurse that he had a bowel movement, and the nurse stated to the resident to wait until she could find a staff to assist with changing the resident. -6:57 a.m.: A nurse walked past the resident and the resident stated he needed to use the bathroom. The nurse did not address the resident. -6:58 a.m.: Resident #27 continued to yell out loudly help, and that he needed to use the bathroom, and help me. -7:00 a.m.: No staff were observed in sight and the resident continued to yell out loudly and repeatedly for help and that he needed to use the men's room. -7:05 a.m.: A nurse approached the resident and stated to the resident that his family would arrive in a couple hours, and that she needed the resident to stop yelling, and that his family had already been contacted and would be here in a couple hours and then walked away. Neither the nurse nor any other staff addressed the resident's request to use the bathroom. -7:05 a.m.: Resident #27 continued to call out loudly for help repeatedly over 20 times without staff attending to the resident. -7:12 a.m.: a nurse was at the nurse's station. The resident stated that he was going to try to walk and that he might hurt himself doing it. No staff responded to the resident. -7:13 a.m.: The resident called out loudly call my family repeatedly, and also called out for help repeatedly. No staff attended to the resident. -7:16 a.m.: The resident called out loudly and repeatedly for help and call my family over 35 times. -7:22 a.m.: The resident stated loudly I'm going to start breaking things. No staff were observed near the resident. The resident attempted to stand up from the gerichair and a voice called out to the resident to sit down. The nurse then approached the resident and stated to the resident that it was too early to call his family. -7:24 a.m. the nurse walked away from the resident, and the resident stated he was going to throw things, and then the resident tried to stand up again. Two nurses were observed at the nurses' station facing away from the resident. One nurse turned to face the resident who was partially standing up from the chair. As the resident attempted to stand up, the wheels of the gerichair were not securely locked and the chair rolled backward until the back of the gerichair contacted the wall that was behind the resident, and the resident landed sitting back in the chair. The nurse quickly approached the resident. The foley catheter bag had landed on the floor, and the nurse picked the foley bag up off the floor and hung it on the gerichair frame. The nurse stated to the resident that we need you to stay here. -7:27 a.m.: The nurse stated she will go get the resident's family's phone number and then they will call, and the nurse would be right back. The nurse then left the area. -7:32 a.m.: Resident #27 yelled for help loudly and repeatedly. No staff attended to the resident. The resident yelled out for help over 35 times. -7:37 a.m.: a therapist staff stopped to talk to the resident and stated that his family would be coming later and that she would come back later and help with his breakfast, and walked away. -7:40 a.m.: The resident yelled out loudly and repeatedly for help and for the police. Since 6:00 a.m., no staff had assisted the resident with using the bathroom or changing him, and no staff had assisted the resident with calling his family. -7:41 a.m.: a staff approached the resident who was yelling out loudly for help. The staff stated that it was early in the morning and that the resident's family lived far from the facility. The staff then walked away from the resident while the resident was still talking to her. No staff was nearby the resident. The resident called out loudly I'm going to start messing things up and then Lady, I'm going to start breaking things.-7:42 a.m.: The resident then stood up from the gerichair and yelled out loudly Lady, I'm going to start breaking things. The resident took several unsteady steps forward. The foley catheter tube became taut as the resident increased distance away from the gerichair where the foley bag was hung on the frame of the chair. The resident yelled out lady very loudly and continued to take small unsteady steps forward, and then yelled out in pain. The foley catheter balloon became dislodged and suddenly fell out of the pant-leg opening of the resident's shorts onto the floor. The resident yelled out in pain loudly and repeatedly. As the resident continued to yell out loudly in pain, a CNA (Staff #17) then approached the resident quickly and called out Resident #27's first name. Without re-assuring the resident or explaining what she was doing, Staff #17 grabbed the resident's right arm with both of the staff's hands and arms, and pulled the resident by his arm toward the gerichair. At the same time, Resident #27 stated No and was trying to walk in the opposite direction that Staff #17 was pulling him by the arm. The floor nurse (Staff #9) who was down the hall, called out don't pull on him, and Staff #17 let go of the resident and walked over to the gerichair and brought it over near Resident #27. The resident stated that he had a bowel movement on himself, and Staff #9 approached the resident and instructed Staff #17 to assist the resident in the bathroom to get him cleaned up, and then Staff #9 would re-insert the catheter. Staff #17 positioned the gerichair directly in front of Resident #27 and said in a rude tone of voice, sit down here. Resident #27 then asked Staff #17 what is this. The CNA did not explain further, and stated again in a rude tone of voice sit in here. Resident #27 asked Staff #17 again the question of what is this, and Staff #17 stated again firmly and rudely sit in there. The resident sat in the gerichair and was wheeled away from the area.An interview was conducted with an LPN (Staff #9) on January 4, 2026, at 10:34 a.m. Staff #9 stated that sometimes staff would sit with the resident on a 1 to 1 basis to help manage his behaviors. Regarding the incident where Resident #27 accidentally pulled out his foley catheter earlier that day, Staff #9 stated she observed the CNA (Staff #17) attempting to guide the resident to the chair, and that both of Staff #17's hands were on Resident #27's one arm, and that she might have pulled him while trying to turn the resident. Staff #9 stated she had told Staff #17 not to pull on the resident. Staff #9 stated she believed Staff #17's tone of voice when speaking to the resident was anxious.An interview was conducted on January 5, 2026, at 11:53 a.m. with a CNA (Staff #30), who stated that if a resident had impaired cognition and had behaviors of yelling out, that she would try to put herself in the resident's shoes and remember that the resident was a human looking for comfort, and that she would try to calm the resident down. Staff #30 stated if a resident had dementia and kept trying to get up from the bed or wheelchair and the resident was unsteady or unsafe to do so unassisted, then Staff #30 would help the resident to sit in a chair by the nurses' station so that the resident was in eyesight of multiple staff members for increased supervision, or try to find an activity that would help calm the resident down. Staff #30 stated that it was not difficult to help calm a resident, just time consuming. Staff #30 stated she was familiar with Resident #27, and the resident yelled out for his family sometimes all night and all day. Staff #30 stated that one night, she had to sit with the resident and hold his hand nearly all night so that he would not continue yelling out.An interview was conducted with a registered nurse (RN / Staff #32) on January 5, 2026, at approximately 12:00 p.m. Staff #32 stated that if a resident had impaired cognition and behaviors of yelling out repetitively or if the resident was trying to get up from a chair or bed and walk unsteadily without assistance, that she would try to console the resident, ask what is wrong, and try to meet the resident's needs. Staff #32 stated she was familiar with Resident #27, and that he had behaviors of yelling out consistently almost all day long.An interview was conducted on January 5, 2026, at 2:10 p.m. with a CNA (Staff #14) who stated that if a resident had impaired cognition with behaviors of yelling out, then Staff #14 would sit and talk to the resident and help calm the resident down. If a resident with impaired cognition was unsafe to mobilize independently, and continued to try to get up from a chair or bed to walk, Staff #14 stated that she would make sure that resident was not in their room alone, that she would place the resident in front of the nurse's station for staff to supervise the resident. Staff #14 also stated she would try to convince management to allow a 1-to-1 staff member to be with the resident. Additionally, Staff #14 stated she would try to get the resident involved in an activity that would help calm the resident and keep them engaged.An interview was conducted with an alert and oriented male resident (#16) on hallway B, on January 6, 2026, at 8:40 a.m. The resident stated that Resident #27 (whom he identified by the resident's first name) would often be screaming loudly. Resident #16 stated that he believed Resident #27 just wanted someone to talk to, and if staff found the right activity for Resident #27, that it would probably calm the resident down.An interview was conducted on January 6, 2026, at 9:02 a.m. with a CNA (Staff #37) who stated that if a resident was confused, had dementia, or appeared to be restless or agitated, that she would approach the resident calmly and try to redirect the resident, give the resident an activity to do, turn on a tv show the resident enjoyed, or try to talk to the resident to see what the resident needed. Staff #37 stated that if a resident was confused and restless, that she would redirect the resident, even if it required 100 times, then she would do that, or she would stay with the resident for a while to help the resident calm down. Staff #37 stated that she would not leave a confused and restless or agitated resident alone or unattended in the hallway if the resident was in that state. Regarding Resident #27, Staff #37 stated that she was familiar with the resident, and he was confused, had memory problems, would forget things after a few minutes, and had behaviors of screaming out a lot.An interview was conducted with a licensed practical nurse (LPN / Staff #9) on January 6, 2026, at 11:36 a.m. who stated that if a resident had dementia or impaired cognition and appeared to be restless or agitated, that she would approach the resident very calmly, at eye level, with no hurried movements, and with a calm, low pitch voice to try to calm the resident. Regarding Resident #27, Staff #9 stated that he had behaviors of near constant yelling and that it had been ongoing the whole time the resident was at the facility. Staff #9 stated that she would try to talk to the providers about his behaviors, and try to talk to the resident to determine why he was yelling, and to re-assure him.An interview was conducted on January 6, 2026, at 1:02 p.m. with the Administrator (Staff #55) after reviewing the facility's video camera footage together. Staff #55 stated that Resident #27 had a lot of behaviors and that the staff were doing the best they could considering that they were also caring for other residents. Regarding Staff #17 pulling on Resident #27, Staff #55 stated he believed she was doing the best she could given the circumstance. Staff #55 stated that it was his expectation for staff to assess resident's needs and assist the residents as needed, and regarding Resident #27's requests to go to the bathroom, Staff #55 stated that he believed the staff could have done a better job of that.A follow up interview was conducted with the Administrator (Staff #55) on January 6, 2026, at 2:58 p.m. Staff #55 stated that he believed having a staff member sit with Resident #27 benefitted him, however when staff walked away, the resident would start yelling again. Staff #55 stated that at the time of Resident #27's incident, there was no staff with the resident, however the staff were within earshot.An interview was conducted with the Director of Nursing (DON / Staff #19) on January 6, 2026, at 3:10 p.m., who stated that if a resident had impaired cognition or dementia, and was agitated or restless, she would expect the staff to approach the resident calmly, to make sure the resident could see the staff, to make eye contact, and to be friendly. If that resident had behaviors of yelling out, then Staff #19 stated that she would expect staff to offer redirection or provide anything that would get the resident to stop yelling, offer a change of scenery, provide a blanket, offer fluids, and for the nurse to determine if there were any medications available to address the agitation. If the resident were to be left with ongoing behaviors of yelling, Staff #19 stated she did not know what effect that would have on the resident who was yelling, but that it would be disruptive to other residents in the facility. Regarding Resident #27, Staff #19 stated that she was aware the resident had yelling behaviors and impulsivity since his admission, and that she had heard from other residents that Resident #27's yelling was disruptive.Review of the facility policy titled Resident Rights / Dignity: Resident Rights, dated January 1, 2024, revealed employees shall treat all residents with kindness, respect, and dignity. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to:a. a dignified existence;b. be treated with respect, kindness, and dignity;c. be free from abuse, neglect, misappropriation of property, and exploitation;d. be free from corporal punishment or involuntary seclusion, and physical or chemical restraints not required to treat the resident's symptoms;e. self-determination;f. communication with and access to people and services, both inside and outside thefacility

Based on review of clinical record, interview, and review of facility policy and procedure, the facility failed to ensure a resident (#27) was administered narcotic medication according to physician order. The deficient practice could lead to physical harm of a resident from overdose of narcotic medication.-Findings include:Resident #27 was re-admitted on [DATE], with diagnoses of acute on chronic congestive heart failure, cardiomyopathy, pneumonia, unspecified dementia, anxiety disorder, and retention of urine.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #27 had a brief interview for mental status (BIMS) assessment score of 9, indicating moderate cognitive impairment.A care plan focus initiated December 5, 2025, revealed Resident #27 had or was at risk for pain, with interventions that included to administer analgesia medication as per orders, to anticipate the resident's need for pain relief and respond as soon as possible to any complaint of pain, to monitor / record / report to the nurse any signs and symptoms of non-verbal pain including yelling out, and for non-medication intervention for pain to be given prior to administration of as needed medication.A Physician Progress Note dated December 9, 2025, revealed the resident had advanced dementia with behaviors.An eMar (Electronic Medication Administration Record) Note dated December 11, 2025, revealed the resident was yelling and screaming throughout the night, and that as needed (PRN) anxiety medication was not effective.A psychiatry provider encounter note dated December 11, 2025, revealed Resident #27 was seen near the nursing station, resting in wheelchair. The note revealed the resident had been yelling and screaming throughout the night, and had been given as needed anti-anxiety medication with no effect, and that nursing stated that the resident did not sleep.A physician order dated December 11, 2025, included for change of condition monitoring every shift for 6 days, due to resident yelling out, and that the physician was notified.A care plan focus initiated on December 11, 2025, revealed Resident #27 had a behavior problem related to impaired cognitive function, impaired safety awareness, verbal behavior (yelling out and banging on table instead of using call light), with a goal that safety would be maintained. Interventions included to administer medications as ordered, and monitor / document for side effects and effectivenessAn eMar Note dated December 12, 2025, revealed the resident woke up off and on and yelled out for his wife, and was redirected as needed.eMar Notes dated December 13, 2025, revealed the resident continued to yell out every now and then, and later, that the resident was constantly yelling out even after needs had been met, and the resident was confused, redirected as needed, and continued to yell out.Another eMar Note dated December 16, 2025, at 9:15 p.m., revealed the resident was yelling and agitated.A care plan focus initiated December 18, 2025, revealed Resident #27 had impaired cognitive function / dementia or impaired thought processes due to impaired decision making. Interventions included to administer medications as ordered.A psychiatry provider encounter note dated December 22, 2025, revealed Resident #27 was noted yelling out when needing assistance and often requires frequent reorientation, and that the resident became restless and yelled out at times.A Daily Skilled Evaluation note dated December 24, 2025, revealed the resident had a foley catheter in place, and had verbal behavior directed at others requiring frequent redirection, and frequently yelled out.A Physician Progress Note dated December 28, 2025, revealed the resident constantly yelled I need help repeatedly.An OT daily Note dated December 29, 2025, revealed the resident was easily confused, upset, and not easily redirected, and that the resident continued to perseverate on going home, and was unable to participate in therapy session.A neurology provider encounter note dated December 30, 2025, revealed Resident #27 was seen lying in bed while yelling for help and unable to verbalize needs when asked about what he needs. The note revealed the resident could not be redirected, and was intermittently yelling, and that per staff, the resident was constantly yelling and shouting all night as well.A Pulmonary Progress Note dated December 30, 2025, revealed the resident was sitting on the edge of the bed, and remained confused, alert and oriented to self only, and was yelling out for his wife.A hospice face sheet for Resident #27 revealed hospice start of care was December 31, 2025.A care plan dated December 31, 2025, revealed Resident #27 was admitted to hospice with diagnosis of senile degeneration of brain, effective January 1, 2026. Interventions included:-Nutrition and hydration to maintain comfort-Provide activities to meet needs-Routine position changes and exercise to comfort and relieve pressure-1 to 1 visits and provide support to family as needed, and to document one to one support-Activities of daily living (ADL) needs per facility protocol and existing plan of care-Medication as ordered to ensure comfortA psychiatry provider encounter note dated January 1, 2026, revealed the resident was seen intermittently yelling for help, and calmed down with redirection. The note revealed that staff reported continuation of the resident's same behaviors of yelling out despite frequent reminders to use the call light, and that the resident presented with limited attention and ability to maintain logical / linear thought. The note revealed the resident's speech was yelling out, short- and long-term memory were poor, concentration was tangential, insight was poor, and judgment was limited, and the resident was confused and required frequent re-orientation. Recommendations included for nonpharmacological strategies such as environmental modifications to ensure safety, structured activities to reduce triggers for wandering and agitation, and consistent sleep routine, and to consider pharmacologic intervention if there was concern for safety of patient/others.A BIMS assessment dated [DATE], revealed Resident #27 had a score of 6, indicating severe cognitive impairment.A physician order dated January 2, 2026, included Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, to give 0.25 ml every 4 hours as needed for pain / shortness of breath.A Behavior Note dated January 2, 2026, revealed Resident #27 continued to have behaviors of yelling throughout the day, and that redirection had no effect. The documentation revealed that as needed (PRN) doses of lorazepam (anti-anxiety medication) and morphine (narcotic medication) were administered into the resident's cheek pocket, pending effectiveness.An Individual Control Drug Record for Resident #27's medication revealed for morphine 5 mg, pre-filled syringe (0.25 ml / 5 mg), that two doses were administered on January 2, 2026, with one dose administered at 10:00 a.m. and one dose administered 2 hours and 10 minutes later at 12:10 p.m.Despite the individual control drug record including that two doses of morphine were administered to Resident #27 on January 2, 2026, review of the progress notes revealed morphine was administered, but did not specify how many doses, or when the administration occurred.Additionally, the Medication Administration Record (MAR) for January 2026, revealed no evidence that any doses of morphine sulfate oral solution 20 mg/ml were administered.An interview was conducted with a registered nurse (RN / Staff #32) on January 5, 2026, at approximately 12:00 p.m. Staff #32 stated that if a resident had impaired cognition and behaviors of yelling out repetitively or if the resident was trying to get up from a chair or bed and walk unsteadily without assistance, that she would try to console the resident, ask what is wrong, try to meet the resident's needs, and if those methods did not work, then Staff #32 would see what medications the resident had available to help with the behaviors. Regarding medication administration, Staff #32 stated that once a physician order was received, the order appeared on the MAR in the electronic medical record (EMR). Staff #32 stated once the medication was administered, it would be documented in the MAR to show that the medication was administered. Staff #32 also stated that controlled substances such as narcotic medications, would also be documented on the narcotic reconciliation sheets (Individual Control Drug Record). Staff #32 stated that nurses document the administration of medication on the MAR because the risk of not doing so would be not knowing exactly when the medication was administered, and that overdose could occur from administering a second dose too soon.An interview was conducted with a licensed practical nurse (LPN / Staff #9) on January 6, 2026, at 11:36 a.m. who stated that if a resident had impaired cognition and had behaviors of yelling out, that it was not good for the resident to medicate the behaviors away, so she would attempt to determine what the resident needed. If a resident had impaired cognition and kept trying to get up from a wheelchair or bed, and was unsafe or unsteady, then Staff #9 stated that she would try to keep the resident where staff could keep eyes on the resident. Staff #9 stated that Resident #27 had behaviors of near constant yelling and that it had been ongoing the whole time the resident was at the facility. Staff #9 stated that she would try to talk to the providers about his behaviors, and try to talk to the resident to determine why he was yelling, and to re-assure him. Regarding medication administration, Staff #9 stated that when a resident is administered a medication, the physician order appears on the MAR, and then the nurse records when the dose is administered. Staff #9 stated that the importance of recording the medication administration in the clinical record would be to verify that the resident received the medication, and prevent an accidental administration of another dose outside of time parameters. Staff #9 stated that the narcotic reconciliation sheet is completed at the beginning and end of each shift.An interview was conducted with the Director of Nursing (DON / Staff #19) on January 6, 2026, at 3:10 p.m., who stated if a resident with impaired cognition or dementia had behaviors of yelling out, then Staff #19 stated that she would expect staff to offer redirection or provide anything that would get the resident to stop yelling, offer a change of scenery, provide a blanket, offer fluids, and for the nurse to determine if there were any medications available to address the agitation. Regarding medication administration, Staff #19 stated that nurses should document medication administered on the MAR. If a nurse did not document a medication administered on the MAR, then Staff #19 stated that the risk could be missing communication that the medication was administered or not, and that the medication could accidentally be administered again. The clinical record was reviewed for Resident #27, and Staff #19 stated that the MAR for January 2026 revealed that no doses of morphine were administered. The physician order for morphine was reviewed, and Staff #19 stated that the morphine was ordered to be given every 4 hours as needed. The narcotic reconciliation sheet for Resident #27's morphine was reviewed and Staff #19 stated that Resident #27 was administered a morphine dose at 10:00 a.m. and again at 12:10 p.m. on January 2, 2026, and that it would not meet her expectation as far as following the physician order. Review of the facility policy titled Medication: Administering Medications, dated January 1, 2024, revealed medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones, or documents in the electronic medical administration record. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:a. the date and time the medication was administered;b. the dosage;c. the route of administration;d. the injection site (if applicable);e. any complaints or symptoms for which the drug was administered;f. any results achieved and when those results were observed; andg. the signature and title of the person administering the drug.Review of the facility policy titled Medications: Controlled Substances, dated January 1, 2024, revealed the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Controlled substances are counted upon delivery. The nurse receiving the medication, along with the person delivering the medication, must count the controlled substances together. Both individuals sign the designated controlled substance record. If the count is correct, an individual resident controlled substance record is made for each resident who will be receiving a controlled substance. Do not enter more than one (1) prescription per page. This record contains:a. name of the resident;b. name and strength of the medication;c. quantity received;d. number on hand;e. name of the prescriber;f. prescription number;g. name of issuing pharmacy;h. date and time received;i. time of administration;j. method of administration;k. signature of person receiving medication; andl. signature of nurse administering medication.Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following:a. Records of personnel access and usage;b. Medication administration records;c. Declining inventory records; andd. Destruction, waste and return to pharmacy records.Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services.

Based on clinical record review, staff interviews and facility documentation and policy review, the facility failed to ensure care and services related to pressure ulcer was provided to 1 of 3 sampled residents (#64). The deficient practice could result in worsening of the resident's pressure ulcer.Findings include:Resident #64 was admitted on [DATE] with diagnoses of fracture of the upper end of the left tibia, type II diabetes with hyperglycemia and pulmonary fibrosis. The late entry admission evaluation note dated September 19, 2024 included that the resident was admitted from a short-term general hospital, had shortness of breath with lying flat, was on 2 liters of oxygen via nares to keep oxygen saturation above 90% while lying flat, and had bowel and bladder incontinence. The Braden scale dated September 19, 2024 revealed a score of 15 indicating the resident had low risk of developing pressure ulcers. The progress note dated September 19, 2024 included the resident was alert to name only and had a stage 4 ulcer to the coccyx with foul odor present. The care plan dated September 19, 2024 revealed the resident had and was at risk for skin impairment: coccyx, left ankle, left biceps, left knee and right elbow. Interventions included to administer treatments as ordered and monitor for effectiveness; to educate me/family/caregivers as to causes of skin breakdown; including: transfer/positioning requirements; importance of taking care during ambulating/mobility, good nutrition and frequent repositioning; to follow facility policies/protocols for the prevention/treatment of skin breakdown; weekly skin assessment; and to monitor/document/report to MD PRN changes in skin statusA physician order dated September 19, 2024 included for weekly skin check. The weekly skin check and wound assessment note dated September 19, 2024 revealed a stage 4 ulcer on the coccyx. The documentation did not include wound descriptions such as measurements, presence/absence of odor, drainage, tunneling, description of the surrounding skin and wound edge/bed.The health status note dated September 21, 2024 included that family was concerned about the bed the resident was in because of her pressure ulcer.The weekly skin check dated September 21, 2024 revealed an unstageable pressure ulcer to the coccyx. The pressure ulcer documentation dated September 21, 2024 included an unstageable pressure ulcer, present on admission, measuring 3 cm (centimeter) x 4.2 cm, with moderate serosanguineous drainage, slight odor, necrotic tissue with surrounding slough. Per the documentation, treatment included Medihoney, alginate then foam dressing; and that, a LALM (low air loss mattress) was requested. Patient and staff educated to turn and reposition Q2.Despite the documentation that the resident had stage 4 pressure ulcer identified on admission, the clinical record revealed no evidence that treatment for the pressure ulcer was initiated until September 21, 2024.A physician order dated September 21, 2024 revealed an order for air mattress per resident's request for wound healing and prevention.Another physician order dated September 21, 2024 included to cleanse the coccyx with NS (normal saline) or wound spray, pat dry, apply Medihoney (topical wound treatment) then calcium alginate (hemostatic/adsorbent topical wound treatment) and cover with foam dressing every day shift and as needed if dressing is soiled or dislodged.The history & physical note dated September 21, 2024 revealed the resident was transferred from the acute care setting to continue treatment at the subacute level patient here for therapy and rehab and management of comorbidities along with the completion of treatment from the hospital. The documentation included resident had dialysis on Saturday and had been febrile, was very lethargic and was on 5 liters of oxygen via mask. Physical examination included resident was alert and oriented x 3 and skin was within normal limits. According to the documentation wound examination was deferred per wound team evaluation and descriptions. The order for the wound treatment to the coccyx was transcribed onto the wound administration record for September 2024. Review of the wound administration record revealed that the treatment was marked as 6 indicating the resident was hospitalized on [DATE].The order for the air mattress was transcribed onto the TAR (treatment administration record) for September 2024. The documentation included that this was administered as ordered on September 21 and 22, 2024.The alert note dated September 22, 2024 included that the resident was admitted to hospital for sepsis.The skin care plan was revised on September 24, 2024 to include the intervention of a pressure-relieving mattress. An interview with the DON (director of nursing) was conducted on January 6, 2026 at 7:35 a.m. The DON stated that the documents regarding resident #64 that she provided were all the facility had related to the resident's pressure ulcer. An interview with the MDS (Minimum Data Set) nurse (staff #25) was conducted on January 6, 2026 at 4:15 p.m. The MDS nurse stated that upon admission, each resident receives a head-to-toe skin assessment; and, if a skin impairment or wound was identified, it is documented in the clinical record and the provider is notified for orders. He stated that treatment begins as soon as provider orders are received. The MDS nurse also said that delays in treatment do not meet facility expectations, as delays can worsen skin impairments or wounds; and, if a delay is identified, the provider, family, and supervisor are notified. Further, he stated that wound care and treatments were expected to be documented each time they were provided; and, if a nurse reported that treatment was given but there was no documentation, the treatment was considered not to have been done. In an interview with a registered nurse (RN/staff #32) conducted on January 6, 2026 at 4:24 p.m., the RN stated that a head to toe skin assessment are conducted upon admission of the resident and this assessment is documented in the electronic health record. She said that if a skin impairment was identified, the nurse was expected to contact the wound care nurse and provider for immediate directions. The RN said that it would not meet facility expectations if the treatment was delayed, especially if delayed by two or three days, as that may delay healing and cause the wound to get infected. The RN stated that documentation was required to prove that the treatment was provided; and, if there was no documentation, then, treatment was not done or provided to the resident. She further stated that if she discovers that there was no treatment for the resident's wounds, she would notify the nurse supervisor, family, and the provider. An interview with the DON (staff #19) conducted on January 7, 2026 at 12:13 p.m. The corporate resource (staff #51) was present during this interview. The DON stated that when a resident comes with an open area/wound, the nurse would assess the wound and document the assessment to include color, size or drainage; but cannot stage the wound. She stated that if the resident's wound on admission had orders, the nurse were expected to transcribe the order onto the TAR and follow the treatment as ordered by the physician. She stated that if there were no treatment orders for the wound upon resident admission, the expectation was for the nurse to notify the notify the provider at the time of assessment. She stated that the facility has a 3rd party wound provider that conducts weekly assessments of the wounds of residents at the facility; and, the nurses conduct weekly skin assessment. The DON said that when wound care was provided, documentation in the clinical record would include the type of wound care given, date/time wound care given, position the resident was placed in to provide wound care, name of the person providing wound care, how the resident tolerated the procedure. and, if there were problems encountered during the provision of care/treatment. She stated that if the resident refused treatment, the reason why the resident refused must also be documented and the nurse should notify the supervisor. Regarding resident #64, the DON stated that she had only been a DON at the facility since November 2025 and all she knew about this resident was that resident #64 went to dialysis Tuesday-Thursday and Saturdays; and that, the resident's admission on [DATE] was a dialysis day. She said that the resident had another dialysis on September 21, 2024 (Saturday) and was discharged from the facility on September 22, 2024 (Sunday). However, the DON stated that she did not know why the resident was discharged because the facility did not facilitate the discharge; so, she can only assume that the resident went to the hospital from dialysis. Further, the DON stated that she does not know whether or not treatment was initiated or provided for resident #64. The corporate resource stated that she reviewed the clinical record of resident #64 and found no documentation that treatment was provided to resident #64. Review of the facility policy on Skin/Wound Management: Pressure Ulcers/Skin Breakdown-Clinical Protocol, effective January 1, 2024 revealed that the nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). In addition, the nurse shall describe and document/report the following: a. Full assessment of pressure sore including location, stage, length, width and depth, presence of exudates or necrotic tissue; b. Pain assessment; c. Resident's mobility status; d. Current treatments, including support surfaces; and, e. All active diagnoses. The staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure ulcers or other skin conditions. The physician will order pertinent wound treatments, including pressure reduction surfaces, wound cleansing and debridement approaches, dressings (occlusive, absorptive, etc.), and application of topical agents. The physician will help identify medical interventions related to wound management; for example, treating a soft tissue infection surrounding an ulcer, removing necrotic tissue, addressing comorbid medical conditions, managing pain related to the wound or to wound treatment, etc.

Based on observations, staff interviews and review of policies and procedures, the facility failed to ensure that food was labeled and stored in accordance with professional standards. The deficient practices could result in food-borne illnesses.Findings include:-Regarding food labeling, dating and storageA kitchen observation was conducted on January 4, 2026 at 7:21 a.m. with the morning cook (staff #6) and revealed the following:-A [NAME] style cooking wine in walk-in dry storage was found with use by date of August 25, 2025--Within the large, three-door freezer, peas and sliced carrot were discovered wrapped in a blue plastic bag and lacked any date labeling.Initial observation of the nourishment refrigerator located close to nurse station was conducted on January 4, 2026, at approximately 8:20 a.m., revealed that the multiple edible items which were almost full capacity in an unorganized fashion and the following items were not labelled and dated:-A transparent plastic container with a red lid containing diced fruit and liquid which was unlabeled and undated- An array of individual snacks, 2 triangle shaped pieces of bread were unlabeled and undated-A transparent rectangular container with a lid which contained 2 round yellow substance on a visible white substance with dark color speckles on top of a yellowish substance. This container was unlabeled and undated-A black plastic container with clear lid containing what appeared to be 3 pancakes and several slices of bacon which was unlabeled and undated- A white styrofoam cup with a lid contained what appeared to be translucent vegetable soup with ice formation on top which was unlabeled and undated-A transparent plastic container containing approximately a 12 oz ounce fruit cup containing purple grapes, green grapes, watermelon and cantaloupe slices with a sell through date of December 16, 2025, were unlabeled-A light blue plastic container with a lid containing what appeared to be meatballs and pasta which was unlabeled and the date on the container was August 26-A black plastic container with a transparent lid containing what appeared to be red raspberries covered with light brownish fuzzymix with what appeared to be blue berries was unlabeled and undatedAn interview was conducted on January 4, 2026, at approximately 8:25 a.m., with a cook (staff #6) who stated that the [NAME] style cooking wine in the walk-in dry storage was not good anymore because it expired last month and needs to be thrown away. The cook then explained that the peas and sliced carrots in blue plastic bag in the freezer were received yesterday in a cardboard box, and due to a lack of space in freezer, Staff #6 removed the blue plastic bag containing sliced vegetables from the box and stored the bag in the refrigerator. Staff #6 then stated that she used the sliced carrot and peas from blue bag yesterday night January 3, 2026, to make turkey pot pie and puree. Staff #6 stated that CNAs' (Certified Nursing Assistant) are responsible for cleaning and throwing out expired food from the nourishment refrigerator.An interview was conducted on dated January 4, 2026, at 4:04 p.m. with a Kitchen Dietary Director (staff #59) who stated that kitchen staff #10, #24, and #3 were responsible for cleaning all nourishment refrigerators every Monday, Tuesday, and Wednesday. Staff #59 then stated that there was lot of food preparation happening in the kitchen due to the holiday party so food got cluttered in the refrigerator. Staff #59 then stated that food should be dated, labelled, and stored no more than 72 hrs. (hours) in the refrigerator due to a risk of food getting cross contamination with other food. Staff #59 then stated that he would not let that happen again. Staff #59 also stated that he provided in-service training regarding labelling, storing, and cleaning of refrigerators to staff #10, #24, and #3 so the staff understand the food policy and all kitchen staff are on the same page. Staff #59 then stated that he emptied all food items from the nourishment refrigerator, and cleaned and disinfected the nourishment refrigerators to start fresh.An interview was conducted on January 6, 2026, at 9:31 a.m., with a Dietary Aide (staff #3) who stated that staff #59 and she were responsible for cleaning all kitchen and nourishment refrigerators. Staff #3 then stated that she mostly cleans all refrigerators every Monday and Wednesday as she does not work on Friday and the weekend. This aide then stated that when resident's families bring in the food it needed to be dated, labelled, and used within 5 to 7 days. Then the aide stated that if food was not dated, labelled, and expired, there would be a risk of a resident getting food poisoning, and may cough and get sick due to bad odor of food.An interview was conducted on January 6, 2026, at 9:55 a.m., with a CNA (staff #37). This CNA stated that if food is brought by family for a resident then the CNA would ensure that the resident was not allergic to the food and then either family or staff would label the food with resident name and date and store in the nourishment refrigerator. Staff #37 stated that maintenance staff are responsible for cleaning nourishment refrigerators every Sunday. Staff #37 also stated that if food brought by family members was not labeled and dated then there would be a health hazard risk and residents could also get sick due to food contamination.A follow-up interview was conducted on January 6, 2026, at 10:14 a.m., with Kitchen Dietary Director (staff #59) who stated that food got cluttered in nourishment refrigerators due to the holiday season last month and that the facility has multiple parties for staff and residents. Staff #59 then stated that nourishment refrigerator had only a temperature log and no cleaning log currently. Staff #59 further stated that he cleaned both nourishment refrigerator this Sunday January 4, 2026, and then created a new cleaning log for nourishment refrigerators and also delegated the cleaning task to staff #3 from Monday through Thursday, and then to staff #24 from Thursday to Sunday. Staff #59 then stated that his expectation from kitchen staff, who do the temperature log daily for refrigerators, is that they should have noticed unlabeled and undated food in refrigeratorsReview of the facility policy titled, Food Brought in from Outside Sources and Personal Food Storage, dated 2021, revealed that foods and beverages brought in from outside sources that require refrigeration or freezing should be labeled with the patient/resident's name and date and stored in the refrigerator/freezer apart from facility food.Review of the facility policy titled, Food Storage and Date marking, dated 2021, revealed that all refrigerated food should be covered, labeled, and dated and routinely monitored to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.

Based on review of clinical record, interviews, and review of facility policy and procedure, the facility failed to ensure the medical record was complete and accurate for one resident (#27). The deficient practice could lead to care team members not being fully aware of a resident's status.-Findings include:Resident #27 was re-admitted on [DATE], with diagnoses of acute on chronic congestive heart failure, cardiomyopathy, pneumonia, unspecified dementia, anxiety disorder, and retention of urine.An admission minimum data set (MDS) assessment dated [DATE], revealed Resident #27 had a brief interview for mental status (BIMS) assessment score of 9, indicating moderate cognitive impairment.A care plan focus initiated December 5, 2025, revealed Resident #27 had or was at risk for pain, with interventions that included to administer analgesia medication as per orders, to anticipate the resident's need for pain relief and respond as soon as possible to any complaint of pain, to monitor / record / report to the nurse any signs and symptoms of non-verbal pain including yelling out, and for non-medication intervention for pain to be given prior to administration of as needed medication.A care plan focus initiated on December 11, 2025, revealed Resident #27 had a behavior problem related to impaired cognitive function, impaired safety awareness, verbal behavior (yelling out and banging on table instead of using call light), with a goal that safety would be maintained. Interventions included to administer medications as ordered, and monitor / document for side effects and effectivenessA physician order dated January 2, 2026, included Morphine Sulfate (Concentrate) Oral Solution 20 mg/ml, to give 0.25 ml every 4 hours as needed for pain / shortness of breath.A physician order dated January 2, 2026, included Lorazepam Intensol oral concentrate 2 mg/ml, to give 1 ml by mouth every 2 hours as needed for anxiety as evidenced by restlessness / agitation, related to anxiety disorder.A Behavior Note dated January 2, 2026, revealed Resident #27 continued to have behaviors of yelling throughout the day, and that redirection had no effect. The documentation revealed that as needed (PRN) doses of lorazepam (anti-anxiety medication) and morphine (narcotic medication) were administered into the resident's cheek pocket, pending effectiveness.An Individual Control Drug Record for Resident #27's morphine 5 mg, pre-filled syringe (0.25 ml / 5 mg), revealed that two doses were administered on January 2, 2026, with one dose administered at 10:00 a.m. and one dose administered 2 hours and 10 minutes later at 12:10 p.m.An Individual Control Drug Record for Resident #27's lorazepam 2mg/ml, revealed that two doses were administered on January 2, 2026, with one dose at 10:00 a.m. and another dose 2 hours and 10 minutes later at 12:10 p.m.Despite the individual control drug records including that two doses of morphine and two doses of lorazepam were administered to Resident #27 on January 2, 2026, review of the progress notes revealed the morphine and lorazepam were administered, but did not specify the number of doses, or when the administration occurred.Review of the Medication Administration Record (MAR) for January 2026, revealed no evidence that any doses of morphine sulfate oral solution were administered. Additionally, the record revealed no evidence that the 2mg/ml doses of lorazepam were administered to the resident in January 2026. Also, under target symptoms / behavior tracking, no episodes of anxiety as evidenced by restlessness were recorded on the MAR for any shifts in January 2026.An interview was conducted with a registered nurse (RN / Staff #32) on January 5, 2026, at approximately 12:00 p.m. Staff #32 stated that if a resident had impaired cognition and behaviors of yelling out repetitively or if the resident was trying to get up from a chair or bed and walk unsteadily without assistance, that she would try to console the resident, ask what is wrong, try to meet the resident's needs, and if those methods did not work, then Staff #32 would see what medications the resident had available to help with the behaviors. Regarding medication administration, Staff #32 stated that once a physician order was received, the order appeared on the MAR in the electronic medical record (EMR). Staff #32 stated once the medication was administered, it would be documented in the MAR to show that the medication was administered. Staff #32 also stated that controlled substances such as narcotic medications, would also be documented on the narcotic reconciliation sheets (Individual Control Drug Record). Staff #32 stated that nurses document the administration of medication on the MAR because the risk of not doing so would be not knowing exactly when the medication was administered, and that overdose could occur from administering a second dose too soon.An interview was conducted with a licensed practical nurse (LPN / Staff #9) on January 6, 2026, at 11:36 a.m. who stated that if a resident had impaired cognition and had behaviors of yelling out, Staff #9 stated that it was not good for the resident to medicate the behaviors away, so she would attempt to determine what the resident needed. Staff #9 stated that Resident #27 had behaviors of near constant yelling and that it had been ongoing the whole time the resident was at the facility. Staff #9 stated that she would try to talk to the providers about his behaviors, and try to talk to the resident to determine why he was yelling, and to re-assure him. Regarding medication administration, Staff #9 stated that when a resident is administered a medication, the physician order appears on the MAR, and then the nurse records when the dose is administered. Staff #9 stated that the importance of recording the medication administration in the clinical record would be to verify that the resident received the medication, and prevent an accidental administration of another dose outside of time parameters. Staff #9 stated that the narcotic reconciliation sheet is completed at the beginning and end of each shift.An interview was conducted with the Director of Nursing (DON / Staff #19) on January 6, 2026, at 3:10 p.m., who stated if a resident with impaired cognition or dementia had behaviors of yelling out, then Staff #19 stated that she would expect staff to offer redirection or provide anything that would get the resident to stop yelling, offer a change of scenery, provide a blanket, offer fluids, and for the nurse to determine if there were any medications available to address the agitation. Regarding medication administration, Staff #19 stated that nurses should document medication administered on the MAR. If a nurse did not document a medication administered on the MAR, then Staff #19 stated that the risk could be missing communication that the medication was administered or not, and that the medication could accidentally be administered again. The clinical record was reviewed for Resident #27, and Staff #19 stated that the MAR for January 2026 revealed that no doses of morphine were administered and no doses of the 2 mg/ml lorazepam were administered. The narcotic reconciliation sheets for Resident #27's morphine and 2 mg/ml lorazepam were reviewed and Staff #19 stated that Resident #27 was administered both morphine and 2 mg/ml lorazepam doses at 10:00 a.m. and again at 12:10 p.m. on January 2, 2026, and that it would not meet her expectation as far as documentation in the clinical record.Review of the facility policy titled Documentation: Charting and Documentation, dated January 1, 2024, revealed all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Documentation of procedures and treatments will include care-specific details, including: the date and time the procedure/treatment was provided, the name and title of the individual(s) who provided the care, the assessment data and/or any unusual findings obtained during the procedure/treatment, how the resident tolerated the procedure/treatment, whether the resident refused the procedure/treatment, notification of family, physician or other staff, if indicated; and the signature and title of the individual documenting.Review of the facility policy titled Medication: Administering Medications, dated January 1, 2024, revealed medications are administered in a safe and timely manner, and as prescribed. Medications are administered in accordance with prescriber orders, including any required time frame. Medication errors are documented, reported, and reviewed by the QAPI committee to inform process changes and or the need for additional staff training. The individual administering the medication initials the resident's MAR on the appropriate line after giving each medication and before administering the next ones, or documents in the electronic medical administration record. As required or indicated for a medication, the individual administering the medication records in the resident's medical record:a. the date and time the medication was administered;b. the dosage;c. the route of administration;d. the injection site (if applicable);e. any complaints or symptoms for which the drug was administered;f. any results achieved and when those results were observed; andg. the signature and title of the person administering the drug.

Based on clinical record review, staff interviews, facility documentation and policy review, the facility failed to ensure protocols for reconciliation of controlled medications were followed by staff to prevent diversion of narcotic medications for 2 sampled residents (#73 and #74). The deficient practice could result in result in risk of harm including inadequate relief of pain and complications associated with the medication use and misuse.Findings include: -Resident #74 was readmitted on [DATE] with diagnoses of acute osteomyelitis of the right ankle and foot, infection and inflammatory reaction due to internal left hip prosthesis and pain in the left hip. The admission evaluation dated February 9, 2024 revealed the resident was admitted on [DATE] from short-term general hospital. The care plan dated February 9, 2024 included that the resident was prescribed with high risk medications and was at risk for pain. Interventions included to administer analgesia medications as per orders, observe for and report any observed adverse effects to provider when clinically significant. A physician order dated February 9, 2024 revealed an order for pain evaluation using pain scale 1-10 every shift. The late entry history & physical note dated February 10, 2024 included that the resident was transferred from the acute care setting to continue treatment at the subacute level patient here for therapy and rehab and management of comorbidities along with the completion of treatment from the hospital. Summary problem list included right foot osteomyelitis s/p (status post) right foot amputation. The physician order summary report revealed an order for oxycodone (narcotic) 5 mg (milligrams), give 1 tablet by mouth every 6 hours as needed for pain 4-10. The order for oxycodone was not transcribed onto the MAR (medication administration record) for February 2024. The narcotic card audit from January 18, 2024 through February 18, 2024 conducted by the DON (Director of Nursing) revealed the oxycodone 5 mg for resident #74 had quantity of 58 dispensed; and, was highlighted. The documentation did not have a check mark and did not indicate whether the medication in the cart or was scanned. -Resident #73 was admitted on [DATE] with diagnoses of atherosclerotic heart disease of native coronary artery without angina pectoris, muscle weakness, and acute hematogenous osteomyelitis of the right ankle and foot. A physician order dated February 6, 2024 revealed Oxycodone-Acetaminophen Tablet 10-325 mg Give 1 tablet by mouth every 6 hours as needed for pain level 1-10. The care plan dated February 9, 2024 included that the resident was on an opiate medication. Intervention included to administer medications as ordered. A physician order dated February 9, 2024 revealed an order for pain evaluation using pain scale 1-10 every shift. The physician progress note dated February 10, 2024 included an interim history that on February 10, 2024 resident complained of leg pain with no issues, Plan was to continue pain medication. The physician progress note dated February 11, 2024 revealed pain control was adequate. Review of the MAR for February 2024 revealed that the order for Oxycodone-Acetaminophen Tablet 10-325 mg was transcribed; and that, it was documented as administered on February 7 and 14, 2024. The late entry NP (nurse practitioner) note dated February 15, 2024 included that resident indicated that pain level was 4/10 and pai was controlled on current medication regimen. The documentation also included that nursing endorsed a goal to wean the resident off of opioid pain medications. Pain regimen included Oxycodone-Acetaminophen Tablet 10-325 mg 1 tab q6 hours PRN (as needed) for moderate to severe pain. The narcotic card audit from January 18, 2024 through February 18, 2024 conducted by the DON revealed the oxycodone-acetaminophen 10-325 mg for resident #73 had quantity of 20 dispensed. The documentation was highlighted, did not have a check mark, and was marked as n/a. The facility investigation dated February 21, 2024 revealed that on 2 nurses who worked the morning shift (6:00 a.m. - 6:00 p.m.) and the NOC shift (6:00 p.m. - 6:00 a.m.) on February 14, 2024 completed medication reconciliation; and that, the bubble pack and the narcotic count sheet for the oxycodone of resident #73 were present. On February 15, 2024 the alleged registry RN (staff #52) accepted the cart from the NOC shift nurse identifying that the narcotics and the count sheet were both present. The investigation included that the alleged registry RN passed the report to the NOC shift nurse on February 15, 2024; but, the narcotic sheet and the bubble pack for the oxycodone of resident #73 were not present; and that, the alleged registry RN concealed this information and did not properly hand off that information in the report. The facility investigation included that when the NOC shift nurse for February 15, 2024 passed the report onto the oncoming morning shift nurse for February 16, 2024 and told the oncoming morning shift nurse that resident #73 was asking for his oxycodone-acetaminophen medication. According to the documentation, there was an order for this medication for resident #73 but neither the count sheet nor the bubble pack were present in the nurse's cart. Continued review of the facility investigation revealed that during the course of their investigation, the camera footage was reviewed and showed that the alleged registry RN entered the medication room and pretended to put medications into a cabinet. The documentation also included that it was clear that the alleged registry RN was stuffing medication bubble packs down the front of her scrubs. Per the documentation, during the facility's audit of all other residents on controlled medications, it was determined that the alleged registry RN removed resident #74's oxycodone 5 mg and had taken total of 58 of this medication out of the facility; and that, this was a discontinued narcotic order for resident #74 and this medication was set to be destroyed. Further review of the facility investigation included that the facility substantiated misappropriation of medications; and that, when the facility reviewed the camera footage it appeared that th alleged nurse placed 2 bubble packs into her scrubs.A review of the January 2025 narcotic log book for the Hall A and D Medication cart was conducted with the assistant Director of Nursing (ADON/staff #8) on January 4, 2026 at 2:37 p.m. The log book included two nurse signatures and the sampled resident narcotic logs matched the quantity of the resident narcotic blister pack. The ADON stated that it was the nursing staff responsibility to audit the narcotic log on each medication cart on a regular basis; and that; 2 nurse signatures were required each shift to ensure accuracy of the narcotic counts. The ADON stated that if the narcotic count was incorrect, the DON is notified and investigation is conducted immediately. Further, the ADON said that narcotic counts were taken seriously in order to prevent the risk of narcotic loss or diversion. An interview was conducted on January 5, 2025 with Registered Nurse (RN/Staff #32) at 8:03 a.m. The RN stated it was never ok to use controlled medications because the narcotic count would be off; and this was against policy to use one residents' medication for another. She stated that in order to prevent narcotic diversion, two nurses will conduct a narcotic count when the medication cart is transferred to the oncoming nurse at shift change. The RN stated that if there were any issues with the count the Director of Nursing will be notified immediately. The RN also stated that all allegations of missed narcotic dosage from a resident were taken seriously; and, possible signs of narcotic diversion included resident having worsening or uncontrolled pain and/or resident not receiving the medicationsIn an interview with a licensed practical nurse (LPN/staff #9) conducted on January 5, 2025 at 9:36 a.m., the LPN said that the oncoming nurse counts all medication cards, bottles, and syringes to verify the quantity of each medication for every resident; and two nurses were required to verify that all resident medications were accounted for in the medication cart. The LPN stated that if there was a discrepancy in the count, the two nurses review the previous three shifts to identify the issue and notify the Director of Nursing (DON). The LPN also stated that nurses were not allowed to administer one resident's medication to another resident; and that, if medications have not yet been received from the pharmacy and a resident's medication was given to another resident, this may be considered drug diversion. Further, the LPN stated that such actions can result in inaccurate medication counts, and if narcotic diversion was suspected, the DON is notified.During an interview with the DON (staff #19) conducted on January 7, 2026 at 12:13 p.m., the DON stated that medication reconciliation happens during shift change and will be conducted by the oncoming nurse and the outgoing nurse. She stated that one nurse will be looking at narcotic sheet and one will be at the physical medication or bubble pack The DON said that the two nurses will verify the number of narcotics and will do card counts first to ensure the number on the reconciliation sheet matches the card count. The DON said that the two nurses would then go through the individual card and do pill count. She stated that if everything matched, the outgoing nurse hands over the keys to the oncoming nurse and it would be business as usual. However, the DON stated that if it does not match, the two nurses will figure out what was off , review the reconciliation sheet or the pill count and would notify her; and that, an investigation would be conducted to find the cause of the discrepancy. The DON stated that if there were major discrepancies (reading through the policy) she will notify the administrator and consultant pharmacy. Further, the DON stated that she only had been the DON for the facility since November 2024 and cannot give details regarding the drug diversion for residents #74 and #73.The facility policy on Medication: Controlled Substances with effective date of January 1, 2024, revealed that the facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976). Only authorized licensed nursing and/or pharmacy personnel have access to Schedule II controlled substances maintained on premises. Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up. The system of reconciling the receipt, dispensing and disposition of controlled substances includes the following: a. Records of personnel access and usage; b. Medication administration records; c. Declining inventory records; and, d. Destruction, waste and return to pharmacy records. Nursing staff count controlled medication inventory at the end of each shift, using these records to reconcile the inventory count. The nurse coming on duty and the nurse going off duty make the count together and document and report any discrepancies to the director of nursing services. Disposal methods are used to prevent diversion and/or accidental exposure to controlled or hazardous substances. Fentanyl patches are disposed of in one of the following ways (per state regulations): a. By folding in half, sticky sides together and flushing down the toilet; or b. Using approved drug disposal products specifically for fentanyl patches.

Based on clinical record review, staff interviews and review of facility documentation and policy, the facility failed to ensure that the Ombudsman was provided a copy of the notice of discharge for 2 of 3 sampled residents (#76 and #70). The deficient practice could result in residents being inappropriately discharged .Findings include:-Resident #76 was admitted on [DATE] with diagnoses of metabolic encephalopathy, COPD (chronic obstructive pulmonary disease) and anxiety. The admission evaluation dated September 16, 2025 included that the resident was admitted from a short-term general hospital via a stretcher for post-op rehabilitation. The skilled needs review dated September 17, 2025 revealed that the IDT (interdisciplinary team) attested that the resident met all the criteria for skilled services and the case manager approved continued stay through September 18, 2025. According to the documentation, the resident was expected to be discharged to community. The social services progress note dated September 17, 2025 revealed that discharge planning was discussed with the resident who reported a plan to discharge back to her home. The physiatry progress note dated September 18, 2025 included discharge planning and disposition to continue discussion with the therapy team, family, and social worker in multidisciplinary team meetings and will further determine as rehab progresses. Per the documentation, the resident will be followed throughout rehabilitation course to manage rehabilitation and any barriers to therapies. The IDT care plan conference dated September 23, 2025 revealed that the resident reported that she planned to discharge back to her home. The skilled needs review dated September 23, 2025 included that the resident expected to be discharged to the community. The PT (physical therapy) daily note dated October 8, 2025 included that therapy discharge was completed and the resident was discharging to home hospice services. The Discharge summary dated [DATE] included that the resident will be discharge to the community with hospice services. The skilled needs review dated October 8, 2025 revealed the resident was expected to be discharged to the community; and, anticipated discharge date was October 9, 2025. The discharge transfer evaluation dated October 8, 2025 revealed the resident was discharging to private home with hospice services. The physician order dated October 9, 2025 revealed that the resident has completed skilled inpatient stay and will be discharged home on October 9, 2025. The discharge MDS (Minimum Data Set) assessment dated [DATE] revealed resident discharged on October 9, 2025. Despite documentation that the resident was discharged , there was no evidence found in the clinical record that the Ombudsman was notified and provided a copy of the notice of discharge of resident #76. -Resident #70 was admitted on [DATE] with diagnoses of speech language deficits and type II diabetes. A A physician order dated March 11, 2024 revealed that the resident had completed skilled inpatient stay and will discharge to home on March 14, 2024. Another physician order dated March 11, 2024 included that resident was discharging with remaining medication and narcotics. The IDT care plan conference dated March 12, 2024 revealed that the resident's plan was to be discharged to home with family. The Discharge summary dated [DATE] included a date of discharge of March 14, 2024; and that, the resident will be discharged with medications. The progress note dated March 14, 2024 revealed resident discharged home in stable condition with family and belongings. There was no evidence found in the clinical record that the Ombudsman was notified and provided a copy of the notice of discharge of resident #70. In an interview with the Director of Nursing (DON/staff #19) conducted on January 7, 2026 at 10:10 a.m., the DON stated that she had only been the DON for the facility since November 24, 2025 and the facility's social services director had only been at the facility for 3 days. The DON stated that social services usually gets notified of a resident's discharge upon discussion of the NOMNC (Notice of Medicare Non-Coverage) during meeting. She stated that the resident and/or resident representative (RR) is then notified in writing regarding the reason for discharge, the effective date of discharge, the location where the resident was going, explanation to the resident's right to appeal the discharge. She also stated that the resident gets a copy of bed hold policy and contact information for the Ombudsman. The facility policy on Admissions/Transfers/Discharges: Transfer or Discharge Notice included that resident and/or representatives are notified in writing, and in a language and format they understand, at least 30 days priori to a transfer or discharge. However, the policy did not include notification of the Ombudsman.

Based on clinical record review, staff interviews and policy reviews, the facility failed to ensure that 1 of 3 sampled residents (#1) received the appropriate inhalation powder per physician orders. The deficient practice could result in uncontrolled symptoms related to chronic obstructive pulmonary disease (COPD). Findings include:Resident #1 was admitted on [DATE] with diagnosis that included chronic obstructive pulmonary disease (COPD), acute respiratory failure, an open wound of abdominal wall and sepsis. A comprehensive care plan initiated on September 15, 2025, revealed that Resident # 1 had COPD with intervention that included to give aerosol or bronchodilators as ordered and to monitor and document the side effects and effectiveness. A progress note dated September 15, 2025, revealed that Tyvaso Dry Powder Inhaler (DPI) was on hold pending provider direction. The progress note goes on to reveal that the facility initially did not have the medication and that the resident's family would bring the Tyvaso DPI to the facility and medication will be house stock once received. A Pulmonary progress note dated September 25, 2025, revealed that the resident and family would like the resident to switch from Yupelri to Tyvaso as the resident was supposed to transition to this medication as outpatient. Further review of the pulmonary progress note revealed that the provider approved the Tyvaso with home supply and held the order for Yupelri. A physician order dated September 25, 2025, revealed a prescription for Tyvaso DPI maintenance kit inhalation powder 16 micrograms (mcg). The order directed 16 mcg be inhaled orally four times a day for 1 week starting September 25, 2025. Review of the Order Summary Report revealed a physician order dated September 25, 2025 for Tyvaso DPI maintenance kit inhalation powder 16 MCG. The order indicated 32 mcg be inhaled orally four times a day for 1 week starting October 2, 2025. An order dated September 25, 2025 prescribed Tyvaso DPI maintenance kit inhalation powder 16 MCG. The order directed 64 mcg be inhaled orally four times a day starting October 9, 2025 and was discontinued October 21, 2025.Review of the Medication Administration Record (MAR) Note dated September 27, 2025, revealed that the 12:00pm dosage of Tyvaso DPI was not administered with a note from Licensed Practical Nurse (LPN/Staff #35) stating that the facility was awaiting delivery.Further Review of the MAR on September 27, 2025, revealed that the resident received the 8:00 a.m. dose and the 4:00 pm does, both on September 27, 2025. Review of the MAR for the month of October 2025, revealed that Tyvaso DPI was not administered on:October 1, 2025 at 12:00, 4:00, and 8:00 p.m.October 2, 2025 at 8:00 a.m. October 3, 2025 at 8:00 a.m., 12:00 p.m., and 8:00 p.m.October 5, 2025 at 8:00 p.m.Further review of the October 2025 MAR revealed that the Tyvaso DPI was administered on:October 1, 2025 at 8:00 a.m.October 2, 2025 at 12:00 p.m., 4:00 p.m., and 8:00 p.m.October 3, 2025 at 4:00 p.m.Review of the MAR note dated October 1, 2025 revealed that the missed doses at 12:00, 4:00, and 8:00 p.m. were on order. There was no indication that the pharmacist or the provider were contacted regarding the missing medication. Review of the MAR note dated October 2, 2025 revealed that the missed does at 8:00 a.m. was on order. There was no indication that the pharmacist or the provider were contacted regarding the missing medication. Review of the MAR note dated October 3, 2025 revealed that the missed doses at 8:00 a.m., 12:00 p.m., and 8:00 p.m. were on order and the pharmacy was notified at 9:26 p.m. that the medication was not available, even though the medication was provided by family and stored in house. An interview with a Licensed Practical Nurse (LPN/Staff # 35) on November 5, 2025 at 1:35 p.m. revealed that if there is no medications in the cart or the storage room then they would call the pharmacy and re-order the medication and notify the provider that they don't have the medication on hand. The LPN denied having any residents or family provide their own medications, and revealed that everything is ordered through the pharmacy. Staff #35 revealed that she was unaware that the Tyvaso DPI was provided by he family and not the pharmacist.An interview with the Assistant Director of Nursing (ADON/Staff # 57) on November 5, 2025 at 2:09 p.m. revealed that Resident # 1's family had brought a box of the Tyvaso DPI to the facility and that the facility never ordered the medication through the pharmacy. ADON revealed that they had to wait to administer the Tyvaso until approval from the pulmonologist was received. The facility started a titration of the medication in September but there was an issue with the October titration and the nurses were confused on the amount to administer. The ADON revealed that due to the confusion, she did not have the daughter bring in a second box of the medication because they never finished the first box of Tyvaso DPI, The ADON reviewed the missed doses on the MAR and revealed that she did not know why those missed doses were marked on order when the family had provided the medication and was in house. A policy and procedure titled, Administering Medications revised April 2019 revealed that medications are administered in accordance with prescriber orders, including any required time frame.

Based on review of documentation, interviews with staff and residents and review of the facility policy, the facility failed to ensure two residents are free from verbal abuse (#5 and #30). The deficient practice could lead to psychosocial harm for residents. Findings include: - Resident #5 was admitted on [DATE] with a diagnosis of traumatic subdural hemorrhage without loss of consciousness, subsequent encounter, essential (primary) hypertension, acute pain due to trauma, gout, unspecified. Review of the care plan dated November 6, 2024, revealed that resident #5 was at risk for falls. An intervention included that the staff would anticipate and meet the residents needs and make sure the residents call light is within reach and encourage the resident to use it for assistance as needed. Additional interventions included; a psychosocial well -being problem related to admission and allow the resident time to answer questions and verbalize feelings, perceptions and fears. A grievance report was completed by resident #5 on November 8, 2024. It stated that resident #5 expressed CNA (Certified Nursing Assistant/ staff #67. The grievance report states the resident self-toiled per her preference and went back to bed and that at some point CAN #67 entered the room and answered the call light, assisted the resident with being scooted up in bed. Per the report the resident had reported CAN # 67 had entered the room abruptly and was throwing stuff on the floor to get to the resident to adjust in bed. The report also states resident #5 reporting CNA #67 was loud, but could not recall what was said. The report indicates the resident requested a nurse and also reported that her call light was out of reach. Review of the Minimum Data Set (MDS) assessment, dated November 11, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which revealed no cognitive impairment, no indicators for mood or behaviors. Further review of the MDS revealed resident required Setup or clean-up assistance with toileting hygiene, substantial/maximal assistance with lower body dressing. Supervision or touching assistance with roll left and right, sit to lying, sit to stand, toilet transfer, walk 10 feet. Resident required partial/moderate assistance with lying to sitting on side of bed. An interview was conducted with resident #5 on November 20, 2024 at 9:30 a.m. Resident #5 stated I had just arrived that day and was placed in the room with another resident. I had gone to the bathroom and went back bed after turning on the call light and waiting 15-20 minutes- I just couldn't wait any longer to go. It was about 2 in the morning- the other resident had turned on the call light. Resident #5 stated she was rude- yelling at me and standing over me saying I was supposed to have someone help me to the bathroom. I told her I couldn't wait any longer, that I had waited 15-20 minutes. Resident stated that CNA # 67 called her and resident #30 trouble makers and was arguing with them for no reason Resident #5 stated she was very angry-you could tell the way she was screaming- she said you wasted my time coming in here and told her well you want help so bad? and threw the call light under my bed. Resident #5 stated the nurse went in the room and asked what is going on because he could hear all the screaming and yelling in the hallway. Resident #5 stated CNA #67 was very agitated. I felt afraid, I felt unsafe and didn't know what was going to happen to me. Resident #5 stated the nurse asked staff #67 to leave the room and told residents #5 and #30 she would not return to their room. Resident #5 stated Executive Director (ED/Staff # 12) went in and completed a report and told her the matter was taken care of and asked her if she now felt safe. Resident #5 stated she felt safe when informed staff #67 would no longer a provide her care. - Resident #30 was admitted to the facility on [DATE] with a diagnosis of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, interstitial pulmonary disease, unspecified, chronic respiratory failure with hypoxia, unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing, need for assistance with personal care. Review of the MDS assessment, dated July 11, 2024, revealed a BIMS score of 15 which revealed no cognitive impairment. Review of the care plan dated July 19, 2024 revealed that resident #30 was at risk for pain. A grievance report was completed by resident #30 on November 8, 2024, involving an incident with staff #67 on November 7, 2024. It stated patient reported that on night of admission patient's roommate had put on her call light and that CNA#67 entered the room abruptly at approximately 0200 and that the CNA was loud and speaking loudly for the time of day while providing care for resident while in bed. The grievance report states resident could not verbalize what the CNA was saying other than than telling her to stop being an intrusion while care was being provided to resident #5. An interview was conducted with resident #30 on November 20, 2024 at 9:48 a.m. with resident #30. Resident #30 stated the following My roommate had just come into the room [ROOM NUMBER]-4 hours before and had not become acclimated to the staff before bedtime. she turned had turned on her light to go to the bathroom and no one came- so she took herself -she really had to go and couldn't wait. the aide finally got there - she had already gone back to bed and the aide woke us up with her screaming- inconsiderate of her time then started arguing that she was running her ragged. saying this to the other resident when I intervened- she was yelling at her and out of control- I told her that the lady had just arrived and didn't know nothing- CNA description- skinny AA-I think her name is [NAME] or [NAME] .has her hair twisted high on her head -she started arguing- blaming both of us for turning on the call light, we asked for the nurse- it was male nurse that came- I'm sure the whole building heard her-she said it was a wasted trip. we both asked that she not care for us anymore and that she not come into our room. The nurse put someone else on duty- she has not been back- It made me angry that she was verbally abusive to both of us. Management came and spoke to us the next day- the day after that a man came and spoke to us, he said he was the manager of the whole facility. I told him she used a very loud tone, that she was angry and out of control, she was flailing her arms- she got very close to the other resident, right in her face in a very intimidating way- towering over and screaming at her. I didn't notice if anything was done with her call light, I was worried about the way she towering over my roommate. she didn't scare me, but it looked like my roommate was and wanted to cry- My experience with her as an was that she was always rushing and did not want to do her work, especially at night- this all happened at night approximately 2-3 in the morning. I made a demand that she needed to be fired. I know what is right and what is wrong- I was a CNA before myself- you don't do what she did to people. On November 20, 2024 at 12:00p.m. resident #30 was informed that her allegations of verbal abuse had been reported to administration. Resident #30 stated they should have known that it was verbal abuse by everything I told them. I told them same thing I told you from the night things happened and how she yelled and screamed at me and [NAME] On November 20, 2024 at 12: 07p.m Executive Director (ED/Staff # 12) and Director on Nursing (DON/Staff #33) brought in paperwork and asked if this surveyor would inform them what was said by the resident. Informed them they would need to complete their own investigation- (ED/Staff # 12) did state that the report was called in due to the online system being down. Both (ED/Staff # 12) and (DON/Staff #33) stated the prior complaints involving CNA staff #67 were taken as grievances and they did not feel what was reported by the residents, as reportable verbal abuse and failed to report the verbal abuse. Each of the three prior complaints involved the same staff member for allegations of verbal abuse. An attempt was made to contact (LPN/Staff#43) on November 20, 2024 at 1:22 p.m with no response. A telephonic interview was conducted on November 20, 2024 at 1:24 p.m. with (CNA/ staff #33). CNA #33 stated she was hired July 2024. CNA #33 stated she was aware that something had happened regarding the resident with a neck brace on D hall and CNA #67. She stated she was asked by (LPN/Staff #43) to swap room with CNA #67 because she was arguing in front of the residents at night and did not care. Staff #33 stated she really has a mouth about the residents and is very critical of them by complaining to the residents about what they should be doing. CNA #33 stated she never wants to help them or answer their call lights. CNA # 33 stated she has had to calm down residents lots of times because she uses very strong words with them because they are not able to help themselves. CNA #33 stated CNA #67 has a bully type attitude, especially with the residents that are not able to help them selves she never wanted to do the work or help them. CNA #33 stated CAN #67 would always ask to swap residents because of not wanting help the residents. CNA#33 stated when CAN #67 did not work the residents were happier. She stated there were a lot of residents who did not want CNA #67 to provide their care. She stated staff # 43 would always have to talk to CNA #67 because she could be heard the way she would speak to the residents. Stating she was not kind and would talk loudly about the residents in the hallway. CNA #33 stated she would always report CNA #67 attitude and the way she spoke to the residents to LPN #43 and LPN #61 and felt they would take care of the issue because they were in charge. CNA #33 stated I would talk to them every night she worked. CNA #33 stated she informed the LPN staff #43 that she considered CNA #67 as verbally abuse in the ways she would make the resident's feel by criticizing them to their face. CNA #33 stated she completed abuse training at Banner hospital. An attempt was made to contact alleged perpetrator, (CNA/Staff #67) on November 20, 2024 at 2:02 p.m with no response. An interview was conducted on November 20, 2024 at 2:54 PM with Licensed Practical Nurse (LPN/Staff #61). Staff #61 stated that he received reported concerns from residents that felt she took forever to answer their call lights and, in the way, she spoke to them. Many of the residents thought she was too loud and disrespectful. LPN # 61 stated the complaints that he received from staff was that she was that she became easily frustrated with the residents. LPN #61 stated that both he and LPN# 43 had multiple conversations with CNA #67 regarding her attitude. LPN # 61 stated he was called into the room of residents #5 and #30. He stated resident #30 informed him that she felt CNA #67 shouldn't be a nurse and further stated that CNA #67 was screaming at Resident #5. He stated resident #5 informed him that CNA #67 was loud and rude further stating that the resident was visibly upset. He stated resident #30 informed him he no longer wanted CNA #67 in their room because of her behavior with resident #5. LPN #61 stated he reported the incident to the Director on Nursing (DON/Staff #33) due to concerns for abuse and because #67 had slammed the resident's door after he had entered their room and of the complaints from staff and other residents. LPN#61 stated he has reported previous concerns to the DON regarding staff #67. An interview was conducted on November 20, 2024 at 3:2 PM with (DON/staff #33). Staff #33 stated she became aware of the grievance regarding residents #30 and #5 during a standup meeting. She denied LPN #61 reporting any concerns to her regarding CNA#67 treatment of residents #30 and #5. She stated she received the information from ED/ Staff #12. DON/staff #33 the process for reporting concerns for abuse are reported to her or to the ED/ Staff #12 who is also the Abuse Coordinator. She stated staff receive training on how to report any allegations for abuse or neglect during orientation training, the online education system and that she also provides staff with abuse education as often as she is able. The DON stated verbal abuse is when someone makes a statement to a resident and how that makes them feel-not necessarily calling them names, but how it makes the patient feel. the intent to hurt the resident's feelings and them perceiving it that way. She stated she would consider screaming at a resident as verbal abuse. She stated ED/ Staff #12 determines what is considered a grievance or something that is reportable. That it is all about what the resident is saying and the severity of the situation. The DON stated grievances are conducted through the facility grievance forms which are completed by family, the resident or by staff, but has found them to be vague not always documenting the resident's verbatim statements. She stated the risks associated with this is that information can be missed as to what actually happened. [NAME] #33 stated Social Services Director/Staff #17 interviews the residents who have filed grievances. The DON stated she has had concerns with staff #17 documentation for an investigation and has educated her. The DON stated staff # 17 is supervised by ED/Staff 12, but is unaware if he had any concerns with the documentation of grievances or investigations. DON/staff #12 stated she was a witness to the follow-up questions regarding residents #30 and #5, the issue with the call light, what was actually reported and review of the camera footage; and based on the information the grievance was resolved. DON/staff #33 stated she did not feel that the residents had reported abuse it was about the intent, given the history the the facility had with CNA #67. An interview was conducted on November 20, 2024 at 3:45 PM with Executive Director (ED/Staff #12). Staff # 12 stated he was notified of the grievance regarding residents #30 and #5 on November 7, 2024 and the grievance was filed by LPN# 61 and given to Social Services. He stated the process for allegations depends on the severity based on the grievance and that he makes the decision when an allegation is processed as a grievance or allegation for abuse. He stated part of the process is to have conversations with residents and staff. He stated he did not have a conversation with LPN #61, but that the DON/staff #33 had, following the reported incident. He stated he spoke to both residents and they reported to him they no longer wanted CNA #67 to provide them care, due to her noise level, being abrupt and causing a lot of ruckus. He stated resident #5 had reported that CNA #67 seemed rushed and bothered and had told her she should not have gone to the bathroom alone. He stated CNA #67 as terminated due to her unprofessionalism, being abrupt and there was no excuse to not have empathy for the patients. Review of employee file for CNA #67 revealed a letter dated 11/10/2024 from CNA #67 of intent to end employment with Haven Healthcare effective 11/24/2024. Further review of the employee file revealed a corrective action form dated 09/30/2024 that CNA #67 had been inappropriate to various residents. The report states four different residents had reported CNA #67 making rude statements and rushing them through care treatments. One of the residents reported CNA#67 had replied you're just trying to get a old black woman to wipe your ass after the resident had requested assistance with toileting. Another resident had reported CNA #67 had got mad and rude after needing to change the resident's sheets after urine had spilled from the bedpan. One resident reported CNA #67 would not help, because she said the resident is independent. This comment lead to the resident feeling uncomfortable. The corrective action form also states CNA#67 informing residents their call lights are not answered due to the building being short staffed. CNA#67 was placed on written warning with staff coaching/counseling. Review of a Corrective Action Form for CNA #67 dated 11/7/2024 revealed a termination for CNA #67 for professional conduct violation citing CNA#67 had unprofessional communication with resident #30 who had filed a grievance that CNA #67 was very rude to her. The grievance determined CNA #67 had demonstrated poor bedside manner and lacked empathy while providing care. The corrective action form states CNA #67 had been counseled twice about her communication with residents. The facility's abuse policy dated 2017, version 0319 states By definition, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, and mental abuse including facilitated or enabled through the use of technology. - Verbal Abuse includes but not limited to: yelling, screaming, cursing, bossing around/demanding, insulting, to race or ethnic group, intimidating.

Based on review of documentation, interviews and review of the facility policy, the facility failed to report alleged abuse for two residents (#5 and #30). The deficient practice could lead to continued abuse for residents. Findings include: - Resident #5 was admitted on [DATE] with a diagnosis of traumatic subdural hemorrhage without loss of consciousness, subsequent encounter, essential (primary) hypertension, acute pain due to trauma, gout, unspecified. Review of the care plan dated November 6, 2024, revealed that resident #5 was at risk for falls. An intervention included that the staff would anticipate and meet the residents needs and make sure the residents call light is within reach and encourage the resident to use it for assistance as needed. Additional interventions included; a psychosocial well -being problem related to admission and allow the resident time to answer questions and verbalize feelings, perceptions and fears. A grievance report was completed by resident #5 on November 8, 2024. It stated that resident #5 expressed CNA (Certified Nursing Assistant/ staff #67. The grievance report states the resident self-toiled per her preference and went back to bed and that at some point CAN #67 entered the room and answered the call light, assisted the resident with being scooted up in bed. Per the report the resident had reported CAN # 67 had entered the room abruptly and was throwing stuff on the floor to get to the resident to adjust in bed. The report also states resident #5 reporting CNA #67 was loud, but could not recall what was said. The report indicates the resident requested a nurse and also reported that her call light was out of reach. Review of the Minimum Data Set (MDS) assessment, dated November 11, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which revealed no cognitive impairment, no indicators for mood or behaviors. Further review of the MDS revealed resident required Setup or clean-up assistance with toileting hygiene, substantial/maximal assistance with lower body dressing. Supervision or touching assistance with roll left and right, sit to lying, sit to stand, toilet transfer, walk 10 feet. Resident required partial/moderate assistance with lying to sitting on side of bed. An interview was conducted with resident #5 on November 20, 2024 at 9:30 a.m. Resident #5 stated I had just arrived that day and was placed in the room with another resident. I had gone to the bathroom and went back bed after turning on the call light and waiting 15-20 minutes- I just couldn't wait any longer to go. It was about 2 in the morning- the other resident had turned on the call light. Resident #5 stated she was rude- yelling at me and standing over me saying I was supposed to have someone help me to the bathroom. I told her I couldn't wait any longer, that I had waited 15-20 minutes. Resident stated that CNA # 67 called her and resident #30 trouble makers and was arguing with them for no reason Resident #5 stated she was very angry-you could tell the way she was screaming- she said you wasted my time coming in here and told her well you want help so bad? and threw the call light under my bed. Resident #5 stated the nurse went in the room and asked what is going on because he could hear all the screaming and yelling in the hallway. Resident #5 stated CNA #67 was very agitated. I felt afraid, I felt unsafe and didn't know what was going to happen to me. Resident #5 stated the nurse asked staff #67 to leave the room and told residents #5 and #30 she would not return to their room. Resident #5 stated Executive Director (ED/Staff # 12) went in and completed a report and told her the matter was taken care of and asked her if she now felt safe. Resident #5 stated she felt safe when informed staff #67 would no longer a provide her care. - Resident #30 was admitted to the facility on [DATE] with a diagnosis of fracture of unspecified part of neck of right femur, subsequent encounter for closed fracture with routine healing, interstitial pulmonary disease, unspecified, chronic respiratory failure with hypoxia, unspecified fracture of upper end of right humerus, subsequent encounter for fracture with routine healing, need for assistance with personal care. Review of the MDS assessment, dated July 11, 2024, revealed a BIMS score of 15 which revealed no cognitive impairment. Review of the care plan dated July 19, 2024 revealed that resident #30 was at risk for pain. A grievance report was completed by resident #30 on November 8, 2024, involving an incident with staff #67 on November 7, 2024. It stated patient reported that on night of admission patient's roommate had put on her call light and that CNA#67 entered the room abruptly at approximately 0200 and that the CNA was loud and speaking loudly for the time of day while providing care for resident while in bed. The grievance report states resident could not verbalize what the CNA was saying other than than telling her to stop being an intrusion while care was being provided to resident #5. An interview was conducted with resident #30 on November 20, 2024 at 9:48 a.m. with resident #30. Resident #30 stated the following My roommate had just come into the room [ROOM NUMBER]-4 hours before and had not become acclimated to the staff before bedtime. she turned had turned on her light to go to the bathroom and no one came- so she took herself -she really had to go and couldn't wait. the aide finally got there - she had already gone back to bed and the aide woke us up with her screaming- inconsiderate of her time then started arguing that she was running her ragged. saying this to the other resident when I intervened- she was yelling at her and out of control- I told her that the lady had just arrived and didn't know nothing- CNA description- skinny AA-I think her name is [NAME] or [NAME] .has her hair twisted high on her head -she started arguing- blaming both of us for turning on the call light, we asked for the nurse- it was male nurse that came- I'm sure the whole building heard her-she said it was a wasted trip. we both asked that she not care for us anymore and that she not come into our room. The nurse put someone else on duty- she has not been back- It made me angry that she was verbally abusive to both of us. Management came and spoke to us the next day- the day after that a man came and spoke to us, he said he was the manager of the whole facility. I told him she used a very loud tone, that she was angry and out of control, she was flailing her arms- she got very close to the other resident, right in her face in a very intimidating way- towering over and screaming at her. I didn't notice if anything was done with her call light, I was worried about the way she towering over my roommate. she didn't scare me, but it looked like my roommate was and wanted to cry- My experience with her as an was that she was always rushing and did not want to do her work, especially at night- this all happened at night approximately 2-3 in the morning. I made a demand that she needed to be fired. I know what is right and what is wrong- I was a CNA before myself- you don't do what she did to people. On November 20, 2024 at 12:00p.m. resident #30 was informed that her allegations of verbal abuse had been reported to administration. Resident #30 stated they should have known that it was verbal abuse by everything I told them. I told them same thing I told you from the night things happened and how she yelled and screamed at me and [NAME] Review of SA database revealed that the allegation of abuse was not reported to the state agency within the required timeframe. On November 20, 2024 at 12: 07p.m Executive Director (ED/Staff # 12) and Director on Nursing (DON/Staff #33) brought in paperwork and asked if this surveyor would inform them what was said by the resident. Informed them they would need to complete their own investigation- (ED/Staff # 12) did state that the report was called in due to the online system being down. Both (ED/Staff # 12) and (DON/Staff #33) stated the prior complaints involving CNA staff #67 were taken as grievances and they did not feel what was reported by the residents, as reportable verbal abuse and failed to report the verbal abuse. Each of the three prior complaints involved the same staff member for allegations of verbal abuse. The facility's abuse policy dated 2017, version 0319 states By definition, abuse is the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, and mental abuse including facilitated or enabled through the use of technology. - Verbal Abuse includes but not limited to: yelling, screaming, cursing, bossing around/demanding, insulting, to race or ethnic group, intimidating.

Based on review of documentation, interviews and review of the facility policy, the facility failed to ensure 3 residents ( #456, #457 and #458) were not abused from one staff member. The deficient practice could lead residents to suffer from psychosocial harm. Findings include: - Resident #456 was admitted on [DATE] with a diagnosis of displaced intertrochanteric fracture of the right femur, chronic systolic heart failure, anxiety disorder, depression, acute pain due to trauma and tachycardia. Review of the Minimum Data Set (MDS) assessment, dated April 4, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which revealed no cognitive impairment. Review of the care plan dated April 4, 2024, revealed that resident #456 was dependent on staff for care. An intervention included that the staff would converse with him while providing care. Review of the care plan dated April 11, 2024 revealed resident #456 was resistive to care. The goal was to demonstrate effective coping skills and encouraging him to participate as much as possible in his care. A grievance report was completed by resident #456 on May 22, 2024. It stated that resident #456 expressed CNA (Certified Nursing Assistant/ staff #42) was not qualified for her job and staff #42 told resident #456 I am 55 and I am not picking you up. - Resident #457 was admitted to the facility on [DATE] with a diagnosis of acute cystitis, , anxiety disorder and depression and during her stay developed a urinary tract infection. Review of the MDS assessment, dated July 11, 2024, revealed a BIMS score of 13 which revealed no cognitive impairment. A grievance report was completed by resident #457 on July 16, 2024, involving an incident with staff #42 on July 15, 2024. It stated Resident told day shift CNA that NOC (night shift) shift CNA, staff #42, got upset and was rude to patient about having to replace bed sheets after urine spilled on them from using the bed pan. Staff #42 was not assigned to resident #457 again. Review of the nursing progress note, dated July 16, 2024 at 12:38 PM stated that the resident #457 had some care issues the night before. Review of the care plan dated July 19, 2024 revealed that resident #457 was dependent on staff for care. - Resident #458 was admitted to the facility on [DATE] with a diagnosis of wedge compression fracture of first lumbar vertebra, enterocolitis due to clostridium difficile, urinary tract infection and orthostatic hypertension. Review of the MDS assessment dated , June 24, 2024 revealed a BIMS score of 14 which revealed no cognitive impairment. Further review revealed the resident required supervision or touching assistance with toileting and hygiene. Review of the care plan, dated June 27, 2024 revealed that resident #458 was a fall risk, had weakness, was unsteady on his feet and was dependent on staff. A grievance report was completed by resident #458 on July 30, 2024, involving an incident with staff #42. The report included resident #458 statement which stated that the CNA (staff #42) was very rude to the resident after he asked for assistance with wiping his bottom after toileting. The statement stated resident #458 struggled with wiping himself due to broken back that required him to wear a TLSO (thoracolumbar sacral orthosis) brace, which made it difficult to twist. The statement further stated, due to his orthostatic hypotension, he gets very dizzy and was scared of passing out or falling. The statement included that the CNA (staff #42) told resident #458 you're just trying to get an old black woman to wipe your ass. An interview was conducted on October 9, 2024 at 10:44 AM with Staff #18, Resident Relations Manager. She stated she was the person who spoke with residents #456, #457, and #458 in regard to the grievances against staff #42. These incidents were brought to the attention of the Director of Nursing (DON, staff #28). It was verified from staff #18 that staff #42 was written up on October 1, 2024. Review of the Corrective Action Form revealed a fourth resident had complained about staff #42 which stated staff #42 would not help because resident was independent. The form also stated that the comment lead to resident feeling uncomfortable. Further review of the Corrective Action Form revealed that staff #42 was counseled, however she refused to sign the form. An interview was conducted on October 9, 2024 with CNA, staff #43 who stated that abuse include resident not being covered up, not being changed and verbal abuse. Staff #43 stated it is 100% abuse when the staff member says you just want me to come in and wipe your ass? to any resident. An interview was conducted on October 9, 2024 at 1:06 PM with Licensed Practical Nurse (LPN, staff #40). Staff #40 stated that it is verbal abuse when the staff member says you just want me to come in and wipe your ass? to any resident. An interview was conducted on October 9, 2024 at 1:11 PM with DON (staff #28). Staff #28 stated that it is a lack of customer service and poor communication and incredibly rude when the staff member says you just want me to come in and wipe your ass? to any resident. Staff #28 stated that it was abuse only if the resident said they felt uncomfortable. When staff #28 was asked if she felt these incidents should have been reported, she stated No, only if it was stated they were uncomfortable should it have been reported. The facility's abuse policy dated 2022, version 0622 states By definition, abuse is the infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish. It includes verbal abuse, sexual abuse, physical abuse, neglect, mental abuse including facilitated or enabled through the use of technology, and misappropriation of property.

Based on review of documentation, interviews and review of the facility policy, the facility failed to ensure the policy for abuse was implemented for 3 residents (#456, #457 and #458). The deficient practice could lead residents to suffer from psychosocial harm and further abuse of more residents from staff member. Findings include: - Resident #456 was admitted on [DATE] with a diagnosis of displaced intertrochanteric fracture of the right femur, chronic systolic heart failure, anxiety disorder, depression, acute pain due to trauma and tachycardia. Review of the Minimum Data Set (MDS) assessment, dated April 4, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which revealed no cognitive impairment. Review of the care plan dated April 4, 2024, revealed that resident #456 was dependent on staff for care. An intervention included that the staff would converse with him while providing care. Review of the care plan dated April 11, 2024 revealed resident #456 was resistive to care. The goal was to demonstrate effective coping skills and encouraging him to participate as much as possible in his care. A grievance report was completed by resident #456 on May 22, 2024. It stated that resident #456 expressed CNA (Certified Nursing Assistant/ staff #42) was not qualified for her job and staff #42 told resident #456 I am 55 and I am not picking you up. - Resident #457 was admitted to the facility on [DATE] with a diagnosis of acute cystitis, , anxiety disorder and depression and during her stay developed a urinary tract infection. Review of the MDS assessment, dated July 11, 2024, revealed a BIMS score of 13 which revealed no cognitive impairment. A grievance report was completed by resident #457 on July 16, 2024, involving an incident with staff #42 on July 15, 2024. It stated Resident told day shift CNA that NOC (night shift) shift CNA, staff #42, got upset and was rude to patient about having to replace bed sheets after urine spilled on them from using the bed pan. Staff #42 was not assigned to resident #457 again. Review of the nursing progress note, dated July 16, 2024 at 12:38 PM stated that the resident #457 had some care issues the night before. Review of the care plan dated July 19, 2024 revealed that resident #457 was dependent on staff for care. - Resident #458 was admitted to the facility on [DATE] with a diagnosis of wedge compression fracture of first lumbar vertebra, enterocolitis due to clostridium difficile, urinary tract infection and orthostatic hypertension. Review of the MDS assessment dated , June 24, 2024 revealed a BIMS score of 14 which revealed no cognitive impairment. Further review revealed the resident required supervision or touching assistance with toileting and hygiene. Review of the care plan, dated June 27, 2024 revealed that resident #458 was a fall risk, had weakness, was unsteady on his feet and was dependent on staff. A grievance report was completed by resident #458 on July 30, 2024, involving an incident with staff #42. The report included resident #458 statement which stated that the CNA (staff #42) was very rude to the resident after he asked for assistance with wiping his bottom after toileting. The statement stated resident #458 struggled with wiping himself due to broken back that required him to wear a TLSO (thoracolumbar sacral orthosis) brace, which made it difficult to twist. The statement further stated, due to his orthostatic hypotension, he gets very dizzy and was scared of passing out or falling. The statement included that the CNA (staff #42) told resident #458 you're just trying to get an old black woman to wipe your ass. The report stated resident #458 did not want staff #42. An interview was conducted on October 9, 2024 at 10:44 AM with Staff #18, Resident Relations Manager. She stated she was the person who spoke with residents #456, #457, and #458 in regard to the grievances against staff #42. These incidents were brought to the attention of the Director of Nursing (DON, staff #28). It was verified from staff #18 that staff #42 was written up on October 1, 2024. Review of the Corrective Action Form revealed a fourth resident had complained about staff #42 which stated staff #42 would not help because resident was independent. The form also stated that the comment lead to resident feeling uncomfortable. Further review of the Corrective Action Form revealed that staff #42 was counseled, however she refused to sign the form. Review of the facility documentation revealed that the incident with staff #42 were not reported nor thoroughly investigated. An interview was conducted on October 9, 2024 with CNA, staff #43 who stated that abuse include resident not being covered up, not being changed and verbal abuse. Staff #43 stated it is 100% abuse when the staff member says you just want me to come in and wipe your ass? to any resident. An interview was conducted on October 9, 2024 at 1:06 PM with Licensed Practical Nurse (LPN, staff #40). Staff #40 stated that it is verbal abuse when the staff member says you just want me to come in and wipe your ass? to any resident. An interview was conducted on October 9, 2024 at 1:11 PM with DON (staff #28). Staff #28 stated that it is a lack of customer service and poor communication and incredibly rude when the staff member says you just want me to come in and wipe your ass? to any resident. Staff #28 stated that it was abuse only if the resident said they felt uncomfortable. When staff #28 was asked if she felt these incidents should have been reported, she stated No, only if it was stated they were uncomfortable should it have been reported. The facility's policy on abuse dated 2022, version 0622 states If abuse is witnessed or suspected, reporting and investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who is reporting will notify the following entities: A. Adult Protective Services B. Ombudsman C. State Survey Agency D. Law enforcement when applicable E. Facility Director of Nursing (DON) 3. DON will notify the following: A. Physician B. Responsible le Party C. VP of Clinical Operations 4. ED will begin investigation immediately and complete within 5 working days using the Abuse Investigation Packet. A minimum of three residents will be interviewed in order to determine if there is a trend. Interviews may also include the Alleged Perpetrator, Witnesses and Staff Members as applicable. 5. Suspected abuse will be reported in accordance with timeframe's and standards required by CMS. 6. If the alleged perpetrator is an employee, they will be immediately suspended pending the results of the investigation. 7. The resident suspected of being abused will be monitored and placed on alert charting. 8. When the investigation is complete, the ED will submit a summary to the entities in #2. 9. All abuse investigation information will be documented and logged according to facility protocol.

Based on review of documentation, interviews and review of the facility policy, the facility failed to report alleged violations of abuse for resident's (#456, #457 and #458) . The deficient practice could lead to further abuse of residents from staff member. Findings include: - Resident #456 was admitted on [DATE] with a diagnosis of displaced intertrochanteric fracture of the right femur, chronic systolic heart failure, anxiety disorder, depression, acute pain due to trauma and tachycardia. Review of the Minimum Data Set (MDS) assessment, dated April 4, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which revealed no cognitive impairment. Review of the care plan dated April 4, 2024, revealed that resident #456 was dependent on staff for care. An intervention included that the staff would converse with him while providing care. Review of the care plan dated April 11, 2024 revealed resident #456 was resistive to care. The goal was to demonstrate effective coping skills and encouraging him to participate as much as possible in his care. A grievance report was completed by resident #456 on May 22, 2024. It stated that resident #456 expressed CNA (Certified Nursing Assistant/ staff #42) was not qualified for her job and staff #42 told resident #456 I am 55 and I am not picking you up. - Resident #457 was admitted to the facility on [DATE] with a diagnosis of acute cystitis, , anxiety disorder and depression and during her stay developed a urinary tract infection. Review of the MDS assessment, dated July 11, 2024, revealed a BIMS score of 13 which revealed no cognitive impairment. A grievance report was completed by resident #457 on July 16, 2024, involving an incident with staff #42 on July 15, 2024. It stated Resident told day shift CNA that NOC (night shift) shift CNA, staff #42, got upset and was rude to patient about having to replace bed sheets after urine spilled on them from using the bed pan. Staff #42 was not assigned to resident #457 again. Review of the nursing progress note, dated July 16, 2024 at 12:38 PM stated that the resident #457 had some care issues the night before. Review of the care plan dated July 19, 2024 revealed that resident #457 was dependent on staff for care. - Resident #458 was admitted to the facility on [DATE] with a diagnosis of wedge compression fracture of first lumbar vertebra, enterocolitis due to clostridium difficile, urinary tract infection and orthostatic hypertension. Review of the MDS assessment dated , June 24, 2024 revealed a BIMS score of 14 which revealed no cognitive impairment. Further review revealed the resident required supervision or touching assistance with toileting and hygiene. Review of the care plan, dated June 27, 2024 revealed that resident #458 was a fall risk, had weakness, was unsteady on his feet and was dependent on staff. A grievance report was completed by resident #458 on July 30, 2024, involving an incident with staff #42. The report included resident #458 statement which stated that the CNA (staff #42) was very rude to the resident after he asked for assistance with wiping his bottom after toileting. The statement stated resident #458 struggled with wiping himself due to broken back that required him to wear a TLSO (thoracolumbar sacral orthosis) brace, which made it difficult to twist. The statement further stated, due to his orthostatic hypotension, he gets very dizzy and was scared of passing out or falling. The statement included that the CNA (staff #42) told resident #458 you're just trying to get an old black woman to wipe your ass. The report stated resident #458 did not want staff #42. An interview was conducted on October 9, 2024 at 10:44 AM with Staff #18, Resident Relations Manager. She stated she was the person who spoke with residents #456, #457, and #458 in regard to the grievances against staff #42. These incidents were brought to the attention of the Director of Nursing (DON, staff #28). It was verified from staff #18 that staff #42 was written up on October 1, 2024. Review of the Corrective Action Form revealed a fourth resident had complained about staff #42 which stated staff #42 would not help because resident was independent. The form also stated that the comment lead to resident feeling uncomfortable. Further review of the Corrective Action Form revealed that staff #42 was counseled, however she refused to sign the form. Review of the facility documentation revealed that all the mentioned incidents with staff #42 were not reported. An interview was conducted on October 9, 2024 with CNA, staff #43 who stated that abuse include resident not being covered up, not being changed and verbal abuse. Staff #43 stated it is 100% abuse when the staff member says you just want me to come in and wipe your ass? to any resident. An interview was conducted on October 9, 2024 at 1:06 PM with Licensed Practical Nurse (LPN, staff #40). Staff #40 stated that it is verbal abuse when the staff member says you just want me to come in and wipe your ass? to any resident. An interview was conducted on October 9, 2024 at 1:11 PM with DON (staff #28). Staff #28 stated that it is a lack of customer service and poor communication and incredibly rude when the staff member says you just want me to come in and wipe your ass? to any resident. Staff #28 stated that it was abuse only if the resident said they felt uncomfortable. When staff #28 was asked if she felt these incidents should have been reported, she stated No, only if it was stated they were uncomfortable should it have been reported. The facility's policy on abuse dated 2022, version 0622 states If abuse is witnessed or suspected, reporting and investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who is reporting will notify the following entities: A. Adult Protective Services B. Ombudsman C. State Survey Agency D. Law enforcement when applicable E. Facility Director of Nursing (DON) 3. DON will notify the following: A. Physician B. Responsible le Party C. VP of Clinical Operations 4. ED will begin investigation immediately and complete within 5 working days using the Abuse Investigation Packet. A minimum of three residents will be interviewed in order to determine if there is a trend. Interviews may also include the Alleged Perpetrator, Witnesses and Staff Members as applicable. 5. Suspected abuse will be reported in accordance with timeframe's and standards required by CMS. 6. If the alleged perpetrator is an employee, they will be immediately suspended pending the results of the investigation. 7. The resident suspected of being abused will be monitored and placed on alert charting. 8. When the investigation is complete, the ED will submit a summary to the entities in #2. 9. All abuse investigation information will be documented and logged according to facility protocol.

Based on review of documentation, interviews and review of the facility policy, the facility failed to investigate and correct alleged violations of abuse for resident's (#456, #457 and #458) from one staff member (staff #42). The deficient practice could lead residents to suffer from psychosocial harm and further abuse of residents. Findings include: - Resident #456 was admitted on [DATE] with a diagnosis of displaced intertrochanteric fracture of the right femur, chronic systolic heart failure, anxiety disorder, depression, acute pain due to trauma and tachycardia. Review of the Minimum Data Set (MDS) assessment, dated April 4, 2024, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, which revealed no cognitive impairment. Review of the care plan dated April 4, 2024, revealed that resident #456 was dependent on staff for care. An intervention included that the staff would converse with him while providing care. Review of the care plan dated April 11, 2024 revealed resident #456 was resistive to care. The goal was to demonstrate effective coping skills and encouraging him to participate as much as possible in his care. A grievance report was completed by resident #456 on May 22, 2024. It stated that resident #456 expressed CNA (Certified Nursing Assistant/ staff #42) was not qualified for her job and staff #42 told resident #456 I am 55 and I am not picking you up. - Resident #457 was admitted to the facility on [DATE] with a diagnosis of acute cystitis, , anxiety disorder and depression and during her stay developed a urinary tract infection. Review of the MDS assessment, dated July 11, 2024, revealed a BIMS score of 13 which revealed no cognitive impairment. A grievance report was completed by resident #457 on July 16, 2024, involving an incident with staff #42 on July 15, 2024. It stated Resident told day shift CNA that NOC (night shift) shift CNA, staff #42, got upset and was rude to patient about having to replace bed sheets after urine spilled on them from using the bed pan. Staff #42 was not assigned to resident #457 again. Review of the nursing progress note, dated July 16, 2024 at 12:38 PM stated that the resident #457 had some care issues the night before. Review of the care plan dated July 19, 2024 revealed that resident #457 was dependent on staff for care. - Resident #458 was admitted to the facility on [DATE] with a diagnosis of wedge compression fracture of first lumbar vertebra, enterocolitis due to clostridium difficile, urinary tract infection and orthostatic hypertension. Review of the MDS assessment dated , June 24, 2024 revealed a BIMS score of 14 which revealed no cognitive impairment. Further review revealed the resident required supervision or touching assistance with toileting and hygiene. Review of the care plan, dated June 27, 2024 revealed that resident #458 was a fall risk, had weakness, was unsteady on his feet and was dependent on staff. A grievance report was completed by resident #458 on July 30, 2024, involving an incident with staff #42. The report included resident #458 statement which stated that the CNA (staff #42) was very rude to the resident after he asked for assistance with wiping his bottom after toileting. The statement stated resident #458 struggled with wiping himself due to broken back that required him to wear a TLSO (thoracolumbar sacral orthosis) brace, which made it difficult to twist. The statement further stated, due to his orthostatic hypotension, he gets very dizzy and was scared of passing out or falling. The statement included that the CNA (staff #42) told resident #458 you're just trying to get an old black woman to wipe your ass. The report stated resident #458 did not want staff #42. An interview was conducted on October 9, 2024 at 10:44 AM with Staff #18, Resident Relations Manager. She stated she was the person who spoke with residents #456, #457, and #458 in regard to the grievances against staff #42. These incidents were brought to the attention of the Director of Nursing (DON, staff #28). It was verified from staff #18 that staff #42 was written up on October 1, 2024. Review of the Corrective Action Form revealed a fourth resident had complained about staff #42 which stated staff #42 would not help because resident was independent. The form also stated that the comment lead to resident feeling uncomfortable. Further review of the Corrective Action Form revealed that staff #42 was counseled, however she refused to sign the form. Review of the facility documentation revealed that all the mentioned incidents with staff #42 were not reported. Further, the facility was unable to provide any documentation that the above incidents were investigated at the time they occurred. An interview was conducted on October 9, 2024 with CNA, staff #43 who stated that abuse include resident not being covered up, not being changed and verbal abuse. Staff #43 stated it is 100% abuse when the staff member says you just want me to come in and wipe your ass? to any resident. An interview was conducted on October 9, 2024 at 1:06 PM with Licensed Practical Nurse (LPN, staff #40). Staff #40 stated that it is verbal abuse when the staff member says you just want me to come in and wipe your ass? to any resident. An interview was conducted on October 9, 2024 at 1:11 PM with DON (staff #28). Staff #28 stated that it is a lack of customer service and poor communication and incredibly rude when the staff member says you just want me to come in and wipe your ass? to any resident. Staff #28 stated that it was abuse only if the resident said they felt uncomfortable. When staff #28 was asked if she felt these incidents should have been reported, she stated No, only if it was stated they were uncomfortable should it have been reported. The facility's policy on abuse dated 2022, version 0622 states If abuse is witnessed or suspected, reporting and investigation will take place in this manner: 1. Executive Director (ED) will be notified. 2. ED and witness who is reporting will notify the following entities: A. Adult Protective Services B. Ombudsman C. State Survey Agency D. Law enforcement when applicable E. Facility Director of Nursing (DON) 3. DON will notify the following: A. Physician B. Responsible le Party C. VP of Clinical Operations 4. ED will begin investigation immediately and complete within 5 working days using the Abuse Investigation Packet. A minimum of three residents will be interviewed in order to determine if there is a trend. Interviews may also include the Alleged Perpetrator, Witnesses and Staff Members as applicable. 5. Suspected abuse will be reported in accordance with timeframe's and standards required by CMS. 6. If the alleged perpetrator is an employee, they will be immediately suspended pending the results of the investigation. 7. The resident suspected of being abused will be monitored and placed on alert charting. 8. When the investigation is complete, the ED will submit a summary to the entities in #2. 9. All abuse investigation information will be documented and logged according to facility protocol.

Based on clinical record review, staff interviews, and policy reviews, the facility failed to ensure three of four sampled residents (#14, #4, #40) were administered scheduled pain medication in accordance with the physician order. The deficient practice could result in residents' pain not being adequately controlled. Findings Include: -Regarding Resident #14: Resident #14 was initially admitted on [DATE] with diagnoses that included COPD, displaced fracture of 5th cervical vertebra, major depressive disorder, and insomnia. A care plan initiated on July 16, 2021 revealed that the resident has chronic pain and takes an opioid and non-opioid analgesic related to chronic pain of the bilateral lower extremities. Interventions that were initiated on March 4, 2021, indicated to administer analgesia medication as per orders. Physician orders revealed the following: -Dated April 5, 2022: Oxycodone HCl Tablet 15 mg (milligram), give 15 mg by mouth (PO) every 4 hours as needed for pain level 4-10 out of 10. -Dated July 10, 2024: Opioid Use: Monitor for constipation, signs/symptoms of delirium/over sedation, change in mental status, and reduced respirations every shift for opioid usage. Review of an Annual Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview of Mental Status (BIMS) score of 15, indicating intact cognition. The assessment also revealed that the resident received pain medications (PRN) as needed, had frequent pain and received opioids. Review of the Medication Administration Record (MAR) dated September 2024, revealed evidence that Oxycodone had been administered for pain levels of 0, which were outside of the provider orders on the following dates: -9/23/2024 at 20:02PM. -9/24/2024 at 1915 PM. -9/25/2024 at 1930 PM. -9/26/2024 at 1942 PM. -9/27/2024 at 1819 PM. -9/30/2024 at 1850 PM. Further review of the clinical record revealed no evidence that the provider had been notified that Oxycodone had been administered outside of parameters on those dates. Continued review of the clinical record revealed no evidence of post administration pain assessments on the above dates. Review of the MAR, dated October 2024, revealed evidence that Oxycodone had been administered for pain levels less than 4, which were outside of the provider orders: -October 2, 2024 at 19:20 PM: pain level 0 -October 5, 2024 at 19:30 PM: pain level 2 Review of the clinical record on October 2, and October 5, 2024, revealed no evidence that the provider had been notified regarding administration of Oxycodone outside of parameters. Further review of the clinical record on October 2, and October 5, 2024, revealed no evidence of post administration pain assessments. An interview was conducted on October 09, 2024 at 12:00 PM with a Licensed Practical Nurse (LPN/staff #40), who stated that she expected nurses to follow physician orders as written including any parameters. She stated that when administering oxycodone, nurses assess the resident's pain levels prior to, and 30-60 minutes after administering the medication, and document the results in a progress note. The LPN also stated that when a resident requests oxycodone outside of parameters the LPN would notify the provider and document in a progress note. The LPN also stated that Resident #14 is alert and is able to make his needs known regarding pain and pain medication, and he typically requests it in the morning and at night. The LPN reviewed the clinical record and stated that there was an order for Oxycodone to be administered every 4 hours as needed for a pain level of 4-10, PRN. She also stated that Oxycodone should not be administered for a pain level less than 4 as written in the provider orders, and that the resident had an order for Tylenol for pain levels of 1-3. The LPN reviewed the October 2024 MAR and stated that Oxycodone had been administered for pain level of 0 on October 2, 2024, and for a pain level of 2 on October 5, 2024, and that the Oxycodone had been administered outside of physician ordered parameters. She further stated that there was no evidence in the progress notes of pain follow up within the hour after administration, or that the provider had been notified. The LPN reviewed the September 2024 MAR and stated that Oxycodone had been administered for a pain level of 0 on 6 occasions, and that this did not follow the providers orders, and there was no evidence in the clinical record that the provider had been notified. She further stated that there was no evidence that a post-administration pain assessment had been completed an hour after the medication had been administered. The LPN further stated that this did not meet the facility process, and that the risk of administering oxycodone outside of the ordered parameters could result in over medication, make it difficult to determine if the medication is effective, and the provider would not be aware if the patient required a new medication order. An interview was conducted on October 9, 2024 at 03:09 PM with the Director of Nursing (DON/staff #28), who stated that she expected medications to be administered as written in the provider orders, including parameters. She also stated that the provider should be notified prior to any medication being administered outside of parameters, and the call should be documented in a progress note. The DON reviewed the clinical record and stated that there was an order for Oxycodone 15 mg to be administered every 4 hours, PRN for a pain level of 4-10 out of 10 (4-10/10). She also stated that she expected that the provider would have been notified for medication administration outside of the parameters. She reviewed the October 2024 MAR and stated that Oxycodone had been administered outside of the ordered parameters on October 2, 2024 and October 5, 2024, and there was no evidence in the clinical record that the provider had been notified. The DON reviewed the September 2024 MAR and stated that there were six occasions that Oxycodone had been administered for a pain level of 0, and that this did not meet the provider orders. She also stated that there was no evidence that the provider had been notified, or that a post-administration pain assessment had been completed. The DON further stated that this did not meet her expectation regarding Oxycodone administration. The DON stated that the risk of administering Oxycodone outside of provider orders could result in the physician not being aware that the patient was receiving medication outside of the parameters. -Regarding Resident #4 Resident #4 was admitted on [DATE] with diagnoses that included opioid dependence, cerebral infarction, post-traumatic stress disorder, major depressive disorder, depression, anxiety disorder, and history of transient ischemic attack (TIA). An Initial Care Plan dated September 13, 2024 with a focus of opiate medication included an intervention to administer medication as ordered. A 5-day Medicare Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 09, which indicated moderate cognitive impairment. The assessment included that the resident had almost constant pain, that interfered with sleep and day-to-day activities. Provider orders revealed the following: - Roxicodone Oral (Oxycodone HCl) tablet 5 mg (milligram), give 1 tablet by mouth every 4 hours as needed (PRN) for pain 1-10/10, dated September 13, 2024, discontinued September 15, 2024. - Roxicodone Oral (Oxycodone HCl) Tablet 5 mg, give 2 tablets by mouth every 4 hours PRN for pain 6-10/10, dated September 15, 2024 and discontinued on October 1, 2024. Review of the September 2024 MAR revealed evidence that Roxicodone 5mg tablet had been administered outside of the ordered parameters for a pain level of 0 on 24 occasions during the month. Review of progress notes revealed no evidence that the provider had been notified that Roxicodone had been administered outside of parameters on 22 of the 24 occasions that the medication had been administered outside of parameters. Further review of provider orders dated October 1, 2024, revealed an order for Oxycodone HCl oral tablet 15 mg, give by mouth every 4 hours PRN for pain level 5 - 10. Review of October 2024 MAR revealed the following administration of Oxycodone 15 mg tablets outside of the ordered parameters: -Pain level of 0, three times, on October 2, October 3, and October 4, 2024. -Pain level of 3, one time, on October 3, 2024. Further review of the October 2024 MAR revealed the following administration of Roxicodone 5 mg tablets outside of the ordered parameters: -Pain level of 0 on October 1, 2024 at 01:36 AM and 05:27 AM. Review of the clinical record revealed no evidence that the provider had been notified that Oxycodone or Roxicodone had been administered outside of parameters in October 2024. An interview was conducted on October 10, 2024 at 09:30 AM, with an LPN (staff #64), who stated that the facility expectation is to follow provider orders as written, including parameters. She also stated when a medication is administered outside of parameters the provider should be notified, and the contact should be documented in progress notes. The LPN stated that Resident #4 has considerable pain and requests pain medication every 4 hours. The LPN reviewed the clinical record and confirmed the provider orders for Oxycodone dated 10/2/2024, for 15 mg every 4 hours as needed for a pain level of 5-10. She reviewed the October 2024 MAR and stated that Oxycodone had been administered outside of parameters on 4 occasions. She further stated that there was no evidence in the clinical record that the provider had been notified on any of the 4 occasions Oxycodone had been administered outside of parameters. The LPN further reviewed the clinical record and stated there were provider orders for Roxicodone 5mg tablet, every 4 hours for pain 6-10/10, ordered on September 15, 2024 and discontinued on October 1, 2024. She reviewed the September 2024 and October 2024 MAR and stated that Roxicodone had been administered outside of parameters for a pain level of 0 on 2 occasions in October, and for a pain level of 0 in September on 24 occasions. She further stated that there was no evidence in the clinical record that the provider had been notified regarding administration of Roxicodone outside of parameters during October or during September for 22 of the 24 times that the medication had been administered outside of parameters. The LPN stated that Roxicodone and Oxycodone had not been administered following provider orders. She further stated that the risk of administering Oxycodone/Roxicodone outside of the ordered parameters could result in lethargy, and in this resident's case, it could exacerbate an opioid dependence. An interview was conducted on October 10, 2024 at 10:07 AM with the DON (staff #28), who stated that Oxycodone had been ordered to be administered for a pain level of 5-10. She reviewed the October 2024 MAR and stated that Oxycodone had been administered outside of parameters, for a pain level of 0 on 4 occasions, and that this did not meet the policy for medication administration. She also reviewed the clinical record and stated that there was no evidence that the provider had been notified. The DON stated that the resident had an order for Roxicodone to be administered for pain level of 6-10/10. She reviewed the October 2024 MAR and stated that Roxicodone had been administered outside of parameters twice in October for a pain level of 0. The DON reviewed the September 2024 MAR and stated that there was evidence that Roxicodone had been administered outside of the provider ordered parameters on 24 occasions in September, and there was no evidence in the clinical record that the provider had been notified on 22 of the 24 occasions. The DON also stated that the resident had a diagnosis of opioid dependence, and the risk could result in not following provider orders, or communicating with the provider. The DON further stated that she spoke with the nurse that administered most of the medications and that he was not documenting correctly. She further stated that he was not documenting the actual pain level at the time the medication had been administered, but was instead documenting the follow-up pain level. The DON stated that the nurse had been trained on how to administer medications, and trained with several nurses for a couple of weeks during orientation. She also stated that during orientation staff are educated on MAR documentation process. 51103 Regarding Resident #40: Resident # 40 was admitted on [DATE] with diagnoses that included acute osteomyelitis, polyneuropathy, heart failure, hypertension, and Type 2 Diabetes Mellitus. A review of the physician's orders dated 9/23/24 called for a pain evaluation to be conducted every shift for Pain Scale 0-10. A review of resident's Medication Administration Record (MAR) revealed an order dated 9/23/24 for an Oxycodone 10 mg tablet to be given by mouth every six hours as needed for a pain level of 7-10. The MAR also revealed an order dated 9/23/24 for an Oxycodone 5 mg tablet to be given every 6 hours as needed for pain level of 4-6. A review of the resident's care plan initiated on 9/23/24 acknowledged resident use of opioids for pain control. Care plan intervention included the administration of analgesia medication as per orders. A review of resident's pain graph from 9/24/24 to 10/1/24 quantified resident pain level as 0, every day except 9/28/24 at 22:47, where the resident reached a level of 8 on a scale of 0-10. Further review of the MAR revealed a tablet of Oxycodone 10 mg was given on 9/27/24 at 20:57, and additionally at 9/30/24 at 21:40 by Registered Nurse (RN)/Staff #22 with a recorded resident pain level of 0. A review of resident's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which suggested resident was cognitively intact. The MDS further recorded the resident's highest pain over the last 5 days was an 8, and also stated that pain occasionally limited the resident's day to day activities. A review of resident's Medication Record Review dated 9/30/24, stated to monitor pain, efficacy, and opioid-related side effects related to oxycodone use. Review of a Nurse Practitioner (NP) progress note dated 10/9/24 at 8:26 am, stated the resident was informed about the risk of opioid medications. It further stated the goal for resident was to discontinue opioid use within the next 7-10 days. Review of the Prescriber's Arizona Medical Board record dated 10/10/24 revealed the provider's specialty as Pain Medicine, with an active license status due to renew 3/23/25. In an interview conducted 10/10/24 at 9:10 am with Certified Nurse Assistant (CNA) /Staff #61, stated that is the responsibility of the CNA to immediately report to the nurse if a resident verbally or physically is showing signs of pain. CNA further voiced an additional responsibility was to ensure that resident was as comfortable as possible. In an interview conducted October 10, 2024 at 9:18 am with Registered Nurse (RN) /Staff # 26 revealed that if opioid administration is dependent upon the resident pain level, the medication should be withheld if pain level is outside of the ordered parameter. On October 10, 2024 at 9:22 am, the Director of Nursing (DON)/Staff #28 reviewed the resident MAR for September 2024. The DON identified two incidents of Oxycodone administered to the resident, when recorded pain level was recorded as a zero. The DON acknowledged that the medication should not have been given outside of the ordered parameter. DON attributed a precipitating factor for the misadministration was nurse's new graduate status. DON stated she has already re-educated the nurse on the proper administration of medications within parameter. According to policy titled Administering Oral Medications, the nurses are required to perform any pre-administration assessments, and to check, and recheck to confirm proper medication dose. The facility policy titled, Pain Management: Pain Assessment and Management, revealed that the medication regimen is implemented as ordered, results of the interventions are documented and communicated directly to the provider when appropriate. Ongoing communication between the prescriber and the staff is necessary for the optimal and judicious use of pan medications. Document the resident's pain level with adequate detail, record the information in the resident's medical record.

Based on an observation, clinical record review, interviews, facility documentation and policies, and review of the State Agency (SA) database, the facility failed to ensure one resident (#1) was not abused by two Certified Nursing Assistants (CNAs/staff #49 and staff #20). The sample size was 4 residents. The deficient practice could result in further resident abuse. Findings include: Resident #1 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the resident's care plans, initiated on [DATE], revealed the following focus areas: -Activities of Daily Living (ADL) included that the resident had a self-care performance deficit related to limited mobility. An intervention included that the resident required one staff member to participate to use the toilet, bathing, personal hygiene/oral care, dressing, and for repositioning/turning in bed. -Bladder incontinence related to limited mobility. Interventions included checking the resident every ,d+[DATE] hours and as needed for incontinence, and wash, rinse, and dry the perineum and change clothing as needed after incontinence episodes. -Bowel incontinence related limited mobility. Interventions included to check the resident every 2 hours and assist with toileting as needed and to provide pericare after each incontinent episode. An admission Minimum Data Set (MDS) assessment dated [DATE] included a Brief Interview for Mental Status (BIMS) score of 11 indicating moderate cognitive impairment. The assessment included that the resident did not have inattention, disorganized thinking, or an altered level of consciousness. The assessment included that the resident had feelings of being down, depressed, or hopelessness. No behaviors were documented. The assessment included that the resident required extensive one to two person physical assistance with bed mobility, dressing, toilet use, and personal hygiene. The assessment did not include diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan, initiated on [DATE], for impaired cognitive function included a goal that the resident would maintain her current level of cognitive function. The intervention for that goal included administering medications as ordered and to monitor/document/report any changes in cognitive function. A diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . An initial psychiatric evaluation dated [DATE] included that the resident was seen for anxiety, depression, and opioid dependence. The evaluation included that the resident reported that her mood was stable except for being disturbed by itching of her skin. The evaluation included that the resident reported that she was doing well with no depressive symptoms or excessive worries. The evaluation included that the resident denied any [CONDITION(S)], [CONDITION(S)] symptoms, Post Traumatic Stress Disorder ([CONDITION(S)]), or suicide attempts. The evaluation included that the resident was calm, pleasant, and cooperative with no acute distress and she was orientated to person, place, and time. The evaluation included that the resident's speech was normal, her mood was untroubled, her affect was appropriate, and her thought process was organized. The evaluation included that the resident had recurrent major depressive disorder that was in remission status. A follow up psychiatric evaluation dated [DATE] included that the resident was not on [CONDITION(S)] medications and felt that none were needed at this time. The evaluation included that the resident was calm, pleasant, and cooperative with no acute distress and was orientated to person, place, and time. The evaluation included that the resident had recurrent major depressive disorder that was in remission status. A review of care documentation for June through [DATE] and January through February 2022 revealed the following: -A CNA (staff #20) assisted the resident with toilet use and personal hygiene care 7 times in June, 7 times in July, 2 times in August, 0 times in September, 1 time in November, 0 times in December, 0 times in January, and 0 times in February. -Another CNA (staff #49) assisted the resident with toilet use and personal hygiene care 3 times in July, 9 times in August, 9 times in September, 19 times in November, and 6 times in December. The staff member was no longer working in the facility after [DATE]. -Documentation for [DATE] was not available and when requested, not provided by the facility. The diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . On [DATE], a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] An anxiety care plan, initiated on [DATE], noted that the resident was receiving anti-anxiety medication. Interventions included to give the medication as ordered and monitor for side effects. A physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . A care plan initiated on February 4, 2022 for antidepressant medication related to depression included a goal that the resident would be free from discomfort or adverse reactions to the therapy. The interventions for this goal included giving medications as ordered, monitor/document/and report symptoms, and behavior tracking for sadness. A psychiatric follow up note dated February 8, 2022 at 11:15 am included that since the last visit, the resident reported to the staff that she and a former staff member (CNA/staff #49) had a relationship that included daily sexual encounters. The note included that the resident had cried several times during the interview stating that if she had known the staff member was with someone else, she would not have done anything with him. The note included that the resident claimed a woman (CNA/staff #20) entered her room and gave her a note. The resident stated the woman said the note was from the former staff member (CNA/staff #49). The note also included that the resident stated it was difficult to tell the effect of the [MEDICATION(S)] on her depression due to the situational exacerbation. The resident said her sleep remains disturbed and she reported chronic mild sadness, grief, and tearfulness and her anxiety was from generalized worry, her cancer diagnosis, and the relationship with the former staff member. The note included that the resident's behaviors were cooperative and tearful and that her mood included dysphoric, depressed, anxious, somber, grief, sadness, and was tearful. The note included that the resident appeared disheveled and fatigued with a sullen, sad affect. The note included that the resident was experiencing situation exacerbation of depression and anxiety over recent end of a sexual relationship with a former staff member. The note also included that the recent start of [MEDICATION(S)] would be evaluated for full effect and dose increasing would be considered based on symptoms and tolerability. Review of a facility investigation revealed that the facility investigated the incident between resident #1 and the CNAs and noted that the resident had alleged a consensual sexual relationship with a former CNA (staff #49). The investigation included that on February 8, 2022 at approximately 9:00 pm, a Nurse Practitioner (NP) entered the resident's room and found her emotionally distraught and crying. The resident informed the NP that she got a letter from a former staff member, a CNA (staff #49), which included that the CNA was breaking off their relationship. The resident said that she and the CNA had a friendship that gradually developed into a sexual relationship. She stated that it started when he was changing her brief and he would be touching her to clean her. She said that he asked if she was uncomfortable and she told him that she was a little bit, but he reassured her that it would be okay and she did not stop him. She said that over time, this gradually increased in frequency, ultimately resulting in sexual intercourse on more than one occasion. The resident expressed that this was consensual. The investigation included that the staff member had been terminated in [DATE] and his termination was not related to this incident. The investigation included a statement from the resident where she stated that I feel like my guts have been kicked in. She said that the CNA (staff #49) made her feel like he really cared about her. She said that it all started when she was admitted and she felt uncomfortable in the beginning but that they became friends which led to a sexual relationship. She stated that it happened every day and that he either would use his hands or he would crawl on the bed with her and penetrate her vagina with his penis. She confirmed that it was staff #49. She stated that the penetration occurred maybe 5 to 6 times and that he mostly used his hands. During the statement, the resident placed her hand on her head and became tearful saying that the situation was embarrassing. She also said she acted like she enjoyed it so that he would hurry up and get it over with and sometimes she would cover her head because she was uncomfortable. She said that when she was in the first room, it was just his hands and didn't start to be penetration until she was moved into a different room. She said that in the beginning she was uncomfortable and would notice that he would rub her a little more than necessary and after a few times, he asked if she was uncomfortable and she said she was to which he would say that it was okay. He told her that he loved her daily and would always come and give her a kiss before he left. She said that after he was no longer working in the facility, another CNA (staff #20) brought her a letter that was from CNA #49. She said that is how she learned that he had a girlfriend and that upset her because she said she would have never done this if she knew that. She said that she had asked him many times before if he had a girlfriend and he would say no and get mad at her for asking. She said he even got mad enough that he did not talk to her for a while one day. She said that the letter ripped her heart out and that she now had to look at it for what it truly was and it hurts. She said that staff #20 had come into her room a couple of times and asked for details about her relationship with staff #49, specifically asking about sex. She did not understand why staff #20 was so interested in her business. The investigation included a witness statement from a CNA (staff #20) which included that she was given the letter from the other CNA (staff #49) and was instructed to give it to the resident. The statement included that the CNA did not open the letter. Continued review of the investigation revealed a copy of the letter that was presented to the resident. The letter indicated that the relationship should not have happened and that what they did together was wrong. The letter included that the CNA had a girlfriend of 6 years and that she knew all about the relationship as he could not keep it from her. The letter included that the CNA said there will never be a relationship between them and that the CNA was moving on. The letter also said that the CNA will not contact the resident and that the resident should not try to contact or find the CNA. Finally, the letter directed the resident to rip up the letter as the writer did not want anyone seeing it. The investigation included a statement from a CNA (staff #49) who wrote that over time he got to know the resident and shared stories about family and the resident's medical history. The statement included that he brought the resident homemade baked goods and offered her encouragement. He wrote that he only communicated with the resident at work and there was no way to tell her goodbye or why he was suddenly not working there any longer because he had been terminated by the facility. The investigation included a second witness statement form which noted that the CNA (staff #49) had been interviewed. He said that he had no knowledge of the letter that was given to the resident, he did not write it, and he denied having a sexual or inappropriate relationship with the resident. The investigation included other staff statements and none of them had any knowledge of the incident between the resident and the two CNAs (staff #20 and staff #49). Other residents were also interviewed with no abuse concerns noted. Review of the personnel record for staff #49 revealed two disciplinary forms. The first was dated [DATE] and included that the staff member received a final written warning for violation of the code of conduct policy in regards to relationships with residents. The second disciplinary form was dated [DATE] and included that the staff member was terminated for professional misconduct toward another staff member. An observation of resident #1 in her room was conducted on February 16, 2022 at 9:25 am. The resident was lying on her right side in her bed. The resident was disheveled in that her gown was twisted up, her hair was uncombed, and her eyes looked red and swollen as if she had been crying. She had a bedside table across her and on the bedside table there were two boxes of tissues with used tissues on the table and in the bed. When asked questions about the relationship with the former staff member, the resident erupted into tears and became visibly shaken. During an interview with resident #1 on February 16, 2022 at 9:25 a.m., she said that she is so embarrassed by what happened between her and the CNA (staff #49). She said that they first met when she was admitted to the facility and at first, he was just really nice to her. She said that she had never worn a brief before but needed it in the facility because of incontinence. She said the CNA would change her brief and it started out with him just wiping around her genitals to get her clean but that over time, the CNA started taking longer and would rub her genitals with his hands more and more. She said that she really liked the CNA and did not want to say anything because touching her made him happy. She said that he then starting putting his fingers inside of her when he was cleaning her and he touched her without gloves on. She said that she lied to the CNA and said she liked it because she was in love with him. She said that they had become close friends and that the CNA was a baker and would bring her things like soda and food including homemade baked goods. She said that mainly, the CNA would use his fingers in a sexual way, but after a while, he started to climb in bed with her. She said that every time he was providing pericare, he would touch her genitals in a sexual manner. She stated that when the CNA started climbing into bed with her, that is when the intercourse started. She said that it happened multiple times and it was always skin to skin with no protection. She said that she did not tell anyone because she felt the sex was part of the relationship and that made it okay. She said that her husband died a year and a half ago and that her husband was the only man she had ever been with. She said that she never received pleasure from the intercourse but the CNA did. She said she thinks the CNA ejaculated inside her every time that they had intercourse. She said that the CNA would spend time in her room discussing religion, life, or just about anything. She said he would kiss her goodbye every time he worked and he would tell her that he loved her. She said that she trusted the CNA. As the interview continued, the resident stated that the CNA always took care of her except when he was suspended. She said that he told her that he was suspended because of a complaint that he was found on top of another resident in the facility. She said this concerned her because she thought that she was the only one. She said she asked the CNA about it and he denied the allegation. During the interview, the resident stated that a female CNA (staff #20) brought her a note from staff #49 that was very hurtful. She said it was a letter to end their relationship and it said that staff #49 had someone else in his life. She said that it was so painful because she had asked him over and over again if he had someone else and he said no. She said that she felt so guilty because she would never want to be the other woman and couldn't imagine how that person felt about her. She said that staff #49 had never written a note before so she had never seen his handwriting. She said that the CNA (staff #20) who brought her the note was cold and distant. She stated again how painful and upsetting the note was and that it hurt her because she felt like staff #49 was leaving her and they had an intimate relationship. Review of the SA database revealed that on [DATE], another resident (not resident #1) at the facility had alleged sexual abuse. This included an allegation that CNA #49 had touched her inappropriately during a brief change and had used his fingers up and down on her private area. This allegation could not be substantiated. There was no report that included an allegation that staff #49 was found on top of another resident (not resident #1). An interview was conducted with a Human Resources staff (HR/staff #58) on February 16, 2022 at 9:35 am. The HR staff said that staff #49 was suspended in the past but she was unable to locate any documentation regarding this suspension. The HR staff said that the only other disciplinary action prior to staff #49's termination on [DATE] was related to code of conduct as he was found bringing cigarettes to a resident and there were other concerns about interactions with other staff members. An interview was conducted on February 16, 2022 at 9:45 am with the Director of Nursing (DON/staff #30) and the Corporate Clinical Resource (staff #57). The DON stated that the CNA (staff #49) had never been suspended for any other allegations of sexual abuse in the past. The DON stated that the allegations in [DATE] involved another staff member, but his name was also brought into it and he was never suspended during that investigation and the allegation was not substantiated due to lack of evidence. The DON stated that there were no allegations of staff #49 being found on top of another resident. During an interview conducted on February 16, 2022 at 10:40 am with a CNA (staff #32), they stated that they had worked with staff #49 often. The CNA said that they would work one hall and staff #49 would work a different hallway. Staff #49 would cover the smoke breaks and worked alone most of the time. An interview was conducted with a CNA (staff #20) on February 16, 2022 at 10:59 am. She stated that she had worked with staff #49 a couple of times a week and that when they worked together, staff #49 always worked on the same hallway. She said that she assisted staff #49 in providing care to the resident but didn't really pay attention to the care staff #49 was providing. She said that she was actually the one who wrote the letter to the resident out of spite and the letter was meant to upset and hurt the resident. She said that she gave the letter to the resident and she lied to the DON about the origin of the letter. She said that the entire letter was made up just to hurt the resident and that staff #49 did not write the letter. She said that she wrote the letter because she did not like the resident. Staff #20's personnel record revealed a disciplinary form dated February 16, 2022 that included that she was terminated for resident abuse. The form included that the staff member disclosed writing a letter to resident #1 with the intention of hurting her. During an interview conducted on February 16, 2022 at 11:48 am with a CNA/Scheduler (staff #37), she stated she had worked on the same hallway that staff #49 worked on. She said that at one point, there was an allegation made by another resident (not resident #1). She stated the allegation was that staff #49 had upset a resident because she saw him with her roommate and the resident said she thought she was dating him. She stated she was not asked to provide a written statement for this allegation and staff #49 was not suspended because the investigation happened during his scheduled days off. An interview was conducted on February 17, 2022 at 11:54 am with the DON (staff #30). The DON stated that prior to the incident with resident #1 and staff #49, a resident (not resident #1) made an allegation that they were in love with one of the staff members and that they felt the staff member was in love with another resident. She stated no one ever named the CNA (staff #49) specifically. The DON stated that they spoke with all the residents involved and because no specifics were identified, nothing could be proven. She stated that staff #49 had brought cigarettes in for a resident and that doing this was the last and final write up because it blurred boundaries, but she said that at that time, that resident stated they did not have a relationship. She stated she could not recall the name of the resident that staff #49 had bought cigarettes for. She stated the termination in December was because of the unfavorable behavior towards staff by the CNA. When discussing the current incident with resident #1, she stated that during the initial interviews with the resident, she was very emotional. She stated that during the interview, the resident stated that she did not like the advances made by the CNA but submitted to them which grew into sexual penetration. She stated that the resident told her that she just wanted the CNA to finish so she could have the emotional relationship after the intercourse. She said that the letter delivered by staff #20 to the resident contained information that there was a relationship between staff #49 and the resident and that it was over. She stated that it was believed that staff #49 had given the letter to staff #20 but that now, staff #20 has indicated that she created the letter just to hurt the resident. An attempt to interview staff #49 was made via telephone on February 17, 2022 at 12:49 pm. A message was left with a request for a call back. The CNA (Staff #49) returned the call on February 18, 2022 at 1:13 pm. He stated that while he worked at the facility, they had shower aides but that he would shower the resident. He stated that the resident took the longest time to finish her showers and it was labor intensive. He stated that the shower usually took 20 minutes or more. He stated there was a lot of flirtation which was verbal but there had never been any direct inappropriate contact. He stated in the [AGE] years as a CNA, he performs personal and peri care alone as it is a very personal experience. He stated that he does cook and did bring the resident homemade baked goods after she received a concerning diagnosis. He stated the facility had a very strict rule on bringing things to residents which he did not have at previous facilities. He said that he never expressed that he loved the resident and he never touched or kissed her. He stated that they would discuss religion and family. He further stated that he did not write a letter to the resident. He said that there were allegations made that he brought cigarettes for another resident but he felt he was being singled out. He said that he once provided photographic evidence on his phone to the DON of substandard care for the resident but no one did anything about it. He said that he was suspended for an allegation of being on top of another resident, however it was dismissed as it never happened. He said that his termination was the result of having had three suspensions at the facility. He said that he has learned in his career that when you have three suspensions, even if the allegations are unsubstantiated, the facility will terminate you. The facility's abuse policy, dated 2017, included that the facility strives to prevent the abuse of all the residents. The policy included that the facility cares for residents with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The policy noted that the facility recognizes that due to the proximity of the residents to another and individual's freedom of choice, that situations may arise where it is not possible to completely prevent all incidents of abuse. Abuse is defined as infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. Abuse includes verbal abuse, sexual abuse, physical abuse, neglect, mental abuse, and misappropriation of property. Potential abusers can include employees. The policy included that instances of abuse of residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. The facility's resident rights policy, revised [DATE], included that all employees shall treat all residents with kindness, respect, and dignity. The policy included that federal and state laws guarantee certain basic rights to all residents of the facility. These rights include to be free from abuse, neglect, misappropriation of property, and exploitation.

Based on clinical record reviews, resident and staff interviews, facility documents and policy and procedures, the facility failed to ensure one resident (#8) was free from neglect which resulted in harm, failed to ensure one resident (#284) was free from verbal abuse by a staff member and failed to ensure that one resident (#283) was free from physical abuse by another resident (#11). The resident census was 41. Findings include: -Resident #8 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the fall care plan revised on 7/11/18 revealed the resident had an actual fall (guided to floor by staff) with no injury. The interventions included to anticipate and meet resident needs, encourage the resident to seek assistance with all transfers, ensure that call light and frequently used items are within reach before leaving the room, keep resident's room free of clutter and well lit, and resident is to be a two person transfer. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident was assessed to have severe cognitive impairment. The functional assessment of the MDS indicated the resident had no impairment with range of motion to her extremities. An Interdisciplinary Team (IDT) Fall Report dated 11/15/18 included that resident #8 had a fall on 11/14/2018 at 1:37 p.m. The events surrounding the fall included that a Certified Nursing Assistant (CNA/staff #67) called over the radio for assistance in the room of resident #8. Staff #67 was observed laying on the floor next to the resident who was also laying on the floor. The CNA was bleeding from his left orbital socket. Resident #8 was on her back with her head resting on the bed frame of her roommate's bed and was in distress and was crying. The note included the CNA was attempting to transfer the resident by himself from the wheelchair to the bed, and lost his balance due to the resident moving in the opposite direction of intended movement. The report included that the Registered Nurse (RN) requested the assistance of the Assistant Director of Nursing/Interim Director of Nursing (ADON/IDON). The resident was observed to have an injury to her right arm and possible injury to her head/neck. The resident was not moved off the floor, her neck was stabilized and 9-1-1 was called. The Fall Report further included that the fall was discussed with the Interdisciplinary Team (IDT) and that the resident had been a two person transfer since 7/2018. Per the report, staff #67 was not using his gait belt during the transfer, and he was transferring the resident by himself without another staff member. According to the fall investigation completed by the IDT, the resident had a witnessed fall with a major injury, which was directly correlated to the fact that the CNA was not following the resident's current plan of care for a two person transfer and was not in compliance with the facility's policy to use a gait belt with all transfers. The CNA was terminated as a result of the IDT investigation. The resident was placed on Alert Charting, the care plan was updated and a Fall Risk Assessment was completed. The physician and responsible party were notified. Review of the CNA task documentation revealed it was updated on 11/15/18 to reflect that resident #8 required the assistance of two staff with transfers. A physician hospital progress note dated 11/16/2018 included the resident was admitted due to being transferred from the wheelchair to standing, and while standing fell out of their grasp. Patient reports the staff person lost their balance while standing, and fell on to the patient. The hospital course included the resident had a humeral head fracture status [REDACTED]. The fall care plan was updated on 11/18/18 to reflect that the resident had a witnessed fall with major injury (right humeral head fracture) on 11/14/18. An observation was conducted on 1/23/19 at 8:46 a.m. of the resident in bed. With the assistance of a Spanish-speaking Certified Nursing Assistant, the resident was asked to move her right arm. The resident demonstrated severe limited ability with range of motion to the right shoulder, right elbow and right wrist. The resident was able to move all fingers on the right hand. An interview was conducted on 1/25/19 at 8:54 a.m. with a CNA (staff #19), who was observed with a gait belt around her waist. Staff #19 stated she always has it with her and it is required to be used for all resident assisted transfers. Staff #19 stated that she checks the Kardex and the Task List to see what specific care is needed for residents or she asks the therapist or nurse. Staff #19 stated if she doesn't feel comfortable transferring a resident, she will ask for help. Staff #19 stated that she remembered they were transferring resident #8 with one person and that she had transferred her by herself more than once, because there was nothing on the Kardex or on the task list to tell her that the resident needed to be transferred with two people. She stated that she doesn't have access to the care plan. An interview was conducted on 1/25/19 at 9:18 a.m. with the ADON (staff #29), who stated that ever since she had been working at the facility (8/08/17), she felt resident #8 was a two person transfer, but it was not determined for her to be a two person transfer until her first fall in (MONTH) (YEAR). Staff #29 stated when she was investigating the (MONTH) fall, the information regarding the need for two persons for transfers was not on the Kardex/Task list, so it was added then. Staff #29 stated she doesn't think the CNA's have access to the care plans, but she wasn't sure. An interview was conducted on 1/25/19 at 9:38 a.m. with the Administrator (Abuse Prohibition Officer/staff #40), who stated that staff are trained on physical, emotional, mental, sexual, financial and verbal abuse and neglect. Staff #40 stated that staff are made aware of what is included in the various types of abuse and that it was just reviewed along with resident rights at the all staff meeting. Staff #40 stated the leadership team will make a determination on whether or not an incident is abuse/neglect. Staff #40 stated neglect examples would include a resident demanding care and was purposely ignored or the provision of goods and services or types of care were not being provided. Staff #40 stated that the CNA (staff #67) was terminated, because of not following the resident's care plan and our policy for transfers. Another interview was conducted on 1/25/19 with ADON (staff #29), who stated she convened the IDT Fall team the day after the fall. She said the appropriate people (physician, responsible party) were notified and the resident was sent out to the hospital. Staff #29 further stated that based on the definition of neglect (as discussed above), she would now consider what occurred as neglect. An interview was conducted on 1/25/19 with the DON (staff #53), who stated that they looked at the fall as any other fall. She said resident #8 had a witnessed fall and sustained a fracture, and was sent to the hospital. She said for those reasons, she didn't feel it was neglect and it was not reported to the State Agency or other agencies. Staff #53 agreed that based on the definition of neglect as discussed, she would now consider what occurred as neglect. An interview was conducted on 1/25/19 at 11:45 a.m., with the CNA (staff #67). Staff #67 stated that he was provided training by the facility on how to do transfers and how to obtain information regarding transfer needs of residents from the computer system. Staff #67 stated the facility policy was to use a gait belt for all transfers and he used a gait belt for all transfers, except for one incident. Staff #67 stated the incident was when resident #8 fell . He said that he had taken the gait belt out of his pocket to use the restroom and didn't put it back and forgot about it. Staff #67 stated that Prior to that day we always used two people to transfer her, but that day I didn't call for help because I was just trying to get her laid down before the end of my shift and I had things to do. -Resident #284 was admitted on (MONTH) 16, 2019, with [DIAGNOSES REDACTED]. Review of the care plan initiated on (MONTH) 17, 2019, revealed the resident was on antidepressant medication related to depression. Interventions included redirection and activities of choice for crying, self-isolation or verbalization of sadness. Review of an activity of daily living (ADL) care plan revealed resident #284 has an ADL self-care performance deficit related to impaired mobility. Interventions included for PT/OT evaluation and treatment as per physicians orders and to encourage resident to participate to the fullest extent possible with each interaction. Review of the nurse's notes dated (MONTH) 19, 2019, revealed the resident was alert and oriented x 4, and has a right leg and left arm in an immobilizer. Per the note, the resident was extensive assist of one person for bed mobility and toileting, and a two-person extensive assist for transfers. The admission Minimum Data Set (MDS) assessment dated (MONTH) 23, 2019, revealed the resident scored a 15 on the Brief Interview for Mental Status (BIM's), indicating the resident was cognitively intact. The MDS also revealed the resident did not have any behaviors. Review of the facility's investigation dated (MONTH) 23, 2019, revealed that on (MONTH) 18, 2019, resident #284 was very upset about her therapy that day. She reported that the therapy staff (#68 and #21) were yelling and cussing at her. The resident reported that she wanted to work with physical therapy (PT), as she had already received a shower from occupational therapy (OT). She stated that when she went to the therapy gym, the therapist (Certified Occupational therapy assistant/COTA/staff #68) told her If you get your butt down here we can work. Resident #284 further reported that the therapists were yelling at her and told her that it took 30 minutes to get her out of bed and walk her and that was her therapy for the day. She stated it was not correct that it took her 30 minutes to get her out of bed. The resident stated that one of the therapists called her a name (B word), but she wasn't sure which one. She said that made her angry and she called the therapist the same name. Further review of the investigative report revealed a statement by the physical therapy assistant (PTA/staff #21). Staff #21 explained that it took 30 minutes for the resident to get out of bed, take a shower and walk 25 feet. After the shower, resident #284 came to the therapy gym and was upset, so she told the resident to sit down and she would explain it to her. Staff #21 reported that as she was explaining the issue regarding the therapy minutes, the resident started to escalate, so she backed off. Staff #21 stated that there were two other therapists in the room, one was an Occupational Therapist (OT/staff #23) and the other was staff #68 (COTA). She reported at that point, staff #68 tried to explain the situation to the resident. Staff #21's statement included that none of the therapists were yelling at the resident. Continued review of the investigative report revealed a statement from staff #23. Staff #23 said when resident #284 entered the gym, she was upset because it took 35 minutes to get her out of bed. Per staff #23, that time was included as part of her therapy and the resident did not understand that. Staff #23 reported that she saw staff #21 back down, when resident #284 started yelling and swearing. Staff #23 stated at that point, staff #68 started to jump in and started yelling If you want therapy get out of bed. Staff #23 stated that resident #284 and staff #68 were yelling at each other. She said that she did not hear anyone say the B word. Staff #23's statement also included that she could see how it was aggressive from the resident's point of view and she wouldn't talk to a patient like that. The investigative report also included a statement by a Certified Nursing Assistant (CNA/staff #51), who was present during the incident. Staff #51 reported that staff #21 was explaining to the resident about her physical therapy minutes and the resident was upset saying that it did not take her 30 minutes to get out of bed. Staff #51 reported that staff #68 was yelling at the resident, as she was trying to get the resident back to her room. Staff #51 stated the resident was strolling away when staff #68 kept at it and told the resident If you don't like it you can always go home. Staff #51 reported that she did not hear any cuss words from anyone. Per the report, a statement from staff #68 revealed that she tried to calm resident #284 down by trying to explain some items to her. Staff #68 reported the resident started wheeling out of the gym and she was trying to explain things to her, so she kept saying loudly Ma'am Ma'am. She stated that she did not think her actions were uncalled for. Review of staff #68's personal employee file revealed that staff #68 had a disciplinary warning on (MONTH) 13, (YEAR). Staff #68 was observed by a staff member talking to another staff member about a resident during a smoking break. It was reported that staff #68 was cussing and using profanity about a resident in front of other residents and a family member, who were a few feet away. Additional documentation via email included that based on their investigation the B word was never used. However, it was determined that staff #68 did yell at the resident even after the resident turned around to wheel herself out of the gym. Due to the previous warnings and this incident, staff #68 lacked the ability to provide good customer service and has demonstrated a pattern of behaviors, as a result staff #68 was terminated. The investigative report concluded that no staff witnessed staff #21 or staff #68 cussing at the resident, therefore the allegation was unsubstantiated. However, despite witnesses reporting that staff #68 was yelling at the resident, even as the resident was attempting to leave the area, the facility did not substantiate that verbal abuse had occurred. During an interview conducted with resident #284 on (MONTH) 23, 2019 at 8:28 a.m., she stated that on (MONTH) 18, 2019 she went to the physical therapy gym to talk to staff about her therapy. She said that a physical therapy assistant (PTA/staff #21) and a certified occupational therapy assistant (COTA/staff #68) were very rude to her. She stated that staff #21 and #68 were yelling at her and staff #68, who has never worked with her before continued to yell at her. She stated that staff #68 was yelling saying If you don't like it you can leave even as the Certified Nursing Assistant CNA (staff #51) was pushing her wheelchair out of the therapy gym. An interview was conducted on (MONTH) 25, 2019 at 8:38 a.m. with staff #21. She stated that on (MONTH) 18, 2019, she was working with resident #284. She stated that they used 30 minutes of therapy time getting the resident up from bed, giving her a shower and they walked the resident. She said the resident came to the therapy gym wanting the remaining minutes of her therapy later that day. Staff #21 said that she tried to explain to the resident that her 30 minutes of therapy was completed, as it had been used up when they got her up from bed to the shower and did some walking. She stated the resident was not happy when she heard this and started arguing in a loud voice, almost yelling. At this point, staff #21 stated that she backed down and said they could talk about it later and the resident was satisfied with that explanation. Staff #21 said that staff #68 was sitting in the corner of the room and tried to reiterate what she had just said, but by this time resident #284 and staff #68 were both yelling at each other. Staff #21 stated the resident was yelling and staff #68 was also yelling back at her. Staff #21 stated that staff #68 could have handled the situation differently and she felt that staff #68 was aggravating the situation further. She stated staff #68 has a tendency to get frustrated and escalates easily. An interview was conducted on (MONTH) 25, 2019, at 9:37 a.m. with the Director of Nursing (DON/staff #53), who stated that they conducted employee interviews during the investigation and based on the employee interviews they determined that it was not abuse, since there were no cuss words used. Staff #53 stated that during their investigation it was determined that only staff #68 was yelling. She stated that they fired staff #68, because she was yelling at a resident and did not provide good customer service. An interview was conducted with staff #51 on (MONTH) 25, 2019 at 11:09 a.m. Staff #51 stated that resident #284 went to the therapy room to speak to staff #21 to see if she was going to get therapy that day. Staff #21 told resident #284 that she already had her therapy for 30 minutes this morning. Staff #51 stated that staff #21 was telling the resident that it took her 30 minutes to get the resident out of bed to the shower, which was her total therapy time for the day. She said that is when staff #68 who was sitting in the far corner intervened and said that resident #284 only has 30 minutes allotted to her and she has used it all. Staff #51 stated that resident #284 turned around to leave and staff #68 started yelling at the resident stating she only gets 30 minutes and that's how much her insurance pays and if the resident does not like it she can leave. Staff #51 stated that there were no swear words used, but staff #68 was yelling at the resident. She stated that staff #68 should have let the other therapist finish her conversation with the resident and not interfere and it would have been easier to explain rather than start yelling. -Resident #11 was admitted on (MONTH) 29, 2003, with [DIAGNOSES REDACTED]. Review of the MDS assessment dated (MONTH) 21, (YEAR), revealed the Brief Interview for Mental Status (BIMS) was not conducted, however, the resident was assessed to have moderate cognitive impairment. The MDS also included the resident had difficulty focusing, was short-tempered and gets restless at times. Review of a care plan revealed that resident #11 displays behaviors of physical aggression. -Resident #283 was admitted on (MONTH) 23, (YEAR), with [DIAGNOSES REDACTED]. Review of the MDS assessment dated (MONTH) 8, (YEAR), revealed a BIMS interview was not attempted as the resident was rarely/never understood. The MDS included that resident #11 had moderate cognitive impairment. A nurse's weekly skin check and wound assessment dated (MONTH) 12, (YEAR) included resident was involved in a resident to resident altercation in which he was struck on the arm. No bruising, laceration, open skin or injury observed from residents altercation . Review of the facility's investigative report revealed that on (MONTH) 12, (YEAR) at approximately 7:00 p.m., resident #11 had been sitting next to resident #283 after dinner at the nurse's station. Resident #283 was talking/mumbling to himself quietly as he does most of the time. Staff observed resident #11 reach over and swing at resident #283's face. The first swing did not make contact, but resident #11 swung again immediately and resident #283 put his forearm in front of his face, so resident #11 made contact with resident #283's shoulder/upper arm. This incident was witnessed by facility staff who separated the residents just as resident #11 made contact with the second swing. An interview was conducted on (MONTH) 23, 2019 at 2:05 p.m., with a CNA (staff #3). She stated the residents were roommates and were seated in wheelchairs side by side at the nurses station. She said that resident #283 was talking to himself like he usually does and resident #11 thought he was talking about him. Staff #3 said that resident #11 is not very verbal and gave resident #283 an agitated look and then tried hitting him. She said when resident #11 missed, he swung again and this time he was able to punch resident #283 on his left arm. She stated that he did not hit him hard. Staff #3 stated they were quick in separating both residents and no injuries were noted on either resident. Staff #3 also stated that resident #11 has exhibited some aggressive behaviors in the past, but can easily be redirected and will calm down in a few minutes if removed from the situation. An interview was conducted on (MONTH) 24, 2019 at 9:52 a.m., with a Registered Nurse (staff #44). She stated that both resident's were sitting at the nurses station when she heard one of the CNA's yell no and that's when she turned and saw the CNA's in between the two residents. She said there were no injuries and they made sure both residents were safe. She said they kept them separated and placed them in separate rooms and did frequent checks (every 15 minutes for an hour then frequently). Staff #44 stated they notified the Administrator and the Director of Nursing. An interview was conducted on (MONTH) 25, 2019 at 9:38 a.m., with the Administrator (staff #40). He stated that abuse is covered in orientation and in staff meetings and is discussed on a weekly basis. He stated when there is a resident to resident altercation, employees should make sure the resident is safe and separate them from the situation. During an interview conducted on (MONTH) 25, 2019 with the Director of Nursing (staff #53), she said when there is a resident to resident altercation, staff should notify the nurse or charge nurse. She stated that staff are aware that they are mandated reporters of any kind of abuse. Review of the facility's Abuse policy revealed the facility will strive to prevent the abuse of all residents. Our objective is to provide a safe haven for our residents through preventative measures that protect every resident's right to freedom from abuse. We care for residents with a [DIAGNOSES REDACTED]. The policy included that by definition, abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Willful, as used in this definition of abuse means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. Abuse includes verbal abuse, sexual abuse, physical abuse and mental abuse. Potential abusers can be residents, employees or family members. The policy also included that If abuse is witnessed or suspected, the resident's safety will immediately be secured. Prompt reporting and investigation will be utilized to identify the validity of findings and reasonable measures will be implemented to deter further incidents of abuse.

Based on clinical record reviews, the facility's investigative reports, hospital records, staff interviews, and review of facility policies, the facility failed to ensure that adequate supervision was provided for one resident (#171) while smoking, which then resulted in a fall with significant injury, and that all interventions to prevent a fall had been implemented for one resident (#56). The sample size was two of four. Findings include: -Resident #171 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident was also legally blind. A fall risk assessment dated [DATE], identified that the resident was at risk for falls, with a score of 16 (per the guidelines a score of 10 or above represented a high risk). A facility form titled, "Safe Smoking Assessment," also dated December 21, 2010, included documentation that the resident was an "Unsafe" smoker. According to the documentation, the resident was unable to see adequately and was unable to demonstrate safe techniques for putting out the matches or lighter and disposing of trash. The assessment also included that as an unsafe smoker, a protective smoking apron/vest was necessary when smoking and that frequent supervision was required while smoking. The admission MDS (Minimum Data Set) assessment included documentation that the resident had highly impaired vision, that he required extensive staff assistance for most ADLs (Activities of Daily Living), including locomotion on and off the nursing unit, and that he had sustained a fall in the previous month. The MDS section titled, Care Assessment Summary, included documentation that falls were identified as a problem and that a fall care plan was developed. A physician's orders [REDACTED]. A risk for falls care plan dated December 22, 2010, included documentation that the resident had sustained a fall on December 22, 2010, and that an ambu alarm was to be applied to the resident when seated in his wheelchair or when in bed for safety and a history of falls. A review of a facility form titled, Documentation-Charting Record, from December 2010, through February 18, 2011, revealed documentation of the above physician's orders [REDACTED]. A nursing note entry dated February 18, 2011, included that the resident had fallen outside after the CNA (certified nursing assistant) left him outside to smoke. According to the documentation, the resident was found lying on his back with the wheelchair tipped over off the curb. The entry also included that as a result, the resident sustained [REDACTED]. A post fall assessment included documentation that the resident had sustained a fall on February 18, 2011 at 8:30 p.m. The documentation included that an x-ray employee had buzzed the outer facility door to report that a resident had fallen. The description of the fall included that the resident was found outside lying on his back with the wheelchair tipped backwards and it appeared that the resident had fallen out of the wheelchair. In addition, the documentation included that the CNA had left the resident outside to smoke and he was trying to find his way back into the building. A continued review of the resident's clinical record revealed a facility form titled, Staff to Physician Communication Form, dated February 20, 2011, included, "After patient's fall recurrent headaches, and he is asking too often for Tylenol." A physician's orders [REDACTED]. A nursing note entry dated February 22, 2011, included that the CT scan of the resident's brain had been obtained and revealed bleeding. The resident was subsequently discharged from the facility and admitted to the hospital's intensive care unit. The hospital records were also reviewed and revealed that the resident had sustained an intracranial bleed. An interview was conducted on December 14, 2011, with the Administrator, who stated that the facility's front door automatically locked at 8:00 p.m., and then you would need to ring the buzzer to enter the facility. He stated that the resident frequently went outside to smoke and that staff would check on him and bring him back into the facility when he was finished smoking. He also stated that the resident had not ever tried to come back into the building himself or get up from his wheelchair while outside, alone. The administrator further stated that if the resident did attempt to get up from his wheelchair while outside alone, the staff would have been able to hear the personal alarm. The administrator acknowledged that the staff were unaware that the resident had fallen until they were notified by the x-ray technician that the resident was on the ground. At this time, he stated that the personal alarm must not have disconnected from the resident and sounded. A second interview was conducted on December 15, 2011, with the DON (Director of Nursing), who also stated that the resident would go outside the front of the building to smoke, and that the staff would take the resident outside and bring him back into the building when he was done. At this time, the resident's smoking care plan and smoking assessment were reviewed. According to the DON, the resident's smoking materials were kept in the medication room and not in a locked drawer in the resident's room, as documented on this care plan. The DON also stated that the resident required frequent checks while smoking, as documented on the smoking assessment, and clarified the degree of supervision to be off and on checks but not constant supervision. Another interview was conducted on December 15, 2011 at 2:15 p.m. with the CNA assigned to care for the resident on the night of the fall. She stated that she had taken the resident outside the front of the building to smoke at approximately 8: 05 to 8:10 p.m. p.m., and had left him alone outside. She stated that she had told the resident, that she would check on him in about 10-15 minutes, after providing care to another resident. According to the CNA, she was not aware that the resident was identified by the IDT (Interdisciplinary Team) to be an unsafe smoker, and that he required frequent supervision while smoking. At this time, she stated that had she known, she would have stayed outside with the resident while he smoked. The CNA further stated that the she also was unaware that the resident had a previous fall and that he was identified to be at risk for further falls. At this time, the CNA stated that on the night of the fall, the resident did not have a personal alarm on while seated in his wheelchair because she was not aware that a personal alarm was required. -Resident #56 was admitted [DATE], with [DIAGNOSES REDACTED]. A review of the clinical record revealed multiple fall risk assessments that identified that the resident was a high risk, with scores of 16-18 (per the guidelines a score of 10 or above represented a high risk). A physician's orders [REDACTED]. A nursing note entry dated December 5, 2011 at 3:44 a.m., included that the resident's roommate had turned on his call light to inform staff that this resident had rolled out of bed to the floor. According to the documentation, the resident was found lying on his side on the floor mat. The entry also included that at the time of the fall, the bed alarm was not in place, as physician ordered and as care planned. A review of a facility form titled Documentation-Charting Record, from October through December 18, 2011, revealed transcription of the above physician's orders [REDACTED]. During an observation conducted on December 19, 2011 at 8:45 a.m., the resident was observed seated in his wheelchair in the dining room, without a personal alarm applied. An interview was immediately conducted with the RN (Registered Nurse), who confirmed that the personal alarm was not on the resident. She stated that the resident was suppose to have the personal alarm on and stated that there was no excuse for not having it. Immediately following the initial observation and staff interview, a CNA was observed to enter the dining room and apply a personal alarm to the resident. An interview was conducted at this time with the CNA, who stated that the resident did not have a personal alarm on when she got him up from bed this morning and that the personal alarm was not in his wheelchair. She stated that she had to go and obtain another personal alarm for this resident. Another facility policy titled, Falls and Fall Risk Management, included, "Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling." The policy also included the following, "...In conjunction with the Attending Physician, staff will identify and implement relevant interventions...to try to minimize serious consequences of falling...." A facility policy titled, Resident Smoking Policy, included, "This facility shall establish and maintain safe resident smoking practices." The policy also included the following: "...The staff shall consult with the Attending Physician and the Director of Nursing Services to determine any restrictions on a resident's smoking privileges...Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues...Any resident with restricted smoking privileges requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking...The staff will review the status of a resident's smoking privileges periodically, and consult as needed with the Director of Nursing Services and the Attending Physician.