Every finding on record at Prescott Village Nursing & Rehabilitation

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure one (#54) of three sampled residents received adequate nutrition by failing to ensure Resident #54's meals and snacks were provided, adequately monitored and documented during the initial days following admission. The deficient practice had the potential to result in inadequate nutritional intake and unintended weight loss.Findings Include:Resident #54 was admitted to the facility on [DATE], with diagnoses including COVID-19, acute bronchitis, pneumonia due to Streptococcus pneumoniae, weakness, atherosclerotic heart disease of native coronary artery without angina pectoris, hyperlipidemia, hypothyroidism, unspecified dementia, dysphagia, major depressive disorder, constipation, difficulty in walking, muscle weakness (generalized), and cognitive communication deficit.The resident's admission weight was 155.0 pounds.A Nutritional Communication Form dated April 28, 2026 revealed that the resident is on regular diet and noted that Resident #54 preferred to have breakfast, lunch, and dinner served in his room.An admission Minimum Data Set (MDS) assessment dated [DATE], revealed that Resident #54 had a Brief Interview for Mental Status (BIMS) score of 15, indicating that the resident was cognitively intact. The MDS further indicated that the resident required set-up and clean-up assistance for eating, indicating that the resident was able to use suitable utensils to bring food and/or liquid to the mouth and swallow food and/or liquid once the meal was placed before the resident.Review of grievance documentation revealed that on May 1, 2026, Resident #54's family member and Power of Attorney (POA) expressed concerns regarding the care provided to Resident #54. The POA stated that Resident #54 was admitted on [DATE], between 4:30 p.m. and 5:00 p.m., and reported to the POA that he had not been served a meal that evening. The POA further stated that Resident #54 reported that dinner had not been served on April 29 or April 30, 2026. The POA also expressed concerns regarding weight loss. A facility note indicated that meals had been served to Resident #54 on the dates of concern, and the grievance was documented as resolved on May 12, 2026.The care plan for Resident #54 revealed a focus initiated May 2, 2026, indicating that the resident was at risk for dehydration, constipation, and malnutrition. Interventions included monitoring and documenting intake and output and monitoring, documenting, and reporting recent or sudden weight loss to the medical director.A physician order dated May 4, 2026, revealed an order for Ensure nutritional supplement twice daily for supplementation.Review of the facility's meal/task documentation for April 28 through May 12, 2026, revealed the following:April 28: No meals were documented and the entry was identified as Not Applicable.April 29: Two meals were documented, and the resident consumed 76-100% of both meals.April 30: No meals were documented and the entry was identified as Not Applicable.May 1: Two meals were documented. The resident consumed 51-75% of one meal and 76-100% of the second meal.May 2: Two meals were documented, and the resident consumed 76-100% of both meals.May 3: Two meals were documented. The meal documented at 9:04 a.m. was 76-100% consumed, and the second meal was 26-50% consumed. The documentation indicated that the resident was offered a supplement or substitute meal.May 4: Two meals were documented, and both meals were documented as 51-75% consumed.May 5: Two meals were documented, and the resident consumed 76-100% of both meals.May 6: Two meals were documented, and the resident consumed 76-100% of both meals.May 7: Two meals were documented, and the resident consumed 76-100% of both meals.May 8: Two meals were documented, and the resident consumed 76-100% of both meals.May 9: One meal was documented, and the resident consumed 76-100% of the meal. At 4:57 p.m., a second meal was documented as refused by the resident.May 10: Two meals were documented, and the resident consumed 76-100% of both meals.May 11: Two meals were documented, and the resident consumed 51-75% of both meals.May 12: Two meals were documented. The resident consumed 51-75% of the first meal and 76-100% of the second meal.The meal/task documentation revealed that on two days, no meals were documented. On the remaining days reviewed, no more than two meals were documented in a day, despite the facility's stated meal schedule of three meals per day. The documentation reflected only one documented meal refusal and one documented instance in which a supplement or substitute meal was offered. The documentation did not establish that all scheduled meals and/or snacks were provided and monitored during the period reviewed.Weights recorded for Resident #54 were as follows:4/28/2026, 155.0 lbs5/1/2026, 148.4 lbs5/5/2026, 148.8 lbs5/12/2026, 146.0 lbs5/19/2026, 143.2 lbs5/24/2026, 143.0 lbs5/26/2026, 142.8 lbsOn August 27, 2026, at 1:05 p.m., a telephone interview was conducted with Resident #54's family member and POA. The POA stated that Resident #54 had lost weight while at the facility and had reported to her that several meals had not been served to him.On August 31, 2026, at 11:30 a.m., an interview was conducted with Certified Nursing Assistant (CNA/Staff #49). Staff #49 stated that meals were served to residents in their rooms daily at approximately 7:30 a.m., 11:30 a.m., and 4:30 p.m. Staff #49 stated that newly admitted residents were served at the next scheduled meal following their arrival and that staff could request a meal from the kitchen if a newly admitted resident was hungry upon arrival. Staff #49 further stated that CNAs were responsible for documenting those meals were served, the percentage of the meal consumed, and whether the resident refused the meal or was offered a substitution.On August 31, 2026, at 11:46 a.m., an interview was conducted with Registered Nurse (RN/Staff #85). Staff #85 stated that when a newly admitted resident needed to eat, she would go to the kitchen and obtain a meal based on the resident's diet order. Staff #85 further stated that CNAs documented the percentage of each meal consumed.On August 31, 2026, at 12:17 p.m., an interview was conducted with the Director of Nursing (DON/Staff #42). Staff #42 stated that Resident #54 was admitted on [DATE], at approximately 4:30 p.m. When asked whether Resident #54 was served a meal on the date of admission, Staff #42 stated that the documentation indicated that he was served a meal and that she had been present with the Assistant Director of Nursing (ADON). Staff #42 stated that the facility had communicated to Resident #54's daughter that he had been served a dinner meal each night. However, Staff #42 acknowledged that the CNA documentation did not contain a time indicating when the meal was served and that on April 30, 2026, a CNA documented breakfast and lunch at the same time.Staff #42 stated that if meals were not provided to a resident, the resident could experience inadequate nutritional intake and weight loss. Staff #42 further stated that Resident #54 had been placed on Ensure because of his weight loss. When asked whether the meal documentation met her expectations, Staff #42 stated that it did not.Staff #42 stated that she was unable to access the task logs for snacks provided to Resident #54 and therefore could not determine if or when snacks had been provided to the resident.Review of the facility's Nourishment and Snacks policy, revised December 2020, revealed that the facility would ensure nourishment and snacks were provided in accordance with the prescribed diet and per the menu rotation.

Based on closed record review, observation of current facility practice, staff and resident interviews, and facility documentation and policy review, the facility failed to ensure that personal property was not misappropriated for one resident (resident #221) out of three. The deficient practice could result in continued misappropriation of resident's property and place residents at risk for financial exploitation.Findings include:Resident #221 initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses that included unspecified kidney failure, chronic obstructive pulmonary disease, acute and chronic respiratory failure, heart failure, and major depressive disorder.The quarterly minimum data set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14, which indicated the resident was cognitively intact. No behaviors were noted on the MDS assessment.A care plan focus dated June 25, 2026 for the resident being at risk for financial and care exploitation.A nursing progress note effective June 25, 2026 revealed that the resident reported to the Assistant Director of Nursing (ADON/Staff #46) at 11:00 a.m. that she felt financially exploited by Certified Nursing Assistant (CNA/Staff #87) that the facility had recently terminated.Record review revealed that the staff #87 signed that she had received and read the facility employee manual in addition to an in-service titled, Theft and Loss Prevention.An interview with resident #221 was conducted on August 27, 2026 at approximately 11:09 a.m., which revealed that the resident spent $169.00 of her own money to book a hotel room for the evening of June 2, 2026 for staff #87. Resident #221 conveyed that staff #87 would regularly share her personal struggles when in her room to provide care. Staff #87 stated to the resident that she did not have a room to sleep in on the night of June 2, 2026 and she planned to sleep in her car with her dog. The resident stated that she paid for the hotel room for staff #87 because her story grasped at her heart. She stated that Staff #87 repaid $80.00 in cash for the hotel room on or around June 6, 2026. Resident #221 was unable to locate the financial record that confirmed she booked the room for the resident. She further stated that she has not been solicited to provide support to other facility staff members.An interview with Certified Nursing Assistant (CNA/Staff #62) occurred on August 27, 2026 at approximately 11:53 a.m., which revealed an understanding of facility policy to not misappropriate a resident's belongings and to not accept gifts from a resident. The CNA stated she would immediately notify the Director of Nursing (DON) and the Administrator if a resident shared they had provided money to a facility staff member.An interview with Licensed Vocational Nurse (LVN/Staff #14) occurred on August 27, 2026 at approximately 11:57 a.m., which revealed that facility staff is trained in both the employee handbook and through regular in-service trainings regarding misappropriation of a resident's belongings. She stated facility policy does not allow for a team member to either solicit or receive money or support from a resident and that she was made aware of the policy upon hire and through in-services.An interview was conducted on August 27, 2026 at approximately 12:00 p.m. with the Director of Nursing (DON/Staff #42), which revealed examples of resident financial abuse that included manipulating a resident into giving money, stealing personal belongings, and taking money from a resident. The DON stated facility policy does not permit facility team members to solicit or accept gifts or money from a resident or their representatives and they are educated through in-service trainings and in the employee handbook. She stated that an internal investigation concluded that resident #221 provided $160.00 to staff #87 to acquire a hotel room on the night of June 2, 2026 and that staff #87 had repaid $80.00 in cash to the resident.The DON stated that staff #87's actions did not meet her expectations, were not compliant with facility policy, and could result in a resident losing money they need for other expenses or losing personal items of value. She stated that staff #87 was terminated on June 25, 2026, prior to the misappropriation being reported, due to deferring duties and responsibilities to other team members, for being resistant to coaching, and for attitude concerns. The DON stated that resident #221 reported her misappropriation concern to the facility upon learning that the CNA was terminated, which resulted in an internal investigation and report. She stated that the facility was not able to obtain a written statement from staff #87 with regard to the incident.A telephonic interview was conducted on August 27, 2026 at approximately 12:52 p.m. with CNA/Staff #87, which revealed that resident #221 had paid for a hotel room for her to stay in on the night of June 2, 2026. Staff #87 stated resident #221 offered her assistance after she had shared her personal financial struggles, which resulted in the resident becoming emotional andcrying. She stated the resident offered her assistance after the concerns were shared because she would sleep better that night knowing staff #87 was not sleeping in her car. She stated that she had repaid $80.00 in cash to the resident. Staff #87 stated that facility policy did not allow facility staff members to solicit or accept money or support from a resident and that she wasmade aware of the policy in the employee handbook upon hire. She further stated that her actions were not compliant with facility policy and could result in imprisonment. Staff #87 stated that she resigned from her position on June 25, 2026 due to lack of full compensation for hours worked at the facility.An interview was conducted with Administrator/Staff #25 on August 27, 2026 at approximately 1:50 p.m., which revealed facility policy does not permit facility staff members to solicit or accept any monetary or material gifts from a resident. Staff #25 stated that Staff #87's actions were not compliant with facility policy and did not meet her expectations.An interview was conducted with Payroll HR Personnel/Staff #43 on August 27, 2026 atapproximately 1:58 p.m., which revealed facility policy is to pay a facility team member for all hours worked, regardless if the hours go above 40 in a pay period. She stated that staff #87 did not address any concerns with the facility with regard to a discrepancy between hours worked and hours compensated and that she did not resign from her position, she was terminated.Review of the facility employee handbook segment titled, Acceptance of Gifts and Gratuities - revised November 2024, revealed employees may not accept gifts or gratuities from any resident, family or friend of a resident, vendor, supplier, or other persons doing business with the Company. In addition, employees are prohibited from borrowing money from or lending money to residents, family or friends of residents, other employees, customers, or suppliers.

Based on clinical record review, staff interviews, and policy review, the facility failed to protect one resident's (#76) rights to be free from resident-to-resident abuse by another resident (#14). The deficient practice could result in residents being physically and emotionally harmed. Findings include:-Regarding Resident #76Resident #76 was admitted to the facility on [DATE], with diagnoses that included a disorder of the thyroid, muscle weakness, mild cognitive impairment, hypertension, and amnesia.An annual Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview of Mental Status (BIMS) assessment score of 14, which indicated intact cognition. The MDS revealed that the resident had not exhibited behaviors directed towards others and that she had amnesia. A change of condition (COC) assessment dated [DATE], revealed that on May 15, 2026, the resident had a resident-to-resident altercation with her roommate/husband, who became confused and started yelling and swinging towards his wife. The COC assessment revealed that the certified nursing assistant (CNA) and the nurse entered the room at the time of occurrence and noted that the resident was yelling, and that the male resident was aggressive and agitated. The COC assessment also revealed that the residents were separated, frequent checks were initiated, and all parties were notified, and that the change of condition involved the resident's husband/roommate becoming agitated and aggressive with her due to confusion. A progress note dated May 15, 2026, at 7:28 p.m. revealed that the nurse was informed by staff that screaming came from the resident room, and that the resident was hit by her spouse, according to the nurse and Certified Nursing Assistant (CNA). The note revealed that the resident had no idea why he was hitting her, and the spouse was removed from the room with skin and pain assessments completed, and the responsible party, Director of Nursing (DON/Staff 28), and the administrator were notified. A progress note dated May 15, 2026, at 7:46 p.m. revealed that the residents were immediately separated and that Resident #76 reported to the nurse that she felt safe, and that Resident #14 was just confused. A progress note dated May 16, 2026, at 4:58 p.m. revealed that the provider was notified of the patient's wishes to share a room with her husband, and agreed that the patient and her husband could be in the same room.A progress note dated May 16, 2026, at 7:30 p.m. revealed that the daughter was asked about the room-sharing situation between Resident #14 and Resident #76, due to being kept separate after the occurrence on May 15, 2026, and the daughter stated that she wanted them back together if they wanted to be put back together, and to follow their wishes. A progress note dated May 16, 2026, at 7:45 p.m. revealed that the nurse asked the resident throughout the day if she was ok or hurting, and the resident told them she was okay and not hurting anywhere. The note revealed that the nurse asked if she remembered what happened the night before, and the resident stated that she remembered police being there. The note also revealed that the nurse asked the resident if she felt safe if her husband came back into the room with her, and the resident stated, It'll be ok because I know you are all here if something happens. A progress note dated May 17, 2026, at 8:31 a.m. revealed that the DON interviewed the resident and that the resident was alert and oriented times three. It was documented that she was happy that her husband was back in the room with her, and that both residents reported they slept well together the night before. A progress note dated May 17, 2026, at 2:47 p.m. revealed that the resident was asked if she wanted her husband to move back into the room with her, or if she would feel more comfortable separate, and the resident stated that she wanted him back in their room and that she was not afraid. The note also revealed that the writer had educated the resident on the possibility of a similar situation happening again, because it was unpredictable, and the resident stated that she understood and would still like him to come back. A care plan focus initiated on May 17, 2026, revealed that the resident was at risk and experienced an altercation with another resident, her husband, with whom she shared a room. The care plan focus had goals that the resident would not experience injury or aggression from her roommate, her husband, and had an intervention to frequently check the room. A care plan focus initiated on May 17, 2026, revealed that the resident had a history of trauma with a goal to create an emotionally and physically safe environment, and had interventions to encourage the resident to verbalize feelings of distress and help the resident deal with anxiety-producing experiences. A progress note dated May 22, 2026, at 10:34 p.m. revealed that the nurse heard screaming coming from the unit, and she found the female resident screaming. The note revealed that the nurse assessed the situation and saw a man grabbing the female's wrist as she was trying to pull away while holding a tissue box. The note further revealed that the nurse approached the couple calmly and gently to redirect the male resident until he released the female. The note also revealed that the CNA approached the male and distracted him while the nurse assessed the female for injuries, and the patient stated, he hit me and grabbed me. The note revealed that the male did not recognize his wife and stated that he did not have a daughter before making confused statements and being separated and removed from the room. The note also revealed that the DON and the daughter of the residents were notified, and that Resident #76 did not have pain or any injuries noted at that time, while Resident #14 was taken to the nurses' station for 1:1 care and given his as-needed medication. The note revealed that the male resident was temporarily moved to another room. A progress note dated May 26, 2026, at 11:41 a.m. revealed that the DON interviewed Resident #76, who reported that she was never hit, and that the nurse reported that the resident shared he was hitting at her but did not connect with her, and that no nursing staff witnessed any hitting, pushing, or other violence. A medical practitioner's progress note dated May 30, 2026, at 9:24 a.m. revealed that the resident had recently been separated from her husband because he was demented and had become increasingly abusive towards her, and that she was quite tearful that day. -Regarding Resident #14Resident #14 was admitted to the facility on [DATE], with diagnoses that included dementia, atherosclerotic heart disease, hypertension, muscle weakness, atherosclerosis, cognitive communication deficit, hypothyroidism, left shoulder pain, and chronic kidney disease.A care plan focus initiated on February 18, 2026, revealed a behavior of verbal threats and yelling noted when CNAs attempted to get the resident into the shower with a goal for the resident to not hit or injure any resident or staff member in the next 90 days. An annual Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview of Mental Status (BIMS) assessment score of 09, which indicated mild cognitive impairment. The MDS also revealed that the resident had not exhibited physical or verbal behaviors directed towards others, and that he had non-Alzheimer's dementia. A progress note dated May 15, 2026, at 7:23 p.m. revealed that the nurse heard screaming on the unit and followed the scream to a room where she noticed Resident #14 hitting at his wife. The note revealed that the nurse intervened and stopped the hitting, and the resident stated, Get that bastard out of here, and you get out of here too. The note revealed that the nurse stated, You were hitting her and the resident stated to get that bastard out of the room. The note further revealed that the nurse saw the night nurse in the hall and explained what had happened, and the DON and daughter were notified of the situation, with the DON reporting that she would notify the administrator. A review of the facility's investigation dated May 15, 2026, revealed that the facility reported that at 7:15 p.m., a CNA heard a female resident yelling and ran into the room where Resident #14 struck Resident #76. The facility investigation revealed an investigation checklist with a resident-to-resident allegation date of May 15, 2026. The facility investigation also revealed that the administrator, DON, Arizona Department of Health Services (AZDHS), Adult Protective Services (APS), Ombudsman, power of attorney, physician, and police were notified of the altercation on May 15, 2026. The facility investigation revealed that Resident #14 woke up at approximately 7:20 p.m. on May 15, 2026, from what he described as a nightmare, was very confused, began yelling and frantically hitting his wife, Resident #76, and was telling her to leave before staff responded immediately and intervened. The facility investigation further revealed that the residents were re-interviewed in the morning, and neither could recall the incident. The investigation also revealed that the Registered Nurse (RN/Staff #92) who was coming onto the night shift on the day of the incident was interviewed and stated that she had just gotten on to her shift when Resident #76 and Resident #14 were yelling, and that the day shift Licensed Practical Nurse (LPN/Staff #70) and CNA ran to the room and broke them up. A continued review of the facility's investigation revealed a written witness statement form dated May 15, 2026, at 7:08 p.m. by the CNA, Staff #35, who stated that she heard a very loud scream and stepped out of another resident's room to see what was happening. The written statement further revealed that the CNA entered Resident #76 and Resident #14's rooms and saw Resident #14 repeatedly slapping his wife and striking her in the face while she tried to dodge his blows. The written statement also revealed that the CNA returned to the room at 7:40 p.m. and asked Resident #76 if she wanted to remain in the same room as her husband, and she replied that she did not. The facility investigation also revealed a written witness statement form dated May 15, 2026, at 7:10 p.m. by the LPN, Staff #70, who stated that she heard screaming down the hall and saw Resident #14 hitting his wife before she intervened and told him to stop hitting his wife. The facility investigation also revealed a written witness statement form dated May 15, 2026, at 7:30 p.m. by the RN, Staff #92, who stated that staff informed her of the incident and that the day shift nurse and CNA reported seeing the male resident hitting the female resident, and that notifications and room arrangements had been made. A medical practitioner's progress note dated May 16, 2026, at 4:50 p.m. revealed that the resident was a [AGE] year-old man who was residing in the same room as his wife in the facility. The note further revealed that the resident became quite aggressive at about 6 p.m. the day before, and he had to be forcibly removed from the room. The note also revealed that the resident's wife also had dementia and did not remember anything that happened with regard to aggressive behaviors, and that she was willing to take Resident #14 back into the room. The note revealed that the resident had not had any aggressive behaviors while his wife had been a resident at the facility, and when he was there by himself, he would become agitated. The note also revealed that the assessment of the resident was that he had dementia with agitation and belligerent behavior, including physical striking of his wife. A social services progress note dated May 17, 2026, at 2:12 p.m. revealed that the resident was involved in an incident with his wife over the weekend, which was reported to the administrator, daughter, and local officials, and that the residents were separated after the incident, but the daughter thought it was safe to put them back in the room together. A COC assessment dated [DATE], revealed that the resident was noted by the nurse and aid to have gotten severely confused and become agitated and aggressive with his roommate/wife. The assessment also revealed that the resident experienced behavioral changes, including physical aggression, danger to self or others, and other behavioral symptoms. The assessment revealed that the dangerous behaviors included hitting, yelling, and swinging arms, and that his behavioral changes included increased confusion, which was causing agitation and aggression. A care plan focus initiated on May 17, 2026, revealed that the resident had severe confusion that increased and caused behaviors including verbal and physical aggression. A care plan focus initiated on May 17, 2026, revealed that the resident experienced severe confusion that caused behaviors of agitation and aggression, at times, with interventions that included, after the occurrence on May 15, 2026, a room move being completed for the safety of the resident's wife and frequent room checks. An alert progress note dated May 24, 2026, at 12:21 a.m. revealed that the resident was moved to another room at 7 p.m., related to a recent incident with his wife, and that the resident was in a single private room. An alert progress note dated May 25, 2026, at 12:45 a.m. revealed that the resident had incidents with his wife on May 15, 2026, and May 22, 2026, and that he was moved temporarily to a single private room for the safety of others, and that he was resting in bed with his as-needed medication given. A social services progress note dated May 27, 2026, at 8:21 a.m. revealed that a trauma assessment was done that day with the resident due to a situation over the weekend between him and his spouse, with whom he shared a room. The note revealed that he did not seem to remember the incident and that the resident and spouse were separated for safety. A telephonic interview was attempted on June 9, 2026, at 12:52 p.m., 1:32 p.m., and 3:06 p.m. with a RN, Staff #92, with no success.A telephonic interview was conducted on June 9, 2026, at 12:54 p.m. with an LPN, Staff #70, who stated that physical abuse was defined as physical contact with a resident, including grabbing an arm, holding someone down, hitting, or slapping. The LPN stated that she witnessed the first time there was a resident-to-resident altercation between Resident #76 and Resident #14 in which Resident #14 hit Resident #76's left cheek with his right hand. The LPN stated that there were no bruises or markings at that time, and that the altercation was witnessed by her, and did happen. The LPN stated that Resident #14 was yelling get that bastard out of here while he was hitting her, and that the LPN witnessed him making contact with her face at least twice while Resident #76 tried to block it. The LPN stated that the couple would have marital spats, and it was reported that there was another allegation of abuse that happened after the altercation she witnessed, but that she was not there for the second altercation. The LPN further stated that Resident #14 moved back into the room after the first altercation, but that they were separated again after the second altercation, and Resident #14 had since passed away. A telephonic interview was conducted on June 9, 2026, at 2:01 p.m. with the Nurse Practitioner (NP/Staff #87), who stated that an altercation occurred between Resident #76 and Resident #14 a couple of weeks ago. The NP stated that the incident occurred when the Resident #14 woke up suddenly, was disoriented, and struck Resident #76, but could not recall which part of her body was hit. The NP stated that he was told that it was a one-time incident and that Resident #76 did not recall the incident when the NP met with her. The NP stated that it was confirmed that Resident #14 made physical contact with Resident #76, and that he was not immediately notified of the incident. The NP stated that the facility did not give him very detailed or specific information about the incident aside from what he said previously. A telephonic interview was attempted on June 9, 2026, at 2:09 p.m. with the Physician (MD/Staff #5) with no success. An interview was conducted on June 9, 2026, at 2:28 p.m. with the DON, Staff #28, who stated that physical abuse was any form of intentional hitting or intentional aggression to cause harm. The DON stated that slapping a resident and aggressively grabbing a resident would both be considered reportable incidents, and that her expectation of staff in witnessing a resident-to-resident altercation would be to separate them immediately, make sure the residents were safe, and then report to her or the administrator immediately. The DON stated that there was a witnessed altercation between Resident #76 and Resident #14 on May 15, 2026, and that she was notified of the incident around 7:30 p.m. by the RN, Staff #92. The DON stated that the nurse witnessed Resident #14 striking Resident #76, and there were no injuries or marks noted. The DON opened the resident's medical record and stated that after the May 15, 2026, incident, she was seeing a note regarding Staff #92, the RN, witnessing another incident where Resident #76 reported that Resident #14 hit her and grabbed her, and he did not recognize her. The DON stated that Staff #92 walked into the residents' room and saw Resident #14 grabbing and holding Resident #76's wrists, and that Staff #92 never reported to the DON the content of the progress note, or that he was agitated. The DON further stated that the note conveyed that there was aggression, the nurse did not report the aggression to her, and that it was her expectation that the note be reported to the DON because she would then be expected to report it to the administrator, who would have to report it to AZDHS, APS, the ombudsman, and police within 2 hours. The DON stated that they did not end up reporting or investigating the second altercation to any of the applicable state agencies, and that the date of the second incident was May 22, 2026. The DON stated that the risk of not following their policy, reporting, or investigating would be the risk against resident safety, and that the handling of the incident on May 22nd was not her expectation. A telephonic interview was conducted on June 9, 2026, at 3:09 p.m. with the interim administrator (Administrator/Staff #9), who stated that physical abuse was defined as forceful contact or unwanted forceful contact, and resident-to-resident abuse was defined as a resident punching, slapping, kicking, pulling, or pushing another resident. The administrator stated that abuse would be a reportable event, and that the timeframe for reporting was 2 hours to the long-term care board, the department of health, the police, the ombudsman, the family, the medical director, and regional staff. The administrator stated that an allegation alone is reportable, and that it was not up to the staff member to decide if an incident was abuse; they would need to let administration know about the allegation. The administrator stated that there was an altercation between a husband and wife who were residents at the facility, and that the POA was requesting the residents to stay in the same room together. The administrator stated that both of the residents had low BIMS scores; they were both impaired, and the husband had a night terror that resulted in an altercation in the middle of May 2026. The administrator stated that he could not recall the result of the investigation. The administrator also stated that the residents did not have any altercations before that one, and the administrator believed there was an incident after the first altercation. The administrator stated that the second incident involved staff hearing a noise in the room, the wife said she was fine, and the husband was confused about where he was, but there was nothing that he was made aware of as far as physical contact. The administrator stated that the progress note in the resident's medical record was an allegation of abuse that would be considered reportable, and that they did not report or investigate the second incident. The administrator stated that it would have been his expectation for staff to report the incident because of the nursing note indicating forceful contact with the grabbing of the wrist. The administrator stated that staff did not follow their abuse policy, a full investigation should have been done, and they needed to report it to the applicable agencies.Review of a policy titled, Abuse Prevention and Prohibition Program, dated January 2026, revealed that each resident had the right to be free from abuse. The policy revealed that the facility had zero tolerance for abuse and that staff must not permit anyone to engage in verbal, mental, or physical abuse. The policy revealed that the facility was committed to protecting residents from abuse by anyone, including but not limited to staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. The policy further revealed that the administrator was responsible for coordinating and implementing the facility's abuse-prevention policies, procedures, training programs, and systems. The policy also revealed that supervisors should have immediately intervened, corrected, and reported identified situations where abuse was at risk of occurring. The policy further revealed that if the administrator received a report of an incident or suspected incident of resident abuse, the administrator or designee would investigate the alleged incident.

Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure that the abuse policy was implemented following an incident of resident-to-resident abuse for two residents (#76 and #14). The deficient practice could result in residents being physically and emotionally harmed.-Regarding Resident #76Resident #76 was admitted to the facility on [DATE], with diagnoses that included a disorder of the thyroid, muscle weakness, mild cognitive impairment, hypertension, and amnesia.An annual Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview of Mental Status (BIMS) assessment score of 14, which indicated intact cognition. The MDS revealed that the resident had not exhibited behaviors directed towards others and that she had amnesia. A care plan focus initiated on May 17, 2026, revealed that the resident was at risk and experienced an altercation with another resident, her husband, with whom she shared a room. The care plan focus had goals that the resident would not experience injury or aggression from her roommate, her husband, and had an intervention to frequently check the room. A care plan focus initiated on May 17, 2026, revealed that the resident had a history of trauma with a goal to create an emotionally and physically safe environment, and had interventions to encourage the resident to verbalize feelings of distress and help the resident deal with anxiety-producing experiences. A progress note dated May 22, 2026, at 10:34 p.m. revealed that the nurse heard screaming coming from the unit, and she found the female resident screaming. The note revealed that the nurse assessed the situation and saw a man grabbing the female's wrist as she was trying to pull away while holding a tissue box. The note further revealed that the nurse approached the couple calmly and gently to redirect the male resident until he released the female. The note also revealed that the certified nursing assistant (CNA) approached the male and distracted him while the nurse assessed the female for injuries, and the patient stated, he hit me and grabbed me. The note revealed that the male did not recognize his wife and stated that he did not have a daughter before making confused statements and being separated and removed from the room. The note also revealed that the Director of Nursing (DON) and the daughter of the residents were notified, and that Resident #76 did not have pain or any injuries noted at that time, while Resident #14 was taken to the nurses' station for 1:1 care and given his as-needed medication. The note revealed that the male resident was temporarily moved to another room. A progress note dated May 26, 2026, at 11:41 a.m. revealed that the DON interviewed Resident #76, who reported that she was never hit, and that the nurse reported that the resident shared he was hitting at her but did not connect with her, and that no nursing staff witnessed any hitting, pushing, or otherwise violence. A medical practitioner's progress note dated May 30, 2026, at 9:24 a.m. revealed that the resident had recently been separated from her husband because he was demented and had become increasingly abusive towards her, and that she was quite tearful that day. -Regarding Resident #14Resident #14 was admitted to the facility on [DATE], with diagnoses that included dementia, atherosclerotic heart disease, hypertension, muscle weakness, atherosclerosis, cognitive communication deficit, hypothyroidism, left shoulder pain, and chronic kidney disease.An annual Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview of Mental Status (BIMS) assessment score of 09, which indicated mild cognitive impairment. The MDS also revealed that the resident had not exhibited physical or verbal behaviors directed towards others, and that he had non-Alzheimer's dementia. A care plan focus initiated on February 18, 2026, revealed a behavior of verbal threats and yelling noted when CNAs attempted to get the resident into the shower with a goal for the resident to not hit or injure any resident or staff member in the next 90 days. A care plan focus initiated on May 17, 2026, revealed that the resident had severe confusion that increased and caused behaviors including verbal and physical aggression. A care plan focus initiated on May 17, 2026, revealed that the resident experienced severe confusion that caused behaviors at times of agitation and aggression, with interventions that included, after the occurrence on May 15, 2026, a room move being completed for the safety of the resident's wife and frequent room checks. An alert progress note dated May 24, 2026, at 12:21 a.m. revealed that the resident was moved to another room at 7 p.m., related to a recent incident with his wife, and that the resident was in a single private room. An alert progress note dated May 25, 2026, at 12:45 a.m. revealed that the resident had incidents with his wife on May 15, 2026, and May 22, 2026, and that he was moved temporarily to a single private room for the safety of others, and that he was resting in bed with his as-needed medication given. A social services progress note dated May 27, 2026, at 8:21 a.m. revealed that a trauma assessment was done that day with the resident due to a situation over the weekend between him and his spouse, with whom he shared a room. The note revealed that he did not seem to remember the incident and that the resident and spouse were separated for safety. A request was made for an initial report and investigation for Resident #14 and Resident #76's altercation on May 22, 2026, and the DON signed and stated that they did not have an investigation for May 22. A telephonic interview was attempted on June 9, 2026, at 12:52 p.m., 1:32 p.m., and 3:06 p.m. with a RN, Staff #92, with no success.A telephonic interview was conducted on June 9, 2026, at 12:54 p.m. with an LPN, Staff #70, who stated that physical abuse was defined as physical contact with a resident, including grabbing an arm, holding someone down, hitting, or slapping. The LPN also stated that the timeframe for reporting and allegation of abuse was right away to the DON, administrator, or any supervisor she could get in touch with. The LPN stated that she witnessed the first time there was a resident-to-resident altercation between Resident #76 and Resident #14 in which Resident #14 hit Resident #76's left cheek with his right hand. The LPN stated that there were no bruises or markings at that time, and that the altercation was witnessed by her, and did happen. The LPN stated that Resident #14 was yelling get that bastard out of here while he was hitting her, and that the LPN witnessed him making contact with her face at least twice while Resident #76 tried to block it. The LPN stated that the couple would have marital spats, and it was reported that there was another allegation of abuse that happened after the altercation she witnessed, but that she was not there for the second altercation. The LPN further stated that Resident #14 moved back into the room after the first altercation, but that they were separated again after the second altercation, and Resident #14 had since passed away. A telephonic interview was conducted on June 9, 2026, at 2:01 p.m. with the Nurse Practitioner (NP/Staff #87), who stated that an altercation occurred between Resident #76 and Resident #14 a couple of weeks ago. The NP stated that the incident occurred when the Resident #14 woke up suddenly, was disoriented, and struck Resident #76, but could not recall which part of her body was hit. The NP stated that he was told that it was a one-time incident and that Resident #76 did not recall the incident when the NP met with her. The NP stated that it was confirmed that Resident #14 made physical contact with Resident #76, and that he was not immediately notified of the incident. The NP stated that the facility did not give him very detailed or specific information about the incident aside from what he said previously. A telephonic interview was attempted on June 9, 2026, at 2:09 p.m. with the Physician (MD/Staff #5) with no success. An interview was conducted on June 9, 2026, at 2:28 p.m. with the DON, Staff #28, who stated that physical abuse was any form of intentional hitting or intentional aggression to cause harm. The DON stated that slapping a resident and aggressively grabbing a resident would both be considered reportable incidents, and that her expectation of staff in witnessing a resident-to-resident altercation would be to separate them immediately, make sure the residents were safe, and then report to her or the administrator immediately, as per the facility policy. The DON stated that there was a witnessed altercation between Resident #76 and Resident #14 on May 15, 2026, and that she was notified of the incident around 7:30 p.m. by the RN, Staff #92. The DON stated that the nurse witnessed Resident #14 striking Resident #76, and there were no injuries or marks noted. The DON opened the resident's medical record and stated that after the May 15, 2026, incident, she saw a note regarding Staff #92, the RN, witnessing another incident where Resident #76 reported that Resident #14 hit her and grabbed her, and he did not recognize her. The DON stated that Staff #92 walked into the residents' room and saw Resident #14 grabbing and holding Resident #76's wrists, and that Staff #92 never reported to the DON the content of the progress note, or that he was agitated. The DON further stated that the note conveyed that there was aggression, the nurse did not report the aggression to her, and that it was her expectation that the note be reported to the DON because she would then be expected to report it to the administrator, who would have to report it to AZDHS, APS, the ombudsman, and police within 2 hours, as per the facility policy. The DON stated that they did not end up reporting or investigating the second altercation to any of the applicable state agencies, and that the date of the second incident was May 22, 2026. The DON stated that the risk of not following their policy, reporting, or investigating would include resident safety, and that the handling of the incident on May 22nd was not her expectation and did not align with the facility's policy.A telephonic interview was conducted on June 9, 2026, at 3:09 p.m. with the interim administrator (Administrator/Staff #9), who stated that physical abuse was defined as forceful contact or unwanted forceful contact, and resident-to-resident abuse was defined as a resident punching, slapping, kicking, pulling, or pushing another resident. The administrator stated that abuse would be a reportable event, and that the timeframe for reporting was 2 hours to the long-term care board, the department of health, the police, the ombudsman, the family, the medical director, and regional staff, as per the facility policy. The administrator stated that an allegation alone was reportable, and that it was not up to the staff member to decide if an incident was abuse; they would need to let administration know about the allegation. The administrator stated that there was an altercation between a husband and wife who were residents at the facility, and that the POA was requesting the residents to stay in the same room together. The administrator stated that both of the residents had low BIMS scores; they were both impaired, and the husband had a night terror that resulted in an altercation in the middle of May 2026. The administrator stated that he could not recall the result of the investigation. The administrator also stated that the residents did not have any altercations before that one, and the administrator believed there was an incident after the first altercation. The administrator stated that the second incident involved staff hearing a noise in the room, the wife said she was fine, and the husband was confused about where he was, but there was no physical contact that he was made aware of. The administrator stated that the progress note in the resident's medical record was an allegation of abuse that would be considered reportable, and that they did not report or investigate the second incident. The administrator stated that it would have been his expectation for staff to report the incident because of the nursing note indicating forceful contact with the grabbing of the wrist. The administrator stated that staff did not follow their abuse policy, a full investigation should have been done, and they needed to report it to the applicable agencies. The administrator stated that the risk of not reporting allegations of abuse was the potential of not protecting the resident through facility intervention. The administrator also stated that the risk of not investigating an allegation of abuse would be that they would not be able to put interventions in place appropriately, and if they are not aware of an allegation, it would be tough for them to follow their process and policy.Review of a policy titled, Abuse Prevention and Prohibition Program, dated January 2026, revealed that each resident had the right to be free from abuse. The policy revealed that the facility had zero tolerance for abuse and that staff must not permit anyone to engage in verbal, mental, or physical abuse. The policy revealed that the facility was committed to protecting residents from abuse by anyone, including but not limited to staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. The policy further revealed that the administrator was responsible for coordinating and implementing the facility's abuse-prevention policies, procedures, training programs, and systems. The policy also revealed that supervisors should have immediately intervened, corrected, and reported identified situations where abuse was at risk of occurring. The policy further revealed that if the administrator received a report of an incident or suspected incident of resident abuse, the administrator or designee would investigate the alleged incident. The policy revealed that the facility would report allegations of abuse immediately, but no later than 2 hours after forming the suspicion, if the alleged violation involved abuse or resulted in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman. The policy also revealed that the administrator would provide the state survey agency, law enforcement, and the Ombudsman with a copy of the investigative report within 5 days of the incident. The policy further revealed that the resident's attending physician and responsible party, if applicable, would also be notified of the allegation and outcome of the investigation.Review of the investigation section of the policy titled, Abuse Prevention and Prohibition Program, revealed that the facility would promptly and thoroughly investigate reports of resident abuse. The policy further revealed that the investigator would take some or all of the following steps: Review all relevant documentation, review the resident's medical record to determine events preceding the alleged incident, interview the person(s) making the incident report, interview any witnesses to the alleged incident, interview the resident (as medically appropriate), interview the resident's Attending Physician as needed to determine the resident's level of cognitive function and medical condition, interview facility staff members who have had contact with the resident during the period of the alleged incident, interview the resident's roommate, family members, and visitors, interview other residents, review all events leading up to the alleged incident, communicate with the administrator daily regarding the progress of the investigation, and prepare an investigation report documenting findings of the investigation. The policy also revealed that witness reports must be given in writing and should be signed and dated. The policy revealed that resident-to-resident altercations must be reported if the altercation was caused by a willful action. The policy also revealed that the presence of a mental disorder or cognitive impairment would not automatically preclude a resident from engaging in deliberate, non-accidental behavior.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that an incident of resident-to-resident abuse involving two residents (#76 and #14) was investigated. The deficient practice could result in residents being physically and emotionally harmed.-Regarding Resident #76Resident #76 was admitted to the facility on [DATE], with diagnoses that included a disorder of the thyroid, muscle weakness, mild cognitive impairment, hypertension, and amnesia.An annual Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview of Mental Status (BIMS) assessment score of 14, which indicated intact cognition. The MDS revealed that the resident had not exhibited behaviors directed towards others and that she had amnesia. A care plan focus initiated on May 17, 2026, revealed that the resident was at risk and experienced an altercation with another resident, her husband, with whom she shared a room. The care plan focus had goals that the resident would not experience injury or aggression from her roommate, her husband, and had an intervention to frequently check the room. A care plan focus initiated on May 17, 2026, revealed that the resident had a history of trauma with a goal to create an emotionally and physically safe environment, and had interventions to encourage the resident to verbalize feelings of distress and help the resident deal with anxiety-producing experiences. A progress note dated May 22, 2026, at 10:34 p.m. revealed that the nurse heard screaming coming from the unit, and she found the female resident screaming. The note revealed that the nurse assessed the situation and saw a man grabbing the female's wrist as she was trying to pull away while holding a tissue box. The note further revealed that the nurse approached the couple calmly and gently to redirect the male resident until he released the female. The note also revealed that the certified nursing assistant (CNA) approached the male and distracted him while the nurse assessed the female for injuries, and the patient stated, he hit me and grabbed me. The note revealed that the male did not recognize his wife and stated that he did not have a daughter before making confused statements and being separated and removed from the room. The note also revealed that the Director of Nursing (DON) and the daughter of the residents were notified, and that Resident #76 did not have pain or any injuries noted at that time, while Resident #14 was taken to the nurses' station for 1:1 care and given his as-needed medication. The note revealed that the male resident was temporarily moved to another room. A progress note dated May 26, 2026, at 11:41 a.m. revealed that the DON interviewed Resident #76, who reported that she was never hit, and that the nurse reported that the resident shared he was hitting at her but did not connect with her, and that no nursing staff witnessed any hitting, pushing, or otherwise violence. A medical practitioner's progress note dated May 30, 2026, at 9:24 a.m. revealed that the resident had recently been separated from her husband because he was demented and had become increasingly abusive towards her, and that she was quite tearful that day. -Regarding Resident #14Resident #14 was admitted to the facility on [DATE], with diagnoses that included dementia, atherosclerotic heart disease, hypertension, muscle weakness, atherosclerosis, cognitive communication deficit, hypothyroidism, left shoulder pain, and chronic kidney disease.An annual Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview of Mental Status (BIMS) assessment score of 09, which indicated mild cognitive impairment. The MDS also revealed that the resident had not exhibited physical or verbal behaviors directed towards others, and that he had non-Alzheimer's dementia. A care plan focus initiated on February 18, 2026, revealed a behavior of verbal threats and yelling noted when CNAs attempted to get the resident into the shower with a goal for the resident to not hit or injure any resident or staff member in the next 90 days. A care plan focus initiated on May 17, 2026, revealed that the resident had severe confusion that increased and caused behaviors including verbal and physical aggression. A care plan focus initiated on May 17, 2026, revealed that the resident experienced severe confusion that caused behaviors at times of agitation and aggression, with interventions that included, after the occurrence on May 15, 2026, a room move being completed for the safety of the resident's wife and frequent room checks. An alert progress note dated May 24, 2026, at 12:21 a.m. revealed that the resident was moved to another room at 7 p.m., related to a recent incident with his wife, and that the resident was in a single private room. An alert progress note dated May 25, 2026, at 12:45 a.m. revealed that the resident had incidents with his wife on May 15, 2026, and May 22, 2026, and that he was moved temporarily to a single private room for the safety of others, and that he was resting in bed with his as-needed medication given. A social services progress note dated May 27, 2026, at 8:21 a.m. revealed that a trauma assessment was done that day with the resident due to a situation over the weekend between him and his spouse, with whom he shared a room. The note revealed that he did not seem to remember the incident and that the resident and spouse were separated for safety. A request was made for an initial report and investigation for Resident #14 and Resident #76's altercation on May 22, 2026, and the DON signed and stated that they did not have an investigation for May 22. A telephonic interview was attempted on June 9, 2026, at 12:52 p.m., 1:32 p.m., and 3:06 p.m. with a RN, Staff #92, with no success.A telephonic interview was conducted on June 9, 2026, at 12:54 p.m. with an LPN, Staff #70, who stated that physical abuse was defined as physical contact with a resident, including grabbing an arm, holding someone down, hitting, or slapping. The LPN stated that she witnessed the first time there was a resident-to-resident altercation between Resident #76 and Resident #14 in which Resident #14 hit Resident #76's left cheek with his right hand. The LPN stated that there were no bruises or markings at that time, and that the altercation was witnessed by her, and did happen. The LPN stated that Resident #14 was yelling get that bastard out of here while he was hitting her, and that the LPN witnessed him making contact with her face at least twice while Resident #76 tried to block it. The LPN stated that the couple would have marital spats, and it was reported that there was another allegation of abuse that happened after the altercation she witnessed, but that she was not there for the second altercation. The LPN further stated that Resident #14 moved back into the room after the first altercation, but that they were separated again after the second altercation, and Resident #14 had since passed away. A telephonic interview was conducted on June 9, 2026, at 2:01 p.m. with the Nurse Practitioner (NP/Staff #87), who stated that an altercation occurred between Resident #76 and Resident #14 a couple of weeks ago. The NP stated that the incident occurred when the Resident #14 woke up suddenly, was disoriented, and struck Resident #76, but could not recall which part of her body was hit. The NP stated that he was told that it was a one-time incident and that Resident #76 did not recall the incident when the NP met with her. The NP stated that it was confirmed that Resident #14 made physical contact with Resident #76, and that he was not immediately notified of the incident. The NP stated that the facility did not give him very detailed or specific information about the incident aside from what he said previously. A telephonic interview was attempted on June 9, 2026, at 2:09 p.m. with the Physician (MD/Staff #5) with no success. An interview was conducted on June 9, 2026, at 2:28 p.m. with the DON, Staff #28, who stated that physical abuse was any form of intentional hitting or intentional aggression to cause harm. The DON stated that slapping a resident and aggressively grabbing a resident would both be considered reportable incidents, and that her expectation of staff in witnessing a resident-to-resident altercation would be to separate them immediately, make sure the residents were safe, and then report to her or the administrator immediately. The DON stated that there was a witnessed altercation between Resident #76 and Resident #14 on May 15, 2026, and that she was notified of the incident around 7:30 p.m. by the RN, Staff #92. The DON stated that the nurse witnessed Resident #14 striking Resident #76, and there were no injuries or marks noted. The DON opened the resident's medical record and stated that after the May 15, 2026, incident, she saw a note regarding Staff #92, the RN, witnessing another incident where Resident #76 reported that Resident #14 hit her and grabbed her, and he did not recognize her. The DON stated that Staff #92 walked into the residents' room and saw Resident #14 grabbing and holding Resident #76's wrists, and that Staff #92 never reported to the DON the content of the progress note, or that he was agitated. The DON further stated that the note conveyed that there was aggression, the nurse did not report the aggression to her, and that it was her expectation that the note be reported to the DON because she would then be expected to report it to the administrator, who would have to report it to AZDHS, APS, the ombudsman, and police within 2 hours. The DON stated that they did not end up reporting or investigating the second altercation to any of the applicable state agencies, and that the date of the second incident was May 22, 2026. The DON stated that the risk of not following their policy, reporting, or investigating would include resident safety, and that the handling of the incident on May 22, 2026, did not meet her expectations. A telephonic interview was conducted on June 9, 2026, at 3:09 p.m. with the interim administrator (Administrator/Staff #9), who stated that physical abuse was defined as forceful contact or unwanted forceful contact, and resident-to-resident abuse was defined as a resident punching, slapping, kicking, pulling, or pushing another resident. The administrator stated that abuse would be a reportable event, and that the timeframe for reporting was 2 hours to the long-term care board, the department of health, the police, the ombudsman, the family, the medical director, and regional staff. The administrator stated that an allegation alone is reportable, and that it was not up to the staff member to decide if an incident was abuse; they would need to let administration know about the allegation. The administrator stated that a facility investigation required statements and conducting an interview with the individuals involved, including staff members who were working, residents in the surrounding area, and the medical director. The administrator further stated that the investigation should be documented in a file and submitted as a 5-day report for all reportables. The administrator stated that there was an altercation between a husband and wife who were residents at the facility, and that the POA was requesting the residents to stay in the same room together. The administrator stated that both of the residents had low BIMS scores; they were both impaired, and the husband had a night terror that resulted in an altercation in the middle of May 2026. The administrator stated that he could not recall the result of the investigation. The administrator also stated that the residents did not have any altercations before that one, and the administrator believed there was an incident after the first altercation. The administrator stated that the second incident involved staff hearing a noise in the room, the wife said she was fine, and the husband was confused about where he was, but there was no physical contact that he was made aware of. The administrator stated that the progress note in the resident's medical record was an allegation of abuse that would be considered reportable, and that they did not report or investigate the second incident. The administrator stated that it would have been his expectation for staff to report the incident because of the nursing note indicating forceful contact with the grabbing of the wrist. The administrator stated that staff did not follow their abuse policy, a full investigation should have been done, and they needed to report it to the applicable agencies. The administrator stated that the risk of not investigating an allegation of abuse would be that they would not be able to put interventions in place appropriately, and if they are not aware of an allegation, it would be tough for them to follow their process. Review of a policy titled, Abuse Prevention and Prohibition Program, dated January 2026, revealed that each resident had the right to be free from abuse. The policy revealed that the facility had zero tolerance for abuse and that staff must not permit anyone to engage in verbal, mental, or physical abuse. The policy revealed that the facility was committed to protecting residents from abuse by anyone, including but not limited to staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. The policy further revealed that the administrator was responsible for coordinating and implementing the facility's abuse-prevention policies, procedures, training programs, and systems. The policy also revealed that supervisors should have immediately intervened, corrected, and reported identified situations where abuse was at risk of occurring. The policy further revealed that if the administrator received a report of an incident or suspected incident of resident abuse, the administrator or designee would investigate the alleged incident. Review of the investigation section of the policy titled, Abuse Prevention and Prohibition Program, revealed that the facility would promptly and thoroughly investigate reports of resident abuse. The policy further revealed that the investigator would take some or all of the following steps: Review all relevant documentation, review the resident's medical record to determine events preceding the alleged incident, interview the person(s) making the incident report, interview any witnesses to the alleged incident, interview the resident (as medically appropriate), interview the resident's Attending Physician as needed to determine the resident's level of cognitive function and medical condition, interview facility staff members who have had contact with the resident during the period of the alleged incident, interview the resident's roommate, family members, and visitors, interview other residents, review all events leading up to the alleged incident, communicate with the administrator daily regarding the progress of the investigation, and prepare an investigation report documenting findings of the investigation. The policy also revealed that witness reports must be given in writing and should be signed and dated. The policy revealed that resident-to-resident altercations must be reported if the altercation was caused by a willful action. The policy also revealed that the presence of a mental disorder or cognitive impairment would not automatically preclude a resident from engaging in deliberate, non-accidental behavior.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure that an incident of resident-to-resident abuse was reported within the required timeframe for two residents (#76 and #14). The deficient practice could result in residents being physically and emotionally harmed.-Regarding Resident #76Resident #76 was admitted to the facility on [DATE], with diagnoses that included a disorder of the thyroid, muscle weakness, mild cognitive impairment, hypertension, and amnesia.An annual Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview of Mental Status (BIMS) assessment score of 14, which indicated intact cognition. The MDS revealed that the resident had not exhibited behaviors directed towards others and that she had amnesia. A care plan focus initiated on May 17, 2026, revealed that the resident was at risk and experienced an altercation with another resident, her husband, with whom she shared a room. The care plan focus had goals that the resident would not experience injury or aggression from her roommate, her husband, and had an intervention to frequently check the room. A care plan focus initiated on May 17, 2026, revealed that the resident had a history of trauma with a goal to create an emotionally and physically safe environment, and had interventions to encourage the resident to verbalize feelings of distress and help the resident deal with anxiety-producing experiences. A progress note dated May 22, 2026, at 10:34 p.m. revealed that the nurse heard screaming coming from the unit, and she found the female resident screaming. The note revealed that the nurse assessed the situation and saw a man grabbing the female's wrist as she was trying to pull away while holding a tissue box. The note further revealed that the nurse approached the couple calmly and gently to redirect the male resident until he released the female. The note also revealed that the certified nursing assistant (CNA) approached the male and distracted him while the nurse assessed the female for injuries, and the patient stated, he hit me and grabbed me. The note revealed that the male did not recognize his wife and stated that he did not have a daughter, before making confused statements and being separated and removed from the room. The note also revealed that the Director of Nursing (DON) and the daughter of the residents were notified, and that Resident #76 did not have pain or any injuries noted at that time, while Resident #14 was taken to the nurses' station for 1:1 care and given his as-needed medication. The note revealed that the male resident was temporarily moved to another room. A progress note dated May 26, 2026, at 11:41 a.m. revealed that the DON interviewed Resident #76, who reported that she was never hit, and that the nurse reported that the resident shared he was hitting at her but did not connect with her, and that no nursing staff witnessed any hitting, pushing, or otherwise violence. A medical practitioner's progress note dated May 30, 2026, at 9:24 a.m. revealed that the resident had recently been separated from her husband because he was demented and had become increasingly abusive towards her, and that she was quite tearful that day. -Regarding Resident #14Resident #14 was admitted to the facility on [DATE], with diagnoses that included dementia, atherosclerotic heart disease, hypertension, muscle weakness, atherosclerosis, cognitive communication deficit, hypothyroidism, left shoulder pain, and chronic kidney disease.An annual Minimum Data Set (MDS) dated [DATE], revealed that the resident had a Brief Interview of Mental Status (BIMS) assessment score of 09, which indicated mild cognitive impairment. The MDS also revealed that the resident had not exhibited physical or verbal behaviors directed towards others, and that he had non-Alzheimer's dementia. A care plan focus initiated on February 18, 2026, revealed a behavior of verbal threats and yelling noted when CNAs attempted to get the resident into the shower with a goal for the resident to not hit or injure any resident or staff member in the next 90 days. A care plan focus initiated on May 17, 2026, revealed that the resident had severe confusion that increased and caused behaviors including verbal and physical aggression. A care plan focus initiated on May 17, 2026, revealed that the resident experienced severe confusion that caused behaviors at times of agitation and aggression, with interventions that included, after the occurrence on May 15, 2026, a room move being completed for the safety of the resident's wife and frequent room checks. An alert progress note dated May 24, 2026, at 12:21 a.m. revealed that the resident was moved to another room at 7 p.m., related to a recent incident with his wife, and that the resident was in a single private room. An alert progress note dated May 25, 2026, at 12:45 a.m. revealed that the resident had incidents with his wife on May 15, 2026, and May 22, 2026, and that he was moved temporarily to a single private room for the safety of others, and that he was resting in bed with his as-needed medication given. A social services progress note dated May 27, 2026, at 8:21 a.m. revealed that a trauma assessment was done that day with the resident due to a situation over the weekend between him and his spouse, with whom he shared a room. The note revealed that he did not seem to remember the incident and that the resident and spouse were separated for safety. A request was made for an initial report and investigation for Resident #14 and Resident #76's altercation on May 22, 2026, and the DON, Staff #28. signed and stated that they did not have an investigation for May 22. Review of State Agency Complaint Database did not reveal that the resident to resident altercation from May 22, 2026 was reported to the state agency within the required timeframe.A telephonic interview was attempted on June 9, 2026, at 12:52 p.m., 1:32 p.m., and 3:06 p.m. with a RN, Staff #92, with no success.A telephonic interview was conducted on June 9, 2026, at 12:54 p.m. with an LPN, Staff #70, who stated that physical abuse was defined as physical contact with a resident, including grabbing an arm, holding someone down, hitting, or slapping. The LPN also stated that the timeframe for reporting an allegation of abuse was right away to the DON, administrator, or any supervisor she could get in touch with. The LPN stated that she witnessed the first time there was a resident-to-resident altercation between Resident #76 and Resident #14 in which Resident #14 hit Resident #76's left cheek with his right hand. The LPN stated that the couple would have marital spats, and it was reported that there was another allegation of abuse that happened after the altercation she witnessed, but that she was not there for the second altercation. The LPN further stated that Resident #14 moved back into the room after the first altercation, but that they were separated again after the second altercation, and Resident #14 had since passed away. A telephonic interview was conducted on June 9, 2026, at 2:01 p.m. with the Nurse Practitioner (NP/Staff #87), who stated that an altercation occurred between Resident #76 and Resident #14 a couple of weeks prior to the interview. The NP stated that the incident occurred when the Resident #14 woke up suddenly, was disoriented, and struck Resident #76, but could not recall which part of her body was hit. The NP stated that he was told that it was a one-time incident and that Resident #76 did not recall the incident when the NP met with her. The NP stated that it was confirmed that Resident #14 made physical contact with Resident #76, and that he was not immediately notified of the incident. The NP stated that the facility did not give him very detailed or specific information about the incident or any other incident between the residents aside from what he said previously. A telephonic interview was attempted on June 9, 2026, at 2:09 p.m. with the Physician (MD/Staff #5) with no success. An interview was conducted on June 9, 2026, at 2:28 p.m. with the DON, Staff #28, who stated that physical abuse was any form of intentional hitting or intentional aggression to cause harm. The DON stated that slapping a resident and aggressively grabbing a resident would both be considered reportable incidents, and that her expectation of staff in witnessing a resident-to-resident altercation would be to separate them immediately, make sure the residents were safe, and then report to her or the administrator immediately. The DON stated that there was a witnessed altercation between Resident #76 and Resident #14 on May 15, 2026, and that she was notified of the incident around 7:30 p.m. by the RN, Staff #92. The DON stated that the nurse witnessed Resident #14 striking Resident #76, and there were no injuries or marks noted. The DON opened the resident's medical record and stated that after the May 15, 2026, incident, she saw a note regarding Staff #92, the RN, witnessing another incident where Resident #76 reported that Resident #14 hit her and grabbed her, and he did not recognize her. The DON stated that Staff #92 walked into the residents' room and saw Resident #14 grabbing and holding Resident #76's wrists, and that Staff #92 never reported to the DON the content of the progress note, or that he was agitated. The DON further stated that the note conveyed that there was aggression, the nurse did not report the aggression to her, and that it was her expectation that the note be reported to the DON because she would then be expected to report it to the administrator, who would have to report it to AZDHS, APS, the ombudsman, and police within 2 hours. The DON stated that they did not end up reporting or investigating the second altercation to any of the applicable state agencies, and that the date of the second incident was May 22, 2026. The DON stated that the risk of not following their policy, reporting, or investigating would include resident safety, and that the handling of the incident on May 22nd was not her expectation. A telephonic interview was conducted on June 9, 2026, at 3:09 p.m. with the interim administrator (Administrator/Staff #9), who stated that physical abuse was defined as forceful contact or unwanted forceful contact, and resident-to-resident abuse was defined as a resident punching, slapping, kicking, pulling, or pushing another resident. The administrator stated that abuse would be a reportable event, and that the timeframe for reporting was 2 hours to the long-term care board, the department of health, the police, the ombudsman, the family, the medical director, and regional staff. The administrator stated that an allegation alone is reportable, and that it was not up to the staff member to decide if an incident was abuse; they would need to let administration know about the allegation. The administrator stated that there was an altercation between a husband and wife who were residents at the facility, and that the POA was requesting the residents to stay in the same room together. The administrator stated that both of the residents had low BIMS scores; they were both impaired, and the husband had a night terror that resulted in an altercation in the middle of May 2026. The administrator stated that he could not recall the result of the investigation. The administrator also stated that the residents did not have any altercations before that one, and the administrator believed there was an incident after the first altercation. The administrator stated that the second incident involved staff hearing a noise in the room, the wife said she was fine, and the husband was confused about where he was, but there was no physical contact that he was made aware of. The administrator stated that the progress note in the resident's medical record was an allegation of abuse that would be considered reportable, and that they did not report or investigate the second incident. The administrator stated that it would have been his expectation for staff to report the incident because of the nursing note indicating forceful contact with the grabbing of the wrist. The administrator stated that staff did not follow their abuse policy, a full investigation should have been done, and they needed to report it to the applicable agencies within 2 hours. The administrator stated that the risk of not reporting allegations of abuse was the potential of not protecting the resident through facility intervention.Review of a policy titled, Abuse Prevention and Prohibition Program, dated January 2026, revealed that each resident had the right to be free from abuse. The policy revealed that the facility had zero tolerance for abuse and that staff must not permit anyone to engage in verbal, mental, or physical abuse. The policy revealed that the facility was committed to protecting residents from abuse by anyone, including but not limited to staff, other residents, consultants, volunteers, staff from other agencies serving residents, family members, legal guardians, surrogates, sponsors, friends, and visitors. The policy further revealed that the administrator was responsible for coordinating and implementing the facility's abuse-prevention policies, procedures, training programs, and systems. The policy also revealed that supervisors should have immediately intervened, corrected, and reported identified situations where abuse was at risk of occurring. The policy further revealed that if the administrator received a report of an incident or suspected incident of resident abuse, the administrator or designee would investigate the alleged incident. The policy revealed that the facility would report allegations of abuse immediately, but no later than 2 hours after forming the suspicion, if the alleged violation involved abuse or resulted in serious bodily injury to the state survey agency, adult protective services, law enforcement, and the Ombudsman. The policy also revealed that the administrator would provide the state survey agency, law enforcement, and the Ombudsman with a copy of the investigative report within 5 days of the incident. The policy further revealed that the resident's attending physician and responsible party, if applicable, would also be notified of the allegation and outcome of the investigation.

Based on closed record review, staff interviews, and review of policies and procedures, the facility failed to ensure informed consents were obtained for psychotropic medications and/or opioids for 3 residents (#42, #8 and #6). The sample size was 4 and the Universe was 50. The deficient practice could lead to residents receiving medications without fully understanding the risks and benefits. This could also increase the likelihood of adverse drug events.Findings include:Regarding Resident #42-Resident #42 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, dysphagia, unspecified Dementia, acute kidney failure, and cognitive communication deficit. Review of the Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated she was cognitively intact. The MDS also revealed Resident #42 was taking antidepressant and opioid medications.Review of the physician's orders for Resident #42 revealed the following:Tramadol HCI 50 Milligrams (MG) tablet, 1 tablet, to be administered by mouth every 6 hours as needed for breakthrough pain (4-5 on pain scale). The original order start date was July 1, 2024. The order was updated five times with the most recent start date of November 4, 2025.Oxycodone HCI 5 mg tablet, 1 tablet, to be administered by mouth every 4 hours as needed for pain scale 6-10. The order start date was November 4, 2025.Trazodone HCI oral tablet 50 MG, give 1 tablet by mouth as needed for insomnia at bedtime.Further review of the Resident #42's Electronic Health Record (EHR) did not reveal a signed consent to administer Tramadol and Oxycodone. It also did not reveal a signed psychotropic consent for Trazodone.The Opioid Medication Informed Consent form, submitted by the facility, revealed a signed consent, with an effective date of November 3, 2025. The consent form did not identify the names of the opioid medications Resident #42 was taking.Review of the November 2025 Medication Administration Record (MAR) revealed that Tramadol 50 milligrams (MG) was administered twenty-two times. The same November MAR further revealed that Oxycodone was administered eight times.Review of the December 2025 MAR revealed that Tramadol was administered three times. The same December MAR further revealed that Oxycodone was administered four times.Review of the January 2026 MAR revealed that Tramadol was administered once. The same January MAR further revealed that Oxycodone was administered six times.Regarding Resident #6-Resident #6 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dysphagia, Dementia, and cognitive communication deficit. Review of the quarterly MDS, dated [DATE], revealed Resident #6 had a BIMS score of 02 which indicated she had severe cognitive impairment. The same MDS also revealed Resident #6 was taking antipsychotic, antianxiety and antidepressant medications.Review of the Order Summary Report revealed physician's orders for the following medications:Alprazolam oral tablet 0.5 MG. Instructions indicated to give two tablets by mouth at bedtime for chronic anxiety. The order start date was noted as February 9, 2024.Paroxetine HCI oral tablet 40 MG. Instructions indicated to give one tablet by mouth one time a day related to depression. The original order start date was noted to be on April 27, 2023. The order was updated two additional times with most current start date of October 8, 2025.Remeron oral tablet 15 MG. Instructions indicated to give one tablet by mouth one time a day for major depressive disorder. The original order start date was noted to be on September 8, 2023. The order was updated eight times with the most current start date of May 30, 2024.Risperdal oral tablet 0.5 MG. Instructions indicated to give half a tablet by mouth one time a day for Dementia related to major depressive disorder. The original order start date was September 19, 2023. The order was updated five times with the most current start date of December 17, 2024.The facility submitted signed consent forms for the following medications:Paxil (Paroxetine) indicating the Medical Power of Attorney (MPOA) verbally consented on August 21, 2025. Remeron was signed by the MPOA on August 21, 2025.Risperidone was signed by the MPOA on December 24, 2024.Regarding Resident #8-Resident #8 was admitted to the facility on [DATE] with diagnoses that include traumatic ischemia of muscle (a condition where severe injury damages blood vessels causing lack of oxygen flow to muscle tissues), opioid dependence with opioid-induced sleep disorder, chronic respiratory failure with hypoxia, and pain in left knee. Review of the Quarterly MDS, dated [DATE], revealed Resident #8 had a BIMS score of 15 which indicated she was cognitively intact. The same MDS also revealed Resident #8 was taking antidepressant and opioid medications.Review of the physician's orders for Resident #8 revealed the following:Dilaudid Oral Tablet 4 MG, 1 tablet, to be administered by mouth three times a day for pain. The order start date was April 16, 2024.Further review of Resident #8's EHR did not reveal a signed consent to administer Dilaudid.Review of Opioid Medication Informed Consent, submitted by the facility, revealed a signed consent, with an effective date of January 5, 2026. The consent form did not identify the name of the opioid medication Resident #8 was taking.An interview was conducted on March 6, 2026 at 8:57 A.M. with Licensed Practical Nurse (LPN/Staff #11). He explained that when a patient is admitted , they would get consents for psychotropic medications and opioids if they come in with the orders. He further explained that if an order is put into place after a resident is admitted , then the nurse who puts the order into the EHR would also obtain the consent from the resident or their responsible party. Staff #11 shared that when he is administering medications to residents, he doesn't look to see if consent has been obtained for opioids and psychotropic medications because there shouldn't be an order in the system (EHR) if consent hasn't been obtained. Staff #11 explained that by not obtaining a signed consent prior to administering the medications could result in residents taking medications that they don't want.An interview was conducted on March 6, 2026 at 9:28 A.M. with the Assistant Director of Nursing (ADON/Staff #1). He shared that residents absolutely need signed consents for their opioid and psychotropic medications. He further shared that the consents were needed so that the resident and/or family are aware of the potential side effects of the medications. Staff #1 explained that once signed consents are obtained, they are then scanned into the EHR if a paper copy is signed or they sign the consents online. He further explained that either way, all signed consents are eventually put into the EHR.An interview was conducted on March 6, 2026 at 10:16 A.M. with the Regional Nurse, Interim Director of Nursing (Staff #101). Staff #101 explained that consents for psychotropic and opioid medications are obtain before the resident is admitted to the facility or upon admission. She further explained that Resident #8 had started taking Cymbalta in August 2024 but it was probably revised. Staff #101 was shown the Opioid Consent form for Resident #8 and she acknowledged that the form did not have the medication name on it. Staff #101 explained that they had created the form in-house and when they created it, they did not leave an area for the name of the medication to be typed up. She also shared that the form was signed on January 5, 2026. She further shared that they did not have an opioid consent form prior to this one so it was created to address that gap. Staff #101 was asked to review Resident #4's opioid consent form, submitted by the facility, and explained that the original form was what was used by the previous facility ownership and it didn't list the name of the medication. Staff #101 explained that the risk of not having signed consents are the residents can't tell them if they don't like the medications or if it didn't work for them in the past.Review of the facility's policy and procedure, titled Psychotherapeutic Drug Management, indicates it was last revised in June of 2020. The policy and procedure described that psychotherapeutic medications will not be administered by the Licensed Nurse until an informed consent by the Resident and/or their responsible party has been obtained and documented by the attending physician.

Based on closed record review, staff interview, and review of policies and procedures, the facility failed to ensure that medications were administered within the parameters established by physician's orders for three (#4, #42, and #52) out of five residents. The universe was 50. The deficient practice could cause over or under dosing of residents, altered mental status, or other health complications.Findings include:Regarding resident #42-Resident #42 was admitted to the facility on [DATE] with diagnoses that included type 2 diabetes, dysphagia, unspecified Dementia, acute kidney failure, and cognitive communication deficit. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #42 had a Brief Interview for Mental Status (BIMS) score of 13 which indicated she was cognitively intact. The same MDS also revealed Resident #42 was taking antidepressant and opioid medications.Review of the Pharmacy Review for Resident #42, dated December 2025 revealed a note, written by the pharmacist to the facility. The note asked the facility to review, with the nursing staff, that pain medications need to be given within parameters.Review of the physician's orders for Resident #42 revealed the following physician's orders:Acetaminophen 325 milligrams (MG) tablet, two tablets, to be administered by mouth every 6 hours as needed for mild pain (1-2 on pain scale) or a fever. Tramadol HCI 50 MG tablet, 1 tablet, to be administered by mouth every 6 hours as needed for breakthrough pain (4-5 on pain scale). Oxycodone HCI 5 mg tablet, 1 tablet, to be administered by mouth every 4 hours as needed for pain scale 6-10. A random sample of the Medication Administration Record (MAR) for the following months were reviewed:Acetaminophen was administered 4 times outside of the established parameters during June 2025. Tramadol was administered 5 times outside of the established pain parameters during November 2025.Tramadol was administered 3 times outside of the established pain parameters during December 2025.Acetaminophen was administered 2 times outside of parameters in January 2026Acetaminophen was administered 3 times outside of parameters in February 2026. Regarding Resident #4-Resident #4 was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery, dysphagia, cognitive communication deficit, and acute kidney failure. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. The same MDS also revealed Resident #4 was taking antidepressant, opioid, and anticonvulsant medications. The physician's orders for Resident #42 revealed an active physician's order for Acetaminophen 325 MG tablet and to give two tablets by mouth every 6 hours as needed for generalized or breakthrough pain rated 1-4.The February 2026 MAR revealed that Acetaminophen was administered outside of parameters on the following dates:February 5, 2026February 6, 2026February 19, 2026The care plan revealed that it was initiated on September 17, 2025. The care plan identified that Resident #4 required pain management due to acute/chronic pain related to the right hip. Identified interventions include administering analgesia per physician's orders. Regarding Resident #52- Resident #52 was admitted to the facility on [DATE] with diagnoses that included encephalopathy unspecified, acute and chronic respiratory failure, and acute kidney failure.The admission MDS, dated [DATE] revealed Resident #52 had a BIMS score of 14 which indicated she was cognitively intact. The same MDS also revealed Resident #52 was taking an Opioid.The physician's orders for Resident #52 revealed an order, dated February 20, 2026, for Oxycodone HCI Oral Tablet 10 MG and to give the medication by mouth every 4 hours as needed for pain rated 6-10. The February 2026 MAR revealed that Oxycodone was administered outside of parameters on February 26, 2026. The MAR further revealed that Resident #52 rated her pain as a 3. An interview was conducted on March 6, 2026 with Licensed Practical Nurse (LPN/Staff #11) at 8:57 A.M. Staff #11 explained that when a resident is having pain, he would then do a pain assessment for the resident and have them rate their pain level. He further explained that the physician's orders for the pain medications have parameters that explain which pain medications are to be given according to the pain level identified by the resident. When asked to review the MAR for Resident #4, Staff #11 identified that there were three days where Acetaminophen was administered outside of parameters during the month of February. When asked to review the MAR for Resident #52, Staff #11 identified that Oxycodone was administered once outside of parameters during the month of February. When asked what the risk, to the residents, would be when medication is not administered according to the Physician's orders, Staff #11 explained there would be a risk of overdose or unnecessary sedation of the residents.An interview was conducted on March 6, 2026 with the Assistant Director of Nursing (ADON/Staff #1) at 9:28 A.M. Staff #1 explained that when residents are experiencing pain, there are pain parameters with the as needed (PRN) medications such as opioids or Tylenol. He further explained that the parameters are in place so Nurses know which medication is appropriate to administer to residents. Staff #1 shared that the risk of not following the identified parameters would be residents experiencing over sedation, lethargy, respiratory distress, or constipation. When asked to review the MAR for Resident #4, Staff #1 identified that during the month of February, Acetaminophen was not administered within parameters. He also shared that the Nurse should have administered Tramadol for the higher pain rating. When asked to review the MAR for Resident #52, Staff #1 identified that during the month of February, Oxycodone was administered outside of parameters one time. He shared that administering Oxycodone for pain rated as a 3 was an overkill.An interview was conducted with the interim Director of Nursing (DON/Staff #101) on March 6, 2026 at 10:16 A.M. Staff #101 shared that staff should ask residents if they are having pain and have the resident rate their pain using the pain scale. Staff are to first offer a non-pharmacological intervention and if that doesn't work then they offer medications. She further shared that some residents don't want to take controlled medications even if they have extreme pain so options are provided to the residents and then staff are to monitor for side effects of the medications. Staff #101 was asked to review the February MAR for Resident #4 and she identified Acetaminophen was administered twice outside of parameters. When asked to review the February MAR for Resident #52, Staff #101 shared that Oxycodone was administered once outside of parameters. When asked to review the February MAR for Resident #42, Staff #101 shared that for Acetaminophen was administered once outside of pain parameters. When asked to review the December 2025 MAR for the same resident, Staff #101 shared that Tramadol was administered three times outside of pain parameters. When asked what were the pain parameters identified on the MAR for Tramadol, Staff #101 shared that it was to be given for pain rated 4-5 but instead was given for pain rated at 7 and 8. Staff #101 shared that based on her review of the MAR, just now, she sees that staff are not following Physician's orders. She further shared that the risk of not following the orders was the residents not being able to get ahead of the pain. She added that staff know residents will say yes to Oxycodone but they still need to follow the physician's orders and have supporting documentation if they plan on going a different route for the pain medications than what is ordered.Review of the facility's undated Policy and Procedure, titled Medication Administration, did not have language referencing administering medications according to pain parameters established by a Physician. Further review of the policy and procedure revealed that that resident's MAR will be reviewed for special considerations for administration including acceptable professional standards and principles. It also explains that prior to administering medications, three checks must be conducted. The three checks consist of comparing the physician's order, pharmacy label, and the MAR to ensure the accuracy of the medications.

Based on closed record review, staff interview, and review of policies and procedures, the facility failed to ensure that a licensed pharmacist performed a medication regimen review (MRR) for four (#4, #6, #8, and #42) out of five residents. The census was 50. The deficient practice could result in residents having preventable harm, functional decline, hospitalizations, or death.Findings include:Regarding Resident #4-Resident #4 was admitted to the facility on [DATE] with diagnoses that included aftercare following joint replacement surgery, dysphagia, cognitive communication deficit, and acute kidney failure. The Quarterly Minimum Data Set (MDS), dated [DATE], revealed Resident #4 had a Brief Interview for Mental Status (BIMS) score of 14 which indicated she was cognitively intact. The same MDS also revealed Resident #4 was taking antidepressant, opioid, and anticonvulsant medications.The Pharmacy Review documents, provided by the facility, revealed there were no Pharmacy Reviews for Resident #4 conducted by a licensed pharmacist for the following months:October 2025November 2025January 2026February 2026There was a pharmacy review conducted during December 2025 which indicated there were no recommendations. Related to Resident #6-Resident #6 was admitted to the facility on [DATE] with diagnoses that include Alzheimer's disease, dysphagia, Dementia, and cognitive communication deficit. The quarterly MDS, dated [DATE], revealed Resident #6 had a BIMS score of 02 which indicated she had severe cognitive impairment. The same MDS also revealed Resident #6 was taking antipsychotic, antianxiety, antidepressant, antibiotic, diuretic and hypoglycemic medications. The Pharmacy Review documents, provided by the facility, revealed there were no pharmacy reviews for Resident #6 conducted by a licensed pharmacist for the following months:September 2025October 2025November 2025January 2026February 2026. There was a pharmacy review conducted during December 2025 which indicated there were no recommendations. Related to Resident #8-Resident #8 was admitted to the facility on [DATE] with diagnoses that include traumatic ischemia of muscle (a condition where severe injury damages blood vessels causing lack of oxygen flow to muscle tissues), opioid dependence with opioid-induced sleep disorder, chronic respiratory failure with hypoxia, and pain in left knee. The Quarterly MDS, dated [DATE], revealed Resident #8 had a BIMS score of 15 which indicated she was cognitively intact. The same MDS also revealed Resident #8 was taking antidepressant and opioid medications.The Pharmacy Review documents, provided by the facility, revealed there were no pharmacy reviews for Resident #8 conducted by a licensed pharmacist for the following months:August 2025September 2025October 2025November 2025January 2026February 2026Related to resident #42-Resident #42 was admitted to the facility on [DATE] with diagnoses that include type 2 diabetes, dysphagia, unspecified Dementia, acute kidney failure, and cognitive communication deficit. The Quarterly MDS, dated [DATE], revealed Resident #42 had a BIMS score of 13 which indicated she was cognitively intact. The same MDS also revealed Resident #42 was taking antidepressant and opioid medications.The Pharmacy Review documents, provided by the facility, revealed there were no pharmacy reviews for Resident #42 conducted by a licensed pharmacist for the following months:September 2025October 2025November 2025December 2025January 2026February 2026An interview was conducted on March 6, 2026 at 9:28 A.M. with the Assistant Director of Nursing (ADON/Staff #1). He explained that the medication review, for all residents, is conducted upon admission with the facility's provider. He further explained that the facility receives a monthly packet from the pharmacist which is reviewed by him and the facility provider. He added that sometimes the pharmacist will make suggestions related to medications which the provider will either agree with or not. The Pharmacy Review document is then sent to medical records. Staff #1 was asked if he could provide the Pharmacy Review records for Resident #42. He confirmed that after reviewing the Pharmacy Review binder, he was not able to locate pharmacy reviews for Resident #42 for October 2025, November 2025, December 2025, January 2026 and February 2026. When asked for the Pharmacy Review records for Resident #8, he confirmed that he was not able to locate the records for Resident #8 for October 2025, November 2025, January 2026, and February 2026. He did share that the December 2025 review was done with no recommendations. Related to Resident #6, Staff #1 verified that he was not able to locate a Pharmacy Review record for Resident #6 for October 2025, November 2025, January 2026, and February 2026. He also verified that the December 2025 review was conducted with no recommendations. Staff #1 explained that he was not able to share if the reviews were conducted for the missing months due to not having the information at hand. He also explained that not having the pharmacy reviews done on a monthly basis was not acceptable because they want to make sure that everyone is looked at. He further stated that there might be some changes that are made to resident medications that do not conform to pharmacy standards. An interview was conducted with the Interim Director of Nursing (DON/Staff #101) on March 6, 2026 at 10:16 A.M. She explained that the pharmacist is at the facility on a monthly basis, but she stated that she believed that the Pharmacy Reviews only needed to be conducted on a quarterly basis. Review of the facility's policy and procedure titled, Drug Regimen Review indicated it was last revised in January 2025. The policy documented that the pharmacist will review each resident's medication regimen at least monthly to detect irregularities, as well as clinically significant risks and any actual or potential adverse outcomes associated with medication use. The policy further documented that the consulting pharmacist will document in the resident's medical record that the pharmacy medication review has been completed.

Based on observations, interviews, and review of facility policies and procedures, the facility failed to ensure food is stored in accordance to food safety standards and sanitation measures are followed regarding hairnets. The facility census was 50. The deficient practice could lead to residents contracting foodborne illnesses. Findings include:An initial observation of the kitchen was conducted on March 3, 2026 at 10:37 A.M. Cook/Staff #68 was observed preparing vegetables at the food preparation counter and did not have a beard net covering his beard. During the same initial observation a container of pickled beets with a use by date of February 27, 2026 was observed on the 3rd shelf in the refrigerator. A second kitchen observation was conducted, in the refrigerator, on March 4, 2026 at 2:36 P.M. A gallon sized ziplock bag containing several partial blocks of pasteurized processed white Swiss cheese was observed. The bag had a received by date of February 23, 2026 and a use by date of March 3, 2026. On March 4, 2026 at 2:41 P.M., in passing, Director of Nutritional Services/Staff #89 shared that she and the cooks are responsible to ensure that food does not expire. They go through their food supply twice a week to check the dates on the food packages. On March 4, 2026 at 2:51 P.M., an interview was conducted with the Cook/Staff #2. He explained that the first date on the food container is the open date and the 2nd date would be the use by date. When shown the gallon ziplock bag containing cheese, he shared that the food should have been tossed. He further shared that they don't typically use Swiss cheese unless it is on the menu and the last time it was on the menu was the week before. However, he couldn't tell with 100% certainty that anyone had requested Swiss cheese for a sandwich. Staff #2 explained that having expired food and serving it to the residents could lead to residents getting sick. An interview was conducted was Cook/Staff #86 on March 3, 2026 at 8:22 A.M. When asked when do hairnets need to be used in the kitchen, she stated that every time a staff member is in the kitchen, they are to use it to prevent hair from falling into the food or onto plates. Staff #86 also explained that when food is brought in, by a vendor, they will put the received date and the use by date on the food packages. She further explained that they cannot serve food past the use by date and at that point, the food should be tossed. Staff #86 also added that they toss the food by the use by date as a precaution because they don't know how long the food item has been out if the use by date is not identified. This could lead to residents getting sick due to a bacterial disease or some type of foodborne illness. An interview was conducted on March 6, 2026 at 8:28 A.M. with Staff #89. Staff #89 explained that hairnets have to be worn upon entering the kitchen and the same applies for the beard guards. She also shared that if food is not discarded by the discard date, it could cause a potential outbreak and residents could get a foodborne illness. Staff #89 further shared that both of these situations did not meet her expectations. Review of the facility's policy and procedure titled, Kitchen Sanitation - Operating and Cleaning indicated that it was last revised January 1, 2025. The policy explained that all kitchen staff must wear hairnets while in the kitchen and a beard guard when needed. It further explained that for food storage, all food items must be clearly labeled and dated upon delivery. It also indicated that when a food item is opened, it must be dated with an expiration date or discard date.

Based on resident and staff interviews, record review, facility documentation and policy review, the facility failed to ensure staffing information submitted was accurate. The census was 50. The deficient practice could result in residents receiving inadequate care due to potential lack of staffing.Findings include:The Payroll-Based Journal (PBJ) Staffing Data Report revealed that the facility consistently triggered for excessively low weekend staffing for three quarters and triggered for one star rating for two of the fiscal year 2025 quarters. Per the report, submitted weekend staffing data was excessively low and had a one star rating.The facility assessment reviewed on October 30, 2025 revealed that the facility was licensed for 58 residents; the current number of residents for the center was 50. Total admissions and discharges in the last year: 290 and 271. The facility had documented on the Daily Nursing Staffing with three nurses on day shift and two on the night shift. Per review of the daily nursing staffing. The facility had a registered nurse (RN) for at least 8 consecutive hours each day. Night shift had 3 certified nursing assistants (CNA) and day shift had four.During resident interviews conducted during the initial pool on March 3, 2026, revealed multiple residents, who were alert and oriented, who reported having to wait long periods of time before receiving assistance they needed. Resident #55 revealed that a nurse worked six days in a row due to open shifts. Resident #47 revealed that the call lights are not answered quickly and it takes forever. Resident #12 stated it can take 30-60 minutes for a call light to be answered. Resident #2 stated the facility was short handed one time and had to wait an hour 30 minutes for someone to answer the call light a couple days ago. Resident #13 felt the facility was under-staffed with CNAs, mostly on day shift.A request was made on March 4, 2026 at 2:55 p.m. for the data submission for staffing, including date, time and what was submitted. On March 5, 2026 at 9:11 a.m. the information was still not available. On the original 807 request for the information, a note was written by administrator Staff #30: timeclock inputs to Xchieve, Xchieve to CMS. At the same time, Staff #30 stated the information is in California and should be getting it any minute. A review was conducted of the PBJ submitter final file validation report obtained from the facility. The Total Employee Link Records portion failed to be submitted.An interview was conducted on March 5, 2026 at 1:05 p.m. with certified nursing assistant (CNA) staff #60 and revealed that the facility just started using agency staff and it has helped with getting daily tasks done. Staff #60 stated that he has had to work with only one other CNA in the building when other staff members have called off from work.An interview was conducted on March 5, 2026 at 1:10 p.m. with licensed vocational nurse (LVN) Staff #11 and revealed that most days (90%) there is enough time to get nursing duties completed on time. Staffing is an issue, especially when someone calls out. If someone calls out, you have to wait until someone comes in before you can leave. Finding replacements can be hard. There has been a lot of turnovers with staff in the past 6 months.An interview was conducted on March 6, 2026 at 10:33 a.m. with administrator Staff #30 and revealed that the expectations for staffing the clinical area of the facility is that they are meeting the state minimum and residents are receiving the care that they need. Staff #30 works with the staffing coordinator and the director of nursing to create the schedules. If the schedule cannot be filled with the facility staff, then agency will be brought in. If staff cannot be found to work, then the management staff will have to come in and cover. For nursing it is the nurse on call or the assistant director of nursing. Direct care staff include, CNAs, LPNs, RNs and therapy. Staff #30 was unable to tell what the turnover rate for nursing was and stated would need to look that up. All staff will swipe in to clock in, when starting to work and ending their shift. That data goes to Xchieve which is a company that sends the data to the Centers for Medicare & Medicaid Services (CMS). Staff #30 does not review the data after submission, someone in payroll reviews. The payroll team is in Texas. Staff #30 was unaware of any triggers with staffing or low star/one star staffing. The PBJ submitter final file validation report (that was obtained from the facility) was then shown to Staff #30. A review of the policy Staffing, Version 1.1 Revised October 2025, revealed that direct care staffing information per day (including agency and contract staff) is submitted to the CMS payroll-based journal system. All inquiries or concerns relative to our facility's staffing should be directed to the administrator or his/her designee.

Based on closed record review, interviews, and review of the facility's policies and procedures, the facility failed to ensure a physician's order was in place prior to one resident's (#60) discharge. The sample size was three and the universe was 50. The deficient practice could result in a resident having an unsafe discharge.Findings include:Resident #60 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following nontraumatic intracerebral hemorrhage affecting the right dominant side, dysphagia, acute kidney failure, and major depressive disorder.The admission Minimum Data Set (MDS), dated [DATE], revealed Resident #60 did not complete a Brief Interview for Mental Status (BIMS) assessment. Instead, staff assessed his cognitive skills for daily decision making as moderately impaired.The discharge MDS, dated [DATE], revealed that staff assessed his cognitive skills for daily decision making as severely impaired.The progress notes revealed an entry, dated November 24, 2025 at 3:54 P.M., indicating Resident #60 was discharged home with a family member.The physician's orders for Resident #60 did not reveal an order for the resident to be discharged from the facility.Resident #60's care plan did not reveal discharge goals or objectives.An undated Discharge Planning Review form indicated the resident was discharged home due to insurance. It was also noted that Resident #60 was not going to have a caregiver after discharge and no home services were in place.On March 5, 2026 at 2:41 P.M. A physician's order for the resident's discharge with home health services was submitted by the facility. Further review of the order indicates it was a verbal order with an order date of November 24, 2025 and was confirmed by the Assistant Director of Nursing (ADON/Staff #1). The printed date on the order was March 5, 2026.A secondary review of the physician's order list did not reveal a discharge order in the order tab Resident #60's EHR (Electronic Health Record).An interview was conducted on March 5, 2026 at 2:45 P.M. with Staff #1. Staff #1 shared that when a resident is discharging from the facility, they need a discharge summary, physician's orders indicating the resident is able to discharge from the facility, and a recapitulation of the resident's stay. Staff #1 further shared that the discharge orders can be found with the regular orders in the electronic health record (EHR). Staff #1 recalled remembering resident #60 and shared that she was issued a Notice of Medicare Non-Coverage (NOMNC) and the family had appealed. He also shared that even if a resident was given a NOMNC, they would still require a physician's order for a discharge and the orders would be in place prior to a discharge. When asked if a Physician's orders for discharge was in place prior to Resident #60 being discharged , he shared that he was asked by the Interim Director of Nursing (Staff #101) to put in the discharge orders today. He further shared that he was not sure of the Physician had given them an actual order for the discharge but recalled that the Physician was aware of the discharge as it was discussed during a Quality Assurance and Performance Improvement (QAPI) meeting. Staff #1 explain that the risk of discharging a resident without a Physician's order would be the resident being discharged when the Physician has a concern, related to the resident, that the facility is not aware of.An interview was conducted on March 5, 2026 at 3:00 P.M. with Staff #101. She explained that residents who discharge from the facility need to have a physician's order prior to discharge. Staff #101 shared that Resident #60 was discharged on November 24, 2025 and that the Physician's order was received the day of the discharge. However, she also confirmed that the discharge order was put into the EHR today.An interview was conducted on March 6, 2026 at 8:57 A.M. with Licensed Practical Nurse (LPN/Staff #11). He shared that everything related to a resident needs a physician's order and this included the discharge of a resident. He explained that they cannot do anything without a physician's order. Related to Resident #60, Staff #11 looked at the EHR and shared there was an order for the resident's discharge with home health services on November 24, 2025; however, he also explained that the order was created yesterday by the ADON (Staff #1). Staff #11 shared that the order tab section of the EHR would be the only place in the system where you could find the physician's orders. He also shared that when it comes to discharging residents, they are usually informed of the upcoming discharges by social services and he assumes that there would be an order for it since it is required. He added that he should be looking to see if there is an order before a resident is discharged from the facility.Review of the facility's policy and procedure, titled Transfer and Discharge revealed it was last revised in June 2020. The policy and procedure explained that residents are transferred or discharged upon a physician's order. It further explained that the resident's clinical record will have documentation from the physician indicating that the transfer/discharge is because it is either necessary for the resident's welfare or the resident's health has improved and no longer required services at the facility.

Based on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to ensure that a code status was accurate and consistent in the medical record for one resident #13 out of 14 sampled residents. The universe was 50. The deficient practice could result in a resident not receiving care consistent with the signed advance directive.Findings include:Resident #13 was admitted on [DATE] and discharged on [DATE] with diagnosis including essential primary hypertension, other acute osteomyelitis of the right ankle and foot, anemia, methicillin resistant staphylococcus aureus infection, rheumatoid arthritis, chronic kidney disease, type 2 diabetes mellitus with diabetic neuropathy, muscle wasting and atrophy, muscle weakness and other abnormalities of gait and mobility.The admission MDS (minimum data set) dated February 20, 2026 revealed that the resident had a BIMS (brief interview of mental status) score of 14, indicating that the resident was cognitively intact.The landing page of the electronic health record (EHR) revealed that the resident had been documented as a full-code.Additional documentation in the electronic health record revealed that the resident had signed a Prehospital Medical Care Directive effective February 19, 2026 which noted that in the event of cardiac or respiratory arrest, the resident opted to refuse any resuscitation measures to include cardiac compression, endotracheal intubation and other advanced airway management, artificial ventilation, defibrillation, administration of advanced cardiac life support drugs and related emergency medical procedures.The physician orders revealed no evidence of a DNR order; however, a review of the progress notes did reveal a medical practitioner note dated February 19, 2026 noting the code status as a DNR.The care plan revealed a focus area noting that a full code CPR (cardiopulmonary resuscitation) was in place effective February 24, 2026. The goal noted that the request for CPR was to be initiated and followed. Interventions documented that the medical record was to be reviewed and ensured that proper documents were signed, that nursing staff were to be consulted regarding any changes in health and that the resident and family were to be counseled regarding any emotional concerns arising from the decision.The Advanced Directives Book on the unit revealed a cover sheet noting resident names and indicated that resident #13 was documented as a full-code.An interview was conducted on [DATE] at 11:18 AM with staff #52, RN (registered nurse). The RN stated that if someone was 'coding' she would utilize the Advanced Directives Book on the unit to confirm whether a resident had a full-code status or DNR in place. Staff #52 stated that it was important to respect the resident's wishes regarding their advanced directives. Staff #52 reviewed the resident's EHR and stated that the landing page did show the resident to be a full-code. She then reviewed additional documents housed under the miscellaneous tab and stated that the resident did have a DNR form which was dated February 19, 2026 and stated that this form should also be in the Advanced Directives Book on the unit. Staff #52 reviewed the documentation on the unit and indicated that the orange DNR form was in the book; however, the RN confirmed that the first page of the book listing all resident names indicated that resident #52 was a full-code. Staff #52 stated that the risk for inconsistent documentation regarding advanced directives could include the resident not getting proper care.An interview was conducted on [DATE] at 12:03 PM with staff #101, interim DON (director of nursing). Staff #101 stated that the expectation regarding advanced directives was that staff should ensure that the order matches if someone is designated as a DNR and to make sure that the documentation is filled out correctly. Staff #101 stated that the information regarding advanced directives could be found in the resident's EHR. She further stated that there should be an order in place indicating that the resident is either a full-code or a DNR and that the resident's choice should be care-planned. Staff #101 stated that documentation needs to match, needs to be appropriate and everyone needs to be on the same page. The DON reviewed the resident's EHR and stated that the resident was a full-code, based on the documentation on the landing page. She then reviewed the miscellaneous tab and located the DNR form that was uploaded on February 19, 2026. She further stated that an order for a DNR was not in place as the information on the landing page in the EHR pulls directly from the orders. Staff #101 further stated that the DNR was also not care planned based on her review. Staff #101 stated that the risk could include having to get clarification to know what to do in an emergency and that takes time. She further stated that this could potential delay CPR, if indicated. An interview was conducted on [DATE] at 8:22 AM with staff #10 CNA (certified nursing assistant). Staff #10 stated that advanced directives were always documented in the EHR, but can also be found on the unit in a binder, if the resident is a DNR. Staff #10 stated that all documentation must be accurate in all areas or staff would not know what to do. He stated that the risk could include staff not acting on the resident's wishes.A review of the policy titled Advanced Directives, with a revision date of August, 2020 revealed that the facility will honor the resident's advanced directives.A review of the policy titled Physician Orders, with a revision date of February 2025 revealed that the purpose of the policy was to ensure that all physician orders are complete and accurate and that the medical records department will verify that physician orders are complete, accurate and clarified as necessary.

Based on clinical record reviews, staff interviews and facility policy and procedures, the facility failed to ensure that a complete and accurate level I PASARR was assessed on admission for one resident (#10). The universe was 50. The deficient practice could result in specialized services not being identified and provided to residents.Findings include:Resident #10 was admitted to the facility on [DATE] with diagnoses that included: generalized anxiety disorder, bipolar disorder, major depressive disorder, bariatric surgery status, post-traumatic stress disorder (PTSD), muscle weakness and morbid obesity.Resident #10's minimum data set (MDS) revealed a brief interview mental status (BIMS) score of 15, meaning the resident was cognitively intact.A care plan focus for Resident #10 revealed the resident was receiving psychotropic medication, Aripiprazole related to diagnosis of (PTSD)/bipolar disorder (behavior management. The date of initiation was January 25, 2026 with a revision on January 26, 2026. The preadmission screening and resident review (PASRR) from the hospital, revealed null for serious mental illness and mental illness.An interview was conducted on March 5, 2026 at 09:46 a.m. with social services clerk Staff #44 and regional licensed masters social worker Staff #102, revealed Staff #44 works on discharge planning from the beginning of admission and does not do anything with the PASRR. Staff #102 continued with giving information regarding PASRRs and that the facility just recently received the information to be able to submit PASRRs electronically. If a hospital inputs incorrect data on the PASRR, the expectation is to correct it immediately. A review of Resident #10's PASRR was conducted during the interview with the null answers and revealed that it meant there were no psychiatric diagnoses while at the hospital. Resident #10's diagnoses were reviewed and had diagnosis of anxiety, bipolar and depression. Staff #102 stated those should have been caught, a review should have been done to make sure a level II did not trigger. Staff #102 continued that Resident #10 had many diagnoses and Staff #49 could catch those when doing the MDS (minimum data set). The first catch is with admissions, MDS and with auditing.An interview was conducted on March 5, 2026 at 12:59 p.m. with MDS nurse Staff #49 and revealed that he was told that social services reviewed the PASRR and does not look to see if they are a level II. Staff #49 has never seen a level II from the hospital. The risk for not having an accurate level I on admission is that the resident would not get the services needed. There are certain facilities that provide that level of care needed.An interview was conducted on March 6, 2026 at 11:06 a.m. with admissions coordinator Staff #3 and revealed that the PASRR is reviewed prior to accepting a resident. A review is conducted by Staff #3 and the central intake team. The Level I PASRR is usually the last thing that is sent over prior to admission and a corporate auditor looks over the PASSR and all the information in the admission agreement.Review of the policy Pre-admission Screening Resident Review (PASRR) Version No. 1.0 Date Revised: 06/2020, all first-time applicants to the facility, regardless of Medicaid status or payer, must undergo a Level I PASRR screening before being admitted to the facility, or on the first day in which Medicaid reimbursement is requested.

Based on clinical record reviews, staff interviews and facility policy and procedures, the facility failed to ensure that a new level I PASARR was completed when a resident was in the facility for more than 30 days for one resident (#10) out of 13. The universe was 50. The deficient practice could result in specialized services not being identified and provided to residents.Findings include:Resident #10 was admitted to the facility on [DATE] with diagnoses that included: generalized anxiety disorder, bipolar disorder, major depressive disorder, bariatric surgery status, post-traumatic stress disorder (PTSD), muscle weakness and morbid obesity.Resident #10's minimum data set (MDS) revealed a brief interview mental status (BIMS) score of 15, meaning the resident was cognitively intact.A care plan focus for Resident #10 revealed the resident was receiving psychotropic medication, Aripiprazole related to diagnosis of (PTSD)/bipolar disorder (behavior management. The date of initiation was January 25, 2026 with a revision on January 26, 2026. Review of the preadmission screening and resident review (PASRR) from the hospital, null for serious mental illness and mental illness. A second level I PASRR was not found after Resident #10 had been at the facility for more than 30 days.An interview was conducted on March 5, 2026 at 09:46 a.m. with social services clerk Staff #44 and regional licensed masters social worker Staff #102, revealed Staff #44 works on discharge planning from the beginning of admission and does not do anything with the PASRR. Staff #102 continued with giving information regarding PASRRs and that the facility just recently received the information to be able to submit a PASRR. If a hospital inputs incorrect data on the PASRR, the expectation is to correct it immediately. Resident #10's diagnoses were reviewed. Anxiety, bipolar and depression. No corrected PASRR and the only PASRR that could be reviewed was the PASRR from the hospital during the interview.An interview was conducted on March 5, 2026 at 12:59 p.m. with MDS nurse Staff #49 and revealed that he was told that social services reviewed the PASRR and does not look to see if they are a level II and has never seen a level II from the hospital. The risk for not having an accurate level I on admission is that the resident would not get the services needed. There are certain facilities that provide that level of care needed.An interview was conducted on March 6, 2026 at 11:06 a.m. with admissions coordinator Staff #3 and revealed that the PASRR is reviewed prior to accepting a resident. A review is conducted by the Staff #3 and the central intake team. The Level I PASRR is usually the last thing that is sent over prior to admission and a corporate auditor looks over the PASSR and all the information in the admission agreement.Review of the policy Pre-admission Screening Resident Review (PASRR) Version No. 1.0 Date Revised: 06/2020, (in bold print) If the facility stay is longer than thirty days, a Level I screening must be performed within 40 days of admission.

Based on observations, clinical record reviews, resident and staff interviews, facility documentation and policy and procedures, the facility failed to ensure nail care was provided for one resident #7 out of 14 sampled. The universe was 50. The deficient practice could result in the resident not having their personal grooming needs met, potential injury or infection.Findings include: Resident #7 was admitted on [DATE] with diagnosis including gastrointestinal hemorrhage, sequelae of cerebral infarction, systolic (congestive) heart failure, anemia, acute kidney failure, acute respiratory failure with hypoxia, age-related osteoporosis, major muscle wasting and atrophy, muscle weakness, dysphagia-oropharyngeal phase, abnormalities of gait and mobility, cognitive communication deficit, need for assistance with personal care and neuromuscular dysfunction of the bladder. The 5-day MDS (minimum data set) dated February 9, 2026 revealed a BIMS (brief interview of mental status) score of 14, indicating that the resident was cognitively intact. The MDS further revealed no indicators of psychosis or noted behaviors. It was further documented in the MDS that the resident had upper extremity impairment on both sides and lower extremity impairment on one side. The care plan revealed that the resident had significant ADL (activities of daily living) deficits as related to health diagnosis, including impairment to both upper and lower extremities, dated February 10, 2026. Noted interventions included that the resident required caregiver assistance with personal hygiene/ oral care and that the resident required extensive assistance to reposition and turn in bed. The electronic medical record (EHR) revealed no documented evidence that issues regarding the resident's finger and toenails had been identified nor that either had been trimmed or cleaned. An observation conducted on March 3, 2026 at 12:01 PM revealed the resident laying elevated in her hospital bed. It was observed that the resident's left toenails were discolored with a yellowish tinge, brittle in appearance and extending a few centimeters above the tip of the toe. The right foot was observed to have an orthopedic-like boot in place. A wound dressing was also observed on the top of the left foot. A subsequent interview with the resident was conducted and she stated that the toenails had not been cut for several months. A secondary observation was conducted on March 4, 2026 at 11:05 AM revealing the resident again laying in an elevated hospital bed with her fingernails visible. One jagged fingernail (thumb) on the left hand was visible and the right hand revealed noted contractures. There was no evidence that the toenails had been trimmed. An interview was conducted on March 4, 2026 at 11:07 AM with staff #88, CNA (certified nursing assistant). Staff #88 stated that nail care is conducted during showers and then documented on the shower sheets. The CNA stated that nails that are jagged or above 1/4 of inch over the top of the nail would need to be trimmed by the CNA's. Staff #88 stated that some residents, if diabetic, would receive toenail care from the podiatrist, but otherwise the CNA would be able to trim the toenails. Staff #88 further stated that the shower sheets are located at each unit and that the nurses review them. The CNA stated that the risk of not trimming the nails could include the resident scratching themselves. An interview was conducted on March 4, 2026 at 11:22 AM with staff #11, LVN (licensed vocational nurse). Staff #11 stated that nail care for fingernails is conducted by CNA's as long as the resident was not 'diabetic'. Staff #11 stated that the documentation regarding nail care would be located in the EHR. Staff #11 stated that the podiatrist would be involved regarding toenail care. On March 4, 2026 at 11:31 AM staff #11 went into the room of resident #7 and stated that the left-hand thumb was jagged and should be clipped. He further stated that the left toenails are much too long and needed to be clipped. He stated that the risk to the resident could include scratches or infection. On March 4, 2026 at 11:33 AM the resident's assigned nurse, staff #52 RN (registered nurse) entered the room of resident #7 and observed the resident's nails. Staff #52 stated that both thumbs were too long and should have been clipped. Staff #52 further stated that the left thumb was jagged and that the toenails appeared to be a couple of centimeters above the top of the toe. Staff #52 explained that issues with nail care should be identified during weekly skin checks and that the issues with this resident's nails should have been caught, especially since the resident was also receiving wound care on the same foot. The RN stated that the CNA's are responsible for providing nail care when they conduct the showers, but stated it ultimately is the nurse's responsibility to identify the issue during skin checks and this had not been identified by either CNA's or the nurse. Staff #52 reviewed the shower-sheets for this resident and stated that nothing had been documented regarding the resident's 'excessively' long nails. Staff #52 further reviewed the skin checks for this resident and stated that a 'scab' had been documented but stated that there was no documentation regarding either the finger or toenails on any skin checks. An interview was conducted on March 4, 2026 at 12:14 PM with staff #101, interim DON (director of nursing). Staff #101 stated that the expectation regarding nail care is that all nails should be trimmed and cleaned underneath. She stated that this was work in progress in the facility. She further stated that nails should be looked at each time the resident is given a shower. Staff #101 stated that those responsible for nail care could include the CAN's, nurses, activities staff or podiatrist. Staff #101 stated that fingernail care would generally be conducted by CNA's unless the resident was diabetic. She further stated that toenail care for diabetics is generally conducted by scheduled podiatry visits. Staff #101 reviewed that resident's EHR for any documentation of podiatry notes or scheduling and stated that she did not see any evidence thereof. Staff #101 stated that the risk for not cleaning and clipping the nails could include germs under the nail bed which could result in infection and if nails are too long the risk of a self-inflicted skin tear. A review of the policy titled Grooming Care of the Fingernails and Toenails with no documented date, revealed that finger and toenails are to be trimmed by CNA's unless the resident exhibits the following conditions: diabetes or circulatory impairments, ingrown/ infected/ or painful nails and nails that are too hard or thick to cut. The policy further noted that the procedure is to be documented in the resident's medical record.

Based on observations, record review, staff interviews and policy review, the facility failed to ensure that medications/treatments are stored properly and not left at the bedside for one resident (#46). The facility census was 50. The deficient practice could result in harm to the residents, and/or visitors who have access to medications.Findings include:Resident #46 was admitted to the facility on [DATE] with the diagnosis that included left hand contracture, dysphagia, major depressive disorder and muscle weakness.The minimum data set (MDS), revealed a brief interview of mental status (BIMS) score of 10 which revealed resident with moderate cognition impairment.The care plan revealed no documentation for medications at the bedside.An observation was conducted on March 03, 2026 at 10:53 a.m. in Resident #46 's room and revealed an overbed table with a disposable bed pad covering the top of the overbed table. Items included a clear resealable bag with gauze, an abdominal pad package and band aids. An opened package of 200 count 4x4 gauze sponges, three individually wrapped blue sponge oral swabs, a silver package containing a wound dressing, a small black tube with a white cap, an opened 0.18 oz skin protectant individual package, a spray bottle of Skintegrity wound cleanser and a nearly full 16-ounce bottle of mineral oil with Lubricant Laxative written in smaller script below the larger printed Mineral Oil.An interview was attempted on March 3, 2026 at 10:55 a.m. with Resident #46 and was unsuccessful.An interview was conducted on March 03, 2026 at 11:03 a.m. in Resident #46 's room with registered nurse (RN) Staff #27 and revealed that the black tube on the overbed table was a tube of Medihoney that is used to treat wounds and staff stated that should not be kept at the bedside, the skin protectant is also a treatment and should not be at the bedside, the wound cleanser is just a cleanser and was not sure if that could be left in the room. Staff #27 did not know if mineral oil is considered a medication. Staff #27 concluded the interview by stating that patients are walking around and could come in and get to those items.An interview was conducted on March 03, 2026 at 11:46 a.m. with certified nursing assistant (CNA) Staff #77 and revealed that no medications or stuff for treatments are allowed to be left at the bedside.An interview was conducted on March 6, 2026 at 09:06 a.m. with regional nurse interim director of nursing (RN DON) Staff #101 and revealed that medications are not left at the bedside. Residents can have medications at the bedside if an assessment has been done, the doctor has been contacted, the self-administration form completed and signed by the resident and someone in the building. Medications are anything that is administered to the residents. Mineral oil is. Staff #101 only was aware of the wound cleanser being at the bedside, not the bottle of mineral oil, the Medihoney, or the skin protectant. The risk for leaving medications at the bedside or in the room is that somebody else could come in there and unintentionally take the meds.Review of the policy Medication Storage, date revised 01/2026 revealed, medications must be stored securely to prevent unauthorized access, diversion, loss, contamination or misuse.Review of the policy Medication-Administration Nursing Manual- Nursing Care VIII. Policy No. -NP-301 Employees Nursing staff, Version No. 1.0 revealed, medications will not be left at the bedside. Review of the policy Self-Administration of Medications revision date 08-2020 revealed that results from the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record on the care plan.

Based on record review, staff interviews, observations, and review of facility policies and procedures, the facility failed to follow infection control standards related to catheters for one resident (#27) out of 14 sampled. The deficient practice could lead to a high risk of CAUTI (catheter-associated urinary tract infections), contamination transfer or tube obstruction.Findings include:Resident # 27 was re-admitted on [DATE] with diagnosis including chronic kidney disease, mild cognitive impairment, weakness, acute kidney failure, urinary tract infection, muscle wasting and atrophy, infection and inflammatory reaction due to other urinary catheter, cognitive communication deficit, obstructive and reflux uropathy, and pneumonia.The 5-day MDS (minimum data set) revealed a BIMS (brief interview of mental status) score of 7, indicating severe cognitive impairment. The MDS further revealed that the resident had an indwelling catheter.The physician's orders revealed an order summary dated February 5, 2026 noting enhanced barrier precautions due to Foley catheter. Another order summary dated February 5, 2026 revealed that catheter care was to be conducted every shift and as needed. An order summary dated February 6, 2026 noted to change the catheter securement device every week.The care plan revealed a focus area dated March 3, 2026 which documented that the resident had an indwelling catheter related to urinary retention/ obstruction with noted interventions including to position the catheter bad and tubing below the level of the bladder and away from the entrance room door and to check tubing for kinks and maintain the drainage bag off the floor.An observation was conducted on March 5, 2026 at 7:39 AM in the 200 hallway. Resident #27 was observed seated in the wheelchair assisted with ambulation by staff #56 PTA (physical therapy assistant). The resident's catheter bag was observed below the wheelchair dragging on the floor. During the observation, staff #56 assisted resident #27 to a standing position and then walking through the hallway with the wheelchair behind the resident and the catheter bag still dragging on the floor.On March 5, 2026 at 7:41 an interview was conducted with staff #52, RN (registered nurse) regarding catheter bag placement. Attention was brought to the catheter bag trailing on the floor behind the resident and staff #52 stated that the bag should never be touching the floor under any circumstances and stated that the risk was an infection control issue. Staff #52 followed the resident to the dinning area where he was now seated and adjusted the catheter bag.An interview was conducted on March 5, 2026 at 7:45 AM with staff #56. Staff #56 stated that he had been assisting resident #27 from his room to the dining area. He stated that the privacy bag cover had been in place but observed the nurse adjusting the resident's catheter bag and stated that the bag was touching the floor and should not have been. Staff #56 stated that risk for the catheter bag touching the floor could include a rupture, pulling on the site and infection.An interview was conducted on March 5, 2026 at 12:53 PM with staff #101, interim DON (director of nursing). Staff #101 stated that the expectation regarding catheter bags is that they are secured, hanging either from the bed or wheelchair and that they should not be on the ground. Staff #101 stated that risk to the resident if the bag is touching the ground is one of infection control.An interview was conducted on March 6, 2026 at 8:22 AM with staff #10, CNA (certified nursing assistant). Staff #10 stated that catheter bags should be covered with a privacy cover, situated on the inside or and between the legs of the resident and properly anchored. Staff #10 stated that a catheter bag should never be allowed to touch the floor and stated that if it did touch the floor, the risk could include infection control or it could 'pop' open.A review of the policy titled Catheter-Care of, with a review date of January 2025, revealed the purpose of the policy was to prevent catheter-associated urinary tract infections (CAUTI) and ensure indwelling catheters are only used when medically necessary. The policy further noted that the catheter is to be anchored with a leg strap to prevent excessive tension on the catheter, which could lead to urethral tears or dislodging of the catheter. Regarding the collection bag, the policy noted to take care to ensure that the collection bag does not touch the floor at any time.

Based on interviews, review of clinical record, and review of facility policy and procedure, the facility failed to ensure a care plan was developed and implemented to meet the needs of a resident (#2) regarding falls. The deficient practice could result in residents not receiving necessary individualized care and services to meet their specific needs.-Findings include:Resident #2 was admitted to the facility on [DATE], with diagnoses that included unspecified intracranial injury without loss of consciousness, Alzheimer's disease with late onset, bipolar disorder, chronic obstructive pulmonary disease, and major depressive disorder.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #2 had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Section GG revealed the resident had no upper or lower extremity functional range of motion impairments on one side. Additionally, Section GG revealed the resident required supervision or touching assistance to perform rolling in bed to the left and right side.A care plan dated August 23, 2022, revealed Resident #2 has had an actual fall due to poor communication/comprehension, poor balance, and self-transfers from bed. Interventions included to keep bed in low position and to place fall mat beside bed on floor when resident is in bed. There was no evidence to specify whether a fall mat should be placed on the left side, the right side, or on both sides of the bed.Review of the clinical record revealed no evidence to specify that a fall mat should be placed on the left side, the right side, or on both sides of the bed.A Weekly Skin Check dated June 13, 2025, revealed Resident #2 had no skin impairments.An e-Interact Summary for Providers note dated June 17, 2025, revealed that the resident's change of condition was related to a fall, and that Resident #2 complained of lower back pain during brief changes. Provider feedback included to administer Tylenol and monitor for any increase in pain.A late entry General Progress Note effective June 17, 2025, and created by the Director of Nursing (DON / Staff #16) on June 22, 2025, revealed the staff nurse assessed the resident on the floor for injuries, no visible injuries noted. The resident was assisted to the bed with two staff assistance using a hoyer lift. The resident's vital signs were within normal limits, and neuro checks administered per protocol after an unwitnessed fall.The clinical record was reviewed and revealed no evidence of whether the resident's bed was low, or that a fall mat was beside the bed at the time of the fall, or if the resident fell onto the fall mat, or what side of the bed the resident fell from.A Health Status Note dated June 18, 2025, revealed the provider was called due to Resident #2's lower back pain, and a new order was received for lumber spine and pelvic x-rays.A Medical Practitioner Note dated June 18, 2025, revealed that Resident #2 was seen because of a fall that occurred during the night. The note revealed that the resident does have a fall mat on one side of bed, but fell on the other side. The resident was in bed, and was found on the floor. The resident complained of back pain and when examined, she was complaining of pain over the left sacral area and left hip area.A Weekly Skin Check dated June 19, 2025, revealed the resident had a nickel size abrasion on the front of the right knee and bruising to the top of the right foot probably from her fall.An interview was conducted on August 27, 2025, at 9:47 a.m. with a Certified Nursing Assistant (CNA / Staff #33) who was the scheduled CNA on Resident #2's hallway during day shift of June 17, 2025. Staff #33 stated that she was not working at the time Resident #2 fell on June 17, and that Staff #33 believed the resident fell after her shift ended. Staff #33 stated that she did not know if Resident #2 was supposed to have a fall mat on the left side, the right side, or both sides of the bed.On August 27, 2025, at 9:55 a.m, a telephonic interview was attempted with a Registered Nurse (RN / Staff #90), who was the scheduled day shift nurse on June 17, 2025, and who was no longer employed by the facility. A voicemail was left for a return call. The staff member did not return the call.A telephonic interview was conducted on August 27, 2025, at 10:17 a.m. with a CNA (Staff #53) who stated that she remembered Resident #2 and her fall on June 17, 2023, and that she was working on the resident's hallway that date. Staff #53 stated that it was around the time of shift change in the evening, and that Staff #53 and the floor nurse (Staff #81) entered Resident #2's room and found her on the floor. Staff #53 stated that the resident's bed was not low, and that right away we saw the bed was high. Additionally, Staff #53 stated that the resident did not have a fall mat at the bedside. Staff #53 stated that Resident #2 is supposed to have fall mats on both sides because she moves around in the bed a lot, and that because the resident has dementia and impaired cognition, she cannot be instructed to only get out of bed on one side. Staff #53 stated that Staff #81 assessed the resident right away and that they assisted the resident with a hoyer lift back into the bed. Staff #53 stated that the resident started screaming in pain when she was back in bed, and that Staff #81 administered the resident Tylenol for the pain, and continued to monitor the resident through the night. Staff #53 stated that after the fall, it was hard to turn Resident #2 in bed, because the resident was in pain.A telephonic interview was conducted on August 27, 2025, at 10:28 a.m. with a Licensed Practical Nurse (LPN / Staff #81). Staff #81 stated that Resident #2 had a fall during her shift on June 17, 2025. Staff #81 stated that she entered the room and noticed Resident #2 was on the floor, and that she assessed the resident, and did not notice any visible injuries, and that Staff #81 and the CNA (Staff #53) assisted the resident back into the bed. Staff #81 stated that she knew that there was no fall mat under the resident at the time of the fall, and that she was not sure if Resident #2 was supposed to have a fall mat, but that there was not a fall mat present.An interview was conducted with an MDS nurse and RN (Staff #7) on August 27, 2025, at 11:26 a.m. Staff #7 stated that the facility develops care plans for residents by incorporating data from assessments that the nurses and other department staff complete, and by creating goals and care plan interventions through collaboration between the Director of Nursing (DON), the Assistant Director of Nursing (ADON), and other departments. Staff #7 confirmed that the interventions to keep bed in low position and to place fall mat beside bed on floor when resident is in bed initiated in 2022 were part of the current care plan. Staff #7 stated that the staff determine if a resident is at risk for falls by completing a fall risk assessment done on admission, and that the care plan gets updated if a resident has a fall. Staff #7 additionally stated that floor staff can access a resident's care plan through the electronic medical record, so that care team members can see what interventions are in place for each resident. The care plan for Resident #2 was reviewed together, and Staff #7 stated that the intervention place fall mat beside bed on floor when resident is in bed means that when the resident is in bed, to have a fall mat beside the bed so that the resident would have a cushion to prevent major injury if they did fall or roll out of bed. Staff #7 stated that unless the care plan specified for the fall mat to be on the left or the right side, then it would mean for a fall mat to be on both sides of the bed.An interview was conducted with the DON (Staff #16) on August 27, 2025, at 12:58 p.m. The DON stated that the MDS nurse facilitates the development of comprehensive care plans for residents, and that interventions are discussed in morning clinical meetings. The DON stated that the facility determines if a resident is at risk for falls by completing fall risk assessments, and then the interventions are discussed in morning meeting to determine which interventions would be best for residents. The DON stated that staff can look up the care plan for each resident through the electronic medical record to see which interventions are in place for each resident. The care plan was reviewed for Resident #2, and the DON stated that the intervention place fall mat beside bed on floor when resident is in bed means to have the fall mat on the side of the bed that the resident was falling to previously. The DON reviewed the clinical record for Resident #2, and could not state which side of the bed the resident was falling to prior to her fall on June 17, 2025. Additionally, the DON stated that the care plan did not specify if the resident was supposed to have a fall mat on the left side, the right side, or both sides of the bed. The DON stated that for Resident #2, a fall mat should have been on both sides of the bed.Review of the facility policy titled Care Planning, revised January 2024, revealed that a comprehensive person-centered Care Plan will be developed for each resident. The Care Plan will include measurable objectives and timetables to meet a resident's medical, nursing, mental and psychosocial needs. Each resident's Comprehensive Care Plan will describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. The Interdisciplinary Team (IDT) will revise the Comprehensive Care Plan as needed at the following intervals: per RAI schedules; as dictated by changes in the resident's condition; in preparation for discharge; to address changes in behavior and care; and other times as appropriate or necessary.Review of the State Operations Manual, Appendix PP, issued August 8, 2024, revealed that under section S483.21(b)(1), the facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The intent is so that each resident will have a person-centered comprehensive care plan developed and implemented to meet his or her preferences and goals, and address the resident's medical, physical, mental and psychosocial needs.

Based on resident and staff interviews, observation, clinical record review, and policy review, the facility failed to ensure one sampled resident (#22) was provided adequate supervision to prevent elopement. The deficient practice could result in other residents eloping. Findings include: Resident #22 was admitted on [DATE] with diagnoses that included displaced fracture of left tibia, dementia, disorientation, concussion and need for assistance with personal care. An admission elopement risk assessment dated [DATE] revealed the resident was a moderate risk with a score of 6. Review of the Minimum Data Set (MDS) dated [DATE] indicated that the resident had a Brief Interview for Mental Status (BIMS) summary score of 10 indicating moderate cognitive impairment. A BIMS assessment conducted on April 15, 2025 revealed that the resident had a summary score of 3/15 indicating severe cognitive impairment. Review of the clinical record revealed an order on April 24, 2025 at 13:00 by the primary care physician (PCP) that the resident may have a wanderguard due to potential for elopement. Further review revealed another order on April 24, 2025 at 21:41 by the PCP that the wanderguards function was to be monitored. An alert charting progress note dated April 28, 2025 at 21:08 revealed the resident was last seen at 19:00 at the nurses station engaging in conversation with the nursing staff. The note further reveals that around 19:28 the nurse was notified by another nurse that hospital staff at the nearby emergency center recognized the resident sitting in the emergency room . The note states that the patient (PT) was dropped off at the emergency room without knowledge of the facility staff. A communication progress note dated April 28, 2025 at 21:58 indicated that staff contacted the residents Power of Attorney (POA) and advised them of the elopement. The note stated that the POA was aware of the resident's BIMs score and wandering. An activity progress note dated April 28, 2025 at 23:49 indicated that an inservice was completed with the overnight shift on the wanderguard system and door alarms. An observation and interview was conducted on May 6, 2025 at 1:30 p.m. for resident #22. The resident was easily agitated and was noted to be on one:one supervision. The resident stated that she wasn ' t aware it would be such a big issue to leave but could not recount the elopement. An interview was conducted on May 6, 2025 at 12:24 p.m., with a Licensed Vocational Nurse (LVN/staff #97). The LVN stated that the facility process is to visually check on the residents, if they have a wanderguard check its placement and check doors when the alarms go off. The LVN further stated that the resident ' s baseline cognition was that she had short term memory impairments.Staff #97 stated that the resident had a wanderguard in place and is now a one:one assist. The LVN recounted that around 7:00 p.m. she was passing meds and noticed the resident at the nurses station with the Director of Nursing (DON). She further stated that around 7:30 p.m. she was notified by another nurse on the unit that resident #22 was at the emergency room and she quickly notified her supervisor. Staff #97 stated that she ensured the resident was okay once she returned to the facility and that her wanderguard was in place. The LVN stated that the wander guard did not set off alarms at the time of the resident ' s elopement. Staff #97 identified the risks to be major or minor injury to the resident. An interview was conducted on May 6, 2025 at 12:37 p.m., with a certified nursing assistant (CNA/staff #58). The CNA stated that residents who are identified as an elopement risk are placed on wanderguards. The CNA stated that resident #22 had a wander guard the night that she eloped. Staff #58 stated that the resident was not a high risk resident when she first arrived but when altered levels of cognition were identified she was placed on the wanderguard. The CNA stated that she was the staff member who left to retrieve the resident and bring her back to the facility. An interview was conducted on May 6, 2025 at 1:38 p.m., with the Director of Nursing (DON/staff #14). The DON stated that residents who are elopement risks have a wanderguard bracelet in place and there are elopement binders at the nurses station. Staff #14 stated that if the resident gets too close to a door the alarms will go off and staff has to respond. The DON further stated that the resident was at first immobile but once she regained mobility became an elopement risk. The DON stated that her wanderguard was in place at the time of the elopement but the front door alarm was not working and she exited through there. Staff #14 stated that she was notified of the elopement at 7:35 p.m. and was told the resident knocked on the door of a nearby ' casita ' . The resident of said ' casita ' called 911 and the resident was taken to the emergency room . The DON identified risks to be massive injury or even death if a resident does elope. The facility's policy and procedure revised August of 2020 titled, ' Wandering and Elopement ' indicated that the facility will reinforce proper procedures for leaving the facility for residents assessed to be at risk of elopement.

Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure safe assistance was provided for one resident (#2) to prevent an accident during a hoyer lift transfer. The deficient practice could result in further incidents of staff providing unsafe assistance, resulting in harm to residents. Findings include: Resident #2 was admitted to the facility on [DATE], with diagnoses including unspecified open wound of right foot, multiple fractures of pelvis with stable disruption of pelvic ring, hypothyroidism, epilepsy, and disorder of bone density and structure. Review of the quarterly minimum data set (MDS) assessment dated [DATE], revealed the resident had a BIMS (brief interview for mental status) score of 15, indicating Resident #2 was cognitively intact. A care plan dated December 11, 2024, revealed the resident has an activity of daily living (ADL) self care deficit and requires mechanical hoyer lift for transfers. Review of the physician orders revealed no evidence of orders for monitoring a change of condition for Resident #2 on March 9, 2025. Review of a physician order dated March 10, 2025, documented at 11:45 AM, indicated for an x-ray of the right femur / of the right knee. Review of a physician order dated March 12, 2025, documented at 1:45 PM, indicated to send the resident to the emergency room (ER) for further evaluation of the right knee. Review of a Health Status progress note dated March 10, 2025, revealed new pain and possible injury to the resident's right leg as of yesterday, discussed with the medical doctor. Right femur and right knee x-rays were ordered and will be done the following day per the staff member with the mobile x-ray company. A documented Change of Condition Evaluation effective March 10, 2025, signed on March 17, 2025, by a Registered Nurse (RN / Staff #26), revealed the change in condition was that, patient injured on 03/9 while being transferred with hoyer. Additionally, the resident was having difficulty with mobility due to new onset of right femur pain. The pain was indicated as acute, and a pain scale level of 8, on the right lower femur. The note indicated that the medical provider was notified on March 10, 2025, at 11:00 AM, and an x-ray was ordered. A Medical Practitioner Note dated March 11, 2025, revealed Resident #2 was seen because of an injury to her right lower extremity. The resident was being transferred in a hoyer lift on March 9, 2025, and developed extreme pain in the right knee. The note indicated that the resident was evaluated by the nurse who noted that the straps on the hoyer lift were not the right ones for the resident. The assessment indicated a contusion to the right knee, and that x-rays pending to rule out fracture. A mobile x-ray report dated March 11, 2025, revealed slight distal cortical disruption with findings consistent with distal femur facture. A Medical Practitioner Note dated March 12, 2025, revealed the right femur x-ray shows cortical fracture and the resident is sent to the ER. Hospital records revealed a progress note dated March 13, 2025, indicating the resident had transferred from the ER to hospital admission and presents with concerns of right knee pain suffered during a hoyer lift transfer. A right knee x-ray report indicated an, oblique fracture involving the distal aspect of the right femur. A hospital discharge summary note dated March 14, 2025, indicated the resident was treated non-operatively for a closed fracture of the right distal femur, and to wear a knee extension brace on the right leg at all times. A facility Reportable Event Record dated March 18, 2025, revealed that on March 9, 2025, two Certified Nursing Assistants (CNAs), Staff #51 and Staff #30, were transferring Resident #2 from her wheelchair to her bed using a hoyer lift. When they started lifting her, the resident said that her leg was still strapped to the wheelchair. The CNAs lowered her back down to the chair, unstrapped her leg, then transferred the resident to the bed. During the transfer, the resident complained of pain in her leg due to the placement of the sling. The CNAs got another CNA (Staff #18) to help get the resident back to bed. Staff #18 came to the room and brought a different sling. The nurse was notified that the resident was in pain within 5 minutes. The nurse administered Tylenol. On March 10, 2025, the physician was notified and an x-ray was ordered. The x-ray was completed on March 11, 2025, indicating findings consistent with distal femur fracture. The resident was sent to the ER, and was transferred to a different hospital for further assessment. No surgical intervention were completed, and the resident returned to the facility on March 14, 2025. Interventions implemented after the incident included, staff were provided transfer education and proper sling sizing and placement; and that staff involved in the incident received additional education and demonstrated proper lift mechanics. A Witness Statement signed March 13, 2025, by a CNA (Staff #51) revealed that on March 9, 2025, at 1:30 PM, Resident #2 needed assistance with changing. The CNA got assistance from a second CNA for a hoyer lift transfer. During the transfer, the resident complained about pain in the inner thigh from the sling straps because of the type of sling being a crossed strap sling. While the resident was being lifted, the resident noticed a strap on her leg and told the CNAs to remove the strap. The resident was lowered back down, and the resident was complaining of pain. Another coworker came to assist. The resident was changed and then offered a different sling, and was then transferred back into the wheelchair. A Witness Statement signed March 14, 2025, by a CNA (Staff #18) revealed on March 9, 2025, during the incident, the CNA was in a different room providing care to another resident. Staff #30 came to the room and asked for assistance with Resident #2. When Staff #18 arrived to the room, Resident #2 was in bed and needed transferred back to her wheelchair. During and after, resident became very upset (yelling and screaming). Staff #18 tried to calm her. After the resident was transferred back in the wheelchair, the resident stated that one of the CNAs forgot to unstrap her leg, and during the lift it pulled on her leg. Staff #18 apologized that it had happened to her, and then left the room to care for other residents. A Witness Statement signed March 18, 2025, by a CNA (Staff #30) revealed on March 9, 2025, at 2:00 PM, Resident #2 was in the wheelchair, and Staff #30 was asked by another CNA (Staff #51) to assist with the transfer. Staff #51 had put the hoyer sling under the resident. The sling was attached to the hoyer. The staff attempted to raise the resident from the wheelchair with the mechanical lift, and then heard the resident yell, and the resident was lowered back down. Another CNA (Staff #18) was called for help, and then Staff #30 was called to another room to provide care. A Witness Statement, undated, and signed by a Licensed Vocational Nurse (LVN / Staff #60), revealed on March 9, 2025, after 2:00 PM, staff approached this nurse reporting that the resident was requesting Tylenol. The nurse went to the resident's room and the resident was sitting in her wheelchair. There were two CNAs in the room, and one reported that, the sling had slipped in transfer. The nurse asked the resident if she wanted a Tylenol. The resident stated, Yes, for my leg. The resident was given Tylenol at 2:26 PM. No visual injuries were noted at this time. At supper time, this nurse asked the resident if the Tylenol helped, and the resident stated that yes, it's better. The resident had no further complaints the rest of the shift. A Witness Statement signed March 15, 2025, by an RN (Staff #26) revealed on March 10, 2025, at 8:00 AM, Resident #2 stated that over the weekend, her right leg became injured after two CNAs used the wrong hoyer sling and that since then, the resident had a lot of pain with movement in her right leg. Resident #2 required frequent pain medication to stay comfortable. That morning, the resident's daughter came to see the resident and stated that the resident's, leg appeared slightly bent and that this was abnormal because her leg has a rod in it and is normally straight. The doctor was notified, and x-rays were ordered. An In-Service Training Report, dated March 18, 2025, revealed a one-on-one training occurred with a CNA (Staff #30) on the subject of mechanical lift. An observation was conducted on March 24, 2025, at 12:45 PM, of Resident #2 sitting in her wheelchair in her room. The resident had her right leg propped on an elevating leg rest, and on the resident's right leg was a leg immobilizing brace. An interview was conducted at this time with Resident #2. The resident stated that she was injured during an incident, had a leg fracture, and now has to wear a leg brace. She stated that the incident occurred during a hoyer transfer, when two CNAs who did not really know her used the wrong hoyer sling, that was for, a much bigger person. The resident stated that she screamed during the transfer; and that, the strap for the hoyer sling was at the wrong place, and was much lower down on her leg than it should have been. She stated that during the transfer, my leg was down. She stated, it was the strap that caused the break in her leg. Additionally, she stated that afterward, Staff #18 came into the room and told the two CNAs that he would take over. She stated she has not seen the two CNAs again since the incident. A telephonic interview was conducted with an LVN (Staff #60) on March 24, 2025, at 1:07 PM. The LVN stated that one of the CNAs had come to her and said that the hoyer lift sling had slipped; and that, Resident #2 was requesting pain medication because her leg was hurting. She stated that the CNAs were not specific in what went wrong with the hoyer transfer. When she went to the resident's room, the resident was sitting up in her wheelchair with a hoyer sling underneath her. She stated the resident asked for pain medication and the nurse administered it. A telephonic interview was conducted with a CNA (Staff #30) on March 24, 2025, at 1:57 PM who stated that herself and the agency CNA, whom she could not recall the name, assisted Resident #2 with putting on a hoyer sling -- because the resident did not have a sling under her initially while she was sitting in the wheelchair. Staff #30 stated that when they used the hoyer lift to raise the resident up, the resident started screaming, and then they lowered the resident back down to the wheelchair. She stated that Resident #2 was indicating her right knee was hurting her and kept putting her hands toward her knee. She stated that the resident usually has a blue strap around her right foot to the wheelchair, and that this strap was still attached. She stated that then she got the other CNA (Staff #18), and then notified the nurse (Staff #60). She stated that Staff #18 and the agency CNA then transferred the resident back to the bed while Staff #30 had to go answer call lights. She stated that as a result of this incident, that she received training and reviewed the whole hoyer transfer process, and had to sign a paper. A telephonic interview was conducted with a CNA (Staff #51) on March 24, 2025, at 2:03 PM, who confirmed that she was an agency CNA contracted to work at the facility. The CNA stated that she was not assigned to Resident #2 on the day of the hoyer transfer incident, but that she was answering a request to transfer Resident #2 from the wheelchair to the bed to provide care. Staff #51 stated that she thought the resident required a hoyer lift to transfer and went to get another staff member. She stated that she requested assistance from Staff #30; and that, the resident did not have a hoyer sling under her in the wheelchair, and that Staff #30 went to get a hoyer sling. Staff #51 stated that she believed from observing the way that the resident was sitting in the wheelchair, that the type of sling that should have been used was a sling that was whole. However, Staff #51 stated that the sling that Staff #60 brought was a different type, it was a sling that, you have to slide in the back of the resident and then cross between the legs. She stated that she was not sure what type of sling to use, but she knew Staff #30 had worked with the resident before, so they put the sling on the resident. Staff #51 stated that then, the two CNAs lifted the resident up in the hoyer lift and the resident still had a strap on her right foot. She stated that this strap was on her foot to hold the resident's foot on the wheelchair legrest to keep it from sliding off. She stated that when using the hoyer, that they had the resident lifted almost to the bed and then had to lower the resident back down. Staff #51 stated that Staff #30 should have removed the foot strap before the transfer because it was on her side, however Staff #51 stated that she unstrapped the resident's foot quickly as soon as she noticed. Then, she stated that Staff #18 walked into the room and helped to, take over the situation, and the resident was then assisted to the bed. Then, the nurse was notified and within 5 minutes assessed the resident. Staff #51 stated that the hoyer sling should never have been missing from the chair originally; and that, there were no other hoyer slings that herself or Staff #30 could find. A telephonic interview was conducted with Resident #2's daughter on March 24, 2025, at 2:29 PM. The resident's daughter stated that her understanding of the incident was one agency staff member and one, not too experienced staff member were using a hoyer to transfer the resident. The resident's daughter stated that, we are trying to set up a meeting where the facility is going to reconstruct the incident to figure out what angle could have caused the injury. She stated that staff at the facility have used phrases such as, the sling slipped to describe what happened during the incident. Additionally, she stated the facility staff have informed her that they will no longer have agency staff care for Resident #2 while she is using the hoyer. An additional telephonic interview was conducted with a CNA (Staff #18) on March 24, 2024, at 2:38 PM who stated that he was in a different room at the time of the hoyer transfer incident involving Resident #2. He stated that he witnessed the aftermath when he walked into the resident's room and saw that the two CNAs that were in the room with Resident #2 were not able to calm her down. Staff #18 stated that the resident was, clearly in pain and distress. Staff #18 stated that there was nothing he could do, except diffuse the situation and try to calm Resident #2 down. He stated that it was clear that at some point during the transfer that the two CNAs assisting had made mistakes, so he asked what had happened. He stated that he was told that one of the CNAs did not position the sling correctly and additionally, that they, forgot to unstrap her leg from the wheelchair legrest. He stated that because the resident has dropfoot on her right foot and had a fused right knee, that she requires a strap to keep her foot from sliding off of the leg rest, and that during the hoyer transfer incident, this strap had not been unstrapped by the CNAs, keeping the resident's foot secured to the leg rest as the resident was being raised in the hoyer lift. He stated that Resident #2, has fear now and, now she's scared of everybody. An interview was conducted with the Director of Nursing (DON / Staff #9) on March 24, 2025, at 4:37 PM, who stated that her expectation for staff to keep residents free from accidents is to follow best practice and the facility policy. She stated for hoyer transfers, there should be two staff members assisting; and that, staff check with the therapy department if they are not sure how to assist a resident with a transfer. The interview continued, and the DON stated that her understanding of the hoyer lift incident with Resident #2 was that a staff CNA and an agency CNA were going to transfer Resident #2 back to bed from her wheelchair. The staff put the sling on the resident, and when the staff lifted the resident, she yelled, and they lowered her back down to her wheelchair. The staff then got additional help from another CNA. The DON stated that statements had been taken from staff, and that nobody had informed her that anything was done incorrectly during the transfer. The DON stated that, we had a stat x-ray in the building, and resident was sent to the ER was diagnosed with a fracture in her femur above the knee. She stated that there was supplemental training done with all staff on hoyer transfers and that each resident's sling will be left in their room. An interview was conducted with an RN (Staff #26) on March 25, 2025, at 8:31 AM. Staff #26 stated that he was not in the facility on the day that the incident occurred with Resident #2 and the hoyer transfer, but was the resident's nurse the following day on March 10, 2025. The RN stated that the night nurse told him there had been an injury the day before, that, maybe there was a wrong sling that was used and caused the resident's leg to hurt. On March 25, 2025, the regional Director of Operations (DO / Staff #89) signed a statement that the facility had no other policies for accidents or incidents other than the policy titled Incident Log. Review of the facility policy titled, Incident Log, dated June 2020, revealed the purpose is to provide a system for the facility to track incidents and analyze trends to identify root cause and improve the quality of care provided to residents. The facility will log incident reports as they occur. In the event of an incident, a licensed nurse or the individual who first witnesses the incident will complete an Incident/Accident Report Form and ensure the following is included: resident name, day and shift which the incident occurred, type, injury, location, severity, and medication/treatment error. Review of the facility procedure titled How to Use a Hoyer Lift, dated October 2013, revealed the U-Sling is a type of hoyer sling that wraps around the thigh and crosses between the legs of the consumer. Review of the facility procedure titled Patient Lifts Safety Guide, undated, revealed that before using a patient lift, check the patient's weight and physical condition to make sure you have the correct lift and sling for the patient's condition. Assess patient's size, weight, and hip measurement. Choose the size of sling based on manufacturer's recommendation for patient's measurement. Choosing correct sling size is critical for safe patient transfer. If the sling is too large, the patient may slip out. If the sling is too small, the patient may fall out or the sling may worsen a patient's condition. Using the wrong type of sling may cause serious injury. Some factors that may affect sling choice between the U-sling and the full-body hammock style sling are patient's size and weight, pressure sensitivity, need for padding, and patient's preferred or medically appropriate position. Review of the manufacturer's instructions for the utilized facility Lift equipment, revised October 24, 2024, revealed the procedure for using the U-Sling included the note that if the patient's legs are extremely rigid, it may work better to bring the left sling leg under the right thigh and the right sling leg under the left thigh instead of threading between the patient's legs. The top of the sling must reach just above the patient's shoulders and the base of the sling should be 2 inches below their tailbone. If you have gone under both legs with the sling legs for a rigid patient, bring the loops straight up along the outside of the legs and hook on the longest loop. Crossing the leg straps is the most common procedure, however caregivers must assess the condition of the patient to determine what method is appropriate.

Based on clinical record reviews, staff interviews, manufacturer's recommendations, and facility documentation and policy, the facility failed to ensure that fall safety interventions were consistently documented and implemented for five residents (#3, #9, #8, #7, and #1) resulting in falls and the facility failed to ensure one resident did not receive an injury from a heating pad (#4). The sample size was 6 residents. The deficient practice increases the risk of accidents and resident harm. Findings include: Regarding falls: -Resident #3 was readmitted on [DATE] with [DIAGNOSES REDACTED]. The resident's blood pressure care plan dated December 19, 2019 revealed the resident had [MEDICAL CONDITION] (low blood pressure) related to reports of feeling fatigue and [MEDICAL CONDITION]. The goal was to have the resident be free of complications related to [MEDICAL CONDITION]. Interventions included to encourage the resident to get up slowly, to sit on the edge of the bed before standing, and to monitor, document, and report any signs of dizziness, [MEDICAL CONDITION], fatigue, and [MEDICAL CONDITION] to the provider as needed. Review of the fall care plan revealed that on December 26, 2018, specific interventions for fall prevention were documented. These included to educate the resident/family and Interdisciplinary team as to causes of fall, encourage resident to participate in activities that promote exercise, physical activity for strengthening and improved mobility, continue to follow recent therapy safety cues, monitor resident for significant changes in gait, mobility, positioning device, standing/sitting balance and lower extremity joint junction and to monitor visual and auditory impairments. A therapy note dated January 25, 2019 included that the resident was to receive RNA (Restorative Nursing Assistance) 3-5 times per week as tolerated including daily gait (walking) with a walker using CGA (Contact-Guard Assist) as tolerated pending blood pressure, and exercise bike for 10-15 minutes to both upper and lower extremities. It also included instructions to monitor vitals and to not ambulate the resident if hypotensive. The resident's restorative care plan dated January 28, 2019 included that the resident had a need for restorative services due to limited mobility related to [MEDICAL CONDITION] and low blood pressure as evidenced by fatigue and unsteady gait. The goal was that the resident would increase level of mobility by walking 100 feet with 1 assist and using a walker. Interventions included active ROM (Range of Motion) using the exercise bike on both upper and lower extremities 3-5 times per week and walking with 1 person assist as tolerated 3-5 times per week pending blood pressure and not to ambulate if hypotensive. Review of the clinical record revealed no evidence that the RNA services were provided to the resident from January 26 through February 18, 2019. The discharge with return anticipated MDS (Minimum Data Set) dated February 19, 2019 revealed that the resident had an unplanned discharge to an acute hospital. The assessment also included that the resident had one fall with no injury since admission or prior assessment. The resident was readmitted to the facility on [DATE]. The PT Plan of Care dated February 27, 2019 included a [DIAGNOSES REDACTED]. Therapy was not recommended as the resident was not agreeable to participate, had low motivation, and poor initiation. The resident's rehab potential was poor due to decreased motivation, [MEDICAL CONDITION] limiting out of bed activities, low endurance and decreased medical status. Discharge plan included RNA program as tolerated. The admission MDS dated [DATE] included a BIMS (Brief Interview for Mental Status) score of 10 indicating resident had moderately impaired cognition. The assessment also included the resident was frequently incontinent of bladder, occasionally incontinent of bowel, was not on urinary or bowel training program, required extensive assistance with 2 people with bed mobility, transfers and toilet use and extensive assistance with 1 person assist with walking in the room. According to the MDS, the resident was not steady and only able to stabilize with human assistance with moving from seated to standing position, walking (with assistive device if used), turning around and facing the opposite direction while walking, moving on/off toilet and surface to surface transfer. It also included there was no RNA performed in the last 7 days of the assessment. There was no evidence in the clinical record that RNA was implemented and provided to the resident as recommended by PT from February 27 through March 10, 2019. Fall #1: March 10, 2019 Review of a fall tool assessment, a fall scene huddle worksheet, a facility incident report, and an incident detail form from March 10, 2019 revealed the following: -A fall tool assessment included the resident scored a 19 indicating high risk for falls. The action plan for the assessment was left blank. -The resident fell at 1:15 p.m. on March 10, 2019. The fall was an unwitnessed fall in the resident's bathroom. The resident was attempting to self-transfer from toilet to wheelchair. The resident was found sitting on the floor in the bathroom in front of his wheelchair. He reported that he was trying to turn around in the bathroom and slipped. The last staff member contact with the resident was unknown. Footwear/shoes was checked under the equipment and safety section. -Predisposing factor included that the resident had weakness/fainted. -No injuries were observed at the time of the fall. -The incident details form indicated that corrective action will be completed including that staff are to assist the resident with toileting. The fall care plan was revised on March 10, 2019 and the following interventions were initiated: -Encourage participation and plan diversional activities that are of resident's interest. -Review bowel and bladder incontinence status and establish and/or review toileting plan based on resident's needs. -Review resident's history of recent or recurrent falls. However, the clinical record revealed no evidence that resident was placed on a toileting program. There was also no evidence in the clinical record to indicate that the resident's footwear had been addressed. The care conference note dated March 14, 2019 included the resident had an order for [REDACTED]. A communication note dated March 14, 2019 included probable room change to be closer to the bathroom. The PT care plan dated March 25, 2019 revealed the resident was referred to therapy to work on improving mobility skills and safety with gait due to recent improvement in medical status and alertness. Without therapy, the resident was documented as being at risk for falls and decline in functional status. The discharge plan was to have the resident receive RNA services. Fall #2: March 27, 2019 Review of a fall tool assessment, a fall scene huddle worksheet, a facility incident report, and an incident detail form from March 27, 2019 revealed the following: -The resident scored a 20 on the fall tool which indicated high risk for falls. -On March 27, 2019 at 12:30 a.m. the resident was found on the floor in his room after attempting to self-transfer. The resident reported he was going to the bathroom and was sitting on the edge of the bed and slipped off. The resident was noted to have lost strength, had his knees buckle, lost his balance, and was incontinent of urine. Predisposing factors included: improper footwear, gait imbalance, impaired vision, and weakness. -No injuries were observed. -The resident was noted to refuse care, does not always call for assistance, and attempts to use the urinal were unsuccessful. -The fall was a repeat incident and there had been previous incidents in the last 30 days. Resident was noted to be impulsive, had poor safety awareness, was non-compliant, refused assistance from staff. -Corrective actions included resident and employee education, care plan reviewed and updated, referral to the physician, medication review, and PT evaluation and treatment. The fall care plan was revised on March 28, 2019 to include the following interventions: -Avoid clothing that is fall risk too lose, slippery, too long; -Review as indicated for significant change in cognition, safety awareness and decision-making capacity; and, -Consult with PT for strength and mobility Although both fall #1 and fall #2 occurred during the resident attempting to self-transfer or go to the bathroom without asking for staff assistance, the clinical record did not include interventions regarding toileting and/or increased supervision of the resident. Also, the resident's improper footwear was not addressed in the clinical record. Fall #3: April 5, 2019 A mood and behavior note dated April 2, 2019 included the resident was found walking by himself in the hallway using his walker. The note documented, gait is halting, shuffling and unsafe; and that a therapist explained to the resident that he should walk only with assistance. Review of a fall tool assessment, a fall scene huddle worksheet, a facility incident report, and an incident detail form from April 5, 2019 revealed the following: -The fall tool assessment included a score of 19 indicating high risk for falls. The action plan section was left blank. -The resident fell at 10:15 a.m. on April 5, 2019. The resident was seen in the room transferring independently into an unlocked wheelchair and slid from the wheelchair to the floor. The resident's gait was unsteady and the wheelchair moved when the resident attempted to self transfer. -No injuries noted. -The care plan was updated. -Staff education was done in regards to locking the wheelchair when at the bedside and the resident was to be referred to PT. Review of the care plan revealed no new fall interventions for the resident. Review of the clinical record revealed that the resident received PT for a total of 8 treatments and had 2 missed treatments. The PT Discharge Summary dated April 29, 2019 revealed the resident was discharged from therapy due to refusal. The summary included that skilled services provided were focused on improving lower extremity strength and force production, dynamic balance, safe mobility training, and gait training with the walker. It noted that the resident demonstrated poor safety with walker management and hand placement when mobilizing, had decreased insight at times and will continue to benefit from supervision for all functional mobility. Precautions were noted and included fall and that the resident reports depth perception deficit. The discharge plan included the RNA program as the resident cooperates. The quarterly MDS assessment dated [DATE] revealed that the resident had some changes in the assessment. These included: -The BIMS score increased to 14 indicating the resident was cognitively intact. -The resident was coded as occasionally incontinent with bladder but always incontinent with bowel and was not on urinary or bowel training program. -The resident required limited assistance with 1 person with bed mobility, transfer, walk in the room and dressing; He required supervision with 1 person with toilet use -The assessment continued to indicate that no RNA was performed. A care conference note dated June 13, 2019 included the resident continued to isolate in his room except for meals, refused activities including in-room music and was independent in toileting but was unsteady at times. Per the documentation, staff were to encourage resident to ask for assistance and to keep the call light within reach as the resident was at risk for falls. Continued review of the clinical record revealed no evidence that the RNA program to address the resident's gait issues was provided as recommended by PT from April 30 through July 10, 2019. Fall #4: July 11, 2019 Review of a fall tool assessment, a fall scene huddle worksheet, a facility incident report, and an incident detail form from July 11, 2019 revealed the following: -The resident scored 20 on the fall tool assessment indicating high risk for falls. The action plan section was left blank. -The resident fell at 7:20 a.m. on July 11, 2019. The fall was unwitnessed and the resident was found on the floor n his room. He was ambulating prior to the fall and had been observed by staff 5 minutes prior to the incident as he was on the toilet. The resident had lost strength, his knees buckled, he got dizzy, and he lost his balance. He was noted to have an a history of his blood pressure dropping and he got dizzy and fell to the floor. -No injuries were noted. -Corrective actions included resident education/training, the care plan was updated, review of blood pressure medications, referral to physician for medication review, and to check blood pressures more frequently. The fall care plan was revised on July 23, 2019 (12 days after the incident) to include an intervention to review medical record for medications or combinations of medication that could predispose to fall or increase fall risk. The clinical record did not include evidence that the resident's medications had been assessed or that the physician assessed the resident's medications or fall risk. Review of the clinical record revealed the resident was transferred to the hospital on August 13, 2019 and came back to the facility on [DATE]. Fall #5: August 15, 2019 A health status note dated August 15, 2019 included the resident insisted on walking to the bathroom from a parked wheelchair outside the door. Per the documentation, the resident holds onto the door and sink, was asked to call for help but resident insisted on being independent. It also included the resident was unsteady at times and complained of being dizzy with position changes. A communication note dated August 15, 2019 revealed a CNA (Certified Nursing Assistant) reported that while the resident was standing at the grab bar in the bathroom, the resident's knees buckled and the CNA assisted the resident to a safe sitting position. It also included the resident did not touch the floor. However, the clinical record revealed no evidence of any documentation or report regarding the details of this fall and any interventions put in place after this fall. There was also no evidence that the physician and family were notified of this fall. A health status note dated August 16, 2019 included the resident was reminded to call for assistance and that staff will provide assistance if the resident wanted to walk. Per the documentation, gait was very unsteady and the resident had a history of [REDACTED]. Fall #6: August 19, 2019 Review of a fall tool assessment, a fall scene huddle worksheet, a facility incident report, and an incident detail form from August 19, 2019 revealed the following: -A fall tool assessment included a score of 20 indicating high risk for falls. The action plan section was left blank. -The resident fell at 12:00 a.m. on August 19, 2019. The fall was unwitnessed and the resident was found on the floor in the room with his legs in the bathroom and his upper body outside the bathroom. He reported that the floor was slick. The resident was noted to be ambulating before the fall, slipped and was not using his walker. -Corrective actions included that the resident and employee education/training will be completed and the care plan was amended. The admission MDS assessment dated [DATE] included a BIMS score of 13 indicating resident was cognitively intact. The assessment also included the resident was occasionally incontinent with bladder and was not on a urinary training program. Further, despite documentation of incidents of the fall on August 19, the MDS assessment revealed no falls was coded. Fall #7: August 21, 2019 Review of a fall tool assessment, a fall scene huddle worksheet, a facility incident report, and an incident detail form from August 21, 2019 revealed the following: -A fall tool assessment included a score of 16 indicating high risk for falls. The action plan was left blank. -At 10:45 a.m. on August 21, 2019 the resident fell . The fall was unwitnessed and the resident was found on the floor of his room next to a transfer surface. The resident was bending over looking for his denture cream and became lightheaded and sat on the floor. The last staff member contact with the resident was at 9:00 p.m. -No injuries were noted. -The care plan was updated. -Corrective actions included resident education/training. A care conference note dated August 29, 2019 included the conference was attended by the resident and the family was present on the phone. Per the documentation, family would like for staff to encourage resident to drink more water to help with the blood pressure issues. It also included the resident gets dizzy at times related to low blood pressure, was a fall risk, had a recent fall and often refused to walk. Per the documentation, staff will continue to offer to walk the resident. Although it was documented that the care plan was updated, there was no evidence the care plan was revised and implemented to include new interventions to address the resident's recurrent falls. Fall #8: October 9, 2019 Review of a fall tool assessment, a fall scene huddle worksheet, a facility incident report, and an incident detail form from October 9, 2019 revealed the following: -A fall tool assessment included a score of 20 indicating high fall risk. The action plan section was left blank. -At 1:05 p.m. on October 9, 2019, the resident was found on the floor in the bathroom. The resident reported that he went to the bathroom in his wheelchair, stood up, and turned to close the door and lost his balance. The resident was found next to the transfer surface. The last staff contact with the resident was at 11:15 a.m. -Equipment and safety concerns were noted and documented that the wheelchair brakes were unlocked and footwear was a concern. The resident had a room change and this was an environmental factor as well. -There were no injuries noted. -Corrective actions included resident education/training and updating the care plan to include RNA services. The fall care plan was revised on October 16, 2019 to include an intervention to provide RNA program to maintain strength and balance. Despite documented as a fall intervention in the care plan, the clinical record revealed no evidence that RNA was implemented. Fall #9: October 26, 2019 A health status note dated October 26, 2019 included that at 11:25 p.m., the resident complained that his wheelchair and floors were slick and caused him to have falls. The resident was alert, was confused about time and reported to staff that he fell at around 8:00-9:00 p.m. and had acquired a scrape on his left buttock. Per the documentation, the nurse and the CNA had been in the resident's room multiple times and the resident was seen sitting in his chair or bed within the time frame reported. It also included that considering the resident's mobilization abilities, there were no calling out during this time. Further, it was documented, the nurse does not believe that if he was on the floor, he could have gotten himself up off the floor. The note documented that a dressing was placed onto the scrape which was assessed as partially scabbed over and does not appear like it just occurred about two hours ago. The clinical record revealed no other documentation or an investigation regarding whether this incident actually happened or not. The NP's (Nurse Practitioner) note dated November 20, 2019 noted the resident's [MEDICAL CONDITION]. The note did not include any documentation regarding the resident's falls. The quarterly MDS assessment dated [DATE] revealed a BIMS score of 12 indicating the resident had moderately impaired cognition. The assessment also included the resident was occasionally incontinent with bladder was not on urinary training program. The assessment included there were 2 falls with no injury and there was no RNA performed in the last 7 calendar days. Fall #10: November 22, 2019 Review of a fall tool assessment, a fall scene huddle worksheet, a facility incident report, and an incident detail form from November 22, 2019 revealed the following: -The fall tool assessment included a score of 20 which indicated high fall risk. The action plan was left blank. -At 11:15 p.m. on November 22, 2019, the resident had an unwitnessed fall and was found half lying and half sitting against his walker and the bathroom wall. The resident was combing his hair at the sink when he became dizzy and fell backwards hitting his head against the wall. His walker was documented to be in the corner of the bathroom and his wheelchair was at bedside. The last contact with staff was at 10:00 p.m. -No injuries were noted. -Corrective actions included resident education/training on the use of the call button and the wheelchair. Review of the communication notes dated November 23, 2019 included the family was informed of the fall and that the resident was not hurt. Per the documentation, the family informed staff that the resident reported his ribs hurt. The resident also reported that the bottom of his rib cage hurts when he gets up. Per the documentation, the resident was underweight and it was suspected that his bones were rubbing against each other. Despite documentation that resident had pain on his rib area following a fall, there was no evidence the physician was notified of the pain. The fall care plan was revised on November 25, 2019 to include the following interventions:-Educate/instruct resident and family on safe use of assistive devices -Remind resident not to bend over to pick up dropped items and encourage the use of grabber or to ask for assistance -Ensure the resident was wearing appropriate footwear fully enclosed, slip resistant shoes when ambulating or mobilizing in the wheelchair Review of RNA documentation from November 2019 revealed the following interventions/task transcribed: 1) Active ROM using the exercise bike 10-15 minutes using resistance levels 3-5 on both upper and lower extremities 3-5 times per week 2) Walking with 1 person assist with walker using CGA as tolerated pending blood pressure and do not ambulate if hypotensive, 3-5 times per week. Continued review of RNA documentation revealed active ROM was not administered as ordered for November 2019. The documentation coded 99 indicating the resident was unavailable on November 4, 5, 12, 19, 22 and 26; coded 98 indicating the resident refused because the resident was tired on November 21, 2019; and, the rest of the boxes representing days in the month were not marked as administered or provided. Further, documentation also revealed training and skill practice with walking was administered as ordered on November 4 and 12, 2019 (only 2 out of 30 days). Per the documentation the resident refused because the resident was tired on November 21 and 22, 2019; was coded 99 on November 5, 19 and 26; and, the rest of the boxes representing days in the month were not marked as administered or provided. The clinical record revealed no documentation of reason why the resident was unavailable for RNA, any reason why the RNA program was not administered as ordered and that the physician was notified from November 1 through 30. Although resident education was documented as a fall intervention, a teaching note dated December 2, 2019 revealed that no teaching was provided to the resident. A nursing note dated December 19, 2019 revealed the resident had history of dizziness, insisting on independent toileting and falls frequently in his room or bathroom. The note indicated that the resident had a stent placed on December 18, 2019 with hopes that he would have less dizzy episodes and decrease the incidence of falls. It was documented that the resident continues to go to the bathroom without asking for help, is unsteady on his feet at times, uses furniture to hold onto when walking and was on RNA services for ambulation with his walker. However, review of RNA documentation from December 1 through 19, 2019 revealed RNA program on active ROM was not administered as ordered and the RNA program on walking with 1 person with walker CGA was documented as administered only on December 16. It was coded as 99 on December 12, 16, 17 and 19; and, the rest of the boxes representing days in the month were not marked as administered or provided. Fall #11: December 21, 2019 Review of a fall tool assessment, a fall scene huddle worksheet, a facility incident report, and an incident detail form from December 21, 2019 revealed the following: -The falls tool assessment included a score of 20 indicating high risk for falls. The assessment included that the resident had not fallen in the last 12 months which was inconsistent with the previous documentation of the resident's falls. The action plan was left blank. -The resident fell at 3:00 a.m. on December 21, 2019. This was an unwitnessed fall where the resident was found on the floor with his brief on. The resident said he was changing his brief before the fall. The resident was noted to have slipped and was restless and not using an assistive device at the time of the fall. The environment was noted to be cluttered and the lighting was poor. The resident was incontinent of urine. -No injuries noted. -The care plan was updated. -Corrective actions included resident education/training. The fall care plan was revised on December 21, 2019 to include the following interventions: -Educate resident/family about safety reminders and what to do if a fall occurs -Resident benefits from interventions that minimize the potential for falls while providing diversion and distraction such as: frequent rounding and reminding resident to use call light when help is needed Although clutter, inadequate or poor lighting, and that the resident slipped were all identified as predisposing factors to the resident's fall, the care plan revision did not include interventions to address these issues to promote resident safety and prevent another fall. Review of the RNA documentation for December 2019 revealed there were no RNA program administered to the resident from December 21 through 31, 2019. On December 30, 2019, the care plan was revised to include interventions to modify the environment to maximize safety and to make sure the wheelchair is locked at bedside. The RNA documentation from January through February 13, 2020 revealed several dates where the resident was coded as not available for RNA or that RNA was not documented as completed. Fall #12: February 13, 2020 Review of a fall tool assessment, a fall scene huddle worksheet, two facility incident reports, and an incident detail form from February 13, 2020 revealed the following: -The falls tool assessment included a score of 20 indicating high risk for falls. The action plan was left blank. -The resident fell at 1:15 p.m. on February 13, 2020. A CNA heard a loud noise from the resident's room and found him lying on his back on the bathroom floor. He reported he fell backwards and hit his head. He did not use the call light and did not use the wheelchair and ambulated to the bathroom without assistance. -He sustained a hematoma and laceration to the back of his head measuring four centimeters. -The resident had occasional labored breathing, short period of hyperventilation, occasional moaning or groaning, and low level speech with a negative quality. -The physician instructed staff to monitor the resident closely and that the resident would be assessed around 3:00 p.m. -Neurochecks were initiated and were negative at first, but then progressed to show altered mental status, difficulty keeping the resident awake, and weakened grips. -The family asked to take the resident to the hospital, so emergency services were called and at 2:25 p.m., the resident was transported to the hospital. A Transfer form dated February 13, 2020 included the resident was alert, disoriented, could not follow simple instructions, ambulates with assistive device, had hearing and vision impairment, had pacemaker, was continent with bladder and bowel and was independent with transfers. Review of hospital records revealed a physician's note dated February 13, 2020 noting that the resident presented for altered mental status after a fall at the facility. Per the note, the resident fell and struck the back of his head, complained of a headache and became increasingly altered. Physical examination included the resident was obtunded, with occipital laceration, pupils were 7 mm (millimeter), equal and non reactive, paced pulse and weak at 60 bpm (beats per minute), had Cheyne-Stokes respirations (a specific form of periodic breathing), decerebrate posturing (abnormal body posture that usually indicate there has been severe damage to the brain), unresponsive to stimuli, with no gag and had a GCS (Glasgow Coma Scale) score of 4 indicating severe acute TBI ([MEDICAL CONDITION]). The hospital documentation included that the resident had brain herniation, subdural bleeding, [MEDICATION NAME] head trauma, [MEDICAL CONDITION] following injury with loss of consciousness with death due to [MEDICAL CONDITION] prior to regaining consciousness. The CT (Computed Tomography) scan of the resident's head without contract conducted on February 13, 2020 revealed an impression of catastrophic head bleed, large left subdural hemorrhage with some associated intraventricular hemorrhage and subarachnoid hemorrhage and severe mass effect and herniation of the brain. The facility investigation dated February 17, 2020 revealed the following information: -12:45 p.m.-A CNA (staff #93) checked on the resident who was found resting in his bed. -1:05 p.m.-Another CNA (staff #63) responded to a loud noise and found resident on the bathroom floor. The resident reported he fell backwards and hit his head. Staff #93 came into the room and applied pressure to the resident's head while staff #63 notified the Registered Nurse (RN/staff #43). Resident was assessed to be alert and oriented after the fall and vital signs were stable. -1:30 p.m.-The resident was slower to respond. -1:40 p.m.-The resident was not following commands. The physician and family were notified. The family requested EMS (Emergency Medical Services). -2:15 p.m.-The paramedic captain asked the supervisor to call family and explain that because of the type of injury the resident had, air transport to level 1 trauma unit was the protocol. -2:25 p.m.-The resident was transferred to the hospital. The written statement dated February 13, 2020 from staff #63 (CNA who first saw the resident on the floor) revealed she was walking down the hall when she heard a loud noise from the resident's room. She ran to the room, heard the resident moaning loudly and saw him on the bathroom floor on his back with his head near the toilet and his feet at the door. The resident reported he fell backwards on the floor and hit his head. She called the nurse (staff #43) and went to get the vital signs machine. When she came back, she found the resident was bleeding from the back of his head and another CNA (staff #93) was in the room and was applying pressure to the resident's head. She was taking the residents vitals when the resident complained of a headache and wanted aspirin ([MEDICATION NAME]). The nurse (staff #43) was also in the room and assessed the resident who wanted to get up and was trying to s(TRUNCATED)