Every finding on record at Resolve Harmony Center, LLC

Based on a review of clinical records, staff and resident interviews, and a review of facility policies and procedures, the facility failed to ensure that one (#1) out of 3 sampled residents was not abused by another resident (#2). The Universe was 62. The deficient practice could lead to physical and psychosocial harm to residents.Findings include:-Regarding Resident #1:Resident #1 was initially admitted to the facility on [DATE] with diagnosis that included unspecified dementia, bipolar, and difficulty in walking.A care plan initiated on October 14, 2025 revealed a focus related to behavioral disturbances related to dementia. Interventions included to distract the resident from wandering.A behavior progress note dated January 7, 2026, at 12:35 p.m., revealed that the resident propelled down the hallway and told one of the staff move out of his fucking way and shut up your fat Bitch. The note included that the resident was educated on the importance of not being rude and the resident raised his arm threatening to hit the staff, if the staff did not move.A behavior progress note dated March 38, 2026, at 5:41 p.m., revealed that the resident was ambulating in the hall with shirt and briefs on and no pants. The note further revealed that the Aide asked the resident to return to the room to don (put on) pants then the resident began to yell and stated Shut up talking to me you black bitch.A behavior progress note dated April 19, 2026, at 4:42 p.m., revealed that the resident exhibited verbally aggressive behaviors towards the female Certified Nursing Assistant (CNA) attempting to get the resident dressed and out of bed. The resident began telling the female CNA to leave him alone and get out of his room in a very loud and aggressive voice. The note then revealed that a male CNA then entered the resident's room after hearing the resident yelling at which time the resident began yelling obscenities at male CNA then called male CNA a nigger. The note then revealed that the Staff gave the resident space and the resident was eventually able to calm himself down before allowing female CNA to assist him in getting out of bed, dressed for the day then into a wheelchair.A care plan initiated on April 22, 2026 revealed a focus related to potential for verbal aggressive behavior related to dementia, ineffective coping skills, and poor impulse control. Interventions included to monitor behaviors.A behavior progress note dated April 26, 2026, at 3:48 p.m., revealed that the resident was yelling at another resident from the hallway I will beat your ass, you fat son of bitch.A minimum data set (MDS) dated [DATE], revealed a BIMS (Brief Interview for Mental Status) score of 0, which indicated severe cognitive impact. The assessment revealed no behaviors present during the assessment period.A facility incident progress report dated July 13, 2026, at 7:16 a.m. revealed that Resident #1 was observed by Licensed Practical Nurse (LPN, staff # 17) with visible bleeding from the eye area, forehead, and bilateral lower extremities. The report further revealed that the resident was assessed from head to toe and was transferred to the hospital for further evaluation.A physician progress note dated July 13, 2026, at 8 p.m., revealed that the physician received a report from a floor nurse indicating that Resident #1 had an altercation with another resident. The note included that the resident had multiple areas with bleeding on the forehead, around the right eye and right lower extremity. The note relayed that the resident was transferred to the ER (emergency room) for further evaluation.A July 14, 2026 revised care plan focus for potential to be verbally aggressive, revealed on July 13, 2026 a resident to resident altercation occurred and initiated additional interventions to monitor behaviors and that the resident's triggers are unfamiliar surroundings, de-escalate by redirection. A hospital records dated July 14, 2026, revealed that Resident #1 came to the hospital after having an altercation with another resident and had some abrasions on his right shin. A CT scan revealed no acute significant neurosurgical relevant injuries. The note included that the resident relayed pain to his right shin and knee when bearing pain.A hospital neurosurgery consult note dated July 14, 20266, revealed the patient arrived with abrasion to face and laceration to the right shin after getting into an altercation with another resident. An alert progress note dated July 15, 2026, revealed that the resident returned from the hospital. An interview was conducted with the resident on July 30, 2026, at 9:25 a.m., who stated that he did not recall the incident between him and Resident #2-Regarding Resident #2Resident #2 was admitted to the facility on [DATE], with diagnosis that included insomnia, delusional, depression, and anxiety.A care plan dated June 11, 2026, revealed that Resident #2 had behavioral disturbances, which included refusal of cares intrusive behaviors related to depression. A care plan dated July 13, 2026, revealed that Resident #2 had an altercation with another resident and interventions included one on one sitter for monitoring behavior and two on one for all cares.A review of the shower sheet dated July 13, 2026, revealed no indication of skin injury.A Psychology progress note dated July 14, 2026, at 11:45 a.m., revealed that Resident #2 was involved in an altercation with another resident who made offensive comments directed at Resident #2, his girlfriend, and his friend which caused a verbal confrontation, disrespectful language, and had escalated for two days due to the residents being in close proximity. A minimum data set (MDS) dated [DATE], revealed a BIMS score of 15, which indicated intact cognition. The assessment included that the resident had a behavior of rejection of care for 1 to 3 days in the last 7 days.An interview was conducted with Resident #2 on July 30, 2026, at 9:06 a.m., who stated that he recalled the incident with Resident #1 that occurred a couple of weeks ago. The resident stated that Resident #1 said fuck you to Resident #2 and his girlfriend, and also called Resident #2's girlfriend is a bitch. Resident #2 also stated that Resident #1 punched him in the face. Resident #2 then stated that he could not punch Resident #1 back because he is paraplegic and could not lift his arm so he used his wheelchair to hit Resident #1. Resident #2 then stated that staff separated both residents and assessed them both for injuries. Resident #2 further stated that he did not get any injury, however, Resident # 1 was sent to the hospital.An interview was conducted on July 30, 2026, at 9:38 a.m., with a Licensed Practical Nurse (LPN/staff # 95) who stated that abuse included verbal, physical, and financial. The LPN stated that the facility process related to a resident-to-resident altercation included separating both residents, notifying the abuse coordinator immediately, and assessing both residents for injuries. The LPN stated that Resident #1 had dementia and would sometimes talk to himself and use the profanity Fuck for himself and that other residents would misconstrued that he was talking to them. The LPN then stated that she heard about the incident between Resident #1 and Resident #2, where one resident hit another resident both residents were separated and assessed for injury after the incident. The LPN stated that Resident #1 was sent to hospital for injuries and assessment, however Resident #2 sustained no injury. The LPN further stated that she would consider the incident between the two residents as a physical altercation.An interview was conducted on July 30, 2026, at 10:36 p.m., with a witness Resident #6, who stated that the incident between Resident #1 and #2 happened approximately 2 weeks ago in the west hallway at night. The Resident stated that she was in coming out when she saw Resident #1 in his wheelchair and was bleeding in his ankle and eyes. Resident #6 then stated that she took Resident #1 to the nurse station and Resident #2 went to the smoking patio. Resident #6 then stated that Resident #1 told Resident #2, her girlfriend, and her Fuck you. The resident then stated that Resident #1 has dementia and that was the first time when altercation happened between Resident #1 and Resident #2. The resident further stated that the incident could have been prevented if Resident #1 was kept close to the nurse station.An interview was conducted on July 30, 2026, at 11:03 a.m., with a Certified Nursing Assistant (CNA, staff # 67) who stated that abuse could be unwanted exploitation, harm to other residents and different types of abuse included verbal, physical, and financial. The CNA stated that the facility process for resident to resident abuse would include separating both residents and notifying the ed supervisor or abuse coordinator immediately. The CNA stated that Resident #1 had dementia and would curse people and use Fuck word for residents. The CNA then stated that she heard from a nurse that Resident #1 was in hospital due to an altercation with Resident #2. The CNA then stated she saw Resident #1 after coming back from the hospital and Resident #1 was wearing a bandage and appeared to have an injury to his right leg between the knee and ankle. The CNA further stated that she would consider the incident as physical abuse from what she heard.An interview was conducted on July 30, 2026, at 2:12 p.m., with an Administrator (staff #77) and a Chief Nursing officer (staff #110). The Administrator stated that the different types of abuse are verbal, physical, sexual, and financial. The Administrator also stated that when staff become aware of abuse they are expected to report the incident immediately to the supervisor, Director of Nursing (DON) or to the administrator. The Administrator stated that on July 13, 2026, in the evening, LPN (staff #17) reported to him via a telephone that Resident #2 had notified LPN regarding hitting Resident #1, and was nervous. The Administrator stated that both residents were then assessed by a nurse for injury. The Administrator stated that as per LPN, Resident #1 had visible bleeding on and around his eyes, forehead, and lower extremities. The Administrator stated that Resident #1 was then sent to hospital for injury and assessment, however no injury was found on Resident #2. The Administrator then stated that he talked to Resident #2 the day after the incident and Resident #2 stated that he hit Resident #1 with his electrical wheelchair. The Administrator stated that Resident #1 had dementia with psychiatric disturbance and behavior of outburst, and Resident # 2 was moved to another room after the incident. , The Administrator also stated that Resident #2's electric wheelchair was replaced with a manual wheelchair for safety. The Administrator then stated that one resident hitting another resident willfully would be considered as a physical abuse, however he stated that the incident between Resident #1 and #2 was not willful hit because there was no intent to harm each other so he would not consider the incident as a physical abuse.A facility policy titled, Resident Rights, dated October 1, 2025, revealed that the resident has a right to be treated with respect and dignity.A facility policy titled, Abuse, Neglect, and Exploitation, dated October 1, 2025, revealed that the facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse.

Based on clinical record review, staff interviews, review of facility documentation and policies, the facility failed to protect the rights of one resident (#2) to be free from physical abuse by another resident (#3). The deficient practice could result in further physical abuse of residents when appropriate actions are not taken.Findings include:-Regarding Resident #2 (alleged victim):Resident #2 was admitted to the facility on [DATE], with diagnoses that included encephalopathy, bipolar disorder, cerebral infarction, fall, and epilepsy.The facility document titled Unsupervised List for residents who smoke revealed that Resident #2 was on the list.A review of the nursing progress notes dated May 14, 2026, at 8:30 PM revealed there was a witnessed Resident to Resident altercation that happened on the smoking patio. Per document, the Residents were separated immediately. The Residents were assessed. The physician, nursing management, administrator, the State Agency, police, families, and the ombudsman were notified of the incident. Resident #2's care plan was updated.A revised care plan dated May 15, 2026, revealed that the resident had a behavioral disturbance which include but was not limited to refusal of care, refusing medications, refusing meals, refusing skin checks, Transphobic; irritable, agitated, verbal aggression, physical aggression related to his diagnosis of Bipolar disorder. The care plan further noted that the Resident had a Resident to Resident altercation. The goal was for the Resident to have fewer episodes of current behaviors. The interventions included for staff to document behaviors, and the Resident's response to the interventions; administer medications as ordered; monitor and document for side effects and effectiveness; provide a calm, quiet environment as needed; and use distracting conversation during cares to divert attention.A social service progress notes dated May 15, 2026, was reviewed. Per the document, the social service staff visited Resident #2 in his room regarding the altercation that occurred on evening of May 14, 2026.A review of Resident #2's quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15.0, indicating that the Resident's cognition was intact. Per resident's behavioral symptoms assessment, there were no behavioral symptoms exhibited.-Regarding Resident #3 (alleged perpetrator):Resident #3 was readmitted to the facility on [DATE], with diagnoses that included chronic obstructive pulmonary disease (COPD), end stage renal disease (ESRD) dependent on dialysis, and heart failure.A review of the nursing progress notes dated May 14, 2026, at 8:30 PM revealed there was a witnessed Resident to Resident altercation that happened in the smoking patio. Per document, the Residents were separated immediately. The Residents were assessed. The physician, nursing management, administrator, the State Agency, police, families, and the ombudsman were notified of the incident. Resident #3's care plan was updated.A social service progress notes dated May 15, 2026, was reviewed. Per the document, the social service staff visited Resident #2 in his room regarding the altercation that occurred on evening of May 14, 2026.A review of the facility document dated May 20, 2026, revealed that Resident #3 was transferred out to the hospital for behavioral symptoms. Further, the document revealed that the visit to the hospital was related to Resident #3's three resident to resident altercations in 2 months, harm to others, and it was a voluntary admission to the hospital.A review of the 5-day investigation report dated May 20, 2026, revealed that on May 14, 2026, in the evening, a Licensed Practical Nurse (LPN/Staff #7) witnessed a resident to resident altercation on the smoking patio between Resident #2 and Resident #3. Also, the camera footage verified the incident. The investigation report revealed that Staff #7 overheard resident #2 and Resident #3 arguing. Staff #7 asked Resident #2 and Resident #3 to stop arguing. Per the investigation report, Resident #3 grabbed a chair and threw the chair. Resident #2 raised his right arm to stop the chair. Resident #2 and Resident #3 were immediately separated. Resident #2 and Resident #3 were assessed. Resident #2 denied any pain and refused any other treatment and assessment. The investigation report also revealed that Resident #2 stated that Resident #3 was talking to him in Spanish but he could not understand so he moved to the other side of the patio to get away from Resident #3. Resident #3 said F*** you and Resident #2 said F*** your a**. Resident #3 grabbed the chair, walked towards Resident #2 and swung the chair at Resident #2. The investigation report revealed that Resident #2 was assessed and found to have a 1.3 cm (centimeter) by 0.5 cm abrasion to his right arm. The investigation report revealed that on May 20, 2026, Resident #3 volunteered to be transferred out to a hospital for behavioral evaluation and psychiatric follow up.An interview was conducted on June 5, 2026, at 8:49 AM with the Assistant Director of Nursing (ADON/Staff #27). The ADON stated that regarding their smoking process, she stated that the residents are assessed for safety. She stated that if a resident was deemed a safe smoker, then the resident can smoke independently, and if not deemed safe, the resident would be supervised and would have an apron. The ADON also stated that abuse could be physical, emotional, financial, verbal, and neglect. She stated that a physical abuse could be touching, hitting, and striking someone. She also said that if she was made aware of or witness an abuse, she would report the abuse to the administrator. She would report it because she is a mandated reporter and the allegation of abuse needs to be investigated. She also said that if the alleged abuse was not reported, the abuse would.On June 5, 2026, at 11:54 AM, attempted to conduct an interview with a Resident in the unsupervised smoking patio. The Resident stated that he did not have time for an interview.On June 5, 2026, at 11:59 AM, attempted to interview Resident #2 in his room. The resident was observed lying in his bed side ways facing the wall and the white linen sheets covering him all the way to his face. The Resident mumbled words that were difficult to understand.A phone interview was conducted on June 5, 2026, at 12:31 PM with LPN (Staff #7). Staff #7 stated she was working on the day of the alleged incident, during a shift change, in the month of May, when she witnessed a resident to resident physical altercation between Resident #2 and Resident #3. She stated that in the smoking patio, Resident #2 expressed that he was harassed by Resident #3. Resident #3 was speaking in Spanish to Resident #2. She stated that she asked Resident #3 to return to his wheelchair. She stated that Resident #3 proceeded to go to his wheelchair, while she administering a medication to her resident. She stated that she observed Resident #3 headed toward Resident #2. She stated that she informed Resident #3 to go back to his chair, but Resident #3 went toward Resident #2, because Resident #2 was underneath the gazebo. She stated that there was also another resident with his visitor in the smoking area, and Resident #3 still proceeded towards Resident #2. She said that she observed Resident #3 picked up a chair and swung at Resident #2. She stated that Resident #3 attempted to swing the chair again but Resident #3 almost fell over, and Resident #3 walked back to his wheelchair. She stated that it was not Resident #3's first time to threaten other residents and staff members. She stated that Resident #3 gets angry when asking for cigarettes or money from any of his roommates in the past. She further stated that Resident #3 was always threatening the residents because he thought that the other residents were saying things about him. Further, she stated that during the resident to resident altercation with resident #2 and Resident #3, Resident #2 was able to block Resident #3 when Resident #3 was trying to swing the chair. She also said that Resident #2 only got a bruise or cut on his arm. She also stated that the resident that she was administering medications to ran inside to get help from the other nurses. Staff #7 stated that she was unable to get in between Resident #2 and Resident #3 during the altercation. Further, she stated that an abuse could be physical, emotional, and if she witnessed or made aware of an allegation of abuse, she would notify the administrator and Director of Nursing (DON) right away, but, first thing she would do was to separate whoever was involved. She stated that with the incident between Resident #2 and Resident #3, she considered it as physical abuse, and she said that she wrote a statement about the incident between Resident #2 and Resident #3.An interview was conducted on June 5, 2026, at 1:06 PM with the DON (Staff #80). The DON stated that abuse is whatever the resident claims to be abuse, she considered it abuse. She stated that abuse could be physical, verbal, sexual, neglect, misappropriation of funds, and emotional. She said that physical abuse could be a resident to resident altercation, hitting, punching, and swinging at a resident. She stated that regarding the incident between Resident #2 and Resident #3, Resident #2 and Resident #3 were having a verbal discussion in the smoking patio, the verbal discussion got heated, Resident #3 grabbed a chair and directed to throw at Resident #2. The DON stated that the incident was a witnessed event. She also stated that the incident was substantiated because it happened. She stated that Resident #3 was transferred to another facility. She further stated that Resident #3 had previous altercations which has been previously investigated and that Resident #3 was transferred to a more appropriate facility due to causing harm to others or to himself.A review of facility policy titled Abuse Prevention, Identification, Investigation, and Reporting Policy with a review date of October 1, 2025, revealed that it is the policy of the facility to provide care to all residents in an environment which is free from abuse of the resident.

Based on clinical record reviews, staff and resident interviews, facility documentation, and policy and procedures, the facility failed to protect the right's of two of four sampled resident's (#1, #2) to be free from physical abuse by another resident. The deficient practice could result in the residents being in an unsafe environment. Findings Include: -Regarding Resident #1Resident #1 was admitted on [DATE], with a diagnosis that included cirrhosis of the liver, Parkinsonism, hydrocephalus, bipolar disorder, and mild cognitive impairment of uncertain.A care plan initiated on October 31, 2025, included a focus for impaired cognitive function with interventions that included communicating with the resident/family/caregivers regarding the resident's capabilities and needs, using the resident's preferred name, providing the resident with necessary cues, and stopping and returning if agitated.A quarterly Minimum Data Set (MDS) dated [DATE], revealed a Brief Interview forMental Status (BIMS) score of 05, indicating severe cognitive impairment.A care plan initiated on February 16, 2026, included focus area related to the resident having behavioral disturbances, which included but were not limited to refusal of care, refusal of medication, verbal and physical abuse, related diagnosis of Parkinsonism, and Cirrhosis of the liver. Interventions included documenting behaviors and residents' responses to interventions, praising any indication of progress or improvement in behavior, providing a program of activities that is of interest to the resident, administering medication as ordered, monitor/ and documenting for side effects and effectiveness, allow the resident to make decisions about treatment regime to provide sense of control, provide a clam, quiet environment as needed, intervention as necessary to protect the rights and safety of others, approach/speak in clam manner, divert attention, remove from situation and take to alternate location as needed. An internal facility incident report dated April 10, 2026, at 09:44 AM revealed that physical aggression was observed by the Activities Assistant (Staff #3) who witnessed a resident-to-resident altercation on the patio between Resident #1 and Resident #2. The report included that Resident #2 slapped Resident #1's head after a verbal confrontation. The report further revealed that the residents were immediately separated by the Activities Assistant. The report revealed a skin assessment for Resident #1 with no apparent injuries, and that Resident #1 nodded his head yes that he felt safe in the facility. Furthermore, it was documented that the residents were monitored every 15 minutes for 72 hours, behavior monitoring was initiated, and patio checks continued. A social services note dated April 10, 2026, revealed that a statement was obtained from Social Resident #1 regarding the incident that occurred earlier that morning. The note relayed Resident #1 stated he was doing fine.A physician's orders dated April 10, 2026, related to change of condition monitoring for behaviors for three days.A Behavioral disturbance care plan, revised April 14, 2026, revealed that Resident #1 had an actual physical behavior on April 10, 2026, and no new interventions were implemented.A further review of the physician's orders dated April 14, 2026, revealed an order for behavioral charting for verbal aggression every shift. A review of Medication Administration Review for April 14, 2026, for behavioral charting for verbal aggression every shift revealed no concerns. A psych Evaluation dated April 16, 2026, at 09:15 AM revealed that another resident struck Resident #1 after Resident #1 stated something to the other party and angered them. An interview was conducted on April 27, 2026, at 09:16 AM with Resident #1, who made head gestures of nodding his head in the direction of up and down, related to having a resident-to-resident altercation, and then he physically touched his head. The resident verbalized slowly; he did not know who it was, but it happened on the patio, and he stated he was in pain afterwards and was scared. He then started nodding his head up and down, agreeing to feeling safe in the facility at this time. -Regarding Resident #2Resident #2 was initially admitted on [DATE], and re-admitted on [DATE], with a diagnosis that included metabolic encephalopathy, and pain.A care plan focus initiated on January 29, 2026, for an incident occurring related to behavioral disturbances, which included but were not limited to refusal of care, refusal of medication, verbal and physical abuse, related diagnosis of End Stage Renal Disease, and seizure activity. Interventions included documenting behaviors and resident responses to interventions, praising any indication of progress/improvement, administering medication as ordered, monitoring/documenting for side effects, and evaluating effectiveness. If reasonable, discuss behavior, explain/reinforce why the behavior is inappropriate and or unacceptable. Intervene as necessary to protect the rights and safety of others. Approach and speak calmly, divert attention, remove from the situation, and take to an alternate location as needed, x-ray to the right arm, referral to an appropriate psychiatric provide as needed. An incident note dated January 30, 2026, at 11:39 AM revealed that the Interdisciplinary team (IDT) met to review the incident that occurred on January 29, 2026, of physical altercation with another resident, but Resident #2, who was a non-aggressor. Resident #2 was on the patio with another resident, where they got into a disagreement, and the other resident got up from the wheelchair and pursued Resident #2. Residents were separated and placed on 15 minutes check till discharged from the IDT team to change in manifestation and or mood, psych provided notification to eval, and appropriate parties were notified. A physician's order with the start date of April 05, 2026 for behavioral charting for verbal aggression and argumentative behavior every day and night shift.A Medication Administration (MAR) note dated April 09, 2026, at 6:15 PM, for behavior charting evidenced by verbal aggression revealed Resident #2 exhibiting aggressive behavior due to changes in the room and Resident #2 cursing at staff and yelling. An internal incident facility report dated April 10, 2026, at 09:45 AM for Resident #2 indicated that a resident-to-resident altercation on the patio between Resident #1 and Resident #2 was witnessed by Staff member #3. It was also documented that Resident #2 slapped Resident #1 on the back of the head after verbal confirmation and skin assessment was completed no apparent injuries were notated for Resident #2. At the time of the internal incident, the facility report revealed that Resident #2 was oriented to person, place, situation, and time. Further, it was noted that both of these residents were separated, and 15-minute checks were initiated for 72 hours for Resident #2, and behavior monitoring was initiated. Patio checks ongoing.A social services note dated April 10, 2026, at 3:27 PM revealed that Resident #2 reported that he was doing well and had no concerns.A MAR note dated April 10, 2026, at 6:24 PM, for behavior charting evidenced by verbal aggression revealed Resident #2 had an incident with another resident. Resident #2 was verbally aggressive to staff and other residents throughout this shift.A review of the five-day investigative reports submitted on April 10, 2026, revealed that the camera footage on April 10, 2026, verified that the incident occurred between Resident #1 and Resident #2, and the incident was verified by the facility. A physician's orders dated April 10, 2026, had orders for a change of condition for behaviors for three days.A Behavioral disturbance care plan, revised April 13, 2026, revealed that the resident #2 had an actual incident on April 10, 2026, and intervention included medication review via long-term care Pharmacy services.A request to review the Camera Footage for April 10, 2026, at 1:47 PM was made, but the Administrator (staff member #12) stated that camera footage was not available as it was deleted after 72 hrs.An interview was conducted on April 27, 2026, at 09:24 AM with Resident #2, who stated that he did not have any altercation with anyone or hit anyone, then started to curse. After that, he was unable to continue the interview. An interview was conducted on April 27, 2026, at 11:16 AM, with the Activities Assistant (Staff #3), who stated that her role as activities assistant was to assist residents with activities. She stated that there are different types of abuse, such as physical, verbal, mental, stealing, and being mean. She stated that the facility process for abuse is to notify our boss immediately or the nurse. The Activities Assistant stated that if she witnessed a resident-to-resident altercation, she would separate the residents and then request assistance via a walkie-talkie. The Activity Assistant stated recently that she observed the physical altercation between Resident #1 and Resident #2 on the smoking patio. She stated that she did not see Resident #2 hit Resident #1, but heard a loud sound of slapping because she was talking to another resident at the time. She stated that when she observed Resident #2 standing, she immediately got in the middle of those two residents, but the walkie talkie was not working, so she asked another Resident, #10, to get her help, and Resident #9 distracted Resident #1 with her phone. The Activities Assistant also mentioned that before the incident, both of the residents were listening to the radio, and no argument was noted.An interview was conducted on April 27, 2026, at 11:52 AM with the Social Services Coordinator (Staff #6), who stated that her role as social services coordinator is to speak to residents, help them with room changes, Arizona Long Term Care Services (ALTCS) application, help residents with social security benefits, do care plan meeting, and be a advocate for the residents. The Social Services Coordinator stated that there are different types of abuse, such as financial, verbal, sexual, and physical. She stated that she was made aware of the resident-to-resident altercation between Resident #1 and Resident #2, a staff member intervened, and the incident was reported by a nurse. The Social Services Coordinator stated that she reported the incident to APS and the Ombudsmen, and then started an investigation. She stated that Resident #1 did not say much, only stating that he felt okay, and that Resident #2 stated that they were playing around and he hit him, but they are friends. An interview was conducted on April 27, 2026, at 12:37 PM with witness Resident #9, who stated that she saw Resident #2 hit Resident #1 on his head with a book on the patio. She stated that the Activity Assistant (Staff #3) separated both residents, and that Resident #9 distracted Resident #2 with her phone by watching videos, then the nurses came and took Resident #1. Resident #9 stated that there was no argument before this incident, that Resident #2 was mad because Resident #1 kept saying the book was his.An interview was conducted on April 27, 2026, at 12:48 PM with a Certified Nursing Assistant (CNA/Staff #4), who stated that there are different types of abuse, such as financial, sexual, physical, mental, emotional, and psychological. She stated the facility's process for physical abuse is to separate the individuals who are involved in the abuse, ensure they are safe, then notify the Administrator, Director of Nursing (DON), Assistant Director of Nursing (ADON), and on weekends, whoever is in charge. She stated that if she sees a resident hit another resident or slap their head, she would separate the residents, and then report it to the nurse who is in charge of those residents and notify the Administrator. She stated that she has not witnessed any resident-to-resident altercation recently. The CNA stated that she had worked with both Residents #1 and Resident #2, but did not witness an altercation between the residents, but heard that they had had one a while ago. She stated that she heard that Resident #2 put his hands on Resident #1. An interview was conducted on April 27, 2026, at 1:02 PM with LPN (staff #5), who stated that there are different types of abuse, such as physical, neglect, verbal, financial, and emotional. She stated that if she witnessed any resident-to-resident altercation, she would try to stop and separate the resident, then report immediately to higher-ups. LPN stated that she will then chart the incident, inform the physician, family member, and do a skin assessment for the residents. She stated that if she witnesses a resident hitting another resident with a book, she would immediately remove the residents and report the incident immediately. She stated that she has worked with Resident #1 but has not heard him having an altercation with any residents.An attempt was made to call Resident #10 on April 27, 2026, at 1:13 PM, who had been identified as being present during the altercation, but the resident did not answer the call or return the call. An interview was conducted on April 27, 2026, at 1:50 PM with the DON (Staff #11), who stated that there are different types of abuses, such as physical, verbal, mental, sexual, neglect, misappropriation of funds, and emotional. She stated she expected staff members to report any incidents of abuse to her, or the executive director (ED), if they are not available in the building, is to notify via phone. The DON stated that staff are expected to separate residents who are involved in an altercation immediately, take them to a different area where they can be monitored, perform 15-minute checks, and skin assessments. She stated that the residents will be monitored for the first 24 hours, and may be extended depending on the behaviors. The DON further stated that she received a report regarding a resident-to-resident altercation between Resident #2 and Resident#1. The DON also stated that camera footage was reviewed and the where the two residents were having a conversation about 3 feet away from each other on smoking patio, then Resident #2 wheeled up to Resident #1 hit him on the head. She stated that there was physical abuse that clearly happened from the camera footage. The DON stated that the incident would be abuse, because Resident #2 hit Resident #1.An interview was conducted on April 27, 2026, at 2:09 PM with Administrator (Staff #12), who stated that there are different types of abuse, such as verbal, physical, sexual, misappropriation of funds, and belongings. He stated that he expected staff to separate the residents when resident-to-resident altercations occur to protect the residents. He stated that staff are expected to report the incidents of abuse to the supervisor and abuse coordinator, which is him. The Administrator stated that once the staff member notifies him, will make sure that the residents were separated and are safe. He stated that then nursing will perform a skin assessment, complete a risk management report, notify appropriate parties such as local police, ombudsmen, APS, family, physician, and have a corrective plan in place for the residents. He stated that based on the video footage, there was a resident-to-resident altercation, where Resident #2 tapped on Resident #1's head. A Policy titled Abuse Prevention, Identification, Investigation, and Reporting Policy with a revision date of October 1, 2025, revealed that all employees are responsible for ensuring that all residents are free from all types of abuse.

Based on the review of the clinical records, staff interviews, and review of facility's policy and procedure, the facility failed to ensure PASARR (pre-admission screening and resident review) were updated appropriately and accurately submitted, when applicable, for six of 8 sampled residents (#17, #24, #26, #30, #40, and #42). The deficient practice could result in residents' medically related social and emotional needs not being met. The census was 50. Findings include: -Regarding Resident #17: Resident #17 was admitted to the facility on [DATE] with diagnoses that included Schizoaffective Disorder Bipolar Type, Congestive Heart Failure, and Type 2 Diabetes Mellitus. The care plan initiated on October 21, 2025, revealed that the Resident uses psychotic medications for Schizoaffective disorder. The intervention included to administer the medications as ordered by the provider and to monitor for side effects. The admission Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 8.0, indicating cognition moderately impaired. The Resident's quarterly MDS assessment dated [DATE], revealed a BIMS score of 15.0, indicating the resident has an intact cognition. A Pre-admission Screening and Resident Review (PASRR) document for Resident #17 was requested on March 12, 2026. The document provided by the facility revealed a completed PASRR level 1 and level 2 dated January 26, 2026, which was completed by the Social Service Director (Staff #22) on January 26, 2026. However, there was no PASRR document found on admission for Resident #17, nor an updated PASRR after the resident stay exceeded 30-days in the facility. An interview was conducted with the Social Service Director (Staff #22) on March 13, 2026, at 11:53 AM. The Social Service Director stated that she completed a level 2 PASRR and she attempted to submit the level 2 PASRR for Resident #17. At 3:05 PM, the Social Service Director stated that she was waiting for the Resident's guardian's signature before she can submit the form. However, Resident #17's PASRR's individual or health care decision maker signature section revealed per the document, a verbal consent was received from the Resident's guardian on January 26, 2026. -Regarding Resident #30 Resident #30 was admitted to the facility on [DATE] with diagnoses that included Schizoaffective Disorder, Bipolar Disorder, and Major Depressive Disorder. The clinical census revealed that the Resident's status was not active in the facility after September 1, 2025, and she had an active status on December 8, 2025. A review of the provider's progress note dated December 9, 2026, revealed that the resident has a medical history of schizoaffective disorder, and that the resident will be a long-term care resident at the facility. An admission MDS assessment for the resident dated December 14, 2025, revealed a BIMS score of 15.0, indicating that the resident has an intact cognition. Further, the assessment revealed that there were no behavioral symptoms exhibited by the resident. A review of the clinical record dated February 17, 2026, revealed a psychiatric evaluation visit was completed for MDD (major depressive disorder), nicotine dependence, other psychoactive substance abuse, bipolar, and schizoaffective bipolar. A review of the care plan which was revised on February 26, 2026, revealed that the Resident had behavioral disturbances, which included but not limited to refusal of care, refusing medications, and having false allegations with the staff. Another clinical record review revealed that the Resident's Pre-admission Screening and Resident Review (PASRR) Level 1 dated September 15, 2025, was completed by another facility that meets the admission criteria for a 30-day convalescent care, and per the document No Referral Is Necessary. But, according to the form, The NF (Nursing Facility) must update the Level 1 at such time that it appears the individual's stay will exceed 30 days. Further review of the PASRR document dated September 15, 2025, revealed that the document was not updated. The section for mental illnesses was left blank. The section for symptoms was left blank. The section for the History of Psychiatric Treatment was left blank. The section for Psychotropic Medications was left blank. The section for Intellectual Disability (ID) and Developmental Disabilities (DD) was left blank. The section for Referral Determination was left blank. And, the section for signature of individual or health care decision maker for consent to a level II PASRR was also left blank. The PASRR document found in the medical record when Resident #30 was admitted on [DATE] was not updated after the resident stay exceeded 30-days in the facility. -Regarding Resident #42: Resident #42 was admitted to the facility on [DATE], with diagnoses that included Schizoaffective Disorder, Depression, and Anxiety Disorder. A review of the admission MDS assessment dated [DATE], revealed a BIMS score of 11.0, indicating that the resident has a moderate cognitive impairment. A care plan was initiated on February 13, 2026, which revealed a focus plan for depression. A review of Resident #42's PASRR revealed per document that a PASRR was completed on March 5, 2026, by the Social Service Director (Staff #22). However, there was no PASRR document found in the resident's medical record when Resident #42 was admitted on [DATE]. An interview was conducted on March 12, 2026, at 12:32 PM with the Social Service Director (Staff #22). The Social Service Director stated that Resident #42's PASRR was completed on March 5, 2026. The Social Service Director said that she was told to stop sending level 1 PASRR until the facility receives their AHCCCS identification number, and the State Agency responsible for the PASRR can process it. At 3:05 PM, the Social Service Director stated that Resident #42's PASRR was not submitted to the State Agency for PASRR as she was told not to send paper PASRR document. -Regarding Resident #26: Resident #26 was admitted to the facility on [DATE] with diagnoses that included Major Depressive Disorder, Anxiety Disorder, Bipolar Disorder, and Schizoaffective Disorder. A review of the admission MDS assessment dated [DATE], revealed a BIMS score of 15.0, indicating cognitively intact. The Resident's care plan initiated on February 15, 2026, revealed that the Resident uses antidepressant medication related to depression. A review of the physician history and physical progress note dated February 16, 2026, revealed that the resident has a past medical history for depression and bipolar disorder. Further, per document, the assessment and plan included depression, bipolar disorder and schizoaffective disorder, and to continue the medication and consult psych. A review of Resident #26's PASRR dated December 22, 2025, revealed that the Resident's PASRR was completed at another facility that meets the admission criteria for a 30-day convalescent care, and per the document No Referral Is Necessary. But, according to the form, The NF (Nursing Facility) must update the Level 1 at such time that it appears the individual's stay will exceed 30 days. Further review of the PASRR document dated December 22, 2025, revealed that the document was not updated. The section for mental illnesses was left blank. The section for symptoms was left blank. The section for the History of Psychiatric Treatment was left blank. The section for Psychotropic Medications was left blank. The section for Intellectual Disability (ID) and Developmental Disabilities (DD) was left blank. The section for Referral Determination was marked for no referral necessary for any level 2. And, the section for signature of individual or health care decision maker for consent to a level II PASRR was also left blank. Despite having a PASRR initiated from the other facility on December 22, 2025, the Resident's PASRR was not updated. Per facility's policy regarding Resident Assessment-Coordination with PASARR Program, all applicants to the facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. An interview was conducted on March 12, 2026, at 8:37 AM with the Social Service Director (Staff #22). The Social Service Director stated that one of her responsibilities included the completion of PASRR for the resident. She said that she was unable to complete PASRRs because her facility has no Arizona Health Care Cost Containment System (AHCCCS) identification number since the facility was owned by a new company. She said that the AHCCCS application was still pending, and without an AHCCCS identification number, she cannot submit a PASRR. She said she was even sending the PASRRs through email and she end up receiving an email stating that it can only be submitted through the online portal. She also said that she can submit the PASRRs without using the online portal until their facility receives its AHCCCS identification number. On March 12, 2026, at 9:03 AM, the Business Office Manager (BOM/Staff #14) was interviewed. The BOM stated that the facility was going through change of ownership since October 1, 2025, and the facility had applied for AHCCCS identification number and the application status was still pending. At 9:11 AM, the Social Service Director and the Regional Financial Coordinator (Staff #77) joined the interview. Regional Financial Coordinator stated that because they are still under acquisition, they have no official AHCCCS identification number and therefore cannot submit anything that requires an AHCCCS identification number. The Social Service Director stated that submitting a PASRR to the State Agency requires an AHCCCS identification number. The Social Service Director stated that regarding providing services to their residents, they have a behavioral team for their residents' behavioral management. The Social Service Director also stated that, if a resident remains in the building for 30 days, she will complete a level 1 PASRR to request a Level 2 PASRR. The Social Service Director stated that PASRR level 1 also is completed upon admission, and if the resident has a serious mental illness (SMI), then she will submit a level 2 PASRR for review. The Social Service Director stated that all residents should have a level 1 PASRR on file, and she has been conducting an audit on who currently do not have a PASRR or a current PASRR. A follow up interview was conducted on March 12, 2026, at 10:45 AM with the Social service Director. Regarding Resident #30's PASRR, the Social Service Director stated that the Resident went out to the hospital on September 1, 2025 and the Resident was readmitted on [DATE]. The Social Service Director stated that the resident has been in the facility for more than 30 days since admission, and the Resident's next PASRR should have been completed on January 8, 2026, and then submitted for a level 2. She said that she will look for the Resident's PASRR in the paper form. She also said that she became an employee of the facility on January 21, 2026, and no one has been able to submit any PASRR since the takeover or transition on October 2025. She said that she has not been able to locate any completed PASRR prior to her employment. Furthermore, the Social Service Director stated that PASRR is important to determine placement is appropriate for the resident. She said that if a Resident's PASRR was not completed, the resident would not be placed appropriately and the level of care they needed would not be appropriately provided. She said that since the PASRRs were not completed and were not sent out for referral, that there was no impact to the residents because they have psych providers at the facility monitoring their residents, their residents were being managed, and they have staff equipped and trained to monitor their residents' behaviors. On March 12, 2026, a facility document was provided to the State Agency surveyor which revealed a letter dated February 6, 2026, that the facility submitted a letter to AHCCCS Division of Member and Provider Services for a provider enrollment application. Another interview was conducted with the Social Service Director (Staff #22) on March 13, 2026, at 11:46 AM. The Social Service Director stated that if a Resident have a PASRR from another state, she would complete a new level 1 PASRR because every state has different policies and she would make sure that she follows the state policy. She said that she does not see a level 1 PASSAR for Resident #36. She said that she completed a 30-day PASRR on February 3, 2026, and the resident did not require a level 2 because resident does not have a serious mental illness (SMI). She said that depression is not SMI. According to the Arizona Health Care Cost Containment System, the Pre-admission Screening and Resident Review (PASRR) Level I is a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified Nursing Facility in order to determine whether an individual might have a mental illness or intellectual disability. A Level I Screening must be completed before an individual can be admitted into a Medicaid- certified nursing facility and can be completed in a hospital, emergency room, doctor's office or in any community setting. The PASRR Level II is a comprehensive evaluation required as a result of a positive Level I Screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate. The determination is the outcome of the Level II evaluation which ensures that Nursing Facility placement is, or continues to be, appropriate, and that services provided to individuals with a MI, ID, or related condition meet the individual's needs, including the need for specialized services. Level II evaluations for individuals with ID are performed by the Department of Economic Security (DES) and evaluations for individuals with MI are coordinated by AHCCCS and performed by a designated entity. For individuals requiring admission to a nursing facility for a convalescent period, or respite care (not to exceed 30 consecutive days), do not require a PASRR Level II Evaluation. If it is later determined that the admission will last longer than 30 consecutive days, a new PASRR Level I Screening must be completed as soon as possible or within 40 calendar days of the admission date to the nursing facility. Review of the facility policy titled Resident Assessment-Coordination with PASARR Program with a revision date of October 1, 2025, revealed that all applicants to this facility will be screened for serious mental disorders or intellectual disabilities and related conditions in accordance with the State's Medicaid rules for screening. -Regarding Resident #24: Resident #24 was admitted on [DATE], with the diagnoses of auditory hallucinations, anxiety disorder, schizophrenia, restlessness and agitation, bipolar disorder, and major depressive disorder. The clinical record revealed no evidence of a completed Level 1 PASARR. The Order Summary Report revealed the following physician orders dated September 30, 2025:which prescribed -Sertraline hydrochloride 50 MG. The order indicated to give 50 mg by mouth one time a day for major depressive disorder, as evidenced by verbalized sadness. The order directed to monitor every shift for antidepressant behavior. A medication care plan initiated on October 15, 2025, pertaining to antidepressant use, revealed that the resident is on antidepressant medication due to depression, as evidenced by verbalized sadness and sleeplessness. Interventions included administering antidepressant medications as ordered and monitoring/documenting side effects. A psychotic medication care plan initiated on October 15, 2025, revealed that the resident is on psychotic medications related to the diagnosis of schizophrenia, as evidenced by auditory hallucinations. Interventions indicated to administer medications as ordered, monitor for side effects and effectiveness every shift, and monitor/record the occurrence of target behaviors. An anti-anxiety medication care plan initiated on October 15, 2025, documented that the resident used anti-anxiety medications related to anxiety, as evidenced by restlessness. Interventions included administering anti-anxiety medications as ordered, and monitoring/documenting side effects/ effectiveness. A physician's order dated October 20, 2025, prescribed Trazodone hydrochloride 50 MG (milligram), to give one tablet at bedtime for depression, as evidenced by insomnia, and to hold for sedation. A quarterly MDS (minimum data set) assessment dated [DATE], revealed that the resident had a BIMS (brief interview for mental status) score of 12, indicating moderate cognitive impairment. The MDS revealed that at the time of the assessment, the resident had diagnoses of anxiety disorder, depression, bipolar disorder, schizophrenia, and auditory hallucinations. Per the MDS, the resident was administered antipsychotic, antianxiety, antidepressant, and opioid during the assessment period. An order dated February 13, 2026, prescribed fluphenazine decanoate injection solution 25 MG/ML, inject 37.5 mg intramuscularly one time a day every 12 days for schizophrenia. A behavioral care plan initiated on February 27, 2026, revealed that Resident #24 had behavioral disturbances, which included refusal of care, related to the diagnosis of schizophrenia. Interventions included documenting behaviors and resident responses to interventions, administering medications as ordered, and referring to a psychiatric provider as needed. An order dated March 9, 2026, prescribed Risperdal oral tablet 0.5 MG and indicated to administer 0.5 mg at bedtime for schizophrenia. Another order dated March 12, 2026, revealed that Resident #24 is to receive fluphenazine decanoate injection 37.5 intramuscularly one time a day every 12 days for schizophrenia. An interview with the Social Services Director (Staff #22), the Business Office Manager (Staff #14), and the Regional Financial Coordinator (Staff #77) was conducted on March 12, 2026, at 9:03 AM. The Regional Financial Coordinator stated that the facility underwent a change of ownership on October 1, 2025, and had to register the facility with the state's Medicaid agency member and obtain an ID (identification). At the time of the interview, and could not provide an exact date of when the paperwork was submitted to the Medicaid agency. The Regional Financial Coordinator stated that without an ID, the facility is unable to submit items such as PASARR screenings, which require an ID. During the same interview conducted on March 12, 2026 at 9:03 AM, the Social Services Director (Staff #22) stated that current mental health concerns were reviewed under behavioral health solutions for psychological testing, supervision, and medication management. The Social Services Director also stated that they had sent a few PASARR applications and had received a response email, which explained that due to the lack of an ID, the state agency is unable to process the PASARR, and that there is a running list of residents whose PASARR had not been processed. The Social Services Director further stated that all residents are admitted with a level 1 PASARR, and a level 2 PASARR if needed. The Social Services Director also stated that residents who stay in the facility over 30 days and have an SMI (serious mental illness) diagnosis would require an updated PASARR to be completed and kept within their records per facility procedure. The Social Services Director said she conducted an audit and listed residents who required resubmission and an updated PASARR. During a follow-up interview with the Social Services Director (Staff #22), on March 12, 2026, at 11:32 AM, the Social Services Director reviewed Resident #24's PASARR and stated that the resident was admitted on [DATE], however, the only PASARR in the resident's clinical record was dated April 5, 2021, and was initiated for another facility. The Social Services Director admitted that did not meet the facility's expectations. Additionally, the Social Services Director stated that the PASARR should have been reviewed for accuracy during admission, and should have been flagged after the resident exceeded 30 days of their stay, as well as during audits. The Social Services Director did not have access to the records prior to January 2026 since it had been prior to her taking over the position, but she acknowledged that Resident #24 should have received an updated PASARR screening. The Social Services Director further stated that the a Level 2 PASARR should have been submitted for determination due to the diagnoses of schizophrenia, bipolar disorder, major depressive disorder, and anxiety disorder. She stated that those conditions warranted a level II screening. The Social Services Director said that the risk of an inaccurate and incomplete PASARR and failure to submit for level II determination could result in inadequate placement in an inappropriate setting, and the resident might not receive appropriate treatment, such as psychiatric care. The Arizona Health Care Cost Containment System (AHCCCS) Medical Policy Manual, regarding the PASARR level I screening tool, revealed that the nursing facility must update the level I at such time that it appears the individual's stay will exceed 30 days. A facility policy titled, Resident Assessment – Coordination with PASARR Program, last reviewed/revised on October 1, 2025, revealed that the facility coordinates assessments with the preadmission screening and resident review (PASARR) program under Medicaid to ensure that individuals with a mental disorder, intellectual disability, or a related condition receives care and services in the most integrated setting appropriate to their needs. The policy indicated that all applicants to the facility would be screened for serious mental disorders and intellectual disabilities and related conditions in accordance with the state's rules. A PASARR level I would be completed before admission, with a determination of either negative or positive. If positive, a comprehensive evaluation would be completed by the appropriate state-designated authority that determines whether the individual has MD (mental diagnosis), ID (intellectual disability), or a related condition, and determines the appropriate setting for the individual's needs. Per the policy, the facility will only admit individuals with an MD or ID who the state has determined to be appropriate for admission. The PASARR would be maintained within the resident's medical record. According to the policy, exceptions to the PASARR screening program include those individuals who are readmitted and/or admitted directly from a hospital, require nursing facility services for the condition for which the individual received care in the hospital, and have been certified by an attending physician before admission that the individual is likely to require less than 30 days of services. A resident not meeting those exceptions and remaining in the facility longer than 30 days must be screened using the state's level I screening process and refer any residents who have or may have MD, ID, or a related condition to the appropriate state-designated authority for a level II PASARR evaluation and determination, and completed within 40 calendar days of admission.

Based on the interview, review of the clinical record, and review of facility policy and procedure, the facility failed to ensure one of 21 sampled residents (Resident #37) was free from accidents and hazards, in regards to safe smoking. The deficient practice can lead to the possibility of burns, fires, smoke inhalation, serious injury, death, and potentially cause facility-wide danger. The sample size is 21. The census was 50. Regarding Resident #37:Resident #37 was admitted to the facility on [DATE], with the diagnosis that included encounter for immunization; multiple sclerosis, unspecified; encounter for therapeutic drug level monitoring; schizoaffective disorder, bipolar type; mood disorder due to known physiological condition, unspecified; generalized anxiety disorder; and other muscle spasm.A safe smoking assessment dated [DATE], revealed that Resident #37 had not been able to smoke a cigarette or utilize a smoking device with safe technique, including lighting matches and/or lighter and disposing of ashes appropriately. The assessment also revealed that Resident #37 had not been able to hold the cigarette or other smoking devices while smoking, not been able to dispose of ashes appropriately while smoking, and not been able to extinguish the cigarette and dispose of it in an appropriate container, before it became dangerously short. A care plan focus initiated on October 21, 2025, revealed that Resident #37 was a smoker and required supervision during smoking, and not suffer injury from unsafe smoking practices through the review date. The care plan focus also revealed that the facility will instruct the resident about smoking risks and about the facility's policy on smoking locations, times, and safety concerns. A smoking policy form signed by Resident #37 and dated on November 14, 2025, revealed that all residents who smoke will have all their smoking materials stored in a secure area, without the ability of anyone to take the materials. If the resident has or holds any cigarettes or combustible material, it will be a direct violation of this policy, and the smoking privilege on the premises will be revoked. It also revealed that this included electronic cigarettes, regardless of the nicotine level, as smoking materials.A quarterly MDS assessment dated [DATE], revealed that Resident #37 had a BIMS score of 13, indicating that Resident #37 had intact cognition, with normal thinking and memory function. A smoking violation document dated March 6, 2026, revealed that Resident #37 received a level 1, verbal education offense for having a lighter/matches. The materials had been confiscated, and a room search had been conducted per the facility policy.On March 11, 2026, at 1:08 PM, an interview was conducted with a CNA (certified nursing assistant/Staff #48), who stated that there was no exact list that stated who was and who was not a resident who smoked in the facility, and that the resident's would tell staff if they were a smoker, and, that the resident's were able to keep their smoking materials on their person. Staff #48 also stated that she was unsure where residents were able to charge their smoking materials and where the smoking materials were to be kept when not in use, stating the risk of a resident who maintained their smoking materials on their person could have the potential risk of burns and fires if not used for the intended purpose. On March 11, 2026, at 1:16 PM, an interview was conducted with an LPN (licensed practical nurse/Staff #51), who had been training another LPN (Staff #2). Staff #51 stated that there are two different expectations regarding smoking in the facility. She further stated that an assessment is conducted with a resident to determine if they can light and hold their own smoking materials. Should it be determined that a resident can do so without complications, then the resident can smoke their materials with no supervision. Staff #51 further stated that should a resident be assessed with any difficulty, then the resident will require supervision during the designated smoking times and area. Staff #51 also stated that it was to her understanding that residents, both supervised and unsupervised, were not allowed to keep their smoking materials on their person, which include cigarettes, lighters, matches, and electronic vapes. Staff #51 further stated that smoking materials were kept within a box and stored in the activities room with the supervision of the activities director and assistants. Staff #51 further stated that she had not witnessed resident's with their smoking materials on their person and not in the appropriate smoking areas, and that if she did observe a resident with smoking materials on their person, she would provide education to the resident on the importance and risk of the materials on their person, confiscate the materials, and advise the resident that the materials could be retrieved from the activities director, as the risk for having the materials on their person could be the possibility of resident's burning themselves, lighting a fire, and sharing their materials with their friends, to which Staff #51 stated resident's were not allowed to do in case of disagreements between residents and potential for altercations.On March 11, 2026, at 1:22 PM, an interview was conducted with the activity's director (Staff #59), who stated that the facility had supervised smokers and unsupervised smokers. Regarding supervised smokers, Staff #59 stated that those residents are designated to smoke in the smoking area near the dining room, with staff supervision, due to being assessed as unsafe to smoke by themselves. Regarding unsupervised smokers, those residents can smoke on their own. Staff #59 further stated that smoking materials are kept in her office under her supervision, for supervised smokers, and that residents who are determined to have unsupervised smoking times can keep their smoking materials on their person. Staff #59 further stated that with the change of ownership, the facility went away with the usage of electronic vapes and that residents were only allowed to have cigarettes, lighters, or matches. She further stated that smoking assessments are conducted at the time of admission, as well as if they are caught smoking in their room. Staff #59 stated uncertainty about whether an assessment would be completed following a change in condition that could affect the resident's ability to smoke. She further stated that at the time of admission, residents are educated on the facility's smoking policy and are required to express understanding and to sign the policy once they acknowledge what they can have, and not have, when and where. Staff #59 stated that the risk of not following the facility's smoking policy is that residents are at risk of catching the facility on fire, burning down the facility, and burning themselves.On March 11, 2026, at 1:36 PM, an interview was conducted with a clinical resource (Staff #78) who stated that residents are assessed for smoking capabilities at the time of admission, and if it is determined that they can light and smoke their materials with no difficulty, they can smoke without supervision. Staff #78 also stated that at the time of admission, an inventory of the resident's items is done, and it is expected to confiscate any contrabands, such as electronic vapes, and to store smoking materials in the activities room and provide education for storing the smoking materials and how to obtain the smoking materials. Staff #78 further stated that should a resident not pass the assessment, they are determined to have supervised smoking, or not at all. Staff #78 further stated that smoking materials are kept in the activities, and can be accessed by nurses with a key, and that residents were not allowed to keep their smoking materials on their person. Staff #78 further stated that electronic cigarettes were not allowed in the facility and were against the facility's policy. Staff #78 stated that the risk of residents keeping smoking materials on their person, and if the facility is unaware, it could put residents at risk of potential harm, such as burns. On March 11, 2026, an interview was conducted with the interim DON (director of nursing/Staff #76) at 1:55 PM. Staff #76 stated that residents were assessed on admission by a nursing staff to determine if a resident requires supervision while smoking or if they're able to smoke unsupervised. Staff #76 also stated that supervised residents can smoke during designated smoking times and that the smoking materials for these residents will be maintained, monitored, and stored by nursing staff. Staff #76 stated that the policy did not state where unsupervised residents can keep their smoking materials; however, she stated that changes to the policy would need to be made as both supervised and unsupervised residents were not allowed to keep their smoking materials on their person, and, that staff is expected to provide education to residents as to why smoking materials should not be kept on their person and where the materials could be retrieved from. Staff #76 further stated that there had not been a separate policy for electronic cigarettes but that residents should not have had them in their room as the risk of having the devices in their room could potential start fires and explode, and that they are expected to be stored properly, meaning away from other residents, and not on their person, with staff until the device is needed. Staff #76 reviewed smoking policies provided to residents that required their signature and stated that the form is proof of an assessment being done, and should be done at the time of admission, annually, and with a change of condition, and signed by the resident for understanding. On March 12, 2026, at 2:05 PM, an interview was conducted with the environmental services director, Staff #30, who stated that she is one of the staff members who provide supervision for the residents who can smoke in the supervised area of the facility. At this point of the interview, an observation was made with Staff #30, in which Resident #37 was observed smoking in the designated area for supervised smoking residents. Staff #30 stated she witnessed Resident #37 with tremors and dropped ash all over her, with no smoking protector present. Staff #30 also stated that Resident #37 didn't have a smoking protector to begin with, and had dropped ashes and her cigarette on her person, and ended up dropping a cigarette on the ground. Staff #30 further stated that the risk of a resident not utilizing a smoking protector while smoking, as it relates to Resident #37, is that she always drops her cigarette and ashes on the ground, and if it had landed on her, she could have burned herself on her skin, and that if an incident were to happen where there is harm to the resident, then the DON is to be notified. Staff #30 further stated that the observation made during this interview would be relayed to the DON for the inclusion of a protector.During a secondary review of Resident #24's electronic health record, a smoking evaluation due to a significant change, dated March 12, 2026, with an effective time of 4:29 PM, revealed that Resident #37 required adaptive equipment that included a smoking apron and staff supervision with lighting and safety reminders.On March 13, 2026, at 12:35 PM, an interview was conducted with the Administrator (Staff #24). Staff #24 stated that residents were not allowed to have smoking materials on their persons; and that the smoking materials would need to be locked in drawers, and all their smoking materials should be kept there until necessary, and if staff are to observe residents with their smoking materials on their person, staff is expected to confiscate the materials and put them in a box, and that the items should not be in their purse or in their wheelchair. Staff #24 stated that a locked cabinet is located in the rooms of the resident and that supervised residents had been previously instructed to keep their smoking materials in these locked cabinets that they have a key for, and that it shouldn't be left unlocked. Staff #24 stated that the facility is in the process of transitioning into a new system, which will be implemented regarding keeping the containers in a certain area and taking what they need, in the reception, for all of the unsupervised smokers, and that the smoking materials of supervised stays will be kept in the activities room and locked. Staff #24 also stated that new admissions are provided with a smoking assessment and a smoking policy to sign and are expected to be put into their files. Staff #24 further stated that electronic cigarettes are not allowed and that those materials would be confiscated during inventory checksStaff #24 stated that implementing the admission process for smoking expectations is important due to the potential risk of fire, smoke, and the possibility of burns, which is a component included in the admission assessment. Regarding Resident #37, Staff #24 stated that Resident #37 had been on restrictions previously due to inappropriate behaviors while smoking or to attain smoking materials from other residents, and that recently, she was determined to be able to smoke under staff supervision.A policy titled 'Resident Smoking', last reviewed and revised October 1, 2025, stated that it is the policy of the facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking, and that safety protections apply. The policy also stated that all residents will be asked about tobacco use during the admission process and during each quarterly or comprehensive MDS assessment process. Residents who smoke will be further assessed, using the 'Resident Safe Smoking Assessment' to determine whether or not supervision is required for smoking, or if a resident is safe to smoke at all. The policy also stated that electronic cigarettes, such as e-cigarettes, vapes, or vapor pens, can catch on fire and/or explode if not handled and stored safely, with additional safety measures that will include but not limited to the use of e-cigarettes in designated smoking areas only; a safe smoking assessment completed on all residents who use e-cigarettes; staff supervision of resident use if indicated; education on the manufacturer's recommendations for use and care of the device; only use of batteries recommended for the device; the encouragement to residents to utilize the devices with safety features; to not use the device around flammable gasses or liquids, such as oxygen, propane, or gasoline; to store loose batteries and extra cartridges away from coins, [NAME], or other metal objects; adequate replacements should the battery become damaged or wet; to charge the device with the intended charger it came with, and not by a cell phone or tablet; that the device to not be left to charge overnight or unattended, and will be charged on a clean, flat surface; and to not be charged in extreme temperatures. The policy also stated that any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas, at designated times, and in accordance with his/her care plan, and should a resident experience a decline in condition or cognition that he/she will be reassessed for the ability to smoke independently and/or to evaluate whether any additional safety measures are indicated. The policy also revealed that the smoking materials of residents requiring supervision with smoking will be maintained by nursing staff.

Based on resident and staff interviews, review of the clinical record, facility documentation, and policy, the facility failed to implement its smoking policy for three residents (#12, #26, and #41). The deficient practice could result in inadequate smoking interventions due to the lack of an assessment and put residents at increased risk for smoking-related incidents. The sample size is 21. The census was 50. Findings include: -Regarding Resident #12 Resident #12 was admitted to the facility on [DATE], with diagnoses of type 2 diabetes mellitus, nicotine dependence, chronic obstructive pulmonary disease (COPD), depression, anxiety, and seizures. A safe smoking assessment dated [DATE], indicated that all smoking materials would be kept in a designated area for safety purposes. A smoking evaluation dated October 9, 2025, revealed that the Interdisciplinary team (IDT) would educate residents on proper storage of lighter and smoking materials per facility and CMS (Centers for Medicare and Medicaid Services) guidelines. A quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating intact cognition. An interview was conducted on March 10, 2026, at 11:46 a.m., with Resident #12, who stated that she smokes in the facility designated smoking area from 7 a.m. to 10 p.m. The resident stated that she stored cigarettes and lighters under the cushion of her wheelchair in her room. The Resident #12 stated that the facility evaluated residents every 6 months for smoking. Resident #12 stated that unsupervised smokers are allowed to keep cigarettes and lighters in their room. An observation was conducted with Resident #12 in her room, on March 11, 2026, at 11:37 a.m., the resident removed an orange colored lighter that was stored under the cushion of her wheelchair in her room. A follow-up interview was conducted on March 11, 2026, at 11:37 a.m., with Resident #12 who stated that she smokes at least 3 cigarettes in a day in the facility designated smoking area. The resident further stated that the Activity Director (staff #59) bought and supplied cigarettes and lighters for the facility's residents. The resident stated that she stores her orange lighter in her room. An interview was conducted on March 11, 2026, at 11:44 a.m., with the activity's director (staff #59). She stated that she provides activities and do weekly shopping for residents. Staff #59 stated that she also purchases cigarettes and lighter for Resident #12 and other residents in the facility. Staff #59 further stated that the facility had supervised smokers and unsupervised smokers. Regarding supervised smokers, Staff #59 stated that those residents are designated to smoke in the smoking area near the dining room, with staff supervision, due to being assessed as unsafe to smoke by themselves. Regarding unsupervised smokers, those residents can smoke on their own. Staff #59 then stated that unsupervised smoker are allowed to keep cigarette and lighter in their room. Staff #59 further stated that Resident #12 keep cigarette and lighter in her room. Staff #59 then stated that risk if resident keep lighter in their room would be catching fire at facility, and burning down the facility and themselves. During an interview conducted on March 11, 2026, at 2:12 p.m., with a Licensed Practical Nurse (LPN/ staff # 46), the LPN stated that residents were not allowed to store cigarettes and lighters in their room because of safety concerns. The LPN reviewed Resident #12's smoking evaluation dated October 09, 2025, and stated that per the evaluation the resident is an unsupervised smoker, but the facility should store the cigarette and lighter for the resident. An interview was conducted on March 11, 2026, at 2:27 p.m. with an LPN (staff # 3), who stated that residents should not have any lighters stored in their room because the resident could cause harm and injury to himself and to the other residents. Additionally, The LPN stated that the lighter could cause a fire and explosion if it was near a supplemental oxygen source. The LPN reviewed the resident's smoking evaluation dated October 09, 2025, and stated that per the evaluation the IDT educated the resident regarding proper storage of cigarette lighters per facility and CMS guidelines. An interview was conducted on March 11, 2026, at 12:35 p.m., with a Director of Nursing (DON/staff #76), who stated that residents are not allowed to store cigarettes and lighters in their rooms and all smoking material should be stored in a locked unit for the residents. She then stated that residents should not store lighters in their rooms because the residents could burn themselves and fire could spread to another room. Regarding Resident #26: Resident #26 was admitted to the facility on [DATE], with a diagnosis that included paraplegia, complete; major depressive disorder, single episode, unspecified; anxiety disorder, unspecified; bipolar disorder, unspecified; and schizoaffective disorder, unspecified. A progress note dated February 13, 2026, revealed that Resident #26 arrived at the facility and had been identified as a smoker and had been orientated to the facility's smoking areas. There was no evidence of a smoking assessment or a signed smoking policy indicated in this note. A care plan focus initiated February 15, 2026, revealed that Resident #64 had been a smoker, and that Resident #26 would not suffer injury from unsafe smoking practices through the review date. It also revealed that the facility will instruct the resident about smoking risks and hazards and about the smoking policy that includes locations, times, and safety concerns. An admission MDS (minimum data set) assessment dated [DATE], revealed that Resident #26 had a BIMS (brief interview of mental status) score of 15, indicating that Resident #26 had intact cognition, with normal thinking and memory function. An initial review of Resident #26's electronic health record revealed no evidence of a smoking assessment or a signed smoking policy per the facility policy. During a secondary review of Resident #26's electronic health record, a smoking evaluation dated March 11, 2026, with an effective time of 3:11 PM, revealed that the IDT (interdisciplinary team) needed to educate on proper storage of lighters and smoking materials as per facility and CMS guidelines, and, that she did not need 1:1 smoking help, she would be able to light and hold without difficulty, and able to demonstrate a safe smoking routine, and that she had been able to extinguish without difficulty in a proper ashtray. Resident #26 required the facility to store her lighter and cigarettes. Regarding Resident #41: Resident #41 was admitted to the facility on [DATE], with the diagnosis that included a personal history of transient ischemic attack and cerebral infarction without residual deficits; major depressive disorder, single episode, unspecified; and polyneuropathy, unspecified. A smoking assessment dated [DATE], revealed that the IDT team needed to educate Resident #41 on proper storage of lighters and smoking materials as per facility and CMS guidelines, and, that she did not need 1:1 smoking help, she would be able to light and hold without difficulty, and able to demonstrate a safe smoking routine, and that she had been able to extinguish without difficulty in a proper ashtray. A care plan focus initiated on October 13, 2025, revealed that Resident #41 had been a smoker and that Resident #41 would not suffer injury from unsafe smoking practices through the review date. It also revealed that the facility will instruct the resident about smoking risks and hazards and about the smoking policy that included locations, times, and safety concerns. A quarterly MDS assessment dated [DATE], revealed that Resident #41 had a BIMS score of 15, indicating that Resident #37 had intact cognition, with normal thinking and memory function. A smoking policy form signed by Resident #41 and dated on November 14, 2025, revealed that all residents who smoke will have all their smoking materials stored in a secure area, without the ability of anyone to take the materials. If the resident has or holds any cigarettes or combustible material, it will be a direct violation of this policy, and the smoking privilege on the premises will be revoked. It also revealed that this included electronic cigarettes, regardless of the nicotine level, as smoking materials. On March 10, 2026, at 9:50 AM, an initial screening interview was conducted with the Resident #26, who also stated that she kept all of her smoking materials, including cigarettes, lighters, matches, and electronic vapes, located on their person and located in the room. On March 11, 2026, at 1:00 PM, an additional interview and observation were done with Resident #26, who stated she had six electronic vapes on her person, and provided a visual of all six electronic vapes. She also stated that she had a box of cigarettes and a lighter on her person, which she had also provided a visual of. Resident #26 also stated that the facility did not provide the resident with a smoking policy to sign at the time of admission. Resident #26 stated that she had been taken outside to the assigned unsupervised smoking area, and the facility determined that she could hold and light her own cigarettes with no difficulties. At this point in the interview, the interim DON (director of nursing/Staff #76) had been called to enter the room and observed the six electronic vapes in her possession and confiscated the devices, as well as cigarettes and a lighter, and then further provided education as to why the items were confiscated, and where she would be able to retrieve her cigarettes and lighter when necessary. On March 11, 2026, at 1:08 PM, an interview was conducted with a CNA (certified nursing assistant/Staff #48), who stated that there was no exact list that stated who was and who was not a resident who smoked in the facility, and that the resident's would tell staff if they were a smoker, and, that the resident's were able to keep their smoking materials on their person, and identified Resident #41 as a resident who not only keeps their smoking material on them, but had been seen with an electronic vape in their room. Staff #48 also stated that she was unsure where residents were able to charge their smoking materials and where the smoking materials were to be kept when not in use, stating the risk of a resident who maintained their smoking materials on their person could have the potential risk of burns and fires if not used for the intended purpose. On March 11, 2026, at 1:16 PM, an interview was conducted with an LPN (licensed practical nurse/Staff #51), who had been training another LPN (Staff #2). Staff #51 stated that there are two different expectations regarding smoking in the facility. She further stated that an assessment is conducted with a resident to determine if they can light and hold their own smoking materials. Should it be determined that a resident can do so without complications, then the resident can smoke their materials with no supervision. Staff #51 further stated that should a resident be assessed with any difficulty, then the resident will require supervision during the designated smoking times and area. Staff #51 also stated that it was to her understanding that residents, both supervised and unsupervised, were not allowed to keep their smoking materials on their person, which include cigarettes, lighters, matches, and electronic vapes. Staff #51 further stated that smoking materials were kept within a box and stored in the activities room with the supervision of the activity director and assistants. Staff #51 further stated that she had not witnessed residents with their smoking materials on their persons. Staff #51 further stated that if she did observe a resident with smoking materials on their person, she would provide education to the resident on the importance and risk of the materials on their person, confiscate the materials, and advise the resident that the materials could be retrieved from the activity director. Staff #51 further stated the risk of having the materials on their person could be the possibility of residents' burning themselves, lighting a fire, and sharing their materials with their friends, to which Staff #51 stated residents were not allowed to do in case of disagreements between residents and potential for altercations. On March 11, 2026, at 1:22 PM, an interview was conducted with the activity's director (Staff #59), who stated that the facility had supervised smokers and unsupervised smokers. Regarding supervised smokers, Staff #59 stated that those residents are designated to smoke in the smoking area near the dining room, with staff supervision, due to being assessed as unsafe to smoke by themselves. Regarding unsupervised smokers, those residents can smoke on their own. Staff #59 further stated that smoking materials are kept in her office under her supervision, for supervised smokers, and that residents who are determined to have unsupervised smoking times can keep their smoking materials on their person. Staff #59 further stated that with the change of ownership, the facility went away with the usage of electronic vapes and that residents were only allowed to have cigarettes, lighters, or matches. She further stated that smoking assessments are conducted at the time of admission, as well as if they are caught smoking in their room. Staff #59 stated uncertainty about whether an assessment would be completed following a change in condition that could affect the resident's ability to smoke. She further stated that at the time of admission, residents are educated on the facility's smoking policy and are required to express understanding and to sign the policy once they acknowledge what they can have, and not have, when and where. Staff #59 stated that the risk of not following the facility's smoking policy is that residents are at risk of catching the facility on fire, burning down the facility, and burning themselves. On March 11, 2026, at 1:36 PM, an interview was conducted with a clinical resource (Staff #78) who stated that residents are assessed for smoking capabilities at the time of admission, and if it is determined that they can light and smoke their materials with no difficulty, they can smoke without supervision. Staff #78 also stated that at the time of admission, an inventory of the resident's items is done, and it is expected to confiscate any contrabands, such as electronic vapes, and to store smoking materials in the activities room and provide education for storing the smoking materials and how to obtain the smoking materials. Staff #78 further stated that should a resident not pass the assessment, they are determined to have supervised smoking, or not at all. Staff #78 further stated that smoking materials are kept in the activities, and can be accessed by nurses with a key, and that residents were not allowed to keep their smoking materials on their person. Staff #78 further stated that electronic cigarettes were not allowed in the facility and were against the facility's policy. Staff #78 stated that the risk of residents keeping smoking materials on their person, and if the facility is unaware, it could put residents at risk of potential harm, such as burns. On March 11, 2026, at 1:46 PM, an interview with Resident #41 was conducted. Resident #41 stated that she had bought her smoking materials during an outing and that she can keep the smoking materials on her person. It was then observed that Resident #41 had what she identified as two boxes of cigarettes, one in her dresser and one in her bag, as well as a lighter in her bag. On March 11, 2026, an interview was conducted with the interim DON (Staff #76) at 1:55 PM. Staff #76 stated that residents were assessed on admission by a nursing staff to determine if a resident requires supervision while smoking or if they're able to smoke unsupervised. Staff #76 also stated that supervised residents can smoke during designated smoking times and that the smoking materials for these residents will be maintained, monitored, and stored by nursing staff. Staff #76 stated that the policy did not state where unsupervised residents can keep their smoking materials; however, she stated that changes to the policy would need to be made as both supervised and unsupervised residents were not allowed to keep their smoking materials on their person, and, that staff is expected to provide education to residents as to why smoking materials should not be kept on their person and where the materials could be retrieved from. Staff #76 further stated that there had not been a separate policy for electronic cigarettes but that residents should not have had them in their room as the risk of having the devices in their room could potentially start fires and explode, and that they are expected to be stored properly, meaning away from other residents, and not on their person, with staff until the device is needed. Staff #76 reviewed smoking policies provided to residents that required their signature and stated that the form is proof of an assessment being done, and should be done at the time of admission, annually, and with a change of condition, and signed by the resident for understanding. Regarding Resident #26, Staff #76 stated that there was no evidence of a signed smoking policy or smoking assessment in her records, and that it would have been expected to have been completed at the time of the resident's admission by nursing or social services, and that her smoking materials were supposed to have been confiscated at time of admission and provided education regarding where to retrieve her materials and why it needed to be stored properly. Regarding Residents #12 and #41, Staff #76 stated that she was not allowed to have their smoking materials on their person for the risk of safety issues should the resident attempt to smoke in the building, or to share the smoking materials. At this point of the interview, it was advised that smoking materials were observed in possession of Residents #12, #26, and #41, and on their persons, and had been identified by the resident as smoking materials. On March 13, 2026, at 12:35 PM, an interview was conducted with the Administrator (Staff #24). Staff #24 stated that residents were not allowed to have smoking materials on their persons; and that the smoking materials would need to be locked in drawers, and all their smoking materials should be kept there until necessary, and if staff are to observe residents with their smoking materials on their person, staff is expected to confiscate the materials and put them in a box, and that the items should not be in their purse or in their wheelchair. Staff #24 stated that a locked cabinet is located in the rooms of the resident and that supervised residents had been previously instructed to keep their smoking materials in these locked cabinets that they have a key for, and that it shouldn't be left unlocked. Staff #24 stated that the facility is in the process of transitioning into a new system, which will be implemented regarding keeping the containers in a certain area and taking what they need, in the reception, for all of the unsupervised smokers, and that the smoking materials of supervised stays will be kept in the activities room and locked. Staff #24 also stated that new admissions are provided with a smoking assessment and a smoking policy to sign and are expected to be put into their files. Staff #24 further stated that electronic cigarettes are not allowed and that those materials would be confiscated during inventory checks. Staff #24 stated that implementing the admission process for smoking expectations is important due to the potential risk of fire, smoke, and the possibility of burns, which is a component included in the admission assessment. A policy titled 'Resident Smoking', last reviewed and revised October 1, 2025, stated that it is the policy of the facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking, and that safety protections apply. The policy also stated that all residents will be asked about tobacco use during the admission process and during each quarterly or comprehensive MDS assessment process. Residents who smoke will be further assessed, using the 'Resident Safe Smoking Assessment' to determine whether or not supervision is required for smoking, or if a resident is safe to smoke at all. The policy also stated that electronic cigarettes, such as e-cigarettes, vapes, or vapor pens, can catch on fire and/or explode if not handled and stored safely, with additional safety measures that will include but not limited to the use of e-cigarettes in designated smoking areas only; a safe smoking assessment completed on all residents who use e-cigarettes; staff supervision of resident use if indicated; education on the manufacturer's recommendations for use and care of the device; only use of batteries recommended for the device; the encouragement to residents to utilize the devices with safety features; to not use the device around flammable gasses or liquids, such as oxygen, propane, or gasoline; to store loose batteries and extra cartridges away from coins, keys, or other metal objects; adequate replacements should the battery become damaged or wet; to charge the device with the intended charger it came with, and not by a cell phone or tablet; that the device to not be left to charge overnight or unattended, and will be charged on a clean, flat surface; and to not be charged in extreme temperatures. The policy also stated that any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking areas, at designated times, and in accordance with his/her care plan, and should a resident experience a decline in condition or cognition that he/she will be reassessed for the ability to smoke independently and/or to evaluate whether any additional safety measures are indicated. The policy also revealed that the smoking materials of residents requiring supervision with smoking will be maintained by nursing staff. The facility policy titled, Smoking, signed by the Resident #12, on November 12, 2025, revealed that smokers will have all their smoking materials stored in a secure area and without the ability of anyone taking the material. Per the policy residents who store cigarettes or combustible material, will be in direct violation of the policy and the smoking privilege on the premises will be revoked.

Based on clinical record review, staff interviews, facility policy, and the Resident Assessment Instrument (RAI) manual, the facility failed to transmit Minimum Data Set (MDS) data for one resident (# 16) within the regulatory timeframe of 14 days after admission. This deficient practice could result in delayed identification of potential risks and care needs. The sample size was one. The universe was 50. Findings Include:Resident # 16 was admitted to the facility on [DATE] with diagnoses that included chronic respiratory failure, atrial fibrillation, and bipolar disorder. The admission MDS, dated [DATE], revealed the Assessment Reference Date (ARD/Observation end date) as October 26, 2025. The signature of the Registered Nurse Assessment Coordinator verified assessment completion on November 3, 2025. The assessment revealed the resident had a Brief Interview Mental Status (BIMS) score of 14, indicating he was cognitively intact.Review of the CMS QIES Third-Party Service Bureau User Request form, dated August 4, 2025, revealed the facility authorized an outside entity to submit Payroll-Based Journal (PBJ) and/or assessment data on the facility's behalf. However, further review of the form indicated that the Minimum Data Set (MDS) submission option was not selected. The user request form also indicated that after submission of the request, if no response was received within two business days, the facility was instructed to contact the helpdesk immediately.Review of the resident's Minimum Data Set Summary, obtained March 11, 2026, revealed the assessment was accepted on December 23, 2025. An interview conducted on March 12, 2026, at 1:00 p.m., with the MDS Coordinator (LPN/Staff #28) confirmed the admission date of October 20, 2025, and stated the observation end date was October 26, 2025. The MDS Coordinator stated that October 26, 2025 was selected as the observation end date, because it was within the allowable 7-day window to allow time for information gathering. The MDS Coordinator stated the MDS assessment process began on October 20, 2025, and was completed on November 3, 2025. The MDS Coordinator further stated all disciplines completed their portions of the assessment within the 14-day completion timeframe and reported no known staffing or documentation delays. The MDS Coordinator acknowledged that, per regulatory expectations, the completed MDS assessment should have been transmitted within 14 days of completion, which she calculated to be by November 17, 2025; however, the assessment was not transmitted until December 23, 2025, which she stated did not meet facility expectation. The MDS Coordinator stated the delay in transmission occurred due to issues within the facility affecting the MDS process. For example, The MDS coordinator stated that the previous MDS coordinator quit unexpectedly, and that the facility decided to use a third-party transmission service. The MDS Coordinator further indicated the assessment was initially delayed due to an incorrect CMS Certification Number (CCN), which required correction before successful transmission. The MDS Coordinator stated once the issue was resolved and approval was obtained, the assessment was transmitted on December 23, 2025, and accepted. The MDS Coordinator stated failure to transmit assessments timely can result in noncompliance with CMS requirements and may impact reimbursement and facility certification status.An interview was conducted on March 13, 2026, at 11:30 a.m. with the Assistant Director of Nursing (ADON/Staff #67). The ADON stated that although it had been several years since she last performed MDS coordination duties, it remains the facility's responsibility to ensure that MDS assessments are completed and transmitted timely in accordance with CMS requirements. The ADON reported that timely completion and transmission of assessments are necessary to meet regulatory expectations and may impact reimbursement and quality indicators. The ADON further stated that assessments are expected to be completed and transmitted on time unless there is a significant issue that prevents CMS from accepting the assessment.On March 13, 2026, at approximately 2:30 p.m., the Executive Director (ED/Staff #24) provided email communications demonstrating that the facility was attempting in good faith to correct the MDS transmission issue. These communications included efforts to address request errors and coordinate with the third-party service bureau and CMS to ensure successful submission of MDS assessments. The ED reported that the facility had been actively working to resolve the transmission issues and referenced the email correspondence as evidence of these efforts.According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.20.1, October 2025), MDS assessments must be completed and transmitted within required timeframes. Comprehensive assessments are required to be electronically transmitted within 14 days of the Care Plan Completion Date. The manual further stated that the failure to meet the required timeframes may result in inaccurate or outdated resident assessment data being used for care planning and regulatory compliance.

Based on clinical record review, interviews, facility documentation and policy, the facility failed to ensure that one resident (#2) received physician-ordered testosterone therapy per physician's order. This deficient practice could result in the worsening of a resident's underlying condition. The sample size was five. The universe was 50. Findings include:Resident # 2 was re-admitted to the facility on [DATE] with diagnoses that included testicular dysfunction.The quarterly Minimum Data Set (MDS) assessment, dated January 6, 2026, revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. On March 7, 2026, a complaint was received through the Arizona Online Complaint Portal alleging that the resident, who had been prescribed testosterone injections every two weeks by a urologist for low testosterone levels, did not receive the medication as scheduled, against accordance with the provider's orders. An order for Testosterone Cypionate Intramuscular (IM) solution 200 mg, dated January 15, 2026, revealed the resident was to receive the injection in the afternoon every 14 days for supplementation. The January 2026 Medication Administration Record (MAR) revealed the resident received the injection on January 15, 2026. The MAR failed to reflect the resident receiving the medication on January 29, 2026. A nursing note, dated February 8, 2026, revealed the resident received the Testosterone IM injection on that date, which was well tolerated by the resident. The clinical record failed to reflect supporting documentation allowing the facility to administer the IM injection exceeding the ordered 14 days. An interview was conducted on March 12, 2026, at 7:08 a.m. with a Registered Nurse (RN/Staff #33). The RN stated that testosterone therapy is important for maintaining the resident's mood and overall well-being. The RN indicated that if the medication is not available, the provider should be contacted, and staff should document notification of the pharmacy. The RN further explained that some medications may be obtained from the automatic medication dispensing cabinet; however, if the medication is not available, the Director of Nursing (DON) can contact the pharmacy to expedite delivery. The RN stated it is important to inform the resident when a medication is not available and to educate them on potential signs and symptoms that may occur if a dose is missed. The RN identified possible effects of missed testosterone injections as including mood swings and fatigue.An interview was conducted on March 13, 2026, at 11:30 a.m. with the Assistant Director of Nursing (ADON/Staff #67). The ADON reviewed the resident's clinical record and stated that an order was written on January 13, 2026, for testosterone 200 mg injection to be administered every two weeks. The ADON reported that the resident previously received the injections at a urology office; however, the resident expressed a preference to receive the injections at the facility. The ADON explained that testosterone therapy is intended to maintain appropriate hormone levels and treat the resident's testicular hypofunction. The ADON further stated that failure to administer the hormone injections as ordered could result in worsening of the resident's condition, including exacerbation of testicular hypofunction, mood swings, and irregularities in vital signs. The ADON stated that the facility expectation was for the provider to have been notified of the missed or delayed doses, in order to allow the provider to evaluate the resident's hormone levels and determine whether any dosage adjustments were necessary. The ADON stated that the expectation is for staff to follow physician orders as written, and if the medication is unavailable or cannot be administered as ordered, the provider should be notified promptly for further direction.An interview was conducted with the resident on March 13, 2026, at 12:20 p.m. The resident stated that he had recently informed his urology clinic of his decision to resume receiving his testosterone injections at the clinic, citing concerns that the facility had not been reliable in administering the injections as scheduled. The resident further stated that the medication is important to his health and expressed concern that his condition could worsen due to inconsistent administration by facility staff.An interview was conducted on March 13, 2026, at 1:11 p.m. with the Interim Director of Nursing (IDON) (Staff #76). During the interview, the IDON reviewed the clinical record and confirmed that a prescribed testosterone injection, ordered on January 13, 2026, was not administered on January 29, 2026, and that there was no supporting documentation indicating that the provider was notified of the missed dose. The IDON also stated that the resident did not receive his next dose of Testosterone until February 8, 2026, which exceeded the 14-day order. The IDON stated that the facility's expectation is that when a medication is unavailable, nursing staff are to notify the provider to receive further instructions. The IDON acknowledged that facility protocol was not followed regarding the missed testosterone dose in January 2026, and confirmed that the expectation for medication administration and provider notification was not met.The facility's Pharmacy Services policy, revised October 1, 2025, revealed the pharmacist is responsible for helping the facility obtain and maintain timely and appropriate pharmaceutical services that supports resident's healthcare needs, goals and quality of life that are consistent with current standards of practice and meet state and federal requirements.

Based on clinical record review, interviews, facility documentation, and policy review, the facility failed to ensure one resident (Resident #5), with a history of Substance Use Disorder (SUD), was not administered pain medications outside provider-ordered parameters. This deficient practice places residents at risk for adverse drug reactions and dependence. The sample size was 5. The universe was 50. Findings include:Resident # 5 was re-admitted to the facility on [DATE] with diagnoses that included aftercare following surgical amputation, paraplegia, cirrhosis of the liver, and alcohol dependence. The opioid consent form, dated December 2, 2025, revealed dependence, and addiction as opioid therapy risks. A behavioral disturbance care plan, related to anxiety and alcohol abuse, revised on December 17, 2025, revealed the resident was to be administered medications as ordered. A paraplegic care plan, revised on January 8, 2026, revealed medications were to be given as ordered, and to provide pain management as needed. The quarterly Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating he was cognitively intact. The assessment indicated the resident received as-needed (PRN) pain medication and reported a worst pain intensity of 7 during the assessment's 5-day look-back period. The assessment also identified that the resident was receiving opioid therapy, which is classified as a high-risk medication.Regarding Oxycodone HCL:An order for Oxycodone HCL (an opioid for pain) 10 mg tablets, instructed staff to give every four hours as needed for a pain level between 5-10. A review of the January 2026 Medication Administration Record (MAR) revealed Oxycodone HCL 10 mg was given outside of parameters on January 18, 2026 at a pain level of 1, and on January 22, 2026 at a pain level of 1. A review of the February 2026 MAR, revealed Oxycodone HCL 10 mg, was given outside of parameter on February 13, 2026 at a pain level of 2. A review of the March 2026 MAR, revealed Oxycodone HCL 10 mg, was given outside of parameter on March 1, 2026 at a pain level of 1. An interview was conducted on March 13, 2026, at 11:30 a.m. with the Assistant Director of Nursing (ADON/Staff #67). During the interview, the ADON reviewed the resident's clinical record and confirmed that the resident was prescribed Oxycodone 10 mg to be administered every four hours as needed for pain levels between 5 and 10. The ADON also reviewed the resident's medical history and noted a history of substance abuse, specifically alcohol abuse. The ADON stated that if a nurse needs to administer medication outside of the prescribed parameters, the provider must be notified. The ADON stated that the expectation is that nursing staff follow the physician's order, and if the medication is not available or administration falls outside of the ordered parameters, the provider should be contacted for further direction. The ADON stated that administration of opioids outside prescribed parameters may increase the risk of dependency, cause adverse reactions, affect vital signs, and alter pain tolerance. In addition, the ADON stated that the provider must be informed to assess the resident's condition and determine whether a dosage adjustment is necessary. An interview was conducted on March 13, 2026 at 12:29 p.m. with the resident. The resident revealed having no issues with his current pain management or opioid therapy. An interview was conducted on March 13, 2026, at 1:11 p.m. with the Interim Director of Nursing (IDON/Staff #76 ). During the interview, the IDON reviewed the resident's clinical record and identified several instances between January and March 2026 in which Oxycodone HCl was administered outside of the prescribed parameters. The IDON stated that the nurses responsible for administering the opioid outside of the ordered parameters on those dates are no longer employed at the facility. The IDON further stated that provider orders are expected to be followed as written and within the established parameters at all times. The IDON reported that the facility was unable to locate any supporting documentation or provider authorization for administering Oxycodone HCl outside of the prescribed parameters on the identified dates. As a result, the DON stated that the facility failed to meet its expectations for the proper administration and management of the resident's opioid therapy. Additionally, the IDON identified that the resident has a history of alcohol abuse and emphasized that caution should be exercised when administering opioids to residents with a history of substance use disorder (SUD), as this may increase the risk of relapse and other adverse outcomes. A review of the facility policy entitled Medication Administration Policy, reviewed/revised on October 1, 2025, revealed that medications are administered as ordered by the physician.

Based on an observation, staff interviews, and the facility policy and procedures, the facility failed to ensure one medication cart was secured when left unattended. The deficient practice could result in residents, visitors and/or staff members having unrestricted access to medications.Findings include:An observation was conducted on March 10, 2026 at 09:32 a.m. for call light responses and revealed on the South Wing, a staff member was preparing medications at the medication cart, collected the medication cup with the medications prepared and walked around the cart and into a resident room that was next to the cart. The medication cart was left facing out into the hallway, was left unattended and unlocked. Evidenced by Licensed Practical Nurse (LPN) Staff #35 leaving the medication cart unsecured and going into a resident room.An interview was conducted on March 10, 2026, at 09:33 a.m. with LPN (Staff #35) who verified that the medication cart was unlocked when she returned from passing medications to a resident. The LPN stated that the risk for leaving a medication cart unlocked and unattended could result in unauthorized staff or residents/visitors accessing the medications.An interview was conducted on March 11, 2026 at 12:24 p.m. with Chief Nursing Officer (CNO) Interim Director of Nursing (CNO/DON/Staff #76), who stated that medication carts should be locked at all times when not in use or when a nurse is not in front of the medication cart. The CNO state that the risk for leaving a medication cart unlocked and unattended could result in unauthorized persons or residents gaining access to medications.The facility policy titled, Medication Storage, reviewed/revised October 1, 2025, revealed that all drugs and biologicals will be stored in locked compartments (i.e., medication carts, cabinets, drawers, refrigerators, medication rooms).

Based on interviews, clinical record review, and review of facility policy and procedures, the facility failed to protect the rights of one of three sampled residents (#38) to be free from abuse by another resident (#21). The deficient practice resulted in a resident-to-resident physical altercation with documented injuries and had the potential to result in ongoing abuse and further harm to other residents.Findings include:Regarding Resident #38:Resident #38 (alleged victim) was admitted to the facility on [DATE], with diagnoses that included disorder of mineral metabolism, pneumonitis due to inhalation of food and vomit, hypertensive urgency, fluid overload, end-stage renal disease, protein-calorie malnutrition, generalized muscle weakness, difficulty walking, asthma, anemia in chronic kidney disease, hyperlipidemia, epilepsy, heart failure, and dependence on renal dialysis.A hospital discharge, Minimum Data Set (MDS) assessment dated [DATE], revealed that the Brief Interview for Mental Status (BIMS) assessment was not recorded. The MDS indicated that Resident #38's cognitive skills for daily decision-making were severely impaired and that he rejected care one to three days during the assessment period. The MDS further noted that Resident #38 used a manual wheelchair for mobility.A care plan, initiated November 4, 2025, identified a focus on fall risk related to decreased mobility and strength. Interventions included medication review for sedatives, antihypertensives, and psychotropics.A nursing progress note entered on January 29, 2026, by Licensed Practical Nurse (LPN) Staff #25 documented that Resident #38's primary physician and nurse practitioner were notified regarding an incident involving another resident.On January 30, 2026, a BIMS assessment was conducted for Resident #38, which revealed a score of 11, indicating moderate cognitive impairment.Attempts were made to interview Resident #38 on February 12, 2026, at 11:20 a.m., 12:13 p.m., and 12:50 p.m.; he was sleeping during each attempt. At 1:52 p.m., Resident #38 declined to speak about the event.-Regarding Resident #21:Resident #21 (alleged perpetrator) was admitted to the facility on [DATE], with diagnoses that included diffuse traumatic brain injury with loss of consciousness of unspecified duration, muscle weakness, difficulty walking, anxiety disorder, insomnia, heartburn, pseudobulbar affect, major depressive disorder, hemiplegia, schizoaffective disorder, depression, seizures, and therapeutic drug level monitoring.A quarterly MDS assessment dated [DATE], revealed a BIMS score of 11, indicating moderate cognitive impairment. The MDS documented no behaviors directed toward others during the assessment period and indicated that Resident #21 used a wheelchair for mobility.A care plan, initiated October 10, 2025, identified verbal and physical aggression, intrusive behaviors, and outbursts as areas of focus. The care plan included the incident that occurred on January 29, 2026.Orders for Resident #21 dated January 8, 2026 included behavior charting every day and evening shift for behavioral monitoring.On January 30, 2026, a nursing progress note was entered into the clinical record for Resident #21 stating that he had behavior issues but was redirected to his room.During an interview conducted with Resident #21 at 11:15 a.m., Resident #21 stated that on January 29, 2026, he was outside on the facility patio speaking with another resident when Resident #38 entered the conversation and began arguing with him. Resident #21 stated that he instigated the physical altercation and that the two began fighting. He further stated that he held Resident #38 down during the confrontation and that the fight continued until they were separated by other residents and staff.The facility's five-day investigation dated February 2, 2026, revealed documentation of a skin assessment for Resident #38 noting a knot on his left hand, a bruise and scrape on his right hand, a scrape on his right knee, and a bruise with two knots on his left leg. The investigation report indicated that the residents were separated, assessed, and monitored after the incident.An interview was conducted on February 12, 2026 at 11:54 a.m., with Licensed Practical Nurse (LPN) Staff #25, who stated that on January 29, 2026, at approximately 6:00 p.m., while the nursing shift was in the middle of shift change, she heard residents on the patio calling for help and that she and two other nurses responded. She further stated that upon arrival, the residents had stopped fighting, and several other residents, including Resident #22 who observed the incident. Staff #25 stated she escorted Resident #38 inside and assessed him and she observed swelling and multiple knots on his hands, and noted bleeding from his knuckles. A telephonic interview was conducted on February 12, 2026 at 12:30 p.m., with an LPN (Staff #41), who stated that she had just arrived to begin her shift shortly after 6:00 p.m. on January 29, 2026, when she responded to the residents' calls for help. She stated that both residents were back in their wheelchairs upon her arrival. She assisted Resident #21, who complained of pain in his finger; however, she observed no visible injury.An interview was conducted on February 12, 2026 at 12:58 p.m. with Resident #22, who stated that on January 29, 2026, she observed Resident #38 verbally confronting Resident #21. She stated that Resident #21 stood up from his wheelchair and grabbed Resident #38, and the two residents began physically fighting. Resident #22 stated that she maneuvered her wheelchair between Residents #21 and #38 in an attempt to separate them while other residents called for help. A review of Resident #22's quarterly MDS dated [DATE], revealed a BIMS score of 15, indicating she was cognitively intact. An interview was conducted with the facility Administrator and Abuse Coordinator (Staff #72) on February 12, 2026, at 1:58 p.m. The administrator stated that unwanted physical contact met the definition of physical abuse. She further stated that the incident between Residents #38 and #21 on January 29, 2026, would be considered abuse and failed to meet the facility's expectations. The Administrator also stated that risks of physical abuse would depend on the circumstances but could include physical injury and psychosocial harm. A facility policy titled, Abuse Prevention, Identification, Investigation, and Reporting Policy, implemented October 1, 2025, revealed that it was the policy of the facility to provide care to all residents in an environment free from abuse.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the rights of one resident (#4) to be free from abuse by another resident (#6). The deficient practice could result in further resident abuse.Findings: -Regarding Resident #4Resident #4 was admitted to the facility on [DATE], with a diagnosis that included schizophrenia, unspecified, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, major depressive disorder, recurrent, unspecified.A review of the Annual MDS (minimum data set) assessment dated [DATE], revealed a BIMS (brief interview of mental status) score of 07, which indicated the resident had severe cognitive impairment. Further review of the MDS revealed no indicators for mood, no indicators for behaviors, but concerns with wandering daily.Review of Care Plan initiated on October 9, 2025, with reviewed/revised date of August 16, 2025, revealed a problem start date on August 12, 2022, for behaviors associated with wandering into other residents' rooms. Further review of the care plan revealed a problem start date on September 23, 2025, with resident #4 involved in an altercation with another resident. Approaches for the assessed problems included providing supervision as indicated, assessing the area with visible bruising, swelling, or open injury present, and separating the resident to a safe area, back to his room.Review of the electronic health record for skin assessments revealed that no skin assessment was documented for the date of the alleged altercation.Review of the progress notes dated September 21, 2025, 20:28, revealed SN (staff nurse) was administering medications on the South hall to Residents, when SN heard a loud verbal outburst and turned to observe Resident #4 in a physical altercation with another Resident, Resident #4 was at the entrance of the other Residents room while the other Resident was facing towards him with his arm raised, drawn back and his fist clenched, SN immediately intervened and separated both parties as Resident #4 verbalized He punched me! Right here. pointing at the left side of his face, SN assessed the area with no visible bruising, swelling or open injury present, SN redirecting Resident #4 to his room with the assistance of the CNA, for safety and further assessment, Resident vitals b/p 110/73 p 85 t 97.2 O299%ra rr 18, Resident denies any pain or discomfort at this time, No acute distress noted, ADON was notified as the first line of contact and facility protocol followed as directed, AZDHS, APS, Phoenix PD, Physician, DON, and case manager notified between the times of 1413-1430, no contact noted on face sheet to notify, Phoenix PD arrived on site around 1700, Police report #2025-01383343, Resident continuously monitored throughout shift with no changes in condition.Review of the Facility Incident Report Form dated September 21, 2025, and reported by the Director of Nursing (DON/Staff#11) documented on the form a description of any type of injury noted on resident #4. The description stated slight redness to skin on L (left) cheek. No bruising or pain. The Facility Incident Report further states that residents #4 and #6 were separated, and resident #6 was moved to another room. However, review of the facility census revealed that resident #6 was not moved from room [ROOM NUMBER]-A to 135-A until September 22, 2025.-Regarding Resident #6Resident was admitted to the facility on [DATE], with a diagnosis that included hemiplegia and hemiparesis following unspecified cerebrovascular disease affecting unspecified side, cerebral infarction due to unspecified occlusion or stenosis of unspecified cerebral artery, and pain, unspecified. Review of the quarterly MDS dated [DATE], revealed a BIMS assessment score of 15, indicating the resident's cognition was intact. However, review of the mood assessment revealed the resident was not assessed due to the resident rarely or never understood. Further review of the MDS revealed no indicators for behaviors, diagnosed with hypertension, aphasia, cerebrovascular accident (CVA, TIA or stroke, non-Alzheimer's dementia, and hemiplegia or hemiparesis.A review of the Care Plan, initiated September 29, 2025, revealed a problem start date of March 26, 2025, for behaviors related to hitting another resident in the past. On September 21, 2025 resident was involved in a physical altercation with another resident. Further review of the care plan revealed problems related to cognitive loss and dementia, and communication-related diagnoses for cerebrovascular accident (CVA) with expressive aphasia. Approaches included anticipating and meeting needs promptly. He was informed that physical altercations are strictly prohibited on this campus. SSD issued a verbal warning concerning the incident, emphasizing that it constitutes a violation of the policies at Suncrest. Moving forward, the resident must refrain from any unwanted or physical altercations; failure to do so may result in a 30-day notice to vacate the campus. Review of the progress notes dated September 21, 2025, 20:26 revealed SN was administering medications on the South hall to Residents, when SN heard a loud verbal outburst and turned to observe Resident [NAME] engaged in a physical altercation with another Resident, Resident [NAME] was seated in his wheelchair at the entrance of his room with his left arm drawn back, and fist clenched, aiming towards the other Resident, SN immediately intervened, providing verbal redirection and separated both residents, Resident [NAME] was redirected to his room and educated on safety measures and expectations for behavior, Resident smiled and laughed in response to SN, for resident safety and the safety of others Resident [NAME] was returned to his bed with staff monitoring, ADON was notified as the first line of contact and facility protocol followed as directed, AZDHS, APS, Phoenix PD, Physician, DON, and case manager notified between the times of 1413-1430, no contact noted on face sheet to notify, Physician ordered labs (CBC, BMP, UA), and facility drug screen, orders and labs submitted, drug screening positive for Buprenorphine and negative for all other substances, Phoenix PD arrived on site around 1700, Police report #2025-01383343.An attempt to interview resident #6 was conducted on October 21, 2025, at 8:56 a.m. The resident was lying in bed resting. Surveyor unable to complete the interview. Resident #6 is diagnosed with aphasia and is only able to respond to yes and no questions with cueing. An interview was conducted on October 21, 2025, at 9:00 a.m. with resident #4 in his room. The resident stated he was punched in the face by a black man about a few weeks ago when I was by my room. The resident reported, [NAME] punched me in my face and pointed with his finger to the left side of his face. Resident #4 stated he was unsure of any discoloration from being punched, but did state that it did hurt and that he had a conversation with the administrator regarding the incident. Resident #4 reported feeling safe now that they moved him to another room the next day. An interview was conducted on October 21, 2025, at 9:08 a.m. with a Registered Nurse (RN/Staff #15). Staff #15 stated that it was reported to her that approximately one month ago, on a weekend, resident #4 was trying to pass down the hallway to his room when resident #6 went over to resident #4 and hit him in the face. Staff #15 stated that resident #6 was moved the following day due to attempting to hit resident #4 the next day. Staff #15 stated that the weekend, Licensed Practical Nurse (LPN/Staff #18) witnessed the altercation, and completed an incident report when it happened. Staff #15 stated the facility provides abuse training to all staff and is responsible for filing reports to the state, after notifying the abuse coordinator, DON, police, and completing a resident assessment for any injuries within two hours of any alleged abuse allegations. An interview was conducted on October 21, 2025, at 9:21 a.m. with Administrator/Abuse Coordinator (Staff #18). A request was made for the facility five five-day report involving residents #4 and #6. Staff #18 stated she had reviewed the videotape of the altercation, and it did not appear that resident #6 struck resident #4 as reported. A request was made to view the videotape in person. Staff #18 stated she would see if the video was still available to view. An interview was conducted on October 21, 2025, at 11:57 a.m. with resident #8. Resident #8 stated she was lying in her bed and was able to see both residents #4 and #6, outside her door in the hallway. She stated she saw resident #6 strike resident #4 on his face with a closed fist, causing resident #4 to yell out. She stated this is when LPN/Staff #13 yelled at resident #6 to stop, as he had his hand raised to hit resident #4 again. She stated that resident #6 is known for hitting other people. She stated the following day, resident #6 attempted to hit resident #4 again while in the same hallway, and this is when they moved resident #6 to another hall.An interview was conducted on October 21, 2025, at 12:05 p.m. with resident #10. Resident #10 stated she was in the hallway when the incident occurred. She stated she was in her wheelchair in front of residents #4 and #6, as resident #4 had moved to allow her pass. She stated she heard LPN/Staff #13 yell out, Resident #6, don't hit him again! She stated she turned in their direction to see resident #6 with his hands raised like he was going to hit resident #4, and that resident #4 was holding his hand to his face, yelling, he hit me on my face. Resident #10 stated LPN/Staff #13 caught resident #6 trying to hit resident #4 again on the next day, and this is why resident #6 was moved to a different hall. Resident #10 stated that resident #6 used to go around bumping other residents with his wheelchair on purpose. An attempt to telephonically interview was conducted on October 21, 2025, at 1:28 p.m. with (LPN/Staff #13). No response, message left for a return phone call.An interview was conducted on October 21, 2025, at 1:01 p.m. with Certified Nursing Assistant (CNA #23). Staff #23 stated that staff are expected to report if they suspect or if they see any form of abuse. Staff #23 stated they are expected to separate the residents, report to their charge nurse, and if nothing is done once they have reported to the nurse, then it is their responsibility to report the incident themselves within a two-hour timeframe. Staff #23 stated there are many different forms of abuse, including sexual, physical, mental, and financial, and resident-to-resident altercations would be considered a form of physical abuse, almost like assault. Staff #23 stated the facility provides abuse training frequently and feels that there is sufficient staffing to provide supervision and monitoring for all the residents in the facility, by working together and recognizing that it is everyone's responsibility to watch all of the residents. An interview was conducted on October 21, 2025, at 1:12 p.m. with the Director of Nursing (DON/Staff#21). The DON stated her expectations for resident-to-resident altercations are to separate the two residents involved, make sure they are okay, by assessing the resident both physically and mentally. The process would also involve notifying the administrator herself and the charge nurse. The DON stated a skin assessment should have been documented in the resident's medical record as a change of condition, so staff could continue to monitor the injury. She further stated the facility would have conducted an immediate room change if the residents were roommates. The DON stated resident #6 was moved the next day, due to the proximity of their rooms. An interview was conducted on October 21, 2025, at 1:28 p.m. with Administrator/Abuse Coordinator (Staff #18). Staff 18 reported that the facility is going through a transitional period and the new owners have implemented new policies and processes to ensure the safety and well-being of the residents. This has involved having conversations with the residents at a resident-council meeting, establishing boundaries and expectations. Staff #18 stated this will also involve re-assessing the residents' needs and behaviors to ensure they are in the right facility and can meet those needs. Staff #18 did not provide the opportunity to view the videotape at exit. Review of the facility policy titled ABUSE PREVENTION, IDENTIFICATION, INVESTIGATION, AND REPORTING POLICY date reviewed/revised October 1, 2025 states It is the policy of this facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. Identification of Abuse, Neglect, and Exploitation included that the facility will have written procedures to assist staff in identifying the different types of abuse - mental/verbal abuse, sexual abuse, physical abuse, and the deprivation by an individual of goods and services. This includes staff-to-resident abuse and certain resident-to-resident altercations.

Based on clinical record review, facility documentation, and staff interviews, the facility failed to protect the rights of residents to be free from abuse by another resident (#777, #222, #444). The deficient practice could result in residents being harmed physically and emotionally. -Regarding Resident to Resident altercation between Resident #1001 and #777: -Resident #1001 was admitted to the facility on [DATE] and discharged on May 22, 2023. Diagnoses included schizoaffective disorder depressive type, dysphagia following cerebral infarction, and human immunodeficiency virus (HIV). The care plan dated April 10, 2023 revealed that the resident was involved in an altercation with another resident. He rammed his chair into the resident's feet. The resident will not be involved in another altercation with another resident through the next review date. Interventions included that the wheelchair was revoked as directed and to monitor the resident's behavior as indicated. The MDS dated [DATE] included a brief a mental status assessment indicating the resident had a moderate cognitive impairment. A progress note dated April 10, 2023 revealed that on April 9, 2023 nursing staff advised this writer that the resident was involved in an altercation with another resident. Loud voices were heard in the main lobby and the receptionist informed this nurse that her resident had been assaulted. Resident (#1001) was visibly upset and had gotten into it with another resident out on the patio. This writer and another nurse went out to the patio to determine what had occurred. The other nurse began to ask questions from the residents on the patio and all the residents stated the same facts, resident (#1001) rammed his chair into resident (#444's) feet several times and then took his good arm and back handed him in the face. Resident (# 444's) wound was immediately treated by his nurse. -Resident (#777) was admitted to the facility on [DATE] with diagnoses that included paraplegia, acute respiratory disorder, and nonpsychotic mental disorder. The MDS dated [DATE] included a brief interview for mental status score of 14 indicating the resident was cognitively intact. The care plan dated April 10, 2023 revealed the resident’s feet were rammed several times by another resident and he was backhanded in the face. Interventions included to administer medication as ordered. The progress note dated April 10, 2023 (late entry) revealed that on April 9, 2023 the resident was involved in an altercation with another resident. Loud voices were heard in the lobby and the receptionist informed this nurse that her resident had been assaulted. Resident (#1001) was visibly upset and had gotten into it with another resident out on the patio. This writer and another nurse went out to the patio to determine what had occurred. The other nurse began to ask questions from the residents on the patio and all the residents stated the same facts, resident (#1001) rammed his chair into resident (#777's) feet several times and then took his good arm and back handed him in the face. Resident (# 777's) wound was immediately treated by his nurse. The five-day investigation dated April 13, 2023 revealed that the video of the patio area was reviewed and both residents were using their wheelchairs as weapons. It was determined that resident (#777) instigated the altercation and he also obtained an injury to his toe. It also revealed that the intial altercation began inside of the building as a verbal altercation and continued when both residents went out to the patio. There were multiple residents on the patio who witnessed the altercation. An interview was conducted on July 17, 2025 at 9:35 a.m. with resident (#905), who stated residents can smoke on the patio any time without supervision. He remembered resident (#1001) got in a fight on the patio with resident (#777). He stated that both residents were throwing punches. An interview was conducted on July 17, 2025 at 10:04 a.m. with the (DON/staff #71), who stated that there is a camera in the smoking area. She stated that he would have reviewed the video footage during the investigation and it should be noted in the 5-day investigation and would have been reviewed by the Business Office Manager. She stated that the residents are allowed to smoke at any time on the patio independently without supervision. An interview was conducted on July 17, 2025 at 9:51 a.m. with a registered nurse (RN/staff #50) who stated that residents are allowed to smoke on the patio without supervision. She stated that if something goes wrong, a resident will usually come in and let the staff know something has happened. She stated that resident (#1001) was aggressive and got frustrated because he was not able to express himself. She stated that if resident (#1001) tried to hit someone with his wheelchair, it was abuse. The facility policy, Abuse and Neglect states that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. - In regards to the altercation between Resident #111 and Resident #222 Resident #111 Resident #111 was admitted [DATE] with diagnoses that included type 2 diabetes mellitus with other specified complications and pain, unspecified. An MDS (Minimum Data Set) assessment dated [DATE] revealed a BIMS (Brief Interview of Mental Status) score of 12, which indicates that the resident had intact cognition at the time of the incident. A progress note dated February 17, 2023 revealed that Resident #222 reported an altercation with him and Resident #111 where both residents were located in the designated smoking area when Resident #222 observed Resident #111 throwing rocks at cats that roam the facility grounds. Resident #222 had told Resident #111 to stop the action. In response, Resident #111 hit Resident #222 in the face. The progress note also revealed that security footage had been reviewed and revealed that Resident #222 did attempt to stop Resident #111 from the action and in response Resident #111 was observed pulling the arm of Resident #222 and punched Resident #111 in the face and ripped his shirt. Indicating that an altercation between Resident #111 and Resident #222 did occur on February 17, 2023. Resident #222 Resident #222 was admitted [DATE] with diagnoses that included unspecified abdominal pain, long term (current) use of anticoagulants, chronic pain syndrome, and bipolar disorder, unspecified. An MDS (Minimum Data Set) assessment January 15, 2023 revealed a BIMS (Brief Interview of Mental Status) score of 14, which indicates the resident had intact cognition at the time of the incident. A progress note dated February 17, 2023 revealed that Resident #222 reported that they were involved in an altercation with Resident #111. The progress note also revealed that Resident #222 had been observed with redness on their nose and the right side of their face, with a torn shirt. Resident #222 had also been observed with anxious behavior, evident by rocking back and forth in their wheelchair with shortness of breath. The progress note also revealed that Resident #222 had been administered pain medications following the incident. Another progress note dated February 17, 2023 revealed that an altercation between Resident #222 and Resident #111 occurred in the designated smoking area where Resident #222 observed Resident #111 throwing rocks at cats that roam the facility grounds. Resident #222 had told Resident #111 to stop the action. In response, Resident #111 hit Resident #222 in the face. The progress note also revealed that security footage had been reviewed and revealed that Resident #222 did attempt to stop Resident #111 from the action and in response Resident #111 was observed pulling the arm of Resident #222 and punched Resident #111 in the face and ripped his shirt. Indicating that an altercation between Resident #111 and Resident #222 did occur on February 17, 2023. An interview was conducted on July 15, 2025 at 9:46AM with a CNA (Certified Nursing Assistant/Staff #100) who stated that although they did not witness any altercations between Resident #111 and Resident #222, that a resident to resident altercation can be identified as abuse. Staff #100 also identified abuse as any action that make cause physical, emotional, financial, sexual, and psychological harm on a person. A telephone interview was conducted on July 15, 2025 at 12:04PM with a CNA (Staff #87) who stated that although they did not witness the altercations between Resident #11 and Resident #222, that resident to resident interactions are defined as abuse if the interaction involved hitting, verbal threats, and utilizing objects to cause harm, per facility’s expectations. An interview was conducted on July 15, 2025 at 2:55PM with a Social Services Director (Staff #33) who stated that although they did not witness the altercations between Resident #111 and Resident #222, that resident to resident interactions where a resident may throw an object to another resident, and as well as, a physical interaction in a common area, are identified as abuse within the facility’s definition and expectation regarding abuse allegations. An interview with Licensed Practical Nurse (LPN/Staff #57) was conducted on July 17, 2025 at 11:30AM, who identified resident to resident physical altercations in a common area, such as an outdoor patio as abuse; and, identified a resident to resident verbal and physical altercation where profanities are exchanged and coffee is thrown from a resident to another resident, as abuse. Staff #57 re-called the altercation between Residents #111 and Residents #222 where the two residents got into a dispute regarding the cats located in the smoking patio of the facility, that escalated into a physical interaction between Resident #111 and Resident #222. Staff #57 also stated that their role as a Wound Nurse limited their interactions with Resident #111 and Resident #222, however, stated that pain and redness on the face of Resident #222 had been monitored and offered a cold compress as needed. Indicating that Resident #222 experienced a physical outcome following the incident that occurred on February 17, 2023. An interview was conducted on July 17, 2025 at 10:38AM with a LPN (Staff #63) who identified resident to resident physical altercations in a common area, such as an outdoor patio as abuse; and, identified a resident to resident verbal and physical altercation where profanities are exchanged and coffee is thrown from a resident to another resident, as abuse. Staff #63 also stated that although they did not witness the altercations between Resident #111 and Resident #222, that Resident #111 exhibited behaviors of verbal and physical aggression with staff and other residents. Staff #63 also stated that Resident #222 exhibited attention seeking behaviors with staff and other residents. An interview was conducted on July 17, 2025 at 11:39AM with the DON (Director of Nursing/Staff# 71) who identified resident to resident physical altercations in a common area, such as an outdoor patio as abuse; and, identified a resident to resident verbal and physical altercation where profanities are exchanged and coffee is thrown from a resident to another resident, as abuse. Staff #71 also stated that the altercation between Resident #111 and Resident #222 on February 17, 2023 were identified as abuse per facility’s expectations. A facility policy, Abuse and Neglect states that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy also defined abuse as the willful infliction of injury, unreasonable confinement, or punishment that can have the result of physical harm, pain or mental anguish or depravation. - In regards to the altercation between Resident #222 and Resident #444 Resident #222 Resident #222 was admitted [DATE] with diagnoses that included unspecified abdominal pain, long term (current) use of anticoagulants, chronic pain syndrome, and bipolar disorder, unspecified. An MDS (Minimum Data Set) assessment April 17, 2024 revealed a BIMS (Brief Interview of Mental Status) score of 12, which indicates the resident had moderate cognitive impairment at the time of the incident. A progress note dated June 23, 2024 revealed that Resident #222 had approached nursing staff and stated their involvement in an altercation with Resident #444 where a verbal disagreement between Resident #222 and Resident #444, that had led to Resident #444 throwing coffee on Resident #222, and then proceeded to throw coffee on Resident #444. Resident #222 had been observed with a spill on their shift that staff identified as coffee. Resident #222 had also stated to the nursing staff that he was hit in the face with the mug that Resident #444 had in his possession. This progress note indicates that an altercation took place on June 23, 2024. Resident #444 Resident #444 was admitted on [DATE] with the diagnosis that included encephalopathy, unspecified; epilepsy, unspecified, intractable with status epilepticus; bipolar disorder, in partial remission, most recent episode hypomanic. An MDS (Minimum Data Set) assessment May 17,2024 revealed a BIMS (Brief Interview of Mental Status) score of 15, which indicates the resident had intact cognition at the time of the incident. A progress note dated June 23, 2024 revealed that an altercation with Resident #444 where a verbal disagreement between Resident #222 and Resident #444, that had led to Resident #444 throwing coffee on Resident #222, and then proceeded to throw coffee on Resident #444. Resident #222 had also stated to the nursing staff that he was hit in the face with the mug that Resident #444 had in his possession. Resident #444 was noted to have no injuries following the incident. This progress note indicates that an altercation took place on June 23, 2024. An interview was conducted on July 15, 2025 at 9:46AM with a CNA (Certified Nursing Assistant/Staff #100) who stated that although they did not witness any altercations between Resident #222 and Resident #444, that a resident to resident altercation can be identified as abuse. Staff #100 also identified abuse as any action that make cause physical, emotional, financial, sexual, and psychological harm on a person. A telephone interview was conducted on July 15, 2025 at 12:04PM with a CNA (Staff #87) who stated that although they did not witness the altercations between Resident #222 and Resident #444, that resident to resident interactions are defined as abuse if the interaction involved hitting, verbal threats, and utilizing objects to cause harm, per facility’s expectations. An interview was conducted on July 15, 2025 at 2:55PM with a Social Services Director (Staff #33) who stated that although they did not witness the altercations between Resident #222 and Resident #444, that resident to resident interactions where a resident may throw an object to another resident, and as well as, a physical interaction in a common area, are identified as abuse within the facility’s definition and expectation regarding abuse allegations. An interview was conducted on July 15, 2025 at 3:12PM with Resident #444 who stated that he did feel safe in the facility, however, re-called an incident with Resident #222 has he stated that Resident #222 had antagonized and terrorized residents when upset. Resident #444 re-called the incident on June 23, 2024 where Resident #222 hit a dining table that Resident #444 had been sitting at and their own coffee cup spilled on themselves. Resident #444 also stated that the incident led to a verbal disagreement that escalated quickly. Resident #444 also stated that the facility had spoke to Resident #222 following the incident and then proceeded to remove themselves from any space that Resident #222 may be located in. An interview was conducted on July 17, 2025 at 10:38AM with a LPN (Staff #63) who identified resident to resident physical altercations in a common area, such as an outdoor patio as abuse; and, identified a resident to resident verbal and physical altercation where profanities are exchanged and coffee is thrown from a resident to another resident, as abuse. Staff #63 also stated that although they did not witness the altercations between Resident #222 and Resident #444, Resident #222 exhibited attention seeking behaviors with staff and other residents. Staff #63 also stated that Resident #444 exhibited attention seeking behaviors and stringent with verbal requests. An interview was conducted on July 17, 2025 at 11:39AM with the DON (Director of Nursing/Staff# 71) who identified resident to resident physical altercations in a common area, such as an outdoor patio as abuse; and, identified a resident to resident verbal and physical altercation where profanities are exchanged and coffee is thrown from a resident to another resident, as abuse. Staff #71 also stated that the altercation between Resident #222 and Resident #444 on June 23, 2024 were identified as abuse per facility’s expectations. A facility policy, Abuse and Neglect states that the resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. The policy also defined abuse as the willful infliction of injury, unreasonable confinement, or punishment that can have the result of physical harm, pain or mental anguish or depravation.

The facility failed to ensure that one resident (#1000) was treated with dignity and respect by another resident.Based on documentation, staff and resident interviews, the facility policy and procedures, the facility failed to ensure that one resident (#1000) was treated with dignity and respect by another resident (#1001). The deficient practice could result in psychosocial harm. Findings included:Resident #1000 was admitted to the facility on [DATE] and discharged on October 3, 2022. The diagnoses included post traumatic disorder (PTSD), major depressive disorder, bipolar disorder, and anxiety disorder.The Minimum Data Set, dated [DATE] included a brief interview for mental status score of 15 indicating the resident was cognitively intact. It also included that the resident ambulated with a wheelchair.The care plan dated September 6, 2022 revealed that the will feel safe through the next review date. The resident reported being sexually assaulted by another resident that he touched and massaged her shoulder while she was sleeping. Interventions included to encourage the resident to stay away from the alleged perpetrator, encourage resident to notify the staff about any concerns that she may have, notify the police department and Adult Protective Services. (APS).A progress note dated September 5, 2022 revealed the resident came to nurse crying and wanting to talk in private. The nurse pulled her away from everyone to see what was wrong. The resident stated that another resident in room [ROOM NUMBER]A touched her arm and was massaging her shoulders while she was sleeping. The resident stated, I was outside in the smoking area last night and something made me wake up and when I did, the resident in room [ROOM NUMBER]A was massaging my shoulders and then ran his hands down my arm. The resident stated that she was scared to report it when it happened but she really didn't want it to happen to someone else and she felt she was ready to say something. This nurse called the Phoenix non-emergent line and sent and officer out to take her statement. AZDHS was called and message was left for them to call back. Awaiting that at this time. The resident is safe in her room and resting at this moment.A social services progress note dated September 6, 2022 revealed that an APS report was filed. A Five Day Report was sent to the Department of Health Services (DHS) and the Ombudsman will be faxed once the report is completed. A social services note dated September 7, 2022 revealed that an investigator from APS came to speak with Resident on this day.A social services note dated September 30, 2022 revealed that the Social Services Director called the police detective and he stated that the case was closed as shoulder rubbing was not a crime. The police officer watched the video and determined that there was no sexual abuse or motivation. -Resident #1001 was admitted to the facility on [DATE] and discharged on May 22, 2023. Diagnoses included schizoaffective disorder depressive type, dysphagia following cerebral infarction, and human immunodeficiency virus (HIV).The care plan dated September 6, 2022 revealed that the resident was accused by two other residents of sexually assaulting them. The resident will have appropriate behavior towards peers through the next review date. Interventions included to monitor the resident diligently of resident activities and behaviors, has high risk to repeat offending and resident is not allowed to come out of his room to go to another resident's room except for smoking, resident was redirected to leave the room, and addressing any behavior issues and notify the supervisor as indicated.The MDS dated [DATE] included a brief interview for mental status score of 8 indicating the resident had a moderate cognitive impairment. It also include that there were no changes in behaviors. A social services note dated September 6, 2022 revealed that the Social Services Director (SSD) spoke with the resident regarding allegations from other residents at the facility. The resident was told that he cannot go into other resident's rooms and to stay away from residents in 128B and 126C. The resident denied doing anything but agreed verbally and nodded his head that he would stay away from these residents.A Director of Nursing note dated September 6, 2022 revealed that the facility checked the security cameras, and resident (#1001) went outside to the smoking area. At the smoking area, resident (#1000) could be seen outside in her wheelchair on her own. Resident (#1001) could be seen to approach, watch her for a while and later, at about 10:30 p.m., he started touching her from the shoulders and going down her back. This was done against her will which the resident reported to staff. The police were alerted and an investigation was started. Now, the resident is not allowed to come out of his room and go into other residents' rooms at this time. The resident can go outside to smoke though. The Police have been furnished with the video that showed the resident's encounter with resident (#1000). An interview was conducted on July 17, 2025 at 10:04 a.m. with the (DON/staff #71), who stated that there is a camera in the smoking area. She stated that he would have reviewed the video footage during the investigation and it should be noted in the 5-day investigation and would have been reviewed by the Business Office Manager. She stated that if resident (#1001) was massaging resident (#1000's) shoulders and back unsolicited, it could be a violation of the resident's rights. She stated that the residents are allowed to smoke at any time on the patio independently without supervision. The risk to the resident being touched when it was unwanted is emotional distress or the resident could be pinched or hurt in some way. An interview was conducted on July 17, 2025 at 10:32 a.m. with the Business Office Manager (BOM/staff #23) who stated that she has received training on resident rights and if a resident was massaging another resident's arms/back and it was unwanted, it was a violation of the resident's rights. She stated that she reviewed the video footage on the patio and resident (#1000) had her eyes closed and resident (#1001) was massaging resident (#1000). The facility policy, Nursing Home Rights states that residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination.

The facility failed to update the fall care plan for one resident.Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to update the fall care plan for one resident (#4). The deficient practice could result in residents not receiving the care needed to prevent further accidents.The findings included:The resident was admitted to the facility on [DATE] with diagnoses that included abnormality of gait, generalized muscle weakness, dorsalgia, usnspecified fall, and wedge compresision fracture of third lumbar vetebra, The resident expired on [DATE]. The MDS dated [DATE] included a brief interview for mental status score of 8 indicating the resident had a moderate cognitive impairment. It also included that the resident had a fall in the last month and had a fracture related fall in the last six months. The fall care plan dated [DATE] stated that the resident was at risk for falls. Review of the plan revealed that all the interventions on the care plan were implemented on [DATE]. There was no documentation to show that the care plan was updated after the resident fell on [DATE]. Review of a nurse's progress note dated [DATE] revealed that resident stated that he slid from his chair and onto the floor next to his bed. The resident was able to lift self back onto chair. The resident stated, I didn't call because I didn't know I needed to. A full body assessment found one bruise on left buttock 6 cm in diameter. The resident also stated also, It is the darn cushion that caused me to slide off the chair. I did not hit my head. The hospice nurse was notified and will continue to monitor the resident. A nurse's note dated [DATE] at 5:50 p.m. revealed that the resident complained of severe back pain a few hours following a fall and wanted to go to emergency room (ER) for evaluation. The hospice nurse was notified, and the okay was given for resident to go the ER. The doctor was notified. The resident was sent by non-emergency transportation to the ER around 5.00 pm. A nurse note dated [DATE] at 7:05 p.m. revealed that CNA notified nurse of patient being on the floor. On entering the room, patient observed sitting on the floor by the window, The resident said he was up walking towards the door but slipped off and fell hard on the floor on his butt. He denied a head strike. A nursing assessment was done and no apparent juries were noted. The vital signs (VSS), range of motion (ROM) to both uppper and lower extremities (BUE/BLE) were within normal limits (wnl). The resident denied pain at the time. Hospice was notified and a nurse came out and assessed the resident. Review of the hospital Discharge summary dated [DATE] revealed that the resident needed to be treated or managed emergently for a lumbar fracture. A progress note dated [DATE] 5:46 a.m. revealed that resident came back from the hospital around 1:00 a.m. with a lumbar spine fracture. No new orders. Resident is stable and vital are (WNL). An interview was conducted on [DATE] at 10:39 a.m. with the Director of Nursing (DON/staff #58), who reveiwed the clinical record and stated that there was no documentation regarding what interventions would be implemented in the care plan after the fall on [DATE]. She reveiwed the care plan for falls and stated that the care plan was not updated after [DATE], and the plan could have included interventions such as moving the resident closer to the nurse station and non-skid socks. She stated that the resident had moved rooms multiple times and was not located near the nursing station. An interview was conducted on [DATE] at 1:10 p.m. with the Assistant Director of Nursing (ADON/staff #74), who stated that when a resident falls, the interdisciplinary team (IDT) has a meeting to discuss whether new interventions are needed and the interventions are given to the MDS Coordinator and the care plan is updated. She reviewed the care plan and acknowledged that the plan was not updated after each fall. She stated that new interventions are added to keep the resident safe. She also stated that she usually moves a resident who falls closer to the nurse's station if a room is available and non-skid socks are standard. The facility policy, Care Plans, Comprehensive Person-Centered states that the comprehensive, person-centered care plan is developed within seven days of the completion of the MDS assessment (Admission, annual or significant change of status), and no more than 21 days after admission.

The facility failed to ensure that one resident's (#484) received services to meet professional standardsBased on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#4) received services that met professional standards. The deficient practice could result in residents not receiving the care needed in a timely manner. Findings included: Resident (#4) was admitted to the facility on [DATE] with diagnoses that included abnormality of gait, generalized muscle weakness, unspecified fall, and wedge compression fracture of third lumbar vertebra, The resident expired on [DATE]. The MDS dated [DATE] included a brief interview for mental status score of 8 indicating the resident had a moderate cognitive impairment. It also included that the resident had a fall in the last month and had a fracture related fall in the last six months. Review of a nurse's progress note dated [DATE] revealed that resident stated that he slid from his chair and onto the floor next to his bed. The resident was able to lift self back onto chair. The resident stated, I didn't call because I didn't know I needed to. Full body assessment found one bruise on L buttock 6 cm in diameter. The resident also stated also, It is the darn cushion that caused me to slide off the chair. I did not hit my head. The hospice nurse was notified and will continue to monitor the resident. A nurse's note dated [DATE] at 5:50 p.m. revealed that the resident complained of severe back pain a few hours following a fall and wanted to go to emergency room (ER) for evaluation. The hospice nurse was notified, and the okay was given for resident to go the ER. The doctor was notified. The resident was sent by non-emergency transportation to the ER around 5.00 pm. A nurse note dated [DATE] at 7:05 p.m. revealed that CNA notified nurse of patient being on the floor. On entering the room, patient observed sitting on the floor by the window, The resident said he was up walking towards the door but slipped off and fell hard on the floor on his butt. He denied a head strike. A nursing assessment was done and no apparent juries were noted. The vital signs (VSS), range of motion (ROM) to both upper and lower extremities (BUE/BLE) were within normal limits (WNL). The resident denied pain at the time. Hospice was notified and a nurse came out and assessed the resident. Review of the hospital Discharge summary dated [DATE] revealed that the resident needed to be treated or managed emergently for a lumbar fracture. A progress note dated [DATE] 5:46 a.m. revealed that resident came back from the hospital around 1:00 a.m. with a lumbar spine fracture. No new orders. Resident is stable and vital are (WNL). An interview was conducted on [DATE] at 10:39 a.m. with the Director of Nursing (DON/staff #71), who stated that when a resident falls, the resident is assessed for injuries. She reviewed the emergency transfer form and stated that the facility called for transportation at 2:16 pm and transportation arrived at 4:19 pm. Then she reviewed the emergency transportation report and stated that the resident was picked up from the facility on [DATE] at 6:43 pm. She stated that the nurse makes the decision as to whether a call is emergent or non-emergent and this looked like it was non-emergent because the transportation didn't arrive immediately. She stated that if the resident fell and was complaining of back pain, he should have been transferred to the hospital emergent status. An interview was conducted on [DATE] at 11:29 a.m. with the nurse who assessed the resident after he fell on the floor (staff #207). She stated that the ambulance was called non-emergent, but if the resident had bad back pain, she would consider it an emergency call because it would mean that something is broken and needed to be fixed. An interview was conducted on [DATE] at 1:10 p.m. with the Assistant Director of Nursing (ADON/staff #74), who stated that there is a risk of waiting a couple of hours a couple of hours to send a resident to hospital with serious back pain because the pain could worsen and if the resident had a previous fracture, it could worsen as well. She reviewed the clinical record and stated that the resident was sent non-emergent to the hospital. She also stated that the resident was experiencing severe back pain after a fall and would usually be sent out emergency status. The facility policy, Fall Accident and Incident Reports states that if the incident involves a fall, check for limited range of motion, bruises, pain, lacerations, swelling, and vital signs. Notify the attending physician. Follow (his or her) orders. Emergency personnel orders must be followed. Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that two residents (#4, #484) received services that met professional standards. The deficient practice could result in residents not receiving the care needed in a timely manner, and could result in a plan of care that did not meet the resident’s needs and prevent falls. -Regarding Resident #484 Resident #484 was admitted to the facility [DATE] with diagnosis including Cardiomyopathy, unspecified, Cerebral infarction, unspecified, Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side. Review of the care plan dated revealed a focus for fall risk with actual fall on [DATE] with bleeding from mid head and right wrist and a fall on [DATE] with skin laceration to the right arm. The approaches included Increased staff supervision with intensity based on resident need and sent to emergency room as ordered. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating cognition intact and extensive assistance with one person for bed mobility and transfers. There were no indicators for mood or behaviors. Further review of the MDS revealed resident occasionally incontinent of urine, always incontinent of bowel AND resident was prescribed anticoagulants and a diuretic. Review of the admission Fall Risk assessment dated [DATE] revealed a total fall risk score of 15.00, identifying the resident as a high fall risk. Review of the fall event report dated [DATE] revealed resident sustained an unwitnessed fall, Th report states prior to the fall the resident was in his wheelchair exercising his arms. The report further states the resident sustained multiple lacerations to his right arm with no reported pain. The report states the resident fell while attempting to place himself to bed and di not wait for assistance from the certified nursing assistant. Further review of the post fall assessment revealed no updated fall risk score. Review of the residents fall risk assessments revealed no further fall risk assessments completed following the admission assessment and the post fall assessment completed [DATE]. Review of the physician orders dated [DATE] revealed an order for Eliquis (apixaban)tablet; 5 mg; amt: 1 tab; oral twice a day. Further review of the physician orders dated [DATE] revealed an order for fall risk assessments to be completed every 3 months. Review of the progress note dated [DATE] revealed “At lunch time this resident decided to put himself to bed and fell on the floor. He has several skin lacerations on his right arm. unable to assess them properly. because they were bleeding sprayed antiseptic on abdominal (abd) pad & wrapped them with cling. took several of personal to life him on the bed.” An interview was conducted on [DATE] at 12:55pm with certified nursing assistant (CNA/Staff #38) , who stated he has been employed with the facility for approximately four weeks. CNA #38 Stated he was assigned fourteen residents and of the fourteen residents he was assigned to could not identify or been informed if any of the residents were a fall risk or had preventative measures in place. The CNA stated he will “just assume everyone is a fall risk.” The CNA also stated the resident’s fall risk information should be in the documentation, but is not and has not received any information during report regarding a resident’s fall risk. The CNA further stated “when I ask the nurses they always say they don't know even if they have been here for a while.” CNA #38 further stated he was unaware of how the residents he is assigned to are supposed to be transferred and “I just use the Hoyer with most of them with another CNA or transfer them myself, they don’t have gait belts here so you have to look for one to transfer someone that’s why I will use the Hoyer. CNA #38 was unable to identify if resident #484 is a fall risk, stating “I don't know, no one has said anything to me otherwise, but like I said I assume everyone is a fall risk.” The CNA #38 stated that residents who are a fall risk should not have their beds in the high position. An observation was made of resident #484 bed position, noting the bed was raised in the high position. The CNA also stated the risks of having a resident bed in the high position and identified at risk for falls “can fall and hurt themselves or break something.” An interview was conducted on [DATE] at 1:01pm with Resident #484, who stated that he will push the call light if he needs assistance press the button and has had no recent falls, but did have a couple of falls in the past. Observation of resident’s bed in the highest position- The Resident stated “ my bed is always this high. An interview was conducted on [DATE] at 1:01pm Licensed Practical Nurse (LPN/Staff #5). LPN/Staff #5 stated she has worked for the facility for two-plus years and her duties include medication pass, check vital signs, occasional wound care and quarterly and weekly assessments. The LPN stated that skin assessments are conducted weekly, elopement and AIMS are conducted quarterly. The LPN also stated fall risk assessments are done quarterly and as needed if there is an event such as a resident fall. The LPN further stated direct care staff such as the certified nursing assistants are informed of a resident’s fall risk and/or any preventative measures for those residents are given report, but “most of the staff have worked for the facility for a long time and they basically know the residents.” Staff #5 stated that new staff are provided with a verbal report regarding a resident fall risk status, but “there is nothing written for them, mostly verbal, we don’t have anything on the doors or in the residents rooms and I think the CNA's have a sheet that explains the residents basic needs. I do think I saw this sheet a long time ago-months ago, but I haven't seen it for a long time or seen any of the CNA's use it.” An interview was conducted on [DATE] at 1:01pm with CNA (Staff #175), who stated that it was her fourth day working for the facility and was assigned ten residents for her shift. The CNA stated she was not made aware of her assigned residents if any of the residents were a fall risk or if any preventative measures were in place for fall prevention. The CNA stated “I always ask for my own safety, but it’s not something they just gave to me.” Further stating “I just go by what the CNA’s will tell me about a resident, but it’s something I had to ask for.” The CNA also stated that she had not been informed if the information provided to her by the other CNA’s is correct or if there is a change of condition for a resident. Staff #175 stated “we are supposed to be informed and we are not. They give us no information I just either ask or go by what the other CNA’s tell me because they have been here longer and if I see a blue mat in the resident's room, then it lets me know that they are at risk, but other than that I really don't know who is a fall risk or what they need to not fall. I make sure they have their call lights and get help with transfers if I can’t do it by myself.” An interview was conducted on [DATE] at 9:58am with Director of Nursing (DON/Staff#71), who stated that the process for residents who are assessed at risk for falls is to refer them to therapy, provide the resident with appropriate equipment, increased supervision, make sure they are in the right bed, have a safe distance to the bathroom and proper bed placement. DON/Staff#71 stated residents are residents assessed for falls on admission and every three months. The DON also stated preventive measures used for those residents identified at risk for falls are low beds, floor mats, call lights within reach. The DON stated that the residents fall risk and preventative measures are communicated to staff verbally through reports from the nurses and the facility has a CNA sheet that has all of the resident’s information and that the nurses are responsible in ensuring the CNA’s are provided with the information needed for the residents they care for. The DON stated that the nurses are responsible in providing the CNA’s with the CNA sheet including the resident’s information, and that the facility ensures staff have the correct information to ensure residents safety. The DON stated that is part of the new hire orientation process and that new staff are supposed to be provided with the residents needs with their assignment. The DON further stated “I talk to the CNAs and remind them during rounds. The DON reported the facility does not have a formal fall management program. “Actually, I don’t know if we have a formal fall management program or not and I should probably know that answer.” Review of the facility policy titled, Falls and Fall Risk Managing, revised [DATE] revealed that based on previous evaluations and current data, the staff will identify interventions related to the resident’s specific risks and causes to try to prevent the resident from falling and try to minimize complications from falling. Environmental risk factors that contribute to the risks of falls included incorrect bed height or width. Further review of the policy states the facility practice is to complete fall risk assessments on the resident upon admission to the facility and every three months thereafter.

Based on clinical record review, staff and resident interviews, and facility policy, the facility failed to protect the rights of four out of the seven sample residents to be free from abuse by another resident. The deficient practice could result in other residents being abused.Findings Include: - Regarding a resident-to-resident altercation that occurred on June 20, 2025 involving Resident # 35, Resident #13, and Resident #72. -Regarding Resident #35Resident # 35 was re-admitted to the facility on [DATE], with diagnoses of anxiety disorder, urinary tract infection, and heart failure. A quarterly MDS (Minimum Data Set) assessment, dated February 2, 2025, revealed a BIMS (Brief Interview for Mental Status) score of 12, indicating moderately impaired cognition. -Regarding Resident #13Resident #13 was admitted to the facility on [DATE], with diagnoses of major depressive disorder, hyperlipidemia, and hypothyroidism A quarterly MDS assessment dated [DATE], revealed that resident #13 had a BIMS score of 15, which indicated that the resident is cognitively intact. -Regarding Resident #72Resident #72 was admitted to the facility on [DATE], with diagnoses of paraplegia, edema, and urinary tract infection. An admission assessment MDS dated [DATE], revealed resident #72 had a BIMS score of 15, which indicated the resident is cognitively intact. A progress note for Resident #35 dated June 21, 2025, revealed that on June 20, 2025, Resident #35 and Resident #13 were relocating kittens across the courtyard to prevent them from being injured, and Resident #72 became verbally and physically aggressive. A progress note for Resident #13 dated June 21, 2025 a, indicated that Resident # 13 reported an incident that had happened the day before. This progress note also noted that resident #13 stated to staff that resident # 72 was in a wheelchair and was attempting to enter the gated area. The progress note also indicated that Resident #13 stated that Resident #72 was informed she could not enter the restricted areas for cats, and that's when Resident # 72 became verbally aggressive and began using profanity towards Resident #13. The progress note revealed that Resident #13 stated that Resident #72 attempted to hit him, he stepped back, and that's when Resident #72 attempted to grab Resident #13's G-tube. This progress note indicated that Resident #35 intervened to prevent Resident #72 from pulling Resident #13's G-tube. In this progress note, Resident #13 also stated that Resident #72 began using her fist and the gate to cause injury to Resident #35. This progress note also revealed that there was a resident who was sent to get staff for assistance. The progress note revealed that the resident had notified nursing staff, and a CNA (Certified Nursing Assistant) arrived at the scene. A late entry progress note for Resident #35 dated June 22, 2025, stating there was an attraction with another resident. Further review of the progress notes revealed that the incident occurred on June 20, per a report from the day shift nurse. Progress further revealed that the resident had bruising on her right arm. The progress note also revealed that this incident was reported to the police, and the police came to the facility on June 21, the day after the incident. The progress note also noted that the Police indicated the situation was a behavioral issue. A progress note for Resident #72 dated June 22, 2025, noted that when the officer came to re-address the previous incident that happened on June 20, the police were not able to interview Resident #72 due to aggressive behaviors exhibited. The progress further noted that Residents #13 and Resident #35 were able to be interviewed. A late entry progress note for Resident #72 dated June 22, 2025, revealed that the resident had an altercation with another resident. The progress note further revealed that the resident was seen attacking another resident by hitting that resident through the gated fence and grabbing another resident's feeding tube, which was witnessed by (CNA/Staff #44). An interview was conducted via phone on July 02, 2025, at 1:21 PM with a Licensed Practical Nurse (LPN/Staff #33) who stated that the incident happened Friday night and she went into work Saturday morning. The LPN (Staff #33) stated that when she was performing resident #35's blood sugar testing, the resident mentioned to her that there had been an incident that had happened the previous night. She also stated that the resident mentioned to her that she was in pain. She further stated that she observed Resident #35's skin and had noticed in 4 different areas on her arm. She also stated that there were 3 indentations from the gate. Additionally, the LPN stated that resident #35 told her that resident #72 was holding a baby cat, all while resident #35 and resident #13 were wanting to move the cats to their designated area. Staff # 33 also stated that Resident #35 explained to her that the reason for moving the cats was that there is a resident who likes to kick the cats. (LPN/Staff #33) stated that Resident #35 told her Resident #13 was trying to enter the designated area for cats. She further stated that Resident #35 also told her that Resident #72 called her, and Resident # 13 was racist.Staff #33 stated that Resident #35 told her that Resident # 13 and she responded by saying ‘no.' (LPN/Staff #33) stated that resident # 35 told her that when resident #72 proceeded to block the gate, resident #13 tried to get through the gate to get help. Staff #33 stated that Resident #35 told her that Resident#13 was unable to get through the gate because they were in a wheelchair. LPN #33 stated that resident # 35 told her that when resident #13 was attempting to leave, Resident # 72 tried to punch him, but he dodged the punch. LPN #33 also stated that resident #72 tried to reach for resident # 13's feeding tube. LPN (Staff #33) stated that resident # 35 told her when this was happening, she went in front of resident #72 and told her ‘no'. Staff #33 stated that resident # 35 told her Resident #72 began to attack her by punching and smashing her arm into the gate. LPN(Staff # 33) further stated that she had notified the DON (Staff #22). LPN staff #33 also stated that she went to lock the gate to prevent further altercation. An interview was conducted on July 02, 2025, at 2:17 PM with a Certified Nursing Assistant (CNA/Staff #44) who stated that she was working in the center west side of the building at the time of the incident. She stated that she heard screaming and yelling. She also stated that she had told a nurse that she believed there was an altercation going on. She further stated that the nurse went back to what she was doing. (CNA/Staff #44) stated she went outside to where the yelling and screaming were coming from. Staff #44 stated that she saw residents near the smoking area door, and those residents were yelling at resident # 72 to get out of the way. CNA, staff# 44, said that when she approached the area of the incident, there was an argument about cats. She further stated that this argument was between Resident # 35, Resident #13, and Resident #72. CNA(Staff #44) stated that resident #72 wanted to go into the area and where Resident #35 and #13 were. She also stated that Resident #35 and Resident #13 were not allowing Resident # 72 to go into the area where they were residing. CNA, staff # 44, stated that resident # 72 was in an electric wheelchair guarding the gate. She also stated that Resident #72 was using her electric wheelchair to bump the gate into Resident # 35. She further stated that she heard Resident # 72 screaming at Resident #35 and Resident #13. Staff# 44 stated that Resident #72 pointed her finger at Resident #72, and #13, and told them that they were evil and possessed. CNA, staff #44, stated that other residents were saying that only Resident #35 and Resident #13 could go back to that area where those cats were. She further stated that these residents said that resident #72 could not go into the area where the cats were. CNA, staff # 44, said that she took Resident #35 and #13 back to their rooms. CNA, staff #44, also stated that she told resident number #72 that she could go to the smoking area or go back to her room.An interview was conducted on July 02, 2025, at 2:59 PM with the Director of Nursing (DON/Staff#22), who stated that abuse training is done every 6 months,she stated that the facility is doing it more frequently and or when an incident arises. Staff # 22 stated that there is in-service training regarding how to report abuse. (DON/Staff #22 ) stated that physical abuse is considered unwanted touch, hitting, and slapping. Staff # 22 said that verbal abuse, in the context of resident-to-resident altercation, would be yelling, inappropriate name calling and threatening. She also stated that abuse is reported to other state agencies and law enforcement. - Regarding a resident-to-resident altercation that involved Resident # 5, Resident #15. -Regarding Resident #5Resident # 5 was re-admitted to the facility on [DATE], with diagnoses of paraplegia, hypothyroidism, and anxiety disorder. A quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed resident #5 had a BIMS (Brief Interview for Mental Status) score of 15, which indicated the resident was cognitively intact. -Regarding Resident #15 Resident #15 was admitted to the facility on [DATE], with diagnoses of hyperlipidemia, dysphagia, and viral pneumonia. A review of the facility self-report revealed that there was a verbal altercation, and resident #5 grabbed and pinched resident #15. The self-report also revealed that Resident #15 had shown a painful expression, and an LPN saw the incident and went to break the two residents up. Further review of the facility report revealed that resident #5 used derogatory terms towards resident #15, who then rammed into resident #5 several times with his wheelchair. A late entry progress note for Resident # 15, dated April 10, 2023, revealed a progress note for resident #15, which noted that loud voices were heard in the main lobby. It was noted that the receptionist informed a nurse that the resident had been assaulted. Further review of the progress notes revealed that the (CNA/Staff #44) began to question residents, and all the residents said that resident # 15 rammed his wheelchair into resident # 5. This progress notes also revealed that resident #5 sustained a wound, which was immediately treated by his nurse. Review of resident # 15's care plan, reviewed or revised on April 15, 2023, noted that the resident was involved in an altercation with other residents. Further review of this care plan revealed that resident # 15 rammed his chair into the resident's feet several times.An interview was conducted on July 02, 2025, at 1:59 PM with (LPN/staff # 33), who stated that abuse training is done every 3 to 6 months. She also stated that abuse training covers neglect, physical, emotional, and verbal abuse. (LPN/Staff #33) stated that when abuse occurs, residents are assessed, and they make sure that the resident is not injured. She further stated that they notify the state agencies, DON, and the Physician. - Regarding a resident-to-resident altercation that involved Resident # 7, Resident #17. -Regarding Resident #7Resident # 7 was re-admitted to the facility on [DATE], with diagnoses of pneumonia, anxiety disorder, and bipolar disorder. A quarterly MDS (Minimum Data Set) assessment dated [DATE], revealed Resident #7 had a BIMS (Brief Interview for Mental Status) score of 11, which indicated the resident was moderately impaired A progress note for Resident #7 dated March 02, 2023, at 15:01, revealed that the resident reported to a certified nurse assistant (CNA) that the day before, his roommate had hit his right arm with a grabber and had shown the cuts on his arm to staff. This progress note further revealed that police were called. A progress note for Resident # 7 dated March 02, 2023, at 19:01, an officer came to investigate the incident and assess the resident. This progress note further indicated the resident roommate was moved to a different room in another hall. -Regarding Resident #17Resident # 17 was admitted to the facility on [DATE], with diagnoses of urinary tract infection, anxiety disorder, and hypokalemia. A facility self-report dated March 6, 2025, revealed that resident # 17 initially denied that he had hit resident #7 and later admitted that he had hit resident # 7 six times. A further review of this facility self self-report revealed that resident # 7 was evaluated and noted to have some bruising and scratching on his hand. A Policy titled Abuse and Neglect revision or revised in October 2021, revealed that the resident has the right to be free from abuse.

Based on clinical record review, staff interviews, facility documentation, and policy review, the facility failed to report alleged violations involving abuse for two residents (#35 and #13 ). The deficient practice resulted in allegations of abuse not being reported, not investigated, and residents not being protected from further abuse.Regarding a resident-to-resident altercation that occurred on June 20, 2025 involving Resident # 35, Resident #13, and Resident #72. -Regarding Resident #35Resident # 35 was re-admitted to the facility on [DATE], with diagnoses of anxiety disorder, urinary tract infection, and heart failure. A quarterly MDS (Minimum Data Set) assessment, dated February 2, 2025, revealed a BIMS (Brief Interview for Mental Status) score of 12, indicating moderately impaired cognition.A progress note for Resident #35 dated June 21, 2025, revealed that on June 20, 2025, Resident #35 and Resident #13 were relocating kittens across the courtyard to prevent them from being injured, and Resident #72 became verbally and physically aggressive. A late entry progress note for Resident #35 dated June 22, 2025, stated there was an interaction with another resident. Further review of the progress notes revealed that the incident occurred on June 20, per a report from the day shift nurse. The progress note also revealed that this incident was reported to the police, and the police came to the facility on June 21, the day after the incident, despite the incident having occurred on despite the incident occurring on June 20, 2025. -Regarding Resident #13Resident #13 was admitted to the facility on [DATE], with diagnoses of major depressive disorder, hyperlipidemia, and hypothyroidism A quarterly MDS assessment dated [DATE], revealed that resident #13 had a BIMS score of 15, which indicated that the resident is cognitively intact. A progress note for Resident #13 dated June 21, 2025, indicated that Resident # 13 reported an incident that occurred the day before. The progress note indicated that resident #13 stated to staff that resident # 72 was in a wheelchair and was attempting to enter the gated area. Resident #13 stated that Resident #72 was informed she could not enter the restricted areas for cats, and Resident # 72 became verbally aggressive and began using profanity towards Resident #13. The progress note revealed that Resident #13 stated that Resident #72 attempted to hit him, he stepped back, and that's when Resident #72 attempted to grab Resident #13's G-tube. This progress note indicated that Resident #35 intervened to prevent Resident #72 from pulling Resident #13's G-tube. The progress note further indicated that Resident #13 stated that Resident #72 began using her fist and the gate to cause injury to Resident #35. The note relayed that a resident had notified nursing staff, and a CNA (Certified Nursing Assistant) arrived at the scene. -Regarding Resident #72:Resident #72 was admitted to the facility on [DATE], with diagnoses of paraplegia, edema, and urinary tract infection. An admission assessment MDS dated [DATE], revealed resident #72 had a BIMS score of 15, which indicated the resident is cognitively intact. A progress note for Resident #72 dated June 22, 2025, noted that when the officer came to re-address the previous incident that happened on June 20, the police were not able to interview Resident #72 due to aggressive behaviors. The progress note further noted that Residents #13 and Resident #35 were able to be interviewed. A late entry progress note for Resident #72 dated June 22, 2025, revealed that the resident was seen attacking another resident by hitting that resident through the gated fence and grabbing another resident's feeding tube. The Progress Note indicated the altercation was witnessed by (CNA/Staff #44). An interview was conducted on July 2, 2025, at 1:06 PMwith a Certified Nursing Assistant (CNA/Staff #777) stated that the abuse training she received covered what to do if they witness abuse and the reporting guidelines. She also stated that abuse would be reported to the nursing staff, the Director of Nursing(DON), and the Assistant Director of Nursing(ADON). She stated that during her abuse training, she learned about physical, financial, and sexual abuse. She stated that physical abuse is when a person gets touched in a manner that they do not approve of. She stated verbal abuse is anything degrading, threatening, or humiliating to a resident.An interview was conducted on July 2, 2025, at 3:13 PM with the Director of Nursing (DON/Staff #22), who stated that the incident between resident # 35 and resident # 72 occurred on Friday evening, and that she was not aware of this incident until Saturday when Staff # 33 called her on the phone. She further stated that the incident occurred in the smoking area around the corner, through the gate, where the cats were, and that resident # 35 was going to take the cats behind the gate. The DON stated that a CNA (Staff # 44) saw the incident and reported it to a nurse. The DON stated that when she came to the facility, an LPN (staff #33) had not called the police or the State Agency. The DON further stated that she instructed the LPN to call the police. The DON stated that when she came to the facility, she conducted the required notifications to the state agency regarding the incident and that on her way out of the facility, Resident #13 made her aware that he was involved in the incident regarding Residents #35 and #72. The DON stated that she amended the report to the State Agencies. The DON also stated that staff are supposed to report any physical abuse, and that they try to do everything within 2 hours, including reporting, and that she did not know what happened or why this incident was not reported timely. The DON also stated that it should have been reported on Friday to the state agency, and that this does not meet their facility expectations. A Policy titled Abuse and Neglect revision, or revised in March 2021, revealed that upon discovery of alleged /suspected abuse, the facility will notify health offices, including the Department of Health, within 2 hours.

Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#2) did not abuse another resident (#4). The deficient practice could result in residents being physically harmed. Findings Include: - Regarding Resident #2: Resident #2 was admitted on [DATE] with diagnoses that included dementia, chronic ischemic heart disease, chronic obstructive pulmonary disease and major depressive disorder. An Admission Minimum Data Set (MDS) dated [DATE] revealed the resident had a Brief Interview for Mental Status score of 13, which indicated the resident is cognitively intact. A progress noted dated February 16, 2023 at 03:10 a.m. revealed that Resident #2 was involved in an altercation with Resident #4 outside on the patio. Resident #4 named Resident #2 as the resident that knocked her tooth out and that Resident #4 hit Resident #2 with a stick. The Police were immediately notified and APS notified. A care plan focus initiated on [DATE] revealed a focus on the resident having potential to behaviors/ altered coping, refuse care, exposing himself, and occasional outbursts of anger. - Regarding Resident #4 Resident#4 was originally admitted on [DATE] with diagnoses that include quadriplegia, C5-C7 incomplete paraplegia, sleep terrors, body dysmorphic disorder. A care plan focus initiated [DATE] revealed a focus on the resident having behavior problems that include choosing to restrict intake for weight loss, refuses wound care, interfering with other resident discharges breaking facility protocol, false accusations toward staff and peers stealing her belongings. A progress note dated February 16, 20223 02:51 a.m. revealed that Resident #2 knocked Resident #4's tooth out during the altercation and Resident #4 hit Resident #2 with a stick. A Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, which indicates the resident is cognitively intact. An interview was conducted on [DATE] at 11:13 a.m. with Resident #4 and revealed that she had been in an altercation before at this facility. Resident #4 revealed that it was with a guy that is no longer in the facility. There was a witness to the altercation, but died last year at another facility. There was a verbal argument and was punched in the mouth, then punched a second time and that was when her teeth were lost. Resident #4 had newly cemented in bridges. The police came and no charges were pressed. An interview was conducted on [DATE] at 11:55 a.m. with Administrator (Staff #6) and revealed that the Licensed Practical Nurse (LPN) staff #3 no longer lives in the country and moved back to [NAME]. Staff #6 did not remember the incident but stated that Resident #4 did loose a tooth because it is written here, and refused treatment. Review of a policy revised in [DATE] titled, Abuse and Neglect Policy revealed that there are different types of abuse including Physical Abuse. Physical abuse includes hitting, slapping, pinching and kicking. Review of a policy revised February 2021 titled Resident Rights reveals that Residents have the right to be free from abuse, neglect, misappropriation of property, and exploitation.

Based on clinical record reviews, resident and staff interviews, facility documentation, policy, and procedures, the facility failed to ensure that residents (154), (145),(125) and (D1) were free from resident-to-resident abuse. The findings include: Resident (154) was admitted to the facility on [DATE], with diagnosis that consisted of hemiplegia and hemiparesis following cerebral infarction affecting the non-dominant side, paraplegia unspecified, type 2 diabetes mellitus with hyperglycemia, morbid obesity, and adjustment disorder. The resident care plan consisted of the following: Resident involved an altercation with another resident. [NAME] states that she was hit a few times by resident and shirt ripped at neckline. was able to point to areas to the left forehead and to the base of the left eye. The left side of the frontal forehead was slightly raised and intact. There is no bruising present at this time. The area below the left eye appears to be puffy with skin intact. The same can be visualized to the top of the lip. All skin is intact with no open areas. The resident will not have altercations with other residents through the next review. Has behavior of false accusations towards staff, repeated complaints of missing items. Endorses conflicting information, and refuses care such as shower. will display appropriate interaction with peers/staff/visitors, and will remain safe over the next 90 days, anticipate and meet needs promptly, assess for contributing factors for behavior. A review of the resident's Brief Interview of Mental Status (BIMS) revealed the resident had a BIMS of 15 suggesting the resident is cognitively intact. A review of the resident's progress notes revealed the following: December 24, 2024, 1205 hours Nursing Note This writer placed a telephone call to the police regarding the resident to resident altercation that occurred on December 24, 2024, at approximately 1120 hours with this resident and her roommate . Awaiting officers to arrive to speak with the residents and obtain incident report number. December 24, 2024, 1323 hours Nursing Note The resident had an altercation with another resident in the same room. The resident has minor injuries treated by wound nurse. Vitals are well within normal limits. The resident was hit in the head. Neuro checks are within normal limits. The police were called to file a report. Medical Director notified. The other resident was moved to a different room. December 24, 2024, 1327 hours Wound care This nurse in to see resident due to altercation with another resident. Resident Alert and oriented X4 able to make needs known. Resident states that she was hit a few times by resident and shirt was ripped at neckline. Resident was able to point to the area to the left of the forehead and to the base of the left eye. The left side of the frontal forehead was slightly raised and intact. The is not bruising present at this time. The area below the left eye appears to be puffy with skin intact. The same can be visualized to the top of the lip. All skin is intact with no open areas. Educated resident of finding and treatment plan may apply cold compressor ice with 20 minutes on 20 minutes off every 2 hours until swelling subsides. Medical Director is aware of event. December 24, 2024, 2200 hours Nursing Note Police arrived to facility on complaint reference this resident and another getting into altercation. Police did interview resident. Resident (145) was admitted to the facility on [DATE], with diagnosis that consisted of: unspecified arterial fibrillation, cerebral infarction due to unspecified occlusion of stenosis of the left middle cerebral artery, unspecified dementia moderate with anxiety, depression. Accidental bite by another person initial contact. The resident care plan consisted of the following: The Resident had an altercation with another resident residing in the same room. Injury to left forearm is a bite mark sustained by human. Imprint of teeth marks present. The resident will not have altercations with another resident through the next review. The resident moved to another room. Fall risk. Resident with maintain current level of mobility with minimal risk of injury over the next 90 days. Anticipate and meet needs promptly. Antipsychotic drug therapy. Resident will have behaviors managed with minimal side effects over the next 90 days. Administer medications per doctors orders. A review of the resident's Brief Interview of Mental Status (BIMS) revealed the resident had a BIMS of 15 suggesting the resident is cognitively intact. A review of the resident's progress notes revealed the following: December 24, 2024, 1205 hours Nursing Note This writer placed a telephone call to the police department regarding the resident-to-resident altercation that occurred on December 24, 2024, at approximately 1120 hours with this resident and her roommate. Awaiting officers to arrive to speak with the residents and obtain an incident report. December 24, 2024 1239 hours Nursing Note Resident had an altercation with another resident residing in the same room. Resident has minor injuries treated by wound nurse. Vitals are within normal limits. The police were called to file a report. Medical Director notified and ordered to clean and monitor resident's injuries for signs and symptoms of infection. Resident's daughter was notified. Resident was moved to a different room. December 24, 2024, 1253 hours Wound Care Altered by DON (37) and Assistant Director of Nursing (ADON 30) resident in altercation with another resident with injury, Resident is alert and oriented X 4 able to needs known. Resident complains of pain relative to chronic pain and have been previously medicated. This nurse (LPN wound nurse 25) performed assessment and observed injury to left forearm. Injury is a bite mark sustained by a human. Measurement 5.5cm X 5.0cm. Imprint of teeth marks present. This is superficial open area noted. The open areas are reddened with scant amount of serosanguineous drainage the peri wound intact. Resident complained of pain to touch. The area was washed and Hibecleanse Solution and Bacroban applied covered with foam dressing. Educated resident of treatment plan. Medical Director has been alerted by SN text order Hibecleanse and Bactroban daily. A review of the facility incident report revealed the following: On December 24, 2024, at approximately 1130 hours resident (154) and resident (145) began yelling at each other which led to them hitting each other in the head and chest. Resident (154) stated that resident (145) became verbally aggressive towards her and started to call her vulgar names. Resident (154) stated that resident (145) began accusing her of spraying perfume in the room and that it was making her sick. Resident (154) stated that resident (145) began to hit her in the head and that she also tore the shirt she was wearing. Resident (154) is wheelchair-bound due to diagnosis that that includes hemiplegia and hemiparesis following a cerebral infarction. Resident (154) further stated that she bit resident (145) on the left arm to get her to stop hitting her. Resident (145) stated that resident (154) hit her several times and bit her on the arm. Both residents were separated and aid was rendered. Witness Statements Licensed Practical Nurse, LPN (14), stated residents were having a dispute about a smell in the room. Both residents were saying inappropriate things to each other. LPN (14) was able to separate them and calm the situation down. About 20 minutes later LPN (14) was notified that the residents had an altercation. Receptionist, staff (69) stated that staff (62) had walked passed her desk informing her that resident (154) and resident (145) were arguing. Staff (69) stated maybe 10 to 15 minutes later she heard resident (154) raising her voice. As (69) is about to go check on their room the two residents (145) and (154) come to her desk. Resident (145) put her arm on the table and that's when she noticed the bite mark on resident (145). The two residents began to argue again and staff (69) stood between them and asked resident (154) to go have a smoke. Housekeeping staff (62) stated he observed resident (145) sitting outside her room with her head in her knees and looking as if she was in pain. Staff (62) stated that he asked LPN, Staff (1) to check on resident (145) and briefly walked with her towards the resident and then walked away. Staff (62) stated that stated that he overheard LPN (1) confirming with resident (145) that she had a bad stomach ache. Staff (62) stated that as he was returning to his cart he happened to hear resident (154) arguing with her nurse about resident (145). Staff (62) further stated that residents (154 & 145) were yelling at each other quite angrily, though he was not sure what was said. Staff (62) stated that resident (154) was raising her voice at her nurse saying you need to listen to me! Certified Nursing Assistant (CNA), staff (3), stated that she entered the room to get her patient up, resident (154), and resident (145) asked if resident (154) could keep it down a bit. Resident (154) asked to hurry up and get out of there. CNA (3) stated that she got resident (154) ready and that resident (154) was yelling at resident (145) about her TV being on all day and that resident (145) got mad. CNA (3) stated that she then left the room. An interview was conducted with resident (154) on January 02, 2025, at approximately 1100 hours. Resident (154) stated that CNA (3) came into the room to help get her up. Resident (154) stated that resident (145) began yelling for them to keep it down. Resident (154) stated that once she got ready and she went to leave the room resident (145) was in the doorway and would not move. Resident (154) stated that she asked resident (145) to move and the two began to argue and resident (145) began hitting her in the head. Resident (154) stated that she then began defending herself by hitting back. Resident (154) stated that she could not get resident (145) to stop hitting her so she bit her on the left arm. Resident (154) stated that staff then arrived and separated them. An interview was conducted with resident (145) on January 02, 2025, at approximately 1110 hours. Resident (145) stated that resident (154) came at her with her wheelchair and that she, resident (145) hit resident (154) and then the two began hitting each other. Resident (145) stated that resident (154) hit her on the arm in the process. Resident (145) stated that staff separated them and that medical attention was given to her bite mark. Interview with the Director of Nursing DON, (37), conducted on January 02, 2025, at approximately 1300 hours. DON (37) advised that while she did not personally witness the incident she did see the video. The DON (37) stated that both residents were hitting each other. The DON (37) advised that there had not been any previous incidents between the two residents. Resident (145) was moved to another room. The expectation is that the residents will be free from abuse. Incident related to residents D1, and 125 Resident (D1) was admitted to the facility on [DATE], with diagnosis that consisted of: restlessness and agitation, unspecified dementia unspecified severity without behavioral disturbance psychotic disturbance mood disturbance and anxiety, unspecified dementia moderate with other behavioral disturbance, cortical age-related cataract left eye. Physician orders consisted of: doxycycline monohydrate tablet 100mg, keflex capsule 500mg, keppra tablet 500mg, Lasix tablet 20mg, risperidone tablet 25mg, and tramadol tablet 50mg. The resident care plan consisted of: A review of the resident's Brief Interview of Mental Status (BIMS) revealed the resident had a BIMS of 06 suggesting severe cognitive impairment. A review of the resident progress notes revealed the following: December 07, 2024, 1001 hours Nurse Practitioner Reason for visit: Follow-up visit to evaluate behavioral symptoms and response to newly initiated medication citalopram. Subjective: The patient presents for follow-up regarding ongoing agitation and dysregulation. Initial symptoms included combative behavior such as hitting staff and throwing objects. He was started on citalopram to address these behaviors. The patient's nurse reports no significant improvement in these behaviors since the last visit. December 09, 2024, 0722 hours Nursing Note This is a late entry, resident has been acting very angry at various individuals and his behavior at times has been violent towards staff. This resident hit me (LPN 12) and cursed me out when I told the night shift nurse about his behaviors, she confessed that he had kicked her too. I sent a text message to Nurse Practitioner and told her about his violent behavior and asked her to evaluate him so that he could be treated with medication for his anger and behavior. December 10, 2024, 1646 hours Nursing Note Resident continues with bad behavior. Came out of his room walking without his wheelchair or walker. I went to his room and followed him with his wheelchair and when he turned around and saw me, he tried again to hit me. Resident has been sitting in front of the nurse's station talking about how tough he is and how this place is no good. December 13, 2024, 0456 hours Nursing Note Resident noted on this writer shift displaying an aggressive/confused attitude and attempting to be combative with staff. Resident walking around without walker/wheelchair with limited stability. December 13, 2024, 1348 hours Nursing Note This writer place a telephone call to the resident's daughter. A message left for her to call this writer/facility (plans are to discuss residents onset of aggressive behavior as evidenced by yelling, trying to strike out at staff and being verbally abusive towards staff, staff advised that resident was observed trying to kick out glass door, awaiting a return phone call from daughter. December 13, 2024, 1352 hours Nursing Note This writer place telephone call to psych provider regarding residents behavior as evidenced by being aggressive towards staff, including trying to kick out glass door. New order received to obtain a urine for urinalysis and urine for culture and sensitivity. Start risperidone 0.25mg 1 po bid. Order noted and will be implemented. Edited By: ADON (30) on 12/13/2024 03:38 PM Reason: Incorrect data This writer place telephone call to psych provider regarding residents behavior as evidenced by being aggressive towards staff, including trying to kick out glass door. New order received to obtain a urine for urinalysis and urine for culture and sensitivity. Start risperidone 0.5mg 1 po bid. Order noted and will be implemented. December 13, 2024 1522 hours Nursing Note Residents' daughter returned the phone call. Residents' aggressive behavior was discussed with daughter including that resident had an altercation with another Resident. Resident was observed by peers hitting another resident. Daughter was advised that the NP had ordered medication to try for aggression (Risperidone 0.25mg a small dose twice a day) and to obtain a urine specimen for analysis to see if he may have urinary tract infection. Daughter states that she is remorseful that her father hit another Resident and is okay with Resident having medications that would help with stabilizing his behavior if needed. December 13, 2024, 1734 hours Nursing Note Nurse Practitioner was called and notified of this resident's altercation with another resident. No further orders at this time. December 13, 2024, 1827 hours Registered Nurse Note Patient continues to be combative, pt. throwing diner tray and makes attempt to enter other patient's room. Concern for UTI and pt. behavior not within baseline. Nurse Practitioner Psych, called and okay to send patient to hospital for evaluation. Patient refuses to get vitals and transportation called and estimated time of arrival 1 and 1/2 hr. Resident (125) was admitted to the facility on [DATE] with diagnosis that consisted of: acuter systolic heart failure, rash and other nonspecific skin eruption, depression unspecified, anxiety disorder due to unknown physiological condition, chronic obstructive pulmonary disease. Physician orders consisted of the following: acetaminophen tablet 325 mg, famotidine tablet 20mg, melatonin tablet 3mg, milk of magnesia 400mg5mL 30min. A review of the resident's Brief Interview of Mental Status (BIMS) revealed the resident had a BIMS of 12 suggesting moderate cognitive impairment. Resident progress notes revealed the following: December 13, 2024, 1531 hours Wound Care Alerted by SN res was struck in the back of head by another res. Res has small contusion to the back of the head measurement 0.3cm x 0.3cm raised area. Resident is alert and oriented x3 At the center of the contusion is a small pin sized open area. Hair was trimmed away to visualize. there was a scant amount of serous drainage. There is no bruising present. Res does c/o pain to touch. This nurse cleansed area with wound cleanser and TAO applied to wound bed and left open to air. Res is currently up in w/c with ability navigate appropriately. SN will continue to monitor for COC and to notify MD December 13, 2024, 1617 hours Registered Nurse Note Res was beat up by another res at the smoking area. A small pin size open area was noted to the back of the head. Vitals: Bp-129/79, P-91, RR-18, Temp-97.7, Pox-96%RA., NP was notified. December 16, 2024 0745 hours Wound Care This nurse in to see res for follow of contusion to the Right back of the head. Res is a/O x3able to make needs known. Res denies any pain. There is no sign of open area present. There is no bruising or evidence of bruising. Resident did not c/o pain when touched. %100 of epithelial tissue present. Discussed with res of healed area. Res stated that he is fi ne. no further treatment necessary TX order closed/resolved. A review of the facility incident report revealed the following: On December 13, 2024, at approximately 1600 hours it was reported to staff that an altercation occurred in the smoking area involving two residents. Resident (D1) was observed striking resident (125) several times in the head. Witness statement from the DON (37): This resident (D1) was in a fight with another resident (reported to me) This resident hit another resident (125) in the head- he had a cut to his head. Resident (D1) was very angry and aggressive. He was saying he was going to kill people. Witness statement from Social Services Director (38): I observed through video surveillance that resident (D1) struck fell ow resident (12) in the head and face area. The incident occurred within the smoking area and was unprovoked. Immediate attention was given to both following occurrence. Medical assessment was properly administered to resident (125). Both parties were monitored for further psychosocial impact. Witness statement from Company President (29): I, (29) witnessed an incident involving residents (125) and (D1). During the incident, I observed (D1) striking (125) in the head and face area. This assault occurred without any provocation from (125). (D1) also stated to me (29) that if I touched his wheelchair he was going to strike me and kill me. Witness statement from resident (150): I, (150) witnessed the incident in the smoking area involving residents (125) and (D1). During the event, I observed (D1) striking (125) in the head and face area. This assault occurred without provocations from (125). Witness statement from RN (4): I observed patient (D1) striking another patient (125) multiple time to his head. Victim was hit with fist from (D1) 3 plus times. Noted bump/open laceration on victim's head after patient was hit multiple times. Patient continued aggressive behavior. Patient thru dinner tray to the floor in the evening as well. Attempted to console but patient (D1) remained aggressive thru shift. Witness statement from resident (107): I, (107), witnessed an incident involving residents (125) and (D1). During the incident I observed (D1) striking (125) in the head and face area. (D1) was not himself. Witness statement from resident (124): I, (124), witnessed an incident involving residents (125) and (D1) During the incident I observed (D1) striking (125) in the head and face area. An interview with DON (37) on January 02, 2025, at approximately 1300 hours revealed that resident (D1) was sent out to the hospital on December 13, 2024, per the psych nurse practitioner. An attempted interview of resident (125) was made on January 02, 2025, at approximately 1310 hours however, he sated he had no recollection of what had occurred. Review of facility policy, Abuse and Neglect (F600), with a revision date of March 2021 provided the following information: Purpose 483.12 Freedom of abuse, neglect, and exploitation. The resident has a right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but not limited to freedom from corporal punishment, involuntary seclusion, and any physical or chemical restraint not required to treat the residents medical symptoms. 483.12(a) The facility must 1. Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion.

Based on observation, interview and record review, the facility failed to properly prevent and/or contain COVID-19. COVID-19 is an infectious disease by a new virus causing respiratory illness with symptoms including cough, fever, new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell, and in severe cases difficulty breathing that could result in severe impairment or death. Specifically, 1. Facility failed to identify the need for and implement Contact/Droplet transmission based precautions and utilized full personal protective equipment (PPE), specifically eye protection or change gown during cares and interactions with sampled resident (R1)'s, whose COVID-19 status was unknown, during the initial 14 day readmission period from hospital in county with high level of community transmission. There was no Contact/Droplet transmission based precautions sign posted outside R1's room to direct staff to use eye protection personal protective equipment (PPE) when entering R1's room. Observed 3 of 3 facility staff (Housekeeper (HK) 2, Activities Aide (AA1) and Receptionist) enter R1's room and stand within 3 feet of R1 without eye protection and then proceeded to care and interact within 6 feet of residents who were on Standard precautions. In addition, Licensed Nurse (LN)1 wore gown in R1's room and did not change gown during 12 hour shift while caring for R1 and other residents who were on Standard precautions only. This failure increased the likelihood for serious injury, serious harm, or death and required immediate action to prevent transmission of COVID-19 to staff and residents. On 7/8/20 at 6:14 PM the Administrator was informed and emailed Immediate Jeopardy (IJ) determination for 42 CFR §483.80 (F880). On 7/9/20 at 5:15 PM Director of Nursing (DON), Assistant DON (ADON), and Infection Preventionist (IP) was informed of determination that immediacy was removed based on onsite verification that IJ removal plan was implemented. Administrator was not onsite during survey on 7/9/20. Additionally, 2. Failed to allow sufficient dwell time for Super Sani cloth disinfecting wipes, per manufacturer's instructions, when cleaning/disinfecting shared glucometer for 2 of 2 sampled residents (R3 and R7). 3. Staff (HK1) did not disinfect high-touch items in resident rooms (room [ROOM NUMBER]) for 1 of 1 observation of daily room cleaning. 5. Failed to change gloves during 1 of 1 sampled resident (R2) incontinence care observation when going from dirty tasks to clean tasks. 6. Failed to maintain adequate social distancing between two random residents (R8 and R9) observed in smoking area when CNA1 placed R8's wheelchair within 5-6 inches on R9 who was not wearing a mask. Findings include: 1. Contact/Droplet Precautions During an interview on 7/8/20 at 11:50 AM IP stated that facility did not have any COVID-19 positive residents but has a COVID-19 quarantine area on North Hall where R1 resides. R1 was the only resident residing in quarantine area. R1 was in the quarantine area because he was still within 14 days of being readmitted from the hospital. IP stated R1 was tested at the hospital and test results showed resident was COVID-19 negative. Observation on 7/8/20 between 2:20 PM and 3:10 PM showed North Hall was a long hallway with rooms on the both sides of the central corridor hallway. One side of North Hall had rooms 101-104 at the far end of the hall. This was the quarantine area. An exit door was observed on one end of the quarantine area and a floor to ceiling clear barrier that spanned both sides of the hallway was on the other end of the quarantine area; which separated rooms 101-104 from rooms 105-110; there were 9 residents (R3, R10-17) residing in rooms 105-110. The clear barrier had a door for entering/exiting the quarantine area. The clear barrier had a white paper taped to it. Nothing was written on the paper. R1 was the only residing in quarantine area. No transmission based precautions signs were posted or isolation carts with PPE supplies were observed at the entrance to the clear barrier or on or near R1's room door. During concurrent interview and observation on 7/8/20 at 2:20 PM showed R1 outside the facility right beyond the quarantine area exit door. R1 stated that he is allowed to smoke in this area and had just finished smoking. R1 stated that he went to the hospital because he didn't wake up one day but returned to the facility last Monday. Receptionist Observation on 7/8/20 at about 2:25 PM showed Receptionist opened door from quarantine area and stepped outside. Receptionist came within 1-2 feet of resident and counted out $10 on the armrest of resident's wheelchair, handed resident money and receipt. Receptionist wore mask and gown but did not wear eye protection. During an interview on 7/8/20 at about 2:45 PM when asked if she was wearing goggles or face shield when she handed R1 money and receipt, Receptionist said no, but I changed my gown. Observation on 7/8/20 at 3:10 PM showed both Receptionist and AA1 in R1's room. Receptionist and AA1 did not wear eye protection. Observation on 7/8/20 from about 2:45 PM to 3:30 PM, after Receptionist spoke with R1 with eye protection, showed Receptionist speak with several residents in Rooms 106-110 coming within a few feet of these residents. Also observed Receptionist interacting, talking, retrieving objects and being in close contact with multiple residents at Reception Desk. HK2 Observation on 7/8/20 at about 2:30 PM showed HK2 in quarantine area. HK2 wore gown, mask and gloves but no eye protection. HK2 entered R1's room and stayed in the room for several minutes mopping, sweeping, bagging trash, and cleaning room. HK2 was within 6 feet of R1 without eye protection. During an interview on 7/8/20 at about 2:45 PM when asked if HK2 wore goggles or eye protection in R1's room, HK2 said, no goggles. Why am I supposed to wear it? If it was a COVID patient, I would wear goggles. Several minutes later, overhead HK2 ask Receptionist if goggles are supposed to be worn in R1's room, Receptionist said, no. Observation on 7/8/20 at about 3:10 PM to 4:00 PM, after HK2 entered R1's room without eye protection, showed HK2 enter Rooms 106, 107, 108 and 110 to clean resident rooms. HK2 was within six feet of these residents. During an interview on 7/8/20 at 3:45 PM HK2 stated that he had three more resident rooms to clean before ending his shift. AA1 Observation on 7/8/20 at about 2:40 PM showed AA1 in R1's room within 6 feet of resident with mask and gown but no eye protection. AA1 bent down and was close to resident's face while resident asked about DVD player. At 7/8/20 at about 2:45 PM observed AA1 again in R1's room. Observation on 7/8/20 at 3:10 PM showed both Receptionist and AA1 in R1's room. Receptionist and AA1 did not wear eye protection. Observation on 7/8/20 at about 3:20 PM, after AA1 entered R1's room without eye protection, showed AA1 talking with residents in rooms [ROOM NUMBERS]. LN1 During an interview on 7/8/20 at about 4:20 PM when asked about PPE worn in R1's room, LN1 stated N95 mask, face shield, gown and gloves. LN1 stated that he passed R1's medications, checked R1's blood sugar, and helped resident today. When asked if LN1 changed his gown after exiting R1's room, LN1 said no, because he doesn't have COVID. Observed LN1's gown was torn at the left breast pocket area where several pens could be seen in uniform pocket under gown. The gown tear was in the same place and manner as observed earlier when surveyor entered the facility at 11:20 AM. LN1 stated that he wore the same gown for his 12 hour shift beginning at 6:00 AM and has been in R1's room and several other resident's rooms, as he was assigned to care for 21 residents (R3, R10-28), including R1, passing meds, checking blood sugars and providing resident assistance wearing the same gown. During concurrent record review and interview on 7/8/20 between 4:20 PM and 6:15 PM with Administrator and IP, IP stated that staff are not wearing eye protection with R1 even though resident is still within first 14 days of readmission from the hospital. IP and Administrator nodded their heads in agreement that facility and hospital are located in Maricopa County, which is COVID-19 hot spot right now, with high level of community transmission. IP agreed that LN1 glasses is not considered eye protection and LN1 absolutely should be changing his gown after exiting R1's room. IP stated that there used to be isolation signage on the clear barrier quarantine area but confirmed she did not see any there. Administrator stated that there was a misinterpretation between quarantine and isolation with PPE and felt the facility had done a great job with setting up clear barrier quarantine area for resident but didn't interpret the need for full PPE, especially since the resident was asymptomatic. When asked about positive COVID status and ability to still transmit [MEDICAL CONDITION] despite being asymptomatic, Administrator did not reply. Surveyor reviewed Centers for Disease Control and Prevention (CDC)'s website with Administrator and IP which showed CDC's Preparing for COVID-19 in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, accessed 7/8/20, under Create a Plan for Managing New Admissions and Readmissions Whose COVID-19 Status is Unknown. Depending on the prevalence of COVID-19 in the community, this might include placing the resident in a single-person room or in a separate observation area so the resident can be monitored for evidence of COVID-19. HCP (Health care personnel) should wear an N95 or higher-level respirator (or facemask if a respirator is not available), eye protection (i.e., goggles or a disposable face shield that covers the front and sides of the face), gloves, and gown when caring for these residents. Residents can be transferred out of the observation area to the main facility if they remain afebrile and without symptoms for 14 days after their admission. In addition, reviewed CDC's Responding to Coronavirus (COVID-19) in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, accessed 7/8/20, which showed Testing residents upon admission could identify those who are infected but otherwise without symptoms and might help direct placement of asymptomatic [DIAGNOSES REDACTED]-CoV-2-infected residents into the COVID-19 care unit. However, a single negative test upon admission does not mean that the resident was not exposed or will not become infected in the future. Newly admitted or readmitted residents should still be monitored for evidence of COVID-19 for 14 days after admission and cared for using all recommended COVID-19 PPE. Review of CDC's Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fcoronavirus%2F2019-ncov%2Finfection-control%2Fcontrol-recommendations.html, accessed 6/23/20, showed Implement Universal Use of Personal Protective Equipment: HCP working in facilities located in areas with moderate to substantial community transmission are more likely to encounter asymptomatic or pre-symptomatic patients with [DIAGNOSES REDACTED]-CoV-2 (severe acute respiratory syndrome coronavirus 2, [MEDICAL CONDITION] that causes COVID-19) infection .They should also: Wear eye protection in addition to their facemask to ensure the eyes, nose, and mouth are all protected from splashes and sprays of infectious material from others. Review of facility policy, Suncrest Healthcare Infection Prevention and Control Program, updated 04/2020, showed Transmission-based precautions will be used when indicated . Transmission-Based Precautions are the second tier of basic infection control and are to be used in addition to Standard Precautions when patients may be infected or colonized with certain infectious agents for which additional precautions are needed to prevent infection transmission Staff will have education regarding when and how isolation should be used for a resident .Standard Precautions are used for all patient care. They're based on a risk assessment and make use of common-sense practices and personal protective equipment use that protect healthcare providers from infection and prevent the spread of infection from patient to patient. Review of R1's progress notes, hospital records, Medication Administration Record [REDACTED]. On 6/26/20, resident was lethargic and unresponsive to sternal rub and stimuli and therefore was sent to the emergency room . R1's [DIAGNOSES REDACTED]. (A disease that makes the person more susceptible to developing infections, as high blood sugar levels can weaken the person's immune system defenses. In addition, some diabetes-related health issues, such as nerve damage and reduced blood flow to the extremities, increase the body's vulnerability to infection). Nursing order was shown for Q (every) shift readmission charting x 12 days to include maintain [MEDICATION NAME] isolation with start date of 7/1/20. Review of Hospital records showed R1 was admitted to the hospital on [DATE] with [DIAGNOSES REDACTED]. On 6/26/20 at 12:43 PM resident was cultured for COVID-19 with results on 6/26/20 at 2:05 showing none detected. There were no additional COVID-19 test results found for 6/26/20 hospitalization . During concurrent record review and interview on 7/9/20 at about 4:00 PM when asked for R1's hospital COVID-19 test results. IP provided copy of 6/26/20 COVID-19 test results, IP stated that no other COVID-19 test results were found. When surveyor informed IP that negative COVID-19 test results were collected on the day resident was discharged from the facility while the resident was in the emergency or the first day of hospital admission and was more indicative of COVID-19 status from the facility and not COVID-19 exposure from the hospital. The resident had potential exposure to COVID-19 on 6/26/20, 6/27/20, 6/28/20 and 6/29/20 while in the hospital. The IP nodded head in agreement and stated that resident potentially had exposure in the hospital without COVID-19 testing done to detect this exposure. IJ removal plan included: *Required PPE signage placed on hall barrier and outside resident room *Isolation cart and materials placed outside resident room *All staff who entered room instructed to change to new PPE *Education and training of facility staff educated on proper PPE for resident and explained proper PPE for quarantined and isolated resident. Signage stated for all new admissions whose COVID status is unknown or negative, for 14 days from admission/readmission, all recommended PPE should be worn during the care of residents under observation, which includes use of N95 mask, eye protection, gloves and gown. These must be removed (in the room) prior to exiting the room. Observation on 7/8/20 at 2:40 PM showed two additional residents (R5 and R6) residing in quarantine area. Record review on 7/8/20 at 2:40 PM showed notice in binder that staff review and sign as part of start of shift screening process. The notice Attention All Staff, dated 7/8/20 update, showed This is to inform you that we had a resident (R4) in 141b who had a change of condition yesterday evening and was sent to the hospital. For further evaluation and treatment. When staff checked with the hospital regarding resident's status. We were informed that the resident tested positive for Covid-19 and is currently admitted to their Covid unit. The other resident's (sic) in room [ROOM NUMBER] were moved to the isolation area of the building as a precautionary measure and were re-tested for Covid-19. The other resident (R1) that normally residents in room [ROOM NUMBER] will remain in isolation per readmission protocol based on CDC Guidelines . During Exit interview on 7/9/20 at 5:15 PM DON, IP and ADON when informed of HK2 cleaning non-quarantine rooms after cleaning quarantine rooms, staff nodded heads that rooms should be cleaned in the order of clean to dirty. 2. Glucometer During a concurrent observation and interview on 7/8/20 at 11:20 AM showed LN1 enter R7's room with gloved hands, Quintet AC glucometer (Glucometer is a blood glucose meters device that measure blood glucose levels), two tissues, lancet, alcohol swab, and strip. LN1 placed tissue on resident's overbed table and place glucometer and other supplies on tissue. LN1 placed strip into glucometer, swab resident's finger with alcohol and then pricked finger with lancet with a small bead of blood shown. LN1 brought glucometer towards blood and blood was shown on the strip inserted in glucometer. Blood sugar reading was obtained. LN1 removed gloves and performed hand hygiene. LN1 walked back to medication cart and wiped glucometer with single wipe from PDI Super Sani-Cloth purple top for approximately 20 seconds. LN1 stated the glucometers were shared and used on multiple residents who received medication from cart. LN1 stated that glucometers were cleaned between residents to make sure not contaminated. LN1 then entered R3's room and repeated same steps to obtain blood sugar measurement with same glucometer used for R7. After obtaining blood sugar measurement, LN1 wiped glucometer with Super Sani-Cloth for about 40 seconds and put glucometer away and stated that blood sugars were done. When asked LN1 to touch glucometer and if glucometer was wet or dry, LN1 stated the glucometer was dry right now. The glucometer did not remain wet for at least two minutes. When asked how long glucometers remained wet from disinfecting wipes, LN1 stated about 40-45 seconds. When asked how long glucometer should remain wet, LN1 stated let it stay dry for 2 minutes and not use it for 2 minutes. During concurrent record review and interview on 7/8/20 at 11:50 with IP and LN1, the label of the Super Sani-Cloth container was reviewed which showed directions to disinfect nonfood contact surfaces only. Unfold a clean wipe and thoroughly wet surface. Allow treated surface to remain wet for a full two (2) minutes. IP stated that she did not know the glucometer needed to be wet for two minutes, thought that it needed to stay dry for 2 minutes, it is so warm/hot here, it won't stay wet. Review of facility policy, Glucometer Machine Policy, revised date 5/2020, showed per the nursing infection control, machines must be disinfected before and after each use. Clean the unit with a non-abrasive hospital grade disinfectant spray the cleaner onto an applicator (towel), then wipe the unit down, let it remain wet for 2 minutes and to air dry. Record review of R3's Medication Administration Record [REDACTED]. In addition, some diabetes-related health issues, such as nerve damage and reduced blood flow to the extremities, increase the body's vulnerability to infection), [MEDICAL CONDITION] and chronic [MEDICAL CONDITIONS] (inflammation of the liver, virus can be transmitted contact with the blood or other body fluids of an infected person). Order for insulin per sliding scale before meals was shown with start date of 2/12/20. Review of CDC's website, at www.cdc.gov, section titled, Infection Prevention During Blood Glucose Monitoring and Insulin Administration, showed that if the glucose meters must be shared, the device should be cleaned and disinfected after every use per the manufacturer's instructions. During Exit interview on 7/9/20 at 5:15 PM DON, IP and ADON, when informed of observation with glucometer disinfecting, no further information was provided. 3. Room cleaning Observation on 7/8/20 at about 1:15 PM HK1 entering room [ROOM NUMBER] wearing gown, gloves, and mask. HK1 held spray bottle containing aquamarine colored liquid and sprayed onto cloth and wiped hand sink, towel dispenser and over bed table with cloth. The label on the spray bottle showed Pro Clean All purpose cleaner pine. No Environmental Protection Agency (EPA) registration number was shown on spray bottle. HK1 got new towel and sprayed onto towel and then wiped lights above bed. HK1 placed Pro Clean on HK cart and sprayed Pro Clean Sani Quad Food service sanitizer (EPA number 6836-70) onto towel and wiped handsink and room and bathroom door knobs. HK1 then cleaned towel bowl, mopped and swept floors. HK1 then doffed gloves and sanitized hands. HK moved housekeeping cart to next room. During interview on 7/8/20 at 3:15 PM HK manager stated that HK should be cleaning and disinfecting all high-touch items in the resident rooms which includes over bed table, bed rails, remote control and call light with Pro Clean all purpose cleaner and then Sani Quad. The Pro Cleaner is to clean items and the Sani Quad is used to disinfect items. When informed of observation of HK1 cleaning room [ROOM NUMBER], HK manager stated that HK1 should have used the Sani Quad after cleaning the over bed table with Pro Clean. The Pro Clean does not have an EPA number because it is not a disinfectant. HK manager stated that the over bed table, bed rails, remote control and call light was not disinfected and should have been. During an interview on 7/8/20 between 4:20 PM and 6:15 PM with Administrator and IP, Administrator stated that heard one HK didn't disinfect room correctly and that will be corrected. Record review of facility document, COVID-19 and Infection Prevention, revised 4/8/20, showed Please continue infection control practices clean all high touch surfaces such as counters, tabletops, doorknobs, bathroom fixtures, toilets, phones, keyboards and bedside tables everyday with epa registered healthcare disinfectant such as bleach or Cavi wipes. Record review of facility document, SHCC [MEDICAL CONDITION], dated 2020, showed Housekeeping will sanitize all railing, doorknobs and frequently touched surfaces Review of CDC Preparing for COVID-19 in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, accessed 7/8/20, under Environmental Cleaning and Disinfection showed Develop a schedule for regular cleaning and disinfection of shared equipment, frequently touched surfaces in resident rooms and common areas; Ensure EPA-registered, hospital-grade disinfectants are available to allow for frequent cleaning of high-touch surfaces and shared resident care equipment. 4. Incontinence care Observation on 7/8/20 at 12:45 PM showed CNA1 and CNA2 provide incontinence care for R2. CNA1 wore gloves and used several wipes to remove large amount of liquid brown stool from resident's briefs and hoyer sling. Without changing gloves or performing hand hygiene, CNA1 placed new brief under resident and then applied cream to resident's buttocks. CNA1 continued touching several items in resident's rooms with same contaminated gloves including doffing and donning resident's pants, foam boots, opening drawers, placing new socks on resident, placing new hoyer sling under resident. After transferring resident from bed to wheelchair, CNA1 then touched resident's wheelchair, cap and attached indwelling catheter bag to wheelchair and then removed gloves and washed hands. During an interview on 7/8/20 at 1:15 PM CNA1 stated that she forgot to change gloves, I should have changed gloves after wiping poop and touching new brief. Record review of R2's progress notes showed resident was admitted on [DATE] with [DIAGNOSES REDACTED]. In addition, some diabetes-related health issues, such as nerve damage and reduced blood flow to the extremities, increase the body's vulnerability to infection), and [MEDICAL CONDITION] (loss of motor function of the legs and lower body) and was incontinent of bowel and bladder. R2's Minimum Data Set (MDS-assessment tool), dated 6/1/20, showed the resident was always incontinent of bowel. During an interview on 7/9/20 at 5:00 PM IP stated that staff should be changing their gloves when moving from dirty to clean tasks during incontinence care. Review of facility policy, Peri Care revised 12/19, showed If resident has had a BM (bowel movement), remove as much as possible using toilet tissue. If this is done, remove gloves and wash hands before finishing cares, reapply gloves. Review of facility policy, Perineal Care for the Incontinent Resident, undated, showed if resident has had BM (bowel movement), remove as much as possible with toilet tissue/or brief before beginning perineal care. Place in bag designated. Remove gloves. Cover resident. Wash hands. Re-apply gloves. (It is important to remove gloves at any time they appear soiled of stool and re-apply new gloves). 5. Social distancing Observation on 7/8/20 at 1:40 PM showed 3 residents outside in the smoking area. All residents were smoking and did not have mask on. Several X markings in yellow tape were noted on the ground, the Xs appeared to be 6 feet apart. CNA1 entered the smoking area and wheeled R8 wheelchair within 6 inches of R9's chair at the table under the tent. After placing R8 at the table, CNA1 walked back into the facility. During an interview on 7/8/20 at 1:45 PM immediately after CNA1 walked back into the facility, when asked to return to smoking area to look where CNA1 placed R8's wheelchair, CNA1 looked at R8's wheelchair and stated that it was too close to R9's chair. R9 turned towards CNA1 and surveyor and stated that they (residents) were too close together and moved her chair away from R9. During an interview on 7/8/20 between 4:20 PM and 6:15 PM with Administrator and IP, Administrator stated the X tape markings on the ground are 6 feet apart to maintain social distancing for smokers while smoking. When informed of CNA1 observation, IP stated that staff are supposed to maintain social distancing and the facility has been auditing for that. Review of CDC Preparing for COVID-19 in Nursing Homes, https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html, accessed 7/8/20, showed Implement aggressive social distancing measures (remaining at least 6 feet apart from others). Remind residents to practice social distancing Review of facility, Smoking Patio Mask Surveillance 6 FT Social Distancing Log, undated, showed a column with times (2PM, 3PM, 4PM, 5PM, 6PM, 7PM, 8PM and 9PM) and another column with staff initials.

Based on clinical record review, interviews, review of facility documentation and policy and procedures, the facility failed to protect one (#8) of three sampled residents from sexual abuse by a staff member (#52). The deficient practice caused the resident harm and has the potential for further abuse resulting in harm to residents. Findings include: Resident #8 was readmitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BI[CONDITION]) score of 11, which indicated the resident was moderately cognitively impaired. The resident exhibited no behaviors during the 7 day look-back period. The MDS also revealed the resident was totally dependent on staff for bed mobility, transfers, and toilet use, and that the resident was always incontinent of bowel and bladder. The resident's care plan included the resident had behaviors such as running into things with his wheelchair, inappropriate grabbing of staff, sexual gestures, and exposed himself to other staff and residents. The care plan did not indicate that the resident made false allegations of abuse, mistreatment, or that he would yell out. A nursing note dated September 22, 2019 at 9:46 PM included the nurse (staff #8), while standing outside the resident's room, heard resident #8 scream why are you molesting me? The note included that the nurse entered the room and saw a Certified Nursing Assistant (CNA/staff #52 #52) with the resident's genitals in his hands, and when the nurse entered the room the CNA held his hands up in the air and stated that he was changing the resident's brief. The note described the CNA as a male who was not wearing gloves and had no supplies such as wipes, washcloths, or briefs to perform a brief change. The note included the CNA was asked to leave the room and that the supervisor, the resident's physician, the Director of Nursing (DON), and the police were notified. A DON progress note dated September 22, 2019 at 11:36 PM indicated that the resident was heard by the nurse on duty to be screaming and was checked because the resident does not normally have that behavior. The note indicated that the nurse had witnessed the CNA touch the resident inappropriately and that the police had been called. Review of the DON progress note dated September 23, 2019 at 4:18 AM revealed the police filed a case of sexual assault and gave instructions for provision of care to preserve evidence for when the forensic nurse returns to conduct an examination. Review of the facility's investigative report revealed that on September 22, 2019 at around 9:45 p.m. a nurse heard the resident scream out and when she went into the room, she saw staff #52 holding the resident's genitals. The CNA let go of the resident's genitals and put his hands up in the air. The CNA was asked what he was doing and he did not answer and walked out of the room. The nurse went into the resident's room and asked the resident what the CNA was doing and he said that the CNA did, inappropriate things to his penis. The CNA told the nurse that you had to know the resident first before you could believe what he is saying. The CNA did not deny nor confirm the allegation. He stated he was cleaning the resident, but it was noted that he was not wearing gloves and did not have any wipes or a washcloth. The report did not indicate if the allegation was substantiated or not, but staff #52's employment at the facility was terminated. In an interview with the resident's family member conducted on September 26, 2019 at 2:31 PM, she stated that the resident had asked her to move him to another facility on the night the incident happened. She also stated that the resident had been living at the facility for four and a half years and had never complained to her that staff had been inappropriate with him. During an interview with a CNA (staff #39) on September 26, 2019 at 3:20 PM, she stated she was on shift when the incident with resident #8 occurred. She stated she didn't know anything was going on until she saw the police. She also stated that since the incident, when she goes in the room to care for resident #8 he is scared. She stated resident #8 will scream and say Are you going to rape me? In an interview with a CNA (staff #15) conducted on September 26, 2019 at 3:30 PM, the CNA stated that she knew of two other incidents of inappropriate behavior by staff #52. She stated one incident involved staff #52 being inappropriate with resident #12. She stated that the incident occurred two days prior to the incident with resident #8 and involved staff #52 changing resident #12's brief. The facility was unable to provide any evidence that the incident between resident #12 and staff #52 was reported or investigated. Continued interview with staff #15 on September 26, 2019 at 3:30 PM revealed that the second incident occurred between another male resident and staff #52. Review of the State Agency (SA) complaint database revealed that a male resident had made an allegation regarding staff #52 on October 21, 2018 in regards to inappropriate touching. The facility report included that there were no witnesses to the alleged touching and that the male resident later recanted his story and said that he just did not like staff #52. In an interview with the DON conducted on September 26, 2019 at 3:30 PM, the DON stated that he had talked with a few residents and that none of them had reported any inappropriate behavior by staff #52. He stated that staff #52 had worked at the facility for six years and had one male resident who requested a different caregiver stating that staff #52 was homosexual and he did not want him providing care to him. In an interview with resident #8 conducted on September 27, 2019 at 9:05 AM, the resident stated that staff #52 had touched him inappropriately on Sunday (September 22, 2019) night. He stated that the police came and spoke with him. He stated that prior to the incident he had not had problems with staff #52. Throughout the interview the resident tightly clutched the hand of the interviewer and had tears in his eyes. In an interview with resident #12 conducted on September 27, 2019 at 9:30 AM, he stated that staff #52 would undress him and put him in bed and then just look at him. He stated that no one saw staff #52 doing this. Resident #12 stated he would yell at staff #52 and told him not to stare at him or he would yell and fight with him and tell him he was going to hell for touching him. The resident stated he had reported staff #52 to the administrator and DON and was told that staff #52 would not be assigned to care for him. He stated he had heard other people talking about staff #52 and they told him that staff #52 was homosexual. The resident also stated that this had been happening since he was admitted to the facility and that it most recently happened two days before the incident with resident #8. Resident #12 stated staff #52 ruined his life and he didn't think that he would ever get over it. In a telephone interview with a Licensed Practical Nurse (LPN/staff #8) she stated that on September 22, 2019, she heard resident #8 yell why are you molesting me? and two loud Oh's when she was preparing his medications outside of his closed room door. She stated she entered the room and saw staff #52 with his hands on resident #8's penis. She stated she asked what he was doing and that he didn't respond but that later he told her that she had to know the resident to believe him. She said this response made no sense to her. She stated that she told staff #52 she knew he wasn't changing resident #8 because he had no gloves, wipes, or towels to give care. She said he left and returned with wipes but she sent him away and had 2 other CNAs provide care to resident #8. She then called 911, the DON, and the resident's physician. She further stated that the day before this occurred, another resident (#12) came to her and said he needed a change in his CNA assignment because staff #52 had been sexually inappropriate with him. In a telephone interview with a CNA (staff #52) conducted on September 27, 2019 at 12:36 PM, he stated that he has not been told of any complaints about him or his care. He said that there was one resident who didn't like him because he is homosexual. He said that he either has another staff member present or trades assignments with another staff member to protect himself from accusations by that resident. He stated that in regards to resident #8, the nurse had lied, as he was only changing resident #8's brief. He stated that resident #8 loves the attention, and that in the three years he had been working at the facility he took care of resident #8 frequently and that resident #8 would ask him are you going to rape me? 3 or 4 times a year. In an interview with the DON conducted on September 27, 2019 at 1:39 PM, he stated immediately at the time of the incident on September 22, staff #52 was removed from care and the nurse let the supervisor know who called him and the police. He stated that staff #52 had not been back in the facility since the incident and that staff #52's employment had been terminated. He stated for the safety of the residents staff #52 cannot come back to the facility. He also stated that he planned to educate the staff about abuse. He stated that the facility had filed a report with the SA regarding an allegation by a male resident regarding staff #52 some time ago. He stated that he was not aware of resident #12's allegations, but just knew that the resident had come to his office and told him that he did not want any homosexual males touching him. He said that he honored this request but had not put anything in writing about this incident. A review of the facility's Abuse and Neglect policy revised February 2018, revealed it is the policy of the facility that residents must not be subjected to abuse by anyone including, but not limited to facility staff. The policy indicates sexual abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. The policy further included that all allegations of abuse and neglect will be investigated by the DON or a designated representative.

Based on observation, clinical record reviews, staff interviews, facility documentation and policies and procedures, the facility failed to ensure care and services were provided to one resident (#166) who was identified as high risk for falls, and failed to ensure one resident (#28) who has cognitive impairment was thoroughly and accurately assessed for safe smoking. The deficient practice could place residents at increased risk for injuries. Findings include: -Resident #166 was admitted to the facility on (MONTH) 1, 2019, with [DIAGNOSES REDACTED]. According to the admission observation form dated (MONTH) 1, 2019, the resident was alert and oriented to person and place, was a 2 person assist with transfers and had weakness to both lower extremities. The Fall Risk assessment dated (MONTH) 1, 2019 included the resident was a high fall risk and required assistance/supervision with mobility, transfers or ambulation. An initial care plan dated (MONTH) 1, 2019 included the resident was a fall/safety risk. A goal was for the resident to have no injury or harm. Interventions included for use of the call light, instruct on safety measures and assess for causal factors; such as orthostatic blood pressure, urge to void, medications and ambulatory gait. A Fall care plan with a start date of (MONTH) 2, 2019 included the resident was a fall risk. A goal was for the resident to maintain current level of mobility, with minimal risk of injury. Interventions were to assist resident to a standing position, keep bed in low position with brakes locked, instruct/encourage safety measures to prevent falls and injury and for staff to perform frequent monitoring and observation to determine safety and prevent falls. A physician progress notes [REDACTED]. Per the note, the resident needed assistance with ADLs (activities of daily living) and needed a CNA (certified nursing assistant) to get him up and out of bed. A progress note written by case management as a late entry dated (MONTH) 24, 2019, revealed it was reported that the resident had a fall from the wheelchair and had an ice pack to his forehead. Review of the fall incident report dated (MONTH) 24, 2019 revealed the resident had a fall from a wheelchair and had an ice pack on his forehead. The incident report did not include what type of injury the resident sustained [REDACTED]. Further review of the fall incident report revealed there were areas to document if the resident exhibited or complained of pain, the resident's level of consciousness, pupil size and response, speech, mental status, upper and lower extremity movement/grasps, vital signs, possible contributing factors, interventions implemented, notifications made and physician orders. However, none of these areas were addressed on the incident report. Despite documentation the resident fell , there was no evidence that the facility had thoroughly investigated the fall and determined any possible causes of the fall. There was also no evidence of any additional interventions which were implemented after this fall, in order to prevent further falls. In addition, there was no clinical record documentation regarding the type of injury that the resident sustained [REDACTED]. A nursing note dated (MONTH) 15, 2019 at 8:20 a.m., included the resident was lying on the floor in his room, with his wheelchair behind him. The note included the resident had a laceration on the top of his head and that interim wound care was provided. Resident #166 was assisted back to his wheelchair and was on neuro check monitoring. The physician was notified and an order was obtained to monitor for any change. Another nursing note dated (MONTH) 15, 2019 at 9:45 a.m. included the resident was lethargic and was bleeding from the laceration, even when pressure was applied. The physician was notified and orders obtained for the resident to be transferred to the hospital. A physician's orders [REDACTED]. Review of the fall incident report dated (MONTH) 15, 2019 included the resident had an unwitnessed fall in their room and sustained a laceration to the top of the head. The resident exhibited confusion of new onset. Interventions included first aid and direct pressure to the wound. Per the report, these interventions were somewhat effective and the injury was not resolved. According to the hospital emergency room records dated (MONTH) 15, 2019, the resident presented with fall forward out of wheelchair and sustained a [MEDICAL CONDITION] from hitting head on dresser. The resident had a stellate laceration overlying the top of the head. CT (Computed [NAME]ography) of the head as well as the cervical spine was done and revealed evidence of C1 (Cervical-1) ring fracture. A nursing note dated (MONTH) 18, 2019 included the resident was admitted to the ICU (intensive care unit). The resident had a C1 cervical fracture right sided ring break and was on spinal precautions, and was on a ventilator. It also included the resident was not arousable, with fair movement in the upper extremities. An interview was conducted on (MONTH) 17, 2019 at 10:18 a.m. with the CNA (staff #85), who was caring for the resident on (MONTH) 15, 2019. Staff #85 stated she was working the morning shift on (MONTH) 15, 2019 and was assigned to the resident that day. She said when she came on shift, another CNA asked her to go to the resident's room. She said when she entered the room, she saw the resident on his knees with his head on the floor and he was bleeding from his head. She said there was a pool of blood on the floor. She said the resident was confused, could not tell if he was in pain and he could not say what happened. She stated the resident was already changed for the day, as the night shift had gotten him up early and then left the resident in the wheelchair by himself. She stated the nurses and the CNA's know that the resident cannot be left by himself, because he was confused and always wanted to get up from his chair. She said the position of the resident when she saw him was as if he had tried to get up from his chair on his own. Staff #85 continued to state that she could not remember the name of the nurse on duty (on (MONTH) 15), but that nurse instructed her and another CNA to lay the resident in bed and do 15 minute checks. She stated that every time she went to check the resident, his wound would not stopped bleeding. She said that she told the nurse the resident needed to be transferred to the hospital, but the nurse did not think so. She said later that morning, the nurse called the supervisor who instructed her to send the resident to the hospital. Staff #85 further stated the resident should not have been left alone in his wheelchair. During an interview with a licensed practical nurse (LPN/staff #48) conducted on (MONTH) 17, 2019 at 12:46 p.m., she stated residents are assessed for fall risk on every interaction made with the resident such as medication administration and after every fall. She stated that she instructs the CNA's to report any changes in the residents, when providing care. Staff #48 said if a resident is assessed to be at risk for falls, she will instruct the CNA to check on the resident more frequently. She stated after each fall, a head to toe assessment is done to check for injuries and the physician and family will be notified. She stated if the fall is unwitnessed, neuro checks will be initiated immediately. She said if a resident has an unknown injury, she will conduct an investigation and ask the CNA's to figure out what might have happened. She said that she will also document in the progress notes what she saw or the details of the fall. She further stated that if the resident has fallen in the past, the care plan should be updated to ensure new interventions were put into place to prevent the resident from falling again. She stated resident's safety is a priority, so she will talk with other staff about how the fall happened, what the resident was doing and new ways to prevent the resident from falling again. She stated everything will be documented in the clinical record. In an interview with a CNA (staff #28) conducted on (MONTH) 17, 2019 at 1:49 p.m., she stated that every time a resident has a fall whether it is witnessed or not and whether or not there is an injury, she notify's the nurse who will then conduct an assessment and call the physician. She stated that after each fall, the CNA's will conduct 15 minute checks and document it in separate paper documentation. She said when a resident is identified as high risk for falls and is sitting in the wheelchair, the resident will be placed close to the nurse's station so anyone can see and intervene immediately if needed. An interview was conducted on (MONTH) 18, 2019 at 10:08 a.m. with the LPN (staff #63), who was the nurse on duty at the time of the resident's fall on (MONTH) 15, 2019. Staff #63 stated that on (MONTH) 15, she entered the resident's room to obtain a blood sugar reading from the roommate, when she saw resident #166 on the floor with blood. She conducted a head to toe assessment and found a laceration on the top of his head. She stated the resident did not complain of any pain and could not tell her what happened. She stated there were two other residents in the room, but they were both confused and could not say what happened. She stated that 2 hours after the incident, the resident's wound continued to bleed and the physician ordered for him to be transferred to the ER (emergency room ). She said that she reported the incident to the DON (staff #55). An interview was conducted on (MONTH) 19, 2019 at 9:54 a.m. with the case manager (registered nurse/staff #83), who wrote the note regarding the fall on (MONTH) 24. Staff #83 stated that when she receives reports of fall incidents whether observed or unwitnessed, she will conduct a head to toe assessment and initiate neuro checks every 15 minutes. She stated that she will ensure that any injuries sustained from the fall are identified and documented. She said she will use nursing judgment to determine whether it is safe to transfer or move the resident from the floor to the bed or chair; and will call the physician. She said that she will conduct an investigation to figure out the events that led to the fall, which include information such as location of the fall, what the resident was doing prior to the fall, what were the factors that precipitated the fall and she will talk to staff who might have witnessed the fall. She said if the fall occurred in a room with other residents, she will ask the residents what happened, even if they have cognitive issues. She stated that she will document her assessments and findings on the Fall Observation Form. She said based on the findings, new interventions/measures will be put in place to prevent another fall. She said that all reports of falls even if it's a resident who has a history of making up stories, will be treated as true and that the nurses are to assess, investigate and document the incident in the clinical record. Immediately following the interview, the fall incident report dated (MONTH) 24, 2019 and the resident's clinical record was reviewed with staff #83. She confirmed there was a lack of details regarding this fall and a lack of new interventions after the fall. She said that day she saw the resident sitting in his wheelchair with an ice pack on his head. She said a CNA told her that the resident had a fall earlier in the day. She further stated that she did not conduct an assessment of the resident at that time and did not know what type of injury the resident had, and did not recall if the details of the fall were investigated. During an interview with the Director of Nursing (DON/staff #55) conducted on (MONTH) 19, 2019 at 12:45 p.m., he stated when a resident has a fall the nurse should assess the resident, conduct every 15 minute checks, investigate the events of the fall and conduct root cause analysis of the fall incident, analyze the interventions and revised the fall interventions as needed. Regarding the fall on (MONTH) 24, 2019, staff #55 stated that he cannot say whether the resident was assessed after the fall, because he could not find any documentation about it. He stated the nurse should have completed the Fall Observation form to include what happened. He further stated because there was no documentation of the details of the fall and how it happened, the fall interventions were not revised. Regarding the fall on (MONTH) 15, 2019, staff #55 stated the CNA (staff #85) sat the resident in his wheelchair and instead of wheeling the resident to the nurse's station, staff #85 left the resident in their room. Review of the policy regarding Fall Risk Assessment revealed the nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff and others, will seek to identify and document resident risk factors for falls. Assessment data shall be used to identify underlying medical conditions that may increase the risk of injury from falls and staff will seek to identify environmental factors that may contribute to falling, such as lighting and room layout. The policy regarding Managing Falls and Fall Risk included that Based on previous evaluations and current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize the complications from falling. It also included that if falling recurs despite the initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Staff will monitor and document each resident's response to the interventions. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help staff reconsider possible causes that may not have previously been identified. -Resident #28 was admitted on [DATE] with [DIAGNOSES REDACTED]. The quarterly Minimum Data Set assessment ((MDS) dated [DATE], revealed resident #28 had severe impaired cognition. The annual MDS assessment dated [DATE] revealed the resident had short and long term memory problems and had moderate impaired cognition. The Smoking Risk assessment dated [DATE], revealed the resident carries cigarettes and lighter and the frequency of use was every few hours. The question regarding general awareness and orientation, which included the ability to understand and follow the facility safe smoking policy revealed the resident had no problem. The total smoking risk assessment indicated the resident was a safe smoker. A review of the Nursing Summary dated 9/2/19, revealed the resident was confused, was unaware and had memory problems. A review of the facility list of the residents who do not need supervision with smoking revealed resident #28 was on the list. An interview with the MDS Coordinator (MDS/staff #77) was conducted on 9/16/19 at 11:16 AM. At this time she reviewed the Smoking Risk assessment for resident #28 and stated that she just watches residents smoke to determine if they are safe. She also stated she could not confirm that resident #28 understood the facility safe smoking policy. An interview with the Director of Nursing (DON/staff #55) was conducted on 9/16/16 at 12:00 PM. He reviewed the Smoking Risk assessment for resident #28 dated 8/2/19 and stated the resident does have memory problems, but is safe to smoke. During an interview with resident #28 on 9/17/19 at 9:32 AM, the resident answered OK to all questions and did not know the date or his room number. Resident #28 was asked what he would do if something caught fire when he was smoking and the resident answered OK. The resident was also asked if he knew the facility's smoking safety rules and again he answered OK. During the interview, there were five packs of cigarettes and a lighter on his bedside table. During an observation on 9/17/19 at 10:00 AM, resident #28 was in the unsupervised smoking area of the facility and he was smoking without supervision. A review of the Interdisciplinary Team progress note dated 9/17/19 at 12:00 PM, revealed the committee determined resident #28 had increased forgetfulness and noted generalized weakness. The note further included that resident #28 was to be placed on a list of supervised smokers for the safety of this resident and others. The facility policy and procedure regarding Smoking Policy dated 8/2019, revealed Smoking is both a fire and health hazard. The purpose was to ensure resident safety and to comply with State, Federal, and Community regulations. An assessment will be completed and documented within 24 hours of admission to determine if the resident will require supervision while smoking. An independent smoking resident must be able to handle cigarettes, must not be dropping ashes on clothing and must be able to make sound judgement about smoking. If deemed necessary, resident with any deficits will be supervised by staff while smoking. Matches, lighters, and cigarettes will be kept at the nurse's station for supervised smokers.

Based on observations, clinical record reviews, hospital record review, staff and resident interviews and review of facility documentation, the facility failed to ensure that one resident (#67) had an increase in supervision to protect this resident from other residents. As a result resident #67 sustained actual harm. The facility failed to adequately supervise and protect five residents (#s 18, 59, 31, 34, and 56) from resident to resident altercations. The facility failed to consistently apply additional safety measures for two residents (#59 and 18) regarding falls. The facility failed to adequately supervise one resident (#59) and as a result the resident sustained [REDACTED].#s 52 and 3) to prevent accidents and injuries. Both residents #s 52 and 3 sustained actual harm. The sample size was 50. Findings include: -Resident #67 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was cognitively impaired. A review of a facility report revealed that on January 1, 2012, resident #67 was hit by another resident (#18) while the residents were in the south hallway. The incident was not witnessed. Resident #67 was sent out to the emergency department. A review of the hospital records dated January 1, 2012, revealed the resident had comminuted bilateral nasal fractures. Clinical record documentation included the resident returned from the emergency department and 15 min checks were initiated, however, the facility was unable to provide evidence that the checks were done. There was also no other documentation which included increased supervision was provided to prevent further incidents from occurring, despite resident #67 sustaining nasal fractures by resident #18. Nursing notes on February 3, 2012, revealed that resident #67 was hit in the jaw after he told his roommate (resident #18), that he needed a shave. No injury was noted. Resident #67 was transferred to the secured unit for safety. The facility was unable to provide any investigative documentation regarding this incident or provide evidence of any increased supervision that was implemented, nor documentation as to why resident #18 was roommates with resident #67, since resident #67 had previously sustained nasal fractures by being hit by resident #18 in January. On February 6, 2012, nursing notes documented that resident #67 had a u-shaped laceration to the left side of the nose which measured 4 centimeters (cm) by 0.3 cm by 0.1 cm and surrounding tissue was edematous. Resident #67 stated that "I think I got hit by a car." One to one supervision was implemented for resident #67, however, there was a lack of documentation as to how long the one to one lasted. The facility was unable to provide any investigative documentation of this incident. Nursing notes dated February 17, 2012, revealed resident #67 was in the hallway with a certified nursing assistant (CNA), when another resident was wheeled by and hit resident #67 in the face, 15 min checks were initiated. There was no investigative report completed and no evidence that the 15 minute checks were done, nor that any additional safety measures implemented or any increased supervision was provided. A review of the nursing notes dated February 29, 2012, revealed an altercation occurred with resident #67 and another resident. There were no apparent injuries. The residents were separated. There was no other documentation of any additional safety measures implemented. On May 4, 2012, a resident to resident altercation occurred between resident #67 and resident #56. Nursing notes documented resident #67 sustained a laceration to the left lateral cheek and that the residents were separated. Review of the facility documentation revealed that on May 4, 2012, a resident to resident altercation between resident #67 and resident #56 occurred. Resident #67 received a laceration on his face from resident #56 when his path to the TV lounge was blocked. Resident #56 received no injuries. The residents were separated and 15 minute checks were implemented, but there was no documentation the checks were done and for how long or any other measures implemented or increased supervision provided. On June 27, 2012 at 8 :45 pm, resident #56 hit resident #67 on the arm, two times. Documentation revealed that that the incident occurred in the hallway and that resident #56 just started hitting resident #67. Clinical record documentation revealed that on June 30, 2012, resident #67 was found on the floor of his room with a right forearm skin tear. There was no investigation completed in order to determine if this incident was related to a resident to resident altercation or another possible cause. No additional safety measures were implemented. Clinical record documentation dated July 27, 2012, included resident #67 was observed to have his arm twisted by another resident. Resident #67 sustained a skin tear to the right upper arm and an abrasion to the right shoulder, chest and left wrist. Interventions only included 15 min checks, however, there was no documentation they were done. On August 14, 2012, resident #67 was hit in the face multiple times by another resident. The other resident then exposed his genitals to resident #67's face. This incident was witnessed by the CNA. The residents were separated and 15 minute checks were initiated. The facility was unable to provide evidence the 15 checks were done or that increased supervision was provided. On August 20, 2012, at 7:00 am the resident was found on the floor in another resident's room by a CNA. The resident sustained [REDACTED]. No investigation was completed in order to determine the possible cause and implement additional safety measures. Nursing notes on August 23, 2012 at 8:00 am, revealed an altercation occurred between resident #67 and another resident. Another resident grabbed both arms of resident #67. No injuries were documented. On August 24, 2012, documentation revealed that the resident #67 continued to have "issues with some residents as in earlier notes. Patient ended up on floor of other resident (room) while CNA blocked both patients from making physical contact." The nurse and CNA separated the residents and started on 15 minute checks. There was no documentation the 15 minute checks were done. The facility was unable to provide any investigative documentation or interventions implemented. Despite multiple resident to resident altercations with injury, there was no documentation that increased supervision was provided along with additional interventions to ensure resident safety. An observation conducted on August 28, 2012 of the secured unit revealed that only one CNA was on the unit. It was also observed that there was no nursing station with a phone on the unit, in order to call for assistance if needed. The CNA at this time was sitting in front of a resident's room trying to keep resident #67 from entering that room. An observation conducted on September 6, 2012, revealed a CNA entering the secured unit. The only other staff member on the secured unit was from environmental services who stood in the door way to the dinning room. An interview was conducted with environmental services at this time who stated he was helping the CNA who had to go to the restroom. He further stated since he was the only staff member present and if the residents became violent, he would need to leave the unit to seek assistance. An interview with the CNA on the secured unit conducted on September 6, 2012, revealed that she was normally the only staff member on the secured unit. The CNA stated that if she required immediate assistance she must leave the unit to seek help. The CNA stated that she did not carry a beeper or a two way radio. The CNA stated that when the three residents on the unit have their smoking time, she goes back and forth between the unit and the outdoor patio. An interview with the registered nurse (RN) on September 6, 2012, revealed that she only went on the secured unit to administer intravenous medications or if she was called to assist if an incident occurred, such as a fall. An interview was conducted on September 6, 2012, with a licensed practical nurse (LPN) assigned to the secured unit. The LPN stated that her assignment was split between the secured unit and the residents outside of the unit. She further stated that if the CNA required assistance she must come out of the unit to seek assistance. -Resident #59 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was alert and oriented with some forgetfullness. Issue regarding resident to resident altercations: On January 22, 2012, the nursing notes revealed that resident #59 had an altercation with another resident (unknown resident) which resulted in a skin tear to the left forearm of resident #59. The notes documented that 15 minute checks were initiated, however, the facility was unable to provide documentation of how long the 15 min checks were done, nor documentation that the 15 minute checks were completed. On March 9, 2012, the nursing notes revealed that a CNA and an office worker heard a call for help from resident #59. Resident #59 was separated from another resident (unknown resident). Resident #59 sustained an injury to the right hand that required the use of a steri strip to stop the bleeding. Documentation included that 15 minute checks were started, but the facility was unable to provide documentation the checks were done. Review of the resident's care plans revealed there were no interventions that addressed any type of increased supervision, due to resident altercations. The facility was unable to provide any investigative documentation regarding the above two incidents, or that any additional interventions were implemented or that any increased supervision was provided to prevent further occurrences. Review of the wound physician notes dated March 13, 2012, revealed the following: open wound of elbow, forearm and wrist complicated, wound #6 presents as a trauma located on the right dorsal hand and measures 2.5 cm length by 0.5 cm width, scant drainage. Wound #7 presents as a trauma located on right forearm and measures 1 cm by 0.5 cm with small amount of drainage. Wound #8 presents as a trauma located on right upper arm and measures 4 cm by 1 cm with a depth of 0.1 cm, 1-25% eschar, 1-25% slough. A review of the clinical record including nursing notes, revealed a lack of evidence how wounds #6, #7, and #8 occurred. The facility was unable to provide an investigative report regarding these wounds which resulted from trauma. There was also no clarification whether the right hand wound mentioned in the physician notes from March 13, was the same wound the resident received on March 9, due to the altercation. Nursing notes dated May 30, 2012, revealed that resident #59 was hit in the face by resident #18. Resident #59 sustained redness to the face. Per the facility investigation an x-ray was obtained, which reported no fracture or dislocation. The police were notified. Interventions included 15 minute checks, however, the facility was unable to provide any documentation the checks were done or for how long, nor any additional interventions or increased supervision that was provided. Further review of the care plans for resident #59 revealed they were not updated to reflect the multiple resident to resident altercations, nor interventions to ensure the resident's safety. An interview with a CNA was conducted on September 6, 2012. The CNA stated that it was not possible to supervise the residents all the time in order to do 15 minute checks. An interview with another CNA was conducted on September 6, 2012. This CNA stated that one day the staff complained that there was not enough staff, due to call offs and were told by administration that "It is what it is." An interview with the Director of Nursing (DON) was conducted on September 6, 2012. The DON stated that whenever a resident experienced an altercation, the nurse was to initiate 15 minute checks and/or behavior charting. She was unable to state how long 15 minute checks were to remain in place, saying each incident would vary. Issue regarding falls: A review of the fall care plan dated February 11, 2011, revealed a potential for actual injury due to refusing to wear glasses, dementia, and psychosis. The care plan was revised on November 14, 2011, with the intervention to provide monitoring and for a bed and wheelchair alarm. On November 15, 2011, the day after the bed and chair alarms were to be implemented per care plan, the nursing notes documented the resident was found on the floor. The resident had attempted to walk and fell , and there were no injuries. The documentation lacked evidence that the alarm had sounded and/or was in use at the time of the fall. The post fall assessment consisted of vital signs taken, no injuries were noted and the physician and family were notified. Interventions included for 15 minute checks, however, the facility was unable to provide any documentation the 15 minute checks were done. On December 5, 2011, the nursing notes revealed that the resident sustained [REDACTED]. The notes lacked documented evidence how the skin tears occurred. The facility was unable to provide any investigative documentation regarding the skin tears. A review of the wound physician notes dated December 19, 2011, revealed the resident had a wound (labeled wound #3) to the forearm from a fall, which measured 1.2 cm by 0.5 cm by 0.1 cm depth, with 25% slough. There was no clinical record documentation or any investigative report to clarify when this fall had occurred or what happened. There was no documentation to clarify if wound #3 was the same skin tear identified on December 5. There was also no documentation that any additional safety measures were implemented. Further review of the care plan revealed it was not updated to reflect the falls, nor were there any additional safety measures documented. An interview with the DON was conducted on September 6, 2012. The DON stated that whenever a resident experienced a fall, the nurse was to initiate 15 minute checks. She was unable to state how long 15 minute checks were to remain in place, saying each incident would vary. Issue regarding sunburn: On April 1, 2012, the nursing notes documented that the resident experienced a sunburn to her lower extremities from sitting outside in the sun. Physician orders [REDACTED]. Clinical record documentation including care plans did not address any additional interventions implemented or address the need for any increased supervision. The facility was unable to provide any investigative documentation regarding the specifics of how this incident occurred, nor any additional measures that were implemented to prevent this from reoccurring. -Resident #31 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was cognitively impaired. A review of the nursing notes dated December 23, 2011, revealed that the resident was observed to be struck on the left cheek by his roommate resident (#18). No injuries were noted. The residents were placed on 15 minute checks. Review of the facility report revealed the residents were placed on 15 minute checks and the two residents would be separated and no longer share the same room. The facility was unable to provide documentation the 15 min checks were done. During the survey, an observation conducted on August 28, 2012, revealed that resident #31 resided in the same room as resident #18. In an interview conducted on September 6, 2012, the DON was unable to explain why the two residents resided in the same room and why there were no 15 minute checks documented. An interview conducted with the administrator on September 10, 2012, revealed that the residents had been separated for a given time, but was not sure why or when the two residents were put back together. He stated they both had short term memory problems so neither one of the residents would recall the incident. The administrator stated that resident #18 had unpredictable episodes of violence and would strike out without any provocation. -Resident #18 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the clinical record revealed the resident was alert and oriented times one. Issue regarding falls: Physician orders [REDACTED]. The resident was identified to be at risk for falls and a care plan was developed. A review of the nursing notes dated February 7, 2012, revealed the resident had a seizure and had fallen on the floor. The resident had removed the alarm and attempted to go to the bathroom. The resident sustained [REDACTED]. It was documented that the resident was slow to speak and the seizure lasted approximately four minutes. The resident was physically aggressive following the seizure and was sent to the emergency department for further evaluation. Physician orders [REDACTED]. Review of nursing notes dated February 25, 2012, revealed that the resident tried to get up, lost his balance and ended up on the floor in a sitting position. No injuries were documented at this time. There was no documentation in the clinical record or any investigative documentation if the fall occurred from the bed or the wheelchair or if the pressure alarm was in place at the time of the fall. Documentation revealed 15 min checks were initiated however, there was no documentation the checks were consistently done or how long they were to be in place. There was also no documentation of any additional interventions implemented. A review of nursing notes dated February 26, 2012, revealed that the resident stood up from his bed to get water when his left leg gave out. Resident was found on the floor with the alarm going off. No injury documented. A review of the fall care plan dated February 26, 2012, revealed the resident was to be on 15 minute monitoring checks. On March 8, 2012, the resident was found on floor with the covers wrapped around him. The resident noted to have a laceration to the left eyebrow. There was no documentation the pressure alarm was in place prior to the fall. Review of the nursing notes dated March 11, 2012, revealed that the resident attempted to go to the bathroom and lost his balance. The resident hit the back of his head on the bed frame and sustained a laceration. The alarm sounded at the time. Review of the falls care plan revealed that it was not updated despite the resident's multiple falls, and no new interventions were implemented to prevent further falls. Nursing notes dated April 25, 2012, revealed the resident stated he had gotten out of his wheelchair and laid down outside. The resident was assessed after being observed with dirt and grass on his back and hair. The notes lacked documentation regarding supervision prior to the incident. The falls care plan was revised in May 2012 (day not documented) which documented the resident was to wear a helmet. There was no other documentation regarding the use of the helmet. Nursing notes on May 2, 2012, revealed the resident was observed in his room with blood on the right side of his face above the eye. The resident stated that he fell . Three steri strips were applied to close the wound. The notes lacked documented evidence that the pressure alarm was in place prior to the fall, nor that he was wearing the helmet. A review of the Minimum Data Set (MDS) functional status dated May 15, 2012, revealed that the resident required supervision for transfers and for walking in his room. Clinical record documentation included that on May 20, 2012, the resident was observed in the hallway by kitchen staff to have tripped and fell to the floor. Documentation did not include the resident was supervised while walking. The resident was wearing his helmet. On June 3, 2012, documentation revealed the resident was ambulating in the hallway, fell and hit his head and sustained a laceration measuring 1.3 cm by 0. 5 cm. Steri strips were applied to the wound. Documentation lacked evidence that the resident was wearing his helmet. On June 17, 2012, documentation in the nursing notes revealed the resident fell on his left shoulder and an X-ray was done. No injury occurred. Documentation lacked evidence the resident was wearing the helmet. On June 21, 2012, the resident was found with dry blood on his left eyebrow and was aggressive and combative during treatment. It was documented the resident was non-compliant with wearing the helmet. There was no documentation regarding any measures implemented to address the resident's non compliance with the helmet or any other safety measures attempted. On July 10, 2012, the resident lost his balance while standing, and fell and hit his elbow. The fall was witnessed by a CNA. Documentation lacked evidence that the resident was wearing the helmet. No further interventions were documented at this time. Per the nursing notes on July 30, 2012, the resident fell in his room and sustained a laceration below the right eye. The documentation did not address if the resident was wearing the helmet. The resident was sent to the emergency room for treatment and evaluation and returned. On August 10, 2012, nursing notes revealed the resident was found outside laying on his right side. The resident sustained [REDACTED]. Resident was sent to the emergency room for evaluation and treatment. Documentation lacked evidence the resident was wearing the helmet. A review of the hospital records dated August 10, 2012, revealed the resident was brought to the emergency department for evaluation of a head wound. The resident had fallen out of his wheelchair and reopened a laceration over the right eye, which had been repaired two weeks ago. The note further documented the resident became aggressive and punched a medical student. The laceration was resutured and the resident returned to the facility. Physician notes dated August 20, 2012, revealed the following documentation: "the resident has been known to hit staff, the resident is able to stand up and get into his wheelchair. Resident wears a helmet for his protection." Despite the resident sustaining more than 12 falls some with injuries, the facility did not provide any consistent increased supervision or ensure the helmet was consistently utilized or address the resident's non compliance with wearing the helmet. Observations conducted on September 28 and 29, 2012, revealed the resident was moving about in his wheelchair independently. The helmet was in place. An interview with the DON conducted on September 11, 2012, revealed that the only post fall assessment is in the nursing notes. She stated that physical therapy had introduced a form last month that may be implemented, however, currently documentation is just in nursing notes. Regarding resident to resident altercations: A review of the nursing notes dated December 23, 2011, revealed resident #18 struck his roommate resident (#31) on the cheek. No injuries were noted. Review of the facility report revealed the residents were placed on 15 minute checks and the two residents would be separated and no longer share the same room. The facility was unable to provide documentation the 15 min checks were done or how long the checks were to be done. A review of a facility report revealed that on January 1, 2012 resident #67 was hit by resident (#18) while the residents were in the south hallway. The incident was not witnessed. Resident #67 was sent out to the emergency department. A review of the hospital records dated January 1, 2012, revealed the resident had comminuted bilateral nasal fractures. Clinical record documentation included resident #67 returned from the emergency department and 15 min checks were initiated, however, the facility was unable to provide evidence the checks were done or for how long. There was also no other documentation which included any increased supervision was provided to resident #18 related to his aggressive behaviors. Nursing notes on February 3, 2012, revealed that resident #18 again hit resident #67 in the jaw after resident #67 told him he needed a shave. The notes documented the residents were roommates at this time. No injury was noted. Resident #67 was transferred to the secured unit for safety. The facility was unable to provide any investigative documentation regarding this incident or provide evidence of any increased supervision that was implemented for resident #18. Review of the nursing notes dated March 6, 2012, revealed resident #18 hit resident #34 once on the right side of the face when he passed him in the hallway. Redness was noted on right hand. Resident #18 stated that he hit the other resident because he was bad. The nursing notes documented that the resident was placed on one to one, however, there was no facility documentation of how long the one to one was done, nor any interventions implemented once the one to one was removed. Nursing notes for May 6, 2012, revealed resident #18 was found laying down in a female's bed. There was no facility documentation any increased supervision was implemented. Nursing notes dated May 30, 2012, revealed that resident #59 was hit in the face by resident #18. Resident #59 sustained redness to the face. Per the facility investigation an x-ray was obtained, which reported no fracture or dislocation. The police were notified. Interventions included 15 minute checks, however, the facility was unable to provide any documentation the checks were done or for how long, nor any additional interventions or increased supervision that was provided to resident #18. Review of resident #18s care plan dated July 2012, revealed the following interventions for behaviors: staff were to encourage resident to stay in dinning room during meal time; to have wheelchair placed away from passing residents when exiting area; to assess the resident for significant change in cognition and agitation; to notify the physician in change of behaviors; and to re-approach if verbally and physically aggressive to others. The care plan did not address the need for any increased supervision, despite multiple resident to resident altercations. An interview with a LPN on the south unit conducted on September 6, 2012, revealed that the resident gives no forewarning before he punches or strikes out. He may go several months before he strikes out again or several days. The nurse further stated that the resident does not reside on the secured unit because he will hit resident # 67 if he comes within striking distance. Interview with MDS coordinator conducted on September 10, 2012, revealed that the resident's behavior was discussed every morning in stand-up meetings and if there was an order to change medication then the care plan was up-dated, but if he has had altercations with staff and or other residents the care plan was not up-dated. She stated with resident #18, his behavior was not medication related and was very unpredictable, therefore his care plan would not be up-dated or changed. The nurse further stated that his placement on an open floor was an executive decision. An interview with the medical director on September 11, 2012, revealed that falls/incidents were discussed in the monthly or quarterly quality assurance meeting which he attends, however, the falls/incidents are not tracked, therefore he was not aware of patterns of falls or resident to resident altercations with this resident, which led to numerous injuries to other residents. -Resident #34 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of a facility report dated March 6, 2012, revealed that the resident was struck in the face when he passed another resident in the hallway. Resident #34 must pass through the other resident's hallway in order to smoke. The facility report revealed a lack of evidence that resident #18 who had been care planned to closely monitor with 15 minute checks was monitored at the time of this altercation. -Resident #3 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Social Service Progress Note dated January 10, 2012, revealed that the resident was alert and oriented times three and was able to make his needs known. He self-propelled in an electric wheel chair, and required total care with activities of daily living. Review of the Nurse's Notes dated January 17, 2012, revealed that a (CNA/staff #2) assisted the resident to reposition on his right side while in bed, and the resident fell off of the bed landing on his back side on the floor. Staff #2 was repositioning the resident on his side to wedge a pillow behind his back, as he continued to roll forward off the edge of the bed. No apparent injury was noted at this time. Review of the Falls Care Plan revealed that the care plan was not updated to reflect this fall, nor were there any new interventions documented. Review of the Nurse's Notes dated January 18, 2012, revealed that another CNA went into the resident's room to give him a bed bath, and noticed his leg was turned outward. The resident denied any pain, as he was a quadriplegic and had no feeling in his legs. The physician was notified and an x-ray was ordered that showed a right femur fracture. A physician's orders [REDACTED]. The MDS revealed that a discharge assessment was completed on January 18, 2012. Section J. of the MDS assessment noted that the resident had a fall with no injuries, despite having sustained a fall with a fracture the previous day. Section G noted that the resident required extensive assistance for bed mobility and physical assistance of one. Review of the hospital history and physical dated January 18, 2012, revealed that the resident had a comminuted right midshaft femur fracture. He was admitted to the hospital for evaluation and treatment. Review of the facility's investigative report revealed that during repositioning of the resident, an upper right hand side rail was raised. The report included as the resident was being turned by the CNA, the resident slipped off the lower side of the bed, which did not have a side rail. The report further documented that if a lower right side rail had been in place at the time of the accident, it likely would have prevented the resident from falling out of bed. The report did not address if there was a need for two staff members to be utilized when turning and repositioning this resident. Further review of the Falls Care Plan revealed it was not updated to reflect the need of the lower side rails, nor did it address the level of assistance this resident required when turning and positioning in bed. An interview was conducted on September 10, 2012, with resident #3. He stated that the CNA (staff #2) was assisting him to reposition on his right side and that he told her he was too close to the edge of the bed and that she needed to pull him back before rolling him on his side. He stated that there were usually two CNAs to turn him. He stated that there was now upper and lower rails in place to prevent this from happening again. An interview was conducted with a CNA on September 4, 2012. The CNA stated that two CNAs should be used whenever turning this resident. An interview was conducted with the DON on September 10, 2012. The DON stated that there should be two CNAs to reposition the resident as he weighs a lot, and cannot help with repositioning. -Resident #52 was admitted to the facility on [DATE], w

Based on observation, medical record review and staff and resident interviews the facility failed to draw a physician ordered lab value for one resident (#49) and failed to ensure that therapeutic drug levels were adequately monitored and maintained. The facility failed to accurately access or adequately monitor or manage pain for four residents (#'s 94, 60, 102 and 35). Findings include: Issue regarding [MEDICATION NAME]: -Resident #49 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the resident's clinical record revealed an admission order dated March 12, 2012, for [MEDICATION NAME] 150 milligrams (mg) to be given orally three times a day but there were no orders for [MEDICATION NAME] levels upon admission. Review of clinical record revealed a telephone order for a stat [MEDICATION NAME] level dated April 7, 2012. The facility received the report at 4:39 p.m. that day with a high level of 37.0 micrograms per milliliter (mcg/ml). The normal range was between 10-20 mcg/ml. Physician orders were received on April 7, 2012 at 5:40 p.m. and acknowledged to hold [MEDICATION NAME] for today and tomorrow and draw [MEDICATION NAME] level on Monday April 9, 2012. Review of clinical record shows that [MEDICATION NAME] level was ordered on April 9, 2012, and drawn with a reported result of 30.4 mcg/ml a potentially toxic dose. The new orders were received to hold [MEDICATION NAME] until April 11, 2012, after a new level was drawn and reported. Review of clinical lab results for April 11, 2012, showed the level was drawn with result reported at 20.6 mcg/ml. New orders received dated April 11, 2012 to restart [MEDICATION NAME] at 150 mg orally every day and recheck [MEDICATION NAME] level April 13, 2012. Review of clinical lab results showed [MEDICATION NAME] level drawn and reported at 13.8 mcg/ml with normals between 10-20 mcg/ml. No new orders received. Review of physician's orders dated April 23, 2012, that [MEDICATION NAME] levels were to be drawn the first Tuesday of every month. Review of the resident's Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. There was no documented evidence that the physician was notified by the clinical staff regarding the missed lab draw on this date. Review of physician's orders showed a new order was obtained to discontinue current blood [MEDICATION NAME] levels and again start [MEDICATION NAME] levels to be drawn on the first Tuesday of every month. The new physician's order was dated May 21, 2012, and now ordered a [MEDICATION NAME] level to be drawn on May 22, 2012 in a.m. Review of resident's clinical labs revealed that the [MEDICATION NAME] level was drawn on May 22, 2012, with reported result at a sub-therapeutic level of 1.7 mcg/ml with normal range between 10-20 mcg/ml. The lab result was noted on the lab that it had been faxed to a Nurse Practitioner for orders or comment. There was no documented evidence in the nurse's notes or on the lab result sheet that either the physician or the nurse practitioner had been called by phone with the low lab results. The nurse practitioner acknowledged the lab result on May 23, 2012, with her initials on the lab result sheet, but no new orders were written. Review of the resident's nurses notes revealed an entry on June 5, 2012 at 3:00 a.m. that a CNA had discovered the resident having a [MEDICAL CONDITION] that started at 2:45 a.m. that continued without stopping. New order was received on June 5, 2012 at 3:45 a.m. to give the resident [MEDICATION NAME] 1 mg sublingual every five minutes until the [MEDICAL CONDITION] stop. Review of nurse notes on June 5, 2012 at 4:15 a.m. that resident was resting comfortably. Next entry on June 5, 2012 at 8:45 a.m. indicated the resident suffered a fall and sustained a skin tear to his right forearm and a "bump" to his forehead. Review of the resident's lab record indicated that the facility drew and received a report for a [MEDICATION NAME] level drawn on June 5, 2012 at 3:40 a.m. but not reported until 10:50 a.m. due to unclear lettering on requisition and tube. The result of the [MEDICATION NAME] level drawn was 0.8 mcg/ml with normal between 10-20 and again the blood level was sub-therapeutic. Review of nurses notes documented that the resident was sent to the emergency room for evaluation of fall and [MEDICAL CONDITION] on June 5, 2012 approximately 10:00 a.m. An interview was conducted on September 11, 2012, via phone, with the Medical Director of the facility. The Medical Director was also the resident's current physician. The doctor stated that the facility had a policy to call the practitioner with critical low or high lab results and not to fax them as it would take to long and that these labs needed to be dealt with immediately. An interview with the director of nurses (DON) was conducted on September 11, 2012 at 8:15 a.m. The DON stated that when handling critical low or high values the nurse who received the report should place a telephone call to the practitioner immediately. The nurse should then note this call either on the lab result sheet or in the resident's nurses notes. She went on to say that it was never acceptable to fax the results unless they received orders via phone from the practitioner to do so. She said this policy has been in effect since before she started at the facility. Requested a policy and procedure for notification of critical lab values to practitioners but no policy was provided. Issue regarding pain: -Resident #94 was readmitted to the facility on [DATE] at 7:30 p.m. after an amputation of his right index finger. Review of physician's orders dated August 27, 2012, revealed an order for [REDACTED]. Further review of physician's orders dated August 27, 2012, revealed an order for [REDACTED]. Finally, there was no indication that the order had been clarified with the physician. There was no documented evidence that the resident's pain was assessed upon admission. Review of the "Pocket care plan" did not address resident pain. Review of a previous care plan dated July 16, 2012, revealed the potential for actual pain related to poly [MEDICAL CONDITION], immobility and [MEDICAL CONDITION] right hand/fingers. The care plan stated the severity was rated was eight out of ten with ten being the most severe pain and that the resident's acceptable pain range was three on a pain scale of ten. The stated goals were that the resident would verbalize pain level within acceptable range and verbalize satisfaction with pain control thru October 2012. The nurses note dated August 27, 2012 at 11:40 p.m. stated "No acute distress noted." Review of a certified nursing assistant's (CNA) statement revealed the resident requested pain medication at midnight on August 27, 2012. The CNA stated she informed the charge nurse of the resident's request for pain medication. Review of the licensed practical nurse (LPN) nursing note dated August 28, 2012, revealed the resident complained of pain at 4:00 a.m. Review of the MAR indicated [REDACTED]. The nursing note documented that the resident was pain free at 5:30 a.m. Further review of the MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Further review of the September MAR indicated [REDACTED]. The nurse documented that his response to the pain was "+" on both occasions. He was medicated with [MEDICATION NAME] (antianxiety medication) on September 5, 6 and 9 2012, with no indication that a pain assessment had been completed, nor any other non medicinal interventions attempted first. An interview was conducted with the DON and the facility administrator on September 7, 2012. Both administrative staff stated that the "pocket care plans" were what they consider their interim care plans even though they did not address all of the resident's care areas or contain any specific resident goals. -Resident #35 was readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Review of the facility care plan for the resident revealed a potential for pain related to [MEDICAL CONDITION] last dated June 12, 2012. Review of the hospice clinical admission notes dated July 14, 2012, revealed that the resident was unable to independently sit upright. The note further stated that the resident had uncontrolled pain with that assessment. Review of physician's orders revealed an order dated July 14, 2012 for [MEDICATION NAME] sulfate Immediate Release 15 mg by mouth every 12 hours. Further review revealed an order for [REDACTED]. Review of the nursing note dated July 14, 2012 stated "pain meds PRN to be sent to facility early AM 7-15-12". Review of the August recap of physician's orders did not reveal the order for breakthrough pain. Resident goals included the resident would verbalize satisfaction with pain control through September 2012. Interventions included to assess for signs and symptoms of pain quarterly and as needed, to notify the doctor of uncontrolled pain, medications as ordered, and to document effectiveness of the pain medication. Review of the resident's MAR for July, August and September 2012 did not reveal the breakthrough pain medication. Further review revealed a pain assessment was not completed for the resident before the scheduled medication for pain or after the medication had been administered. An interview was conducted with the DON on August 6, 2012 at 2:45 p.m. The DON stated that when a resident was given scheduled pain medication the staff did not have to do a post medication pain assessment. -Resident #102 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A review of the physician orders dated August 25, 2012, revealed the orders for [MEDICATION NAME] 50 mg every 12 hours and [MEDICATION NAME] 75 mg every eight hours for pain. [MEDICATION NAME] 10 mg was ordered every four hours as needed for pain as well as 5 mg (no scale was written and no clarification was obtained). [MEDICATION NAME] 10 mg was ordered to be administered every eight hours for pain control. On August 27, 2012, the physician ordered to discontinue the [MEDICATION NAME] due to insurance and begin [MEDICATION NAME] mg three times a day. At this time [MEDICATION NAME] 1 mg was ordered to be administered three times a day for anxiety. A review of the interim care plan dated August 27, 2012, revealed that despite the resident's medical [DIAGNOSES REDACTED]. A review of the MAR indicated [REDACTED]. On August 28, 2012, at 1:00 PM the resident was observed at the nursing station crying and pleading with the nurse to please call the doctor to get any kind of pain medication that her insurance would approve of because she could not stand this pain. The nurse at the station was heard telling the resident that the order had been changed and as soon as the pharmacy delivered the medication, she would bring her the pain medication. As noted above, this was not provided until 9:00 PM that evening. The resident was to receive [MEDICATION NAME] 1 mg three times a day for anxiety. The first dose was signed out on August 29 2012, at 7:30 AM. A review of the sign out sheet for individual controlled substance revealed that on September 1, 2012 at 8:00 am the resident was given 2 mg instead of 1 mg, at 3:00 PM the resident again received 2 mg and at 10:00 PM she received 1 mg. On September 2, 5 and 6, 2012, this was again repeated, so that on these days instead of receiving 3 mg as ordered the resident received 5 mg a day. An interview with the registered nurse (RN) who administers medications was interviewed on September 7, 2012. The RN stated that she would determine how much medication to administer based on the resident assessment and that was why she administered 15 mg of [MEDICATION NAME] when the physician had ordered 10 mg or 5 mg for pain. The RN was not aware that she was required to clarify the physician orders so that it was clear when to give 10 mg and when to give 5 mg of [MEDICATION NAME]. However, the records indicated that she was not the only one administering 15 mg of [MEDICATION NAME], multiple nurses on different shifts were also administering in incorrect doses. A review of the narcotic records revealed that consistently the resident was given 15 mg of [MEDICATION NAME] from August 26, through September 3, 2012, with the exception of August 27, 2012 she was given only 10 mg at 12:00 PM, on August 28, 2012 at 9:45 AM she was given 25 mg, then at 1: 45 PM she was given 10 mg of [MEDICATION NAME]. A review of the Narcotic Emergency Box sign out sheet revealed a lack of evidence that any medication had been signed out for the resident during this time period. A review of the contents revealed that [MEDICATION NAME], MS Contin, [MEDICATION NAME] were all available. An interview conducted with the DON on September 10, 2012, revealed that nursing has been in-serviced on clarification of pain medication ordered without perimeters. The nurse must call the physician and have the orders clarified. When the medication is given the nurse must indicate by using the scale of 1 - 10 the pain level of the resident then they were to use the same scale to assess the effectiveness of the medication. The nurses were instructed to also never document the effectiveness of the medication by using the word "effective". The DON further stated that when a resident was first admitted to the facility and has a prescription faxed to the pharmacy but requires the medication prior to delivery she has the ability to call the pharmacy to obtain permission to use the E Kit. The DON stated that nursing should have notified her of the resident's need for pain medication in order to provide the medication immediately. -Resident #60 was admitted to the facility on [DATE], and readmitted to the facility on [DATE], with [DIAGNOSES REDACTED]. An admission order was written on March 17, 2012, for the use of [MEDICATION NAME] IR 5 mg orally every four hours as needed for pain. A review of the March MAR indicated [REDACTED]. However, no documented evidence that [MEDICATION NAME] was given to the resident on March 25, 2012, and no documented evidence that the resident's pain was evaluated before and after administration of the as needed pain medication. Review of the Nurse's Notes dated March 25, 2012, revealed that the resident was in pain and asking for pain medication, but was told that her pain medication had not been delivered by pharmacy. At 3:50 p.m. the resident called 911 and was taken by ambulance to the emergency room where she was treated for [REDACTED]. An interview was conducted on September 6, 2012, with a licensed practical nurse (LPN). The LPN stated that she had tried multiple times to refill the resident's pain medication order, but that the fax number on the facility's pharmacy re-order form was wrong. Each time that she tried to send the order, she would call the pharmacy and they would tell her that they had not received the order. Review of the facility's policy on Administration of Medication revealed "...Purpose: to assure that each resident receives the proper medications at the correct time as ordered by their physician...Record any pertinent information in the medical record. This includes response to PRN medication..." Review of the policy regarding admissions stated "...Purpose: to provide a head-to toe assessment of the resident to identify areas such as but not limited to birth marks, ostomy sites, site of scars, rashes, bruises, pressure signs, [MEDICAL CONDITION], pressure sores, burns, general cleanliness of the resident's body, hair and nails, etc. It is also designed to determine what the resident can do for himself and how the facility can begin maintaining or attaining resident's highest practicable level of well-being...Equipment:..Admission Nursing Assessment Forms."

Based on clinical record reviews, hospital record reviews, facility policy and documentation reviews, and interviews, the facility failed to ensure one resident (#1) was properly assessed upon a change in condition, when the resident's blood pressure (BP) became low and her condition changed, which resulted in a delay in physician notification and treatment for [REDACTED].#2) was adequately monitored and assessed when she exhibited a functional decline following a fall, and failed to adequately assess leg [MEDICAL CONDITION], which resulted in a delay in identification and treatment of [REDACTED].#3) with a [DIAGNOSES REDACTED]. Seven residents were sampled. Findings include: -Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) assessment reflected that the resident had impaired cognition, required assistance with transferring and walking, and had fallen within the previous month. Upon admission the resident was assessed to be at high fall risk. The resident was also being treated by physical therapy. A care plan dated "6/10" identified the resident's potential for injury related to loss of balance, cognitive changes, and history of falls. The goal was for the resident to remain safe. An intervention included to "Assess for change in condition/function" and "Notify Dr." A nursing note written at 5 p.m. on June 22 reported that the resident had sustained a fall out of her wheelchair. She was assessed to have range of motion (ROM) without pain, and no signs of injury were detected. The therapy notes for June 23, indicated that the resident walked 15 feet, while utilizing a walker and assistance. However, on June 24, the therapy note indicated the resident was "not very cooperative" and only walked five feet. A Medicare Denial of Payment letter was issued on June 24 due to the resident's nonparticipation with therapy. It was documented by the therapist on June 25, that the resident would not walk, and would only stand up. Per the documentation, she continued to be "uncooperative" through June 29. The nursing notes were reviewed and revealed that the resident was assisted out of bed to the wheelchair. The nursing notes also included that the resident's family member was notified of the Medicare notice for "non participation" and that the family member wanted more "detailed" information. Documented only was that "someone from therapy" or the unit manager were to return the family member's call. Despite the ongoing resistance by the resident to participate, particularly when she was performing on the first few days of therapy and in consideration of the recent fall, no investigation or ongoing evaluation was done to determine causative factors. The June 27, 2010, nursing note indicated [MEDICAL CONDITION] to the "R (right) ankle" despite previous documentation of left shin area [MEDICAL CONDITION]. At noon on June 28, a nurse wrote that the resident had no complaints of pain or discomfort and that the left shin laceration dressing was intact. The following day, on June 29, a nursing note reported that the nurse practitioner saw the resident due to complaints of pain upon transfer, yelling and anxiety. A telephone order was then written that included x-rays to the left hip, pelvis and femur. At 4:30 p.m. the nurse wrote that the resident's family was concerned because she was "not talking or responding like she usually does." Before the x-rays were done the resident was sent out to the hospital per the family's request. Review of the hospital information revealed the resident was assessed to have a left leg that was "swollen and painful to touch," with bruising on the whole left thigh. She was seen by an orthopedic physician who noted her left leg was "obviously short and rotated." She was diagnosed with [REDACTED]. The physical therapist that treated the resident was interviewed on October 26, and said the resident seemed to be progressing with therapy regarding walking, but that after only a few days she stood up, walked a few feet, then "cried out in pain" and would not walk any further. Additionally, when the resident was seated in the wheelchair and the therapist performed leg exercises, the resident had no issues with the right leg, but when the therapist worked with the left leg the resident "reacted as if she was mad" about having to move her leg. The therapist said nursing staff was made aware of the resident's pain. Final review of the resident's closed clinical record revealed no evidence that nursing provided any evaluations of the resident's pain, decline in physical functioning, or made any referrals to the physician. Further, there was conflicting documentation regarding the location of the [MEDICAL CONDITION], and a failure to provide thorough assessments of the condition. Administration was interviewed and explained the process that was followed after a fall. For residents with impaired cognition, x-rays were ordered to the areas that had the potential for injury from the fall. That was done proactively to rule out any fracture that may not have been identified from the assessment due to the resident's inability to report. In addition, the director of nursing (DON) stated a fracture may have occurred, yet range of motion could be done without pain, the resident may be able to walk, and there may be proper alignment of body parts, therefore the x-ray was important. Concerning resident #2, the DON said she thought an x-ray of the hip was taken immediately after the fall and was negative. She was unaware of any reason why an x-ray would not have been taken. -Resident #1 was readmitted to the facility on [DATE], with a history of stroke with left-sided weakness, [MEDICAL CONDITION] disorder, hypertension, and kidney injury from prerenal azotemia. She was assessed upon admission as oriented to person, place, time and situation, and able to make her own decisions. She independently used an electric wheelchair and required some assistance with all activities of daily living. The resident was prescribed [MEDICATION NAME] (antihypertensive) to be administered very morning and "PRN" (as needed) [MEDICATION NAME]. From August 6 through 13, the resident's daily blood pressure (BP) averaged about 120-130 systolic and 70 diastolic, and her heart rate remained around 78 to 88 (beats per minute), as documented on the vital sign record. Blood tests done on August 11 showed the resident's blood urea nitrogen (BUN) was 27 (normal range from 8-25), and creatinine was 1.03 (0.6-1.5), indicating properly functioning kidneys. Included in a nursing note at 6:30 a.m. on August 13, was that the resident's [MEDICAL CONDITION] bag contained a large amount of "watery loose stool with undigested food." In addition, the resident was experiencing more pain than usual and had no relief from the [MEDICATION NAME] that was administered. A telephone order was written at 6:40 a.m. on August 13, specifying that the resident's physician was to see her that day. But, there was no evidence the physician made a visit to the resident that day. According to the vital sign record, during the evening shift of August 13 the resident's BP was 98/50. The vital sign record showed that during the subsequent night shift, the resident's BP was 80/50. No evidence was found showing that the nurse rechecked the BP to verify it, or that the physician was notified of the low BP. Per the medication record, the resident was administered the [MEDICATION NAME] for complaints of pain at 3:30 a.m. on August 14, and one hour later the medication was observed to have been effective. The nursing note included the resident was "crying from pain" to her abdomen, and also that her [MEDICAL CONDITION] bag held "liquid stool and undigested food." A 6:30 a.m. nursing note included a BP of 90/56, with no evidence of physician notification or further assessment. The nurse documented in a note on August 14, that the resident's dose of [MEDICATION NAME] was held that morning due to a BP of 98/47 and a heart rate of 62. There was no evidence the physician was made aware of the held medication and the circumstance. By 11 a.m. the nurse wrote the resident was "very lethargic, unable to follow verbal commands" and was displaying "involuntary movement" of her arms. Also noted was that the afternoon medications were held due to the resident's "decreased LOC (level of consciousness)." Despite this apparent change in condition, and the holding of medications, there was no proof the medical provider was contacted until 1:15 p.m., two and a half hours after the change in consciousness, and nearly a full day since the first sign of a change. A telephone order was given to send the resident to the hospital. Rather than send the resident emergently, an ambulance transport company was called at 1:30 p.m., and it was 4:05 p.m. when the resident was transported to the hospital. Per the hospital documentation, the resident presented in the emergency room as lethargic, disoriented and confused, and with unresponsive, restricted pupils and "profound [MEDICAL CONDITION]," with a BP of 60/30. Her BUN was 99 and creatinine was 2.20, thus she was diagnosed with [REDACTED]. The nurse who worked the August 13th evening shift was interviewed. After review of the resident's vital sign record, she said the BP of 98/50 did not alarm her, but that she should have taken the vital signs again during the shift to check if the BP was still low. She said, had the BP been down to 60/40, the resident's color been off (e.g. blue or purple), or had she shown other signs of a change such as lethargy, she would have called the physician. Other nurses were interviewed and said, had a BP been reported to them that was lower than normal, they would have gone and taken a manual cuff reading themselves. If they confirmed it was low, they would have notified the physician. That was also the expectation expressed by the DON during an interview on October 27. The DON also said that although the 98/50 BP may not have been significant enough to report, once the BP remained low, and the resident showed the other changes, the physician should have been notified and treatment initiated. -Resident #3 was admitted on [DATE], and had current [DIAGNOSES REDACTED]. She was assessed via the MDS as cognitively impaired but able to walk independently. On January 6, 2009, the physician ordered [MEDICATION NAME] (anti-[MEDICAL CONDITION] drug) 300 milligrams (mg) at night. On September 1, 2009, an order was written for a [MEDICATION NAME] level lab test every month while the resident was taking [MEDICATION NAME]. Review of the lab test results from October 2009 and January 2010 showed the level within normal limits. The result of the March 2 test showed the level was low at 8.2 (normal range 10-20). A telephone order was written to increase the dose to 400 mg at night and check the level in a week. On March 10, the level was 7.1, so an additional dose of [MEDICATION NAME] was added, 100 mg in the morning, and the level was again to be checked in a week. The level drawn on March 17 was within normal limits. However, the result of the test was not located in the resident's clinical record; the laboratory had to provide the results during the survey. On April 2, rather than testing for [MEDICATION NAME] level, a [MEDICATION NAME] level was checked. The resident had neither an order to take [MEDICATION NAME] nor to have her blood level checked. As a result, on April 9 a telephone order was written to discontinue checking [MEDICATION NAME] levels (which had never been ordered). Handwritten on the May 2010 physician recapitulation (recap) orders was that the monthly [MEDICATION NAME] level was discontinued on April 9, and there was a line drawn through the order. On August 18, a pharmacist recommendation form was written asking for the results of the monthly [MEDICATION NAME] level since it was not in the clinical record. There was no evidence this recommendation was acted on by the facility. Review of the September 2010 recap orders revealed the absence of the monthly [MEDICATION NAME] level test. The resident continued on the 500 mg per day [MEDICATION NAME] regimen. Per a nursing note, on September 7 the resident complained of feeling dizzy. A telephone order was received for [MEDICATION NAME] (antiemetic) as needed for dizziness. Lab tests were also ordered, yet not a [MEDICATION NAME] level. The resident continued to feel dizzy, and on September 9, 10 and 11, fell as a result of the dizziness. She sustained no injury. Despite the resident's falls and continual complaints of feeling dizzy, no order was written to check her [MEDICATION NAME] level. On September 14, the resident was observed with left-sided weakness and facial droop; she was transferred to the hospital. Review of the hospital documentation revealed the resident's [MEDICATION NAME] level was 44, she was toxic and was suspected to have had [MEDICAL CONDITION] activity which caused the weakness and facial droop. In addition, the high level had been causing her to feel dizzy and fall. A facility nurse was interviewed on October 27, who said the physician ordered the frequency with which to test the [MEDICATION NAME] level, but that if a resident underwent [REDACTED]. Further, if there was no standing order on the recap orders, the nurse who reviewed the recap was expected to contact the physician to get an order for [REDACTED]. The DON was also interviewed on October 27, and stated an expectation as documented above (in the previous interview), but stated the facility had no written policy concerning [MEDICATION NAME] use, monitoring, or management. During a telephone interview on October 28, the pharmacist said there were general guidelines that were expected to be followed for a resident with an order for [REDACTED]. For stable management of [MEDICATION NAME] use, the pharmacist recommended checking the level every six months. She stated she had noticed the lab result was not in the chart in August, so referred to the DON for follow-up since the resident had an order for [REDACTED]. Facility policy and procedures were requested regarding changes in resident condition, what constitute a change, what monitoring was required, how were changed communicated to the physician and when, etc, but the facility had no established policies or procedures above the MDS significant change in assessment components.

Based on clinical record reviews, interviews, and facility policy review, the facility failed to ensure one resident (#2) was provided necessary fall prevention interventions, which resulted in a fall with significant injury, and failed to ensure adequate investigation was done into the cause of another resident's (#3) falls, leading to hospitalization for Dilantin toxicity. Four residents who fell were sampled. Findings include: -Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The admission Minimum Data Set (MDS) showed the resident had impaired cognition, required assistance with transferring and walking, and had fallen within the previous month. Upon admission the resident was assessed for fall risk and determined to be at high risk. A care plan dated June 2010 (no actual day of initiation was documented) identified the resident's risk for injury related to a fall, yet failed to include specific interventions, other than skilled therapy, that were to be in place to prevent the potential for a fall. One intervention was to use devices or equipment as indicated, yet what those devices were was not explained. Other interventions addressed what was to be done after the resident fell . Noted on the June 21 physical therapy evaluation was that the resident required physical assistance to stand up, had poor standing balance, and fair (meaning she required physical assistance) sitting balance. She was oriented only to herself and had no pain. A nursing note written on June 22 reported the resident was found in the hallway sitting in front of her wheelchair; she had stood up to fix her dress and fell . She was later discovered to have suffered a left hip fracture. Despite this actual fall, no reassessment of the resident's safety needs was conducted, and no interventions were put in place. Licensed staff were interviewed on October 26 and 27, and reported the resident had tried to get out of bed frequently, so a low bed was used. Also, one nurse said she had kept the resident with her during medication pass since the resident would try to stand up from the wheelchair, was unsafe to do so, and needed close supervision. Both staff said no alarm was used to the chair to alert staff when the resident tried to stand up. The unit manager was interviewed on October 27 and said the resident's family had informed staff that the resident had fallen at home several times, but that the staff failed to find out the circumstances of when and how the resident fell (so as to implement appropriate prevention measures). She also said no alarm was used, and that after the resident's fall on June 22, no interventions were put in place to prevent the potential for another fall. -Resident #3 was admitted on [DATE], and had current [DIAGNOSES REDACTED]. She was assessed via the MDS as walking independently. Review of the resident's fall risk assessments from October 2009 through July 2010, showed the resident fell on ly once or twice. On March 10, 2010 the resident's dose of Dilantin was increased to 100 milligrams (mg) in the morning and 400 mg at night. On March 17 a Dilantin blood level was checked and was within normal limits. There was no evidence another level was tested . Per a nursing note on September 7, the resident complained of feeling dizzy. A telephone order was received for Meclizine (antiemetic) as needed for dizziness. Lab tests were also ordered, yet not a Dilantin level. Documented on September 8 was that the resident continued to feel dizzy, and on September 9, she fell to the floor during a shower. She sustained no injury. A care plan was put in place on September 9, which addressed the resident's fall. Documented on September 10, was that the resident remained dizzy and she slid from the bed to the floor. She again sustained no injury. One of the interventions included on the actual fall care plan was to "research fall patterns," yet there was no evidence that was done. Despite the resident falling two days in a row, and continually complaining of feeling dizzy, the facility failed to conduct a thorough investigation into the falls in an attempt to determine the possible causes. On September 10 the monthly summary form was completed and included the resident was "confused" and had "poor memory." The same day, another fall care plan was initiated, with an intervention to remind the resident to ask for assistance for safety reasons. That intervention is contradictory to the assessment which determined the resident had poor memory. While trying to walk to the bathroom on September 11, the resident fell to the floor, saying she "got dizzy." A telephone order was written that day to use a bed alarm for safety and increase the frequency with which the Meclizine could be given. This resident, who had no problems walking independently in the past, fell three times in as many days, and yet the facility still did not investigate the cause of the falls, but rather increased the frequency of Meclizine and added a bed alarm. Daily nursing notes included the resident's complaints of feeling dizzy, and increasingly of her inability to walk. She also began to eat all meals in her room since she could not walk to the dining room. A telephone order was written on September 12 to check for a urinary tract infection, the result of which was negative. On September 14, the resident was transferred to the hospital. Review of the hospital documentation revealed the resident's Dilantin level was 44 (normal: 10-20), and had been the cause of the dizziness and falling. Certified nursing assistants familiar with the resident were interviewed and reported that the resident had been independent with activities, including walking and using the bathroom, before she started to feel dizzy. Once she began to feel dizzy, the resident would not want to get out of bed and could no longer safely walk by herself. That went on for about a week before she went to the hospital. The director of nursing was interviewed on October 27 and said the purpose of investigating a fall was to determine the circumstances surrounding it and put measures in place to prevent it from potentially happening again. It was apparent that the investigations into the falls of resident #3 neither led to any determination as to a cause, nor provided the facility with direction as to how to prevent another fall. The Fall Prevention Program policy included general statements about what the facility was to do to protect residents, based on resident assessment and evaluation of the physical environment. The procedure involved investigating falls, yet included no direction as to what the investigation was to consist of, who was to do it, or what the purpose of it was.

Based on clinical record reviews, interviews, and review of hospital records, the facility failed to ensure the fluid needs of two residents (#s 1 and 2) were assessed in order to ensure sufficient fluid intake to maintain hydration, and also failed to monitor resident #1's fluid intake. Both residents required hospital admission for dehydration and acute [MEDICAL CONDITION]. Findings include: -Resident #1 was readmitted to the facility on [DATE], with a history of kidney injury from prerenal azotemia, and a [MEDICAL CONDITION] due to colon resection for [MEDICAL CONDITION]'s disease. A hydration assessment, signed by a nurse on the day of admission, was incomplete, therefore the resident's risk for dehydration was not determined. Blood work done on August 11, showed the resident's blood urea nitrogen (BUN) was 27 (normal range 8-25), and creatinine was 1.03 (0.6-1.5), indicating properly functioning kidneys. The nurse practitioner progress note from that day included the resident was having diarrhea. Despite the diarrhea, there was no indication the facility identified the need to increase fluids, encourage fluids, or monitor fluid intake closely. Per an August 12 nursing note, the resident said she would neither eat nor drink because she was unhappy with being in the facility. Other nursing notes from throughout the resident's stay revealed she often refused to eat. Noted by nursing on August 13, was the resident's [MEDICAL CONDITION] bag contained a large amount of "watery loose stool." A telephone order was written on August 13, specifying that the resident's physician was to see her that day. There was no evidence that was done. Also on August 13, a nutritional risk assessment was started, but was incomplete. The form, which included components of identifying dehydration risk, was also to include the resident's fluid needs, which it did not. Although the resident had already been identified as having diarrhea, it was not circled on the assessment form, meaning the person who started the form was unaware of the resident's diarrhea, a risk factor which fell in the highest risk category. Further, the facility was unable to provide any evidence that the resident's fluid intake was monitored on a daily basis. The facility utilized meal intake records which were to include food an fluid intake at meals. There was no intake record in the clinical record and the facility was unable to locate it. On August 14, the resident was transferred to the hospital, where she was found to have acute kidney injury, with a BUN of 99 and creatinine of 2.20, which resolved with intravenous fluid hydration. -Resident #2 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She was assessed via the Minimum Data Set to require set-up with eating. She also required total assisntance with mobility and extensive assistance with other activities. The hydration assessment completed upon admission identified the resident at high risk for dehydration, as she required assistance with obtaining fluids, had an infection, and was disoriented. There was no evidence that staff used that information to develop a plan to prevent the resident from becoming dehydrated. The nutritional risk review, dated June 23, contained an area to specify fluid needs, yet failed to include the resident's needs. In addition, the form was incomplete as no nutritional risk assessment had been done, and the resident's daily fluid intake was not documented, though there was an area to do so. A nutrition care plan, also dated June 23, identified the resident was at risk for dehydration, yet no proactive interventions were put in place, the only intervention was to monitor for signs of dehydration, which was a reactive approach. The resident's fluid intake at meals was recorded on the meal intake form, and ranged from 360 milliliters (ml) per day to 960 ml per day, half of the days she consumed 720 ml. Without a nutritional needs assessment having been done, there was no way for the staff to know whether or not the resident was meeting her daily fluid needs. On June 29 the resident was discharged to the hospital, where she was diagnosed with [REDACTED]. In the emergency room her BUN was 130 and creatinine was 5.25. During an interview on October 27, a nurse reported that it was the admitting nurse that completed the hydration risk assessment. If a resident was identified at high risk for dehydration, interventions would be put in place such as increasing fluids at meals. The dietary manager was also interviewed on October 27. She said she started the assessment forms, and completed the data gathering, but it was the dietitian that did the nutritional risk assessment, including the needs assessment. In the interim, between the time the resident was admitted and the dietitian completed the fluid needs assessment, staff were to monitor resident's fluid intake at meals, yet whether or not the resident was meeting their needs was undetermined until the assessment was done. Concerning residents #1 and 2, the dietary manager said the dietitian was in the building once per week, and may have missed their assessments by a day. However, both residents were in the facility for over a week, so the assessments should have been completed based on the dietitian's schedule. The facility's policy on hydration program and intake and output (I&O) monitoring was reviewed and failed to include the monitoring of fluid intake for residents not ordered I&O monitoring, how to handle dehydration, both the history of and potential for, and how to monitor hydration status.