Every finding on record at Santa Rosa Care Center

Based on the facility observation, staff and resident interviews, and policy review, the facility failed to report to state agencies a serious injury to a resident within the required timeframe for 1 of 3 (Resident #1) residents. Failure of reporting could result in delay in investigation of possible abuse by the appropriate agencies. Findings include:Resident # 1 was re-admitted on [DATE] with diagnoses that included hemiplegia and hemiparesis due to cerebral infarct involving the right dominant side, contracture of the right wrist, need for assistance with personal care, muscle weakness, schizoaffective disorder, bipolar type, major depressive disorder, and anxiety disorder. A comprehensive care plan initiated on November 26, 2025, revealed that the resident had right-sided hemiplegia/hemiparesis due to cerebrovascular disease. Further review of the care plan revealed that the resident had behaviors, including false accusations. A quarterly Minimum Data Set (MDS) dated [DATE], revealed that the Brief Interview for Mental Status (BIMS) assessment was a 15, which indicated Resident # 1 is cognitively intact. Further review of the MDS revealed the resident did not have any mood or behavioral indicators.A comprehensive care plan initiated on January 7, 2026, revealed that the resident has an activity of daily living (ADL) self-care performance deficit. Further review of interventions revealed Resident # 1 on two person cares due to false accusations.A Nursing note dated January 23, 2026 at 10:26 a.m. revealed that Resident # 1 reported right shoulder pain. The nursing note also revealed that the physician was notified, and a STAT x-ray order was placed. The Director of Nursing (DON), Assistant Director of Nursing (ADON), Unit Manager (UM), and administrator were notified. A Nursing note dated January 23, 2026, at 2:53 p.m. revealed the x-ray finding of a moderately displaced comminuted fracture of the surgical neck of the right humerus. An Orthopedic Report dated January 23, 2026, revealed that Resident # 1 was being transferred when she started having pain in her right shoulder. Further examination revealed swelling and bruising over the proximal humerus with tenderness on palpation. A facility investigation dated January 23, 2026 revealed an interview with the Certified Nursing Assistant (CNA/Staff #34) who reported that he and another CNA (Staff #10) transferred Resident # 1 from the wheelchair to the bed using a Hoyer lift in accordance with facility protocol and safe transfer procedures without incident. A reportable incident was reported to the state agency by the facility regarding the transfer of Resident # 1 on February 18, 2026, 26 days after the facility was made aware of the fracture. The facility started its investigation with regard to the transfer of Resident # 1 on January 23, 2026, but did not report to the appropriate state agency until after Adult Protective Services (APS) reported the incident to the facility on February 18, 2026. An Interview with Resident # 1 on February 20, 2026, at 11:42 a.m. revealed that on January 22, 2026, Certified Nursing Assistant (CNA/Staff # 34) picked up Resident # 1 by wrapping his arms around the Resident's shoulders and picked her up from the wheelchair to the bed even though Resident #1 was to be transferred by Hoyer lift. Resident # 1 reported hearing a crack and feeling pain. Resident #1 revealed that she let Staff #34 know there was pain, but did not do anything about it. She reported that she notified the morning Licensed Practical Nurse (LPN/Staff # 60) about the pain and bruising to the Resident's arm. Resident # 1 revealed that at the time of the transfer, there was another CNA (Staff # 10) in the room with Staff # 34. Resident #1 did report the incident to the Director of Nursing (DON/Staff # 82), who had interviewed Resident #1 regarding the incident. A phone call with Staff # 34 on February 20, 2026 at 12:09 p.m., was attempted, but staff member did not answer, and voicemailbox was full. An interview with LPN (Staff # 60) on February 20, 2026, at 12:43 p.m., revealed that on January 23, 2026, resident #1 came to staff #60 during med pass, requesting to see the doctor, but did not say why. Staff #60 made notifications of the pain to the provider, DON and Assistant Director of Nursing (ADON/Staff #2). Staff # 60 reported that the provider came out and talked with Resident # 1 regarding the injury and ordered an x-ray of her right shoulder. Staff # 60 reported that the results of the x-rays came in on her shift and she reported a fracture to Resident #1's right arm to her ADON. An interview with CNA (Staff # 108) on February 20, 2026, at 1:04 p.m. revealed that on the morning of January 23, 2026, Resident # 1 had informed Staff # 108 that her arm was sore, but Resident # 1 let Staff #108 and CNA (Staff # 129) transfer her via the Hoyer lift with no reported pain. Once up, she stated that Resident # 1 went to tell LPN Staff # 60 about the pain. Staff # 108 revealed that Resident # 1 is always a 2-person Hoyer lift.In an interview with ADON (Staff # 2) on February 20. 2026, at 1:13 p.m., revealed that she received a call from Staff #60 regarding Resident #1's pain and that Staff # 60 was going to notify the doctor. Staff # 2 also revealed that she was notified of the fracture that same day and notified the DON, who had followed up with orders from the physician. An interview with DON (Staff # 82) on February 20, 2026, at 1:43 p.m. revealed that on January 23, 2026, Resident # 1 approached the DON and reported that her right shoulder hurt and that someone had incorrectly transferred Resident # 1. DON revealed that the physician was immediately notified, and an investigation was started. She reported interviewing the accused staff on January 23, 2026, as well as other staff and residents. The DON revealed not making the required notifications to the state agency, APS, Ombudsman, and Police because she thought she did not have to if the complainant was known to give false accusations, even though a major injury had occurred and the DON was investigating the cause of the injuryA policy and procedure titled Reporting Alleged Violations of Abuse, Neglect, Exploitation, Mistreatment dated July 2025, revealed that the facility will ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made if the events that cause the allegation involves abuse or results in serious bodily injury.

Based on clinical record review, interviews, and review of facility policy and procedures, the facility failed to ensure one resident (#87) was free from abuse from another resident (#16). The deficient practice resulted in one resident (#87) sustaining injuries.Based on clinical record review, interviews, and review of facility policy and procedures, the facility failed to ensure one resident (#87) was free from abuse from another resident (#16). The deficient practice resulted in one resident (#87) sustaining injuries.Findings include:Related to Resident #87-Resident #87 was admitted to the facility on [DATE] with diagnoses that included Aphasia, other specified intracranial injury without loss of consciousness, sequela, Anxiety disorder and Schizoaffective disorder, Bipolar type.Review of the quarterly Minimum Data Set (MDS), dated [DATE] indicated the Brief Interview for Mental Status (BIMS) was not completed. However, staff assessed Resident #87's cognitive skills for daily decision making to be moderately impaired. The same assessment also noted that Resident #87 exhibited other behavioral symptoms that were not directed towards others every 4-day days during the assessment period.Review of the care plan, initiated on December 21, 2021, indicated Resident #87 had a behavior problem related to his Schizoaffective disorder, Bipolar type and intermittent explosive disorder as evidenced by his restlessness, irritability, and decreased appetite. Interventions included administering medications as ordered, monitoring and documenting the side effects of the medications, anticipate and meet the resident's needs, and 1:1 attempt to figure out why or what is causing the behaviors due to the resident's word salad and difficulty communicating his thought process.Review of a Nursing Note, dated October 12, 2025 at 6:03 P.M., revealed that the Assistant Director of Nursing (ADON/Staff #41) notified the resident's provider and case manager of a resident-to-resident altercation, via e-mail. Review of an Incident Note, dated October 12, 2025 at 10:01 P.M., revealed it was created by Licensed Practical Nurse (LPN/Staff #8). The note indicated that around 5:27 P.M. Resident #87 had a verbal disagreement with his roommate (Resident #16) regarding a light in the room. The roommate had pushed Resident #87 which caused the resident to lose his balance and fall. The same note indicated that an assessment of Resident #87 was done and it was determined that he sustained a 4-centimeter (cm) laceration to the back of his head. The bleeding was cleaned and bandaged and Resident #87's vital signs were within normal limits. The note shared that both residents were able to be successfully redirected and the roommate was moved to a different room.An interview with Resident #87 was attempted on October 30, 2025 at 3:26 P.M. However, the resident was not interviewable. He was observed to have a hat on his head so alleged wounds were not able to be observed. Resident #87 was not willing to remove the hat when asked.Related to Resident #16-Resident #16 was admitted to the facility on [DATE] with diagnoses that included Dementia, mild with other behavioral disturbance, adjustment disorder with mixed anxiety and depressed mood, and insomnia.Review of the admission MDS, dated [DATE] indicated Resident #16 had a BIMS score of 12 which indicated he has moderate cognitive impairment. The same MDS also noted Resident #16 exhibits hallucinations, delusions, wandering, and other behavioral symptoms not directed towards others every 1-3 days during the assessment period.Review of the care plan, initiated on September 8, 2025 indicated Resident #16 had a behavioral problem related to Dementia with agitation and anxiety as exhibited by his exit seeking, restlessness, delusions, and inability to fall/stay asleep. Interventions included administering medications as ordered, monitoring and documenting side effects of the medications, anticipate and meet the resident's needs, and to intervene as necessary to protect the rights and safety of others.Review of the clinical record revealed a Psych follow-up note dated October 8, 2025 at 12:45 P.M. The note indicated that Resident #16 was to restart Risperidone 0.5 milligrams (mg) every evening due to increased behaviors and delusions after recent discontinuation. The note also indicated the resident was to be monitored for changes in behavior or perception and that a follow-up will be done in two weeks.Review of a Progress Note, dated October 11, 2025 at 8:01 P.M. revealed that Resident #16 was transferred to the current facility, from another facility, after assaulting another resident. It also noted that Resident #16 did not recall assaulting another resident at his previous facility.Review of a Nursing Note, dated October 11, 2025 at 10:17 P.M. was exhibiting increased irritability and was verbally aggressive when being redirected. It took staff several attempts to have the resident take his bed time medications.Review of an Incident Note, dated October 12, 2025 at 9:38 P.M. and created by Staff #8, revealed that around 5:27 P.M. a verbal disagreement took place between Resident #16 and his roommate regarding a light in the room. It also noted that the roommate sustained a 4 cm laceration to the back of his head while Resident #16 had his room assignment changed to a different room.A Nursing Note, dated October 13, 2025 at 1:12 P.M. indicated that the incident was reviewed with the nursing team and management. It was then decided to relocate Resident #16 to a different unit due to his behaviors and agitation that the resident causes to others due to his impulsivity. The note also indicated that Resident #16's provider and guardian was informed of the unit change.An interview was conducted with Resident #16 on October 31, at 8:38 A.M. Resident #16 did not recall hitting or pushing anyone. When asked why he was moved to his current unit, he indicated that he assumed it was because someone decided that he would be a better fit on the current unit. He was unable to explain why he would be a better fit.An interview was conducted with LPN/Staff #8 on October 30, 2025 at 2:50 P.M. Staff #8 recollected hearing yelling from where she was at the nurses' station. She then went to investigate the noise and entered the room of Resident #87 and #16. She continued to explain that she observed Resident #87 on the floor leaning against the dresser and Resident #16 standing by the bathroom. She shared that Resident #16 told her he had pushed Resident #87 because he wanted the bathroom light on and Resident #16 wanted it off. Staff #8 explained that Resident #87 sustained a 4-centimeter laceration on his head and his vitals were stable after the incident. There were no changes in Resident #87's neurological status. She also described Resident #16 as someone who is intrusive and can get agitated when other residents in the unit don't listen to him. He often needs to be redirected by staff.An interview was conducted with Certified Nursing Assistant (CNA/Staff #14) on October 31, 2025 at 8:51 A.M. Staff #14 recalled hearing a loud noise and herself and another CNA ran to the noise and saw Resident #87 on the floor with his head against the dresser. She explained that they had helped him up and she applied pressure to a wound on the back of his head which was bleeding. Resident #16 was moved to a different unit. Staff #14 explained that both residents had been having multiple disagreements about the room light being off/on and Resident #16 had been increasingly agitated leading up to the event but he had never been physical before.An interview was conducted with the Director of Nursing (DON/Staff #3) on October 31, 2025 at 9:06 A.M. Staff #3 described abuse as when someone is not receiving proper care, medical attention, or is harmed by staff or other residents. She also explained the incident as where one resident was wanting the bathroom light on while the other resident wanting the bathroom light off. Resident #16 then pushed Resident #87 out of the way and he then fell and hit the back of his head on the floor. Staff #3 described Resident #87 as someone who is very clean and likes to sleep in the dark. Staff then separated the two residents and moved Resident #16 to a different room before eventually moving him to a different unit. She also indicated that Resident #87 sustained a laceration to the back of her head and that she believed it was 4-centimeters. Staff #3 explained that Resident #16 had never exhibited physical aggression towards others and he was new to the current facility. There was no indication that he had physical aggression towards others prior to be admitted to the current facility. When asked to read the October 11, 2025 progress note, she indicated the note mentioned Resident #16 had physical aggression behaviors at his previous facility. Staff #3 explained that when new residents are admitted , they are put in the locked unit to observe their behaviors and to determine if the unit is a good fir for them or if they can be put in a less restrictive unit. When asked what the risk to the residents are if they are abused by other residents, Staff #3 shared that residents could fall, have physical injuries, can be affected mentally, become depressed, or self-isolate. She also indicated that this situation she would consider this abuse due to the fact that Resident #16 willfully harmed Resident #87.Review of the policy titled Identifying Types of Abuse, dated 2001 indicated that Abuse was the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. It also identified resident-to-resident abuse as a type of abuse.

Based on observations, staff interviews, and review of policies and procedures, the facility failed to ensure that food was served in accordance with professional standards of food service safety. The deficient practices could result in food-borne illnesses.Findings Include:An initial kitchen observation was conducted on August 26, 2025, at 08:26 AM in conjunction with the Dietary Director (Staff # 116). During observation of the food preparation area, two sanitizer buckets, one containing a dish rag, were observed in the food preparation area where a bowl of pudding/pie mix was being prepared. A portable, blue plastic fan was observed sitting on a metal rack, blowing across the food server's side of the tray line. The blades of the fan were noted to be caked with thick, brownish-gray colored dirt.During observation of tray-line service on August 27, 2025, at 11:15 AM, a slice of cucumber was observed to fall off the plate onto the tray. Dietary Aide, Staff #77, was observed to pick up the item and place it back onto the plate with his hand. The tray line was stopped, and Staff # 204 was asked if she had observed any breach in practice. Staff # 204 stated, he should not have touched the food with his hand and returned it to the plate. The dietitian stated that this did not meet her expectations and identified the risk as contamination of the food and possible infection. The Dietary Director (Staff #116) was advised of the observation and stated that picking up food and putting it on the plate did not meet his expectations. The Dietary Director stated that the risk would be contamination and that he would use the observation as a part of an upcoming staff in-service.An interview with Dietary Aide (Staff # 77), was conducted on August 28, 2025, at 12:40. The Dietary Aide stated that standard kitchen practices are to wash hands on entering and exiting the kitchen at the handwashing sink. Staff # 77 stated that it is not necessary to wear gloves when working the tray line because he does not touch the resident's food. The Dietary Aide further stated that he was aware that he should not have touched the item that fell off the plate, but it was automatic. He stated that the risk to the resident would be low to medium, and the potential risk to the resident could be that whatever was on the tray could move to the food. A review of the Hand Washing Policy, located in Chapter 4: Sanitation and Infection Control, copyright 2021, from Nutrition Alliance, LLB by BDA, Inc., revealed that employees will wash hands as frequently as needed throughout the day using proper hand washing procedures (and surrogate prosthetic device washing procedures as appropriate). The procedure revealed that hands and exposed portions of arms (or surrogate prosthetic devices) should be washed immediately before engaging in food preparation and during food preparation, as often as necessary to remove soil or contamination and to prevent cross-contamination when changing tasks. The policy further revealed that staff will be educated on the importance of handwashing and retrained and reminded as necessary on the above guidelines.

Based on observations, staff interviews, and review of facility policies, the facility failed to store food in accordance with professional standards for food service safety. This deficient practice has the potential to increase the risk of foodborne illness and compromise resident healthFindings Include:An initial kitchen observation was conducted on August 26, 2025 at 08:26 AM in conjunction with the Dietary Director, (Staff # 116). During observation of the food preparation area, two sanitizer buckets, one containing a dish rag, were observed in the food preparation area where a bowl of pudding/pie mix was being prepared. A portable, blue plastic fan was observed sitting on a metal rack, blowing across the food server's side of the tray line. The blades of the fan were noted to be caked with thick, brownish-gray colored dirt.An observation on August 26, 2025, revealed pork and turkey on the bottom shelf of the freezer that were not labeled or dated. Additional observations revealed that two bags of frozen breadsticks and one bag of frozen fish patties were stored with no labels, including open or expiration dates.Further observation revealed twenty-four packages of small corn tortillas, one package of cooked and peeled eggs, one bag of opened, diced onions, one thirty-two-ounce bag of Bountiful Harvest cauliflower, two bags of wilted, brown, shredded, lettuce, one open box of mushrooms, one open box of carrots and one partially peeled and used cucumber wrapped in plastic wrap stored in the refrigerator with no labels to include open or expiration dates.An observation of surface sanitation solutions containing a quaternary ammonia product was conducted on August 26, 2025 at 08:50 AM, which revealed that all Sani-buckets tested at 400 parts per million using visual assessment of test-strip color change.Temperature logs for the walk-in freezer, four-door freezer, the reach-in, and walk-in refrigerators revealed adequate temperatures and daily monitoring. Unit refrigerators reflected adequate temperature monitoring and revealed no resident or staff food items in the refrigerators.Observation of pureed food preparation on August 27,2025 at 10:40 AM revealed that pizza was prepared and pureed with tomato sauce. The observation revealed that ingredients were measured for each portion prepared. At one point, staff # 19, was observed to drop the lid of the blender that was being used to prepare the puree. The lid was taken to the sink for washing and sanitizing. The Dietary Director, (Staff #116) advised a dietary aide that it was not permissible to dry the lid with a paper towel, stating it needed to air dry completely before use. A contract dietitian, (Staff # 204) also present during the observation confirmed that using a lid that had not completely dried would not meet her expectation, as the risk would be possible cross-contamination of the food.Temperature checks of all pureed foods were adequate and within safe serving parameters. The consistency of the pureed foods revealed appropriate consistency without visible lumps or inconsistent texture.A tray-line observation was conducted on August 27, 2025, at 11:15 AM which revealed positive communication between a dietary aide (staff # 77), and cook (Staff #111), who was serving as a second dietary aide and the serving cook, (Staff # 19), who used tray-ticket software to identify and confirm dietary orders for residents. Both dietary aides performed hand-hygiene prior to starting tray preparation; the cook (Staff #111) donned gloves, the other, (Staff # 77), did not. An observation of tray line practices revealed that the facility does not use plate warmers due to the risk of using them in a facility where many residents are diagnosed with behavioral symptoms. The Dietary Director (Staff # 116) stated that for similar concerns, only two units receive stainless steel utensils while the remaining units receive plastic utensils. During the tray-line service, a slice of cucumber was observed to fall off the plate onto the tray. Dietary Aide, Staff #77 was observed to pick up the item and place it back onto the plate with his hand. The tray line was stopped and Staff # 204 was asked if she had observed any breach in practice. Staff # 204 stated, he should not have touched the food with his hand and returned it to the plate. The dietitian stated that this did not meet her expectations and identified the risk as contamination of the food and possible infection. The Dietary Director (Staff #116) was advised of the observation and stated that picking up food and putting it on the plate did not meet his expectations. The Dietary Director stated that the risk would be contamination and that he would use the observation as a part of an upcoming staff in-service.Pre-service food temperatures for all prepared foods were within acceptable temperature ranges, which included: pizza at 170 degrees, mechanical soft, ground beef at 200 degrees, vegetables at 178 degrees and salad at 38 degrees. The sample food tray revealed adequate temperatures, and all foods met acceptable standards for appearance and taste.An observation of the dry food storage area was conducted on August 27, 2025, at 1:40 PM which revealed separate areas for the storage of regular canned goods and dented cans. Three dented cans were observed in the storage room; however, they were located away from the regular canned goods. The Dietary Director (Staff # 116) stated that dented cans are stored separately until a full case is completed and then returned to the food vendor for crediting to the facility. An observation of emergency food and water storage areas revealed adequate storage practices and sufficient supply. The outside trash area was clean and free of evidence of pests. The lids of the dumpsters were closed; however, on August 28, 2025, at 08:00 AM, one of three dumpster lids was observed to be open upon arrival to the facility and remained open at 12:15 PM and 15:30 PM. The open dumpster lid was reported to the Dietary Director (Staff # 116) and promptly closed.An interview with the Dietary Director (Staff #116) was held on August 26, 2025 at 09:00 AM who identified Shamrock Foods as the facility's food distribution source. The facility uses contracted dieticians who hold weekly 'WIN meetings for discussion of residents' dietary needs by monitoring weight, intake, and food-related behaviors. The Dietary Director stated that fresh produce should be labeled with a use-by date, and the process for food rotation is 'first-in, first-out.' Staff #116 stated that if a staff member reported to work while ill, they would be sent home, stating, No one stays if they are sick. The Dietary Director stated that if staff are injured while working, for example, if they incur a cut on their finger,) the injury would be cleaned and bandaged, and the staff member would be instructed to apply a 'finger condom' before returning to work; and further stated that if the injury was severe, the employee would be sent out for care.The Dietary Director stated that food handler cards are not required for staff. A review of Pima County inspection notice revealed no deficiencies.A review of the policy titled Food Receiving and Storage, revised November 2022, revealed that foods shall be received and stored in a manner that complies with safe food handling practices. The policy further stated that all foods stored in the refrigerator or freezer are covered, labeled, and dated with a use-by date. The policy identified critical control points in food preparation and serving processes as those which control can be exercised to reduce, eliminate, or prevent or eliminate the possibility of a food safety hazard. The policy specified some of these points as thawing, cooking, cooling, holding, reheating of foods and employee hygienic practices.

Based on clinical record reviews, staff interviews, and facility observations, the facility failed to ensure that medications were stored in accordance with professional standards for one resident (#66) out of a sample of 23. This deficient practice has the potential to compromise medication safety.Findings Include:Resident # 66 was admitted on [DATE], and readmitted on [DATE], with diagnoses that included: chronic obstructive pulmonary disease, atherosclerotic heart disease, morbid obesity, hypothyroidism, major depressive disorder, anxiety disorder, tremor, hyperlipidemia, osteoarthritis, fibromyalgia, obstructive sleep apnea, Type II Diabetes Mellitus with diabetic neuropathy, restless legs syndrome gout, edema, insomnia, cataracts, alcohol use, unspecified with alcohol-induced persisting dementia, personal history of Covid-19, heart failure, chronic respiratory failure, vitamin D deficiency, low back pain, paroxysmal atrial fibrillation, and hyperesthesia. A review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed that the resident had a visual impairment that interfered with the ability to read regular print in newspapers or books. The resident was able to understand others and make herself understood. The Brief Interview of Mental Status (BIMS) revealed a score of 15 that indicated intact cognition. The MDS further revealed that the resident exhibited no hallucinations, delusions, or physical behavioral symptoms directed towards others, but exhibited verbal behaviors and other behavioral symptoms not directed to others 1-3 days during the rating period. The MDS revealed that the resident had range of motion limitation to bilateral upper and lower extremities and was non-ambulatory. The MDS further revealed that the resident required set-up assistance for eating and oral hygiene, maximum assistance for upper body dressing and was dependent in toileting, hygiene, shower, lower-body dressing, personal hygiene, and putting on and taking off footwear. The MDS revealed that the resident was always incontinent of bowel and bladder. The resident was identified as being totally dependent on 1 staff member for locomotion using a wheelchair.Physician orders revealed orders for weekly skin assessments on scheduled shower days and an order for Nystatin Powder 100,000 units/gram to be applied to the peri-area and abdominal folds topically, two times a day for candidiasis; may be applied following incontinence episodes. The physician orders further revealed that the resident may use transfer bars and side rails to assist with bed mobility. There were no observed changes in physician orders, and a review revealed no orders for self-administered medications. The physician orders further revealed that the resident used oxygen via nasal cannula at 1-3 liters per minute by nasal cannula to maintain oxygen saturation greater than 88 percent.A review of the comprehensive care plan dated June 3, 2025, revealed that the resident had a self-care deficit and was at risk for skin breakdown due to limited mobility related to incontinence, disease processes and morbid obesity. The care plan further revealed that the resident could be resistant to care.A review of skin assessments on August 13, 2025, August 16, 2025, August 20, 2025, and August 22, 2025 revealed that no new skin issues or conditions were identified. The investigation revealed no deficient practices in the identification, monitoring, and treatment of moisture-associated skin damage.An observation during initial resident screening revealed a container of miconazole powder 25% at the resident's bedside on an overhead shelf behind and above the resident's bed.An interview was conducted with Certified Nursing Assistant (CNA), Staff #118, on August 26, 2025 at 09:48 AM. The CNA stated that she had been working at the facility for only two weeks and would defer questions about medications to the nurse. Staff #188 further stated that medications are kept in locked medication carts and that medications are not allowed in the resident's room. The CNA stated that the risk of medications in the room could be related to HIPAA. An interview was conducted with Licensed Practical Nurse (LPN), Staff #59, on August 26, 2025, at 09:52 AM. The LPN stated that a medication is anything that is prescribed by a doctor's orders, including over-the-counter medications, IV medications, oral medications, injectable medications, topical preparations, or powders. When asked if a powder could be a medication, the LPN stated, Yes, I consider everything a medication. Staff # 59 stated that there should never be a medication at the patient's bedside unless there is a doctor's order for it. When questioned about the risk to the resident if a medication was at the bedside, the LPN stated that many residents have a cognitive decline and that if an order for medications at the bedside was obtained, she would complete an assessment to make sure that the resident was able to use the medication correctly. Staff #59 reported that there was one resident in the hallway that had an order to self-administer ear drops for ear wax removal, but that she monitored the resident when using the drops. The LPN was advised of the observation of the antifungal medication at resident #66's bedside and asked her to pull up the resident's orders for review. Staff #59 pulled up the resident's electronic health record, checked for the order, and stated that no order for self-administration of medications was identified. The LPN stated that this did not meet her expectations as the medication should not be at the bedside and identified that the related risk could be overuse or increased cost. The LPN stated that there could also be a risk of infection, but this was unlikely since both residents in the room are bedridden, and further stated, this was no excuse. The LPN also noted a possible risk of medication ingestion. Staff #59 stated that she is strict with the team in her hallway and provides oversight and training to all staff on her assigned hallway, providing daily orientation. An interview with the Director of Nursing (DON), Staff #203, was conducted on August 28, 2025, at 11:55 AM regarding medication administration. The DON stated that medication self-administration requires a physician's order that permits the resident to administer their own medication. Staff #203 stated that If ordered, the nurse would assess the patient's ability to administer their own medication. The DON stated that she thought that there may have been one resident on the A hall who had this type of order, for an inhaler, but the request came in recently, and she had not yet had time to follow up. The DON stated that if the resident was assessed to have the ability to self-administer the medication, an update to the care plan would also be required. Staff # 203 stated that finding a medication at a patient's bedside that has not been ordered would not meet her expectation and identified the risk as because many of the residents at the facility have behavioral issues, someone could ingest the medication, the resident could use the medicine incorrectly, or another resident could find the medication and use it. The DON stated that she will do a sweep of all resident rooms and remove any medications that are not ordered to be held at bedside, and conduct an in-service, reminding all clinical staff that this is not acceptable.A review of the Administering Medication Policy from the Nursing Services Policy and Procedure Manual for Long-Term Care, Copywrite 2001, MED-PASS, INC, Version 2.1, revised April 2019, revealed that only persons licensed or permitted by this state to prepare, administer, and document the administration of medications may do so. The policy further revealed that residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely.

Based on clinical record reviews, staff interviews, and facility policies, the facility failed to ensure that necessary respiratory care was provided for one resident (#2). Sample size was 23. The deficient practice could lead to residents not receiving appropriate respiratory care.Findings Include:Resident # 2 was admitted to the facility on [DATE], with diagnoses that included: acute respiratory failure with hypoxia and chronic obstructive pulmonary disease.A review of the comprehensive Minimum Data Set (MDS), dated [DATE] revealed that the resident had adequate levels of hearing and the ability to make himself understood and to understand others. However, the resident had a moderate visual impairment that permitted him to identify objects, but not to read newspaper headlines. The Brief Interview of Mental Status (BIMS) revealed a score of 09, which indicated a moderate level of cognitive impairment. The Patient Health Questionnaire-2 (PHQ-2) revealed a score of 00, which indicated no symptoms of depressed mood and required no further evaluation. The MDS revealed that Resident #2 had no hallucinations or delusions; however, they exhibited physical and verbal behaviors directed towards others and other behavioral symptoms not directed towards others, one to three days of the rating period. The MDS further revealed that the resident had a limited range of motion of both upper and lower extremities, and used a wheelchair for mobility. The MDS revealed that the resident was dependent in toileting, showering/bathing, upper and lower body dressing, putting on and taking off footwear, personal hygiene, and tub/shower transfers. The MDS identified the resident as incontinent of bowel and bladder and revealed that the resident reported occasional low back pain at a level '9' on a 0-10 numeric scale. The MDS revealed that the resident had a stage 3 pressure ulcer, and was at risk for developing further pressure ulcer or injuries.A review of the comprehensive care plan dated August 8, 2025, revealed that the resident was dependent on staff for meeting emotional, intellectual, physical, and social needs related to immobility, anxiety, dementia, and a cognitive communication deficit. The care plan revealed that the resident had Chronic Obstructive Pulmonary Disease (COPD), with a related goal of remaining free from signs or symptoms of respiratory infections through the review date. Interventions supporting this goal included giving aerosol or bronchodilators as ordered, monitoring any side effects and effectiveness, monitoring for difficulty breathing, reminding the resident not to push beyond endurance, monitoring for signs or symptoms of acute respiratory insufficiency, including anxiety, confusion, restlessness, shortness of breath at rest, cyanosis, or somnolence. The care plan further stipulated that the resident would be monitored for anxiety, staff would offer support and encourage the resident to vent frustrations, fears and provide reassurance and PRN medications for anxiety as ordered. The care plan also indicated that the resident would receive oxygen administration via nasal prongs as ordered.A review of a physician's progress note dated August 8, 2025, indicated that the resident had COPD, and that he would receive Ipratropium-Albuterol nebulizer treatments every 4 hours as needed, Symbicort Inhalation every 12 hours, self-report dyspnea with exertion, and use continuous supplemental oxygen at 2 liters per minute at rest and with exertion. The progress note revealed that the goal oxygen saturation level was to remain above 88%, and that if oxygen saturation rate fell below 88% with exertion, the oxygen would be increased to 3-4 liters per minute. A review of the resident's oxygenation records revealed that his pulse oximetry ranged between 90 and 97 percent, and they had no episodes of oxygen desaturation.A progress note dated August 19, 2025, at 15:46 PM, revealed that the resident received a chest x-ray to screen for tuberculosis, with results indicating positive infiltrates in the left lower lung. The same note revealed that the resident stated that he was always short of breath and used supplemental oxygen. However, the resident denied fever, chills, cough, or increased fatigue. The progress notes revealed that the resident was being treated by the wound care team for a pressure ulcer of the left ear related to the use of the oxygen cannula; however, a care plan conference summary dated August 14, 2025, revealed that the skin was intact. Additionally, the care plan conference note made no reference to oxygenation or oxygen orders.A review of physician orders revealed that the resident received orders to start a ten-day course of cefdinir 300 mg twice daily and doxycycline 100 mg twice daily for community-acquired pneumonia on August 19, 2025.An order dated January 23, 2025, included a notation to change oxygen tubing and mask every month on the 1st and the 15th; however, no order for oxygen administration was identified in the physician orders. During an observation on the unit on August 28, 2025, at 10:43 AM the resident was seated in his wheelchair with the nasal oxygen cannula in place, the cannula in his nose, however, the concentrator was turned off. Closer observation revealed that the oxygen tubing was connected to a portable oxygen tank in a holder on the wheelchair. The oxygen tank was also turned off. The resident stated when asked if he was having trouble breathing or felt short of breath, Yes, I am short of breath. The resident also stated that he felt no oxygen flowing through the cannula, stating, No, I cannot feel any air in my nose. Certified Nursing Assistant (CNA), Staff # 118, was called to the room, upon checking the oxygen tank, turned it on, stating that she had been helping the resident prepare for an off-site appointment. Staff #188 stated that if oxygen is ordered, it should be on.An interview was conducted with Licensed Practical Nurse (LPN), Staff #59, on August 28, 2025, at 10:46 AM, who stated that the oxygen was off because the resident was getting ready to go to a dental evaluation in hopes of being fitted for dentures. The LPN stated that the oxygen was not off for too long and that the resident's reports of shortness of breath were behavioral. The LPN stated that the expectation for continual oxygen is that the resident will have oxygen on and working at all times. Staff # 59 stated that the event would not meet orders for oxygen administration, but it was understandable due to the resident's situation. The LPN assessed the resident and confirmed oxygen delivery at two liters per minute and reported that the resident's respirations appeared unlabored and that the resident was able to speak in full sentences.A new verbal order was entered on August 28, 2025, at 13:33 PM by staff #59 from the resident's current primary care provider to administer oxygen continuously via nasal cannula or concentrator, may titrate to maintain Spo2 greater than 90 percent.An interview with Certified Nursing Assistant (CNA), Staff # 114, was conducted on August 29, 2025, at 09:16 AM. The CNA reported that oxygen is administered for shortness of breath, and if a resident's oxygen level is lower than 90 percent, she would let the nurse know. The CNA confirmed that resident # 2 was on oxygen continuously. Staff # 114 stated that the resident received a shower the previous Friday, and the staff did not take the oxygen tank into the shower. The CNA stated that without oxygen, the resident got scared and stated that he could not breathe. Staff # 114 stated that if the resident refused to use oxygen or if he was short of breath, she would notify the nurse.An interview with Licensed Practical Nurse (LPN), Staff # 59, on August 29, 2025, at 09:22 AM. The LPN stated that when a resident is on oxygen and reports shortness of breath, she would check for crimps in the tubing, make sure that the oxygen is on, raise the head of the bed, check the oxygen saturation level, and observe for dusky fingernails or clamminess. In the event that the symptom was related to resident behaviors, the LPN stated that she would go through all the motions, just the same. The LPN stated that if the resident was symptomatic, such as being lethargic, non-responsive, or with oxygen saturation below the doctor's specified parameters, she would immediately notify the doctor. Staff #59 stated that she was aware that resident #15 is on continuous oxygen except for in the shower. When asked if the shower exception was noted in the physician's orders, she stated that she was not sure. The LPN stated that when residents are known to take off the cannula, additional rounding is initiated to ensure that they keep it on. The LPN further stated that resident # 15 will ask for oxygen when his oxygen saturation levels are at ninety-five percent.An interview with Unit Manager, Staff # 412, was conducted on August29, 2025, at 09:41 AM. The Unit Manager stated that it was her expectation that all orders for oxygen should be in Point Click Care (PCC), the facility's electronic health record. Staff # 412 further stated that she may have missed the order, but would check to confirm that it was there. The Unit Manager stated that she processed resident #15's admission orders and did not put in an order for oxygen and identified the potential risk to the resident as hypoxia.An interview was conducted with the Director of Nursing (DON), Staff # 61, on August 29, 2025, at 10:45 AM. The DON stated that it was her expectation that oxygen should only be administered when ordered by a physician. The DON further stated that if administered without a physician's order, it would not meet her expectations, as the resident may not get the correct care.A review of the Oxygen Administration Policy, (C)2001 MED-PASS, Inc., Respiratory and Pulmonary conditions chapter, Level III, indicated that staff are to verify that there is a physician's order and review the physician's order or facility protocol for oxygen administration. The policy further stated that staff would review the resident's care plan to assess for any special needs of the resident.

Based on clinical record reviews, staff interviews, and facility policy review, the facility failed to ensure that one resident (#16) had a physician's order for dialysis. The sample size was 23. This deficient practice has the potential to result in residents receiving dialysis without appropriate medical authorization.Findings include:Resident #16 was admitted to the facility on [DATE] with diagnoses that include End Stage Renal Disease (ESRD), unspecified atrial fibrillation, and chronic pain syndrome.A review of the Minimum Data Set (MDS), dated [DATE], revealed the resident had a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident is cognitively intact. The same MDS also indicated the resident was receiving dialysis.Review of Resident #16's care plan, initiated on October 14, 2024 and revised on October 21, 2024 indicated he needed hemodialysis related to renal failure and ESRD. Interventions identified on the care plan indicated dialysis days was on Tuesdays, Thursdays, and Saturdays.A review of the physician's orders revealed no current orders for dialysis. However, there was an order, dated that indicated the resident was to hold their blood pressure medications on dialysis days which was identified as Mondays, Wednesdays, and Fridays.The Treatment Administration Record (TAR) and Medication Administration Record (MAR) did not reveal a current order for dialysis.An interview was conducted on August 27, 2025 with Certified Nursing Assistant (CNA/Staff #118) at 12:50 P.M. When asked if Resident #16 received dialysis, she stated that she did not know. She added that she typically works weekends but was working today for additional coverage.An interview with Resident #16 was conducted on August 27, 2025 at 12:55 P.M. He shared that he received dialysis on Mondays, Wednesdays, and Fridays. He added that he usually leaves the facility at 1:30 P.M. and returns at 6:00 P.M.On August 27, 2025 at 1:00 P.M. [NAME] Clerk/Staff #506 was overheard telling Staff #118 that Resident #16 was going to be leaving for his dialysis appointment soon.An interview was conducted on August 28, 2025 at 9:14 A.M. with CNA/Staff #54. Staff #54 shared that Resident #16 went to his dialysis appointment yesterday (August 27, 2025) and she believed that he goes twice a week.An interview was conducted on August 28, 2025 with Licensed Practical Nurse (LPN/Staff #414) at 9:21 A.M. When asked how he knows if a resident is receiving dialysis, Staff #414 explained that the resident would have a shunt bracelet, he would then ask the patient (if they were receiving dialysis), he gets reports from the CNAs and other nurses, and he would check the resident's orders as there would be orders indicating what days the resident would go to dialysis and where they would go. He would then communicate this information to the resident. Staff #414 indicated that he believed Resident #414 goes to dialysis and he then checked the resident's order list. As Staff #414 was checking the orders on the laptop, another unnamed staff walked by and was heard telling him to check the resident's appointment book/sheet. Staff #414 then pointed out the schedule in the appointment book that listed Resident #16's transportation and dialysis information. Staff #414 was then asked if Resident #16 had a current order for dialysis. He then shared that he did not see an order for dialysis for Resident #16. Staff #414 acknowledged that if a resident is sent out for dialysis, they need to have an order for it.An interview was conducted with the Director of Nursing (DON/Staff #61) on August 28, 2025 at 9:37 A.M. Staff #61 confirmed that if a resident was receiving dialysis, they would need an order. Staff #61 was asked to confirm that Resident #16 had a current order for dialysis. After reviewing the physician's orders list, she shared that she did not see a current order. She did share that they had an order for dialysis in the past that indicated Resident #16 received dialysis on Tuesdays, Thursdays, and Saturdays. However, he was recently at the hospital and came back on August 25, 2025. Staff #61 continued to explain that the dialysis order was not put back into the system. Staff #61 shared that not having a current order in the system did not meet her expectations. She expected orders to be put into the system with the correct days when the return from the hospital. Staff #61 shared that by not having current orders for dialysis, the resident would be at risk for adverse effects in various ways. They might receive treatment that they don't need depending on what the treatment is.On August 28, 2025 at 10:05 A.M. a secondary review of Resident #16's Physician's orders revealed a new order for Dialysis on Mondays, Wednesdays, and Fridays at an offsite Dialysis facility. The order was transcribed by The Assistant Director of Nursing (ADON/Staff #119) on August 28, 2025 at 9:40 A.M.Review of the facility's policy, titled Hemodialysis, indicated that it was implemented in April 2025. The policy indicates that the facility will ensure that the physician's orders for dialysis include: the type of access for dialysis and location, the dialysis schedule, the nephrologist name and phone number, transportation arrangements to and from the dialysis facility, any medication administration or withholding of specific medications prior to dialysis treatments, and any fluid restrictions if ordered by the physician.

Based on clinical record reviews, staff interviews, and facility policies, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level I screening was accurately completed for one resident (#41). The sample size was #21. The deficient practice could potentially lead to residents not receiving appropriate placement and services to identified mental health needs. Findings include:Resident #41 was admitted to the facility on [DATE] with diagnoses that included Hemiplegia and Hemiparesis following cerebrovascular infarction affecting right dominant side (weakness and/or complete paralysis on the left side of the body due to a stroke), schizoaffective disorder bipolar type, major depressive disorder, anxiety disorder, and vascular dementia.A review of the quarterly Minimum Data Set (MDS), dated [DATE] revealed Resident #41 had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident is cognitively intact. Verbal behaviors and wandering was noted in the MDS assessment. It was also noted that Resident #41 is taking antidepressants but was not taking antipsychotics. Review of Resident #41's physician's orders from the resident's previous placement, dated October 10, 2022, identified the primary diagnosis as Hemiplegia and Hemiparesis following unspecified cerebrovascular disease. It also listed Vascular Dementia with behavioral disturbance as the 7th diagnosis.Review of Resident #41's pre-admission PASARR, dated October 11, 2022 and completed by the previous facility, indicated Resident #41 had schizoaffective disorder, major depression disorder, and anxiety disorder. The same form indicated the resident did not have a primary diagnosis of dementia or Alzheimer's disease. It was also noted that the resident had been receiving mental health services from the in-patient Behavioral Health Team and she was taking psychotropic medications. The referral determination indicated there was no referral necessary for a Level II PASARR.The care plan, initiated on October 12, 2022 and revised on July 9, 2025 indicated Resident #41 had schizoaffective disorder bipolar type and a history of opioid abuse. Identified goals included having her behaviors monitored by Behavioral Health Services. Interventions included administering medications as ordered, respect (the resident's) decisions/choices (related) to 2-person care, and attempt to figure out the cause of the behaviors. A second care plan, initiated on October 12, 2022 and revised on June 10, 2025, indicated Resident #41 was taking psychotropic medications due to irritability, voicing sadness due to her diagnosis. The goal was for Resident #41 to be free from psychotropic related complications and interventions included administering psychotropic medications as ordered, monitoring for side effects and effectiveness, and documenting and reporting adverse reactions to the physician.Review of Resident #41's post-admission PASARR, dated October 12, 2022 and signed off by the Social Services Director (SSD/Staff #522), indicated Resident #41 had a primary diagnosis of dementia or Alzheimer's disease. The same PASARR indicated that this was verified by a comprehensive mental status exam. It was noted that a psychiatric/behavioral evaluation was completed by an external Mental Health agency in 2022. The referral determination indicated that a referral was not necessary for a Level II PASARR.Review of an Encounter note from the external Mental Health agency indicated the Psychiatric-Mental Health Nurse Practitioner (PMHNP) saw Resident #41 on October 18, 2022 at the current facility for a Behavioral Health Team meeting. The Encounter note listed the following diagnosis for Resident #41:- Schizoaffective disorder, bipolar type- Opioid dependence- Cocaine dependence- Cognitive deficits following unspecified cerebrovascular diseaseAn interview was conducted on August 29, 2025 at 10:04 A.M. with Staff #522. Staff #522 confirmed that the initial PASARR from the discharging facility did not identify a primary diagnosis of dementia. When asked who completed the post admission PASARR, dated October 12, 2022, Staff #522 confirmed that she completed it and that it listed the primary diagnosis for Resident #41 as dementia. When asked how she determined that the primary diagnosis was dementia, Staff #522 shared that she looked at the resident's History and Physical, the pre-admission PASARR, and why she was being admitted - she was not being admitted for behaviors. Staff #522 shared that she will meet with the medical records team and they would have a round table discussion as to what the primary diagnosis would be. She indicated that she knew Resident #41 was admitted with a primary diagnosis of stroke but she was unable to locate documentation indicating the primary diagnosis should have been dementia. Staff #522 shared that she did not have a copy of the comprehensive mental status exam that she used to verify the primary diagnosis of dementia. She added that she called Resident #41's Public Fiduciary to see if she had a copy of the exam report but she did not have it as well. Staff #522 stated that a resident with Schizophrenia and on psychotropic medications without a primary diagnosis of dementia should have been referred to a Level II PASARR. She also shared that the risk to the resident for not referring her to a Level II would be not providing the level of service that the resident might need. If a resident were to also have behavioral issues, they would need to make sure that services are commensurate with the diagnosis. Staff #522 also confirmed Resident #41 had a BIMs score of 15.An interview was conducted with the Director of Nursing (DON/Staff #61) on August 29, 2025 at 10:35 A.M. Staff #61 explained that she would get the diagnosis of an incoming resident from the Physician's orders from the previous facility or get it off the PASARR. She shared that the PASARR is primarily managed by the Admissions/Staff #8 and Social Services (Staff#522). When asked how she determines the primary diagnosis of a resident, she shared that the first diagnosis listed in the Electronic Health Record (EHR) is typically the primary. Staff #61 identified the primary diagnosis for Resident #41 as Hemiplegia and Hemiparesis following Cerebral Vascular Disease. When asked if there is ever a round-table discussion to review potential new admissions and their primary diagnosis, she shared that they don't and that (Staff #8) and the Administrator (ADM/Staff #730) will meet and screen potential residents and then the business office will verify their insurance. Once that is all done, Staff #61 then reviews the packet and looks at the resident's diagnosis, medication list, behaviors, and if they need any special equipment to determine if we are able to meet their needs. Staff #61 shared that if the PASARR is not filled out correctly, then the risk to the residents would be them not being able to get the appropriate services they need.An interview was conducted with Staff #8 on August 29, 2025 at 10:44 AM. Staff #8 shared that the incoming resident's case manager will tell her the resident's primary diagnosis or sometimes it is in their admission packet. She then confirms the primary diagnosis with the resident's insurance. When asked if dementia was the primary diagnosis for Resident #61, she shared that her primary diagnosis was Hemiplegia and Hemiparesis following cerebral infarction of the right side. Staff #8 added that it was confirmed by Resident #41's case manager. Staff #8 also shared that the primary diagnosis on the paperwork from the previous facility she was at, dated October 3, 2022, did list Hemiplegia was her primary diagnosis.Review of an undated policy titled, Pre-admission Screening and Resident Review (PASRR) states Social Services to review for PASRR on new admission/Create new PASRR for new admission for completion of assessment for non-convalescent Care Stay (SRCC stays are non-acute). Review of Diagnosis trigger PASRR II criteria: - Mental Illness, Symptoms- Adaptation to change- DDD (Developmental Disabilities)- Provide history of Developmental and psychiatric treatment (if available)

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#235) were free from physical abuse resulting in injury by other residents (resident #205). The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #235 was admitted to the facility on [DATE] with diagnosis that include Diabetes Mellitus type 2, Benign Prostatic hyperplasia, Chronic obstructive pulmonary disease, Dementia, and Hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 99 which indicated the resident had severe cognitive impairment. A behavioral care plan revised June 5, 2023 revealed the resident is at risk for impaired thought processes related to vascular dementia, with a noted intervention of keeping the resident's routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. -Resident #205 was admitted to the facility on [DATE] with diagnoses that include Psychotic disorders with hallucinations, Seizures, Post-traumatic stress disorder, depression, aneurysm, cerebral infarction, and hypertension. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12 which indicated the resident had mild cognitive impairment. Review of information received from the SA complaint tracking system revealed that on April 22, 2023 a facility reported incident was received that revealed on April 22, 2023 at 9:26 a.m. It was alleged that behavioral resident #205 had bit fellow behavioral resident #235 on the hand, causing resident #235 to pull resident #205's hair. It further stated this is the first incident between the two residents, that had resident #205 was relocated to another unit within the facility. A review of progress notes for resident #235 dated April 22, 2023 at 9:26 a.m. revealed a resident to resident altercation. Was observed by staff member resident #235 pulling resident #205's hair. The note continues that the resident was removed from the room after separating the two residents. Further assessment noted a puncture like area to the palm and thumb area of the left hand of resident #235. The note concludes that the don, administrator, and provider were notified. A progress note for resident #235 dated April 22, 2023 at 8:56 p.m. noted resident #235 quiet this pm with no noted behaviors. No complaint of discomfort from left palm and thumb area, will continue to monitor. A progress note for resident #235 dated April 25, 2023 at 12:29 p.m. noted resident #235 revealed resident #235 was seen by behavioral health for a follow up related to resident to resident altercation. The note concludes that no changes made to staff and will continue to monitor for issues and side effects and to follow up with behavioral health in 4 weeks. A progress note for resident #235 dated April 26, 2023 at 9:07 p.m. noted resident #235 revealed No complaint of discomfort from recent bite to left hand, and no noted signs of infection. A progress note for resident #235 dated April 29, 2023 at 1:08 p.m. noted resident #235 revealed Left hand bite punctures continue to resolve. An interview was conducted with a Certified nursing assistant (CNA/staff #78) on June 11, 2025 at 1:54 p.m. The CNA stated she has worked at the facility for 1 year. The CNA stated that when a resident conflict happens she tries to separate the residents immediately and deescalate the situation, and then notify the nurse. She further stated that when physical abuse is suspected the process in the same, separate and make the residents safe and then report to the nurse and up the chain of command. An interview with the Director of Nursing (DON/staff #21) was conducted on June 13 2025 at 11:30 a.m. The DON stated she has been here since 2011, but for the last 4 years as the director of nursing. The DON stated that she remembers resident #205, and stated that he was not aggressive and kind of kept to himself. She stated he would eat in the dining room, and that to be honest she didn't recall the incident involving the bite. The DON accessed the clinical record during this interview to review details of the incident. The DON stated after review that they did report it appropriately and provided that documentation. The DON stated that resident #205 was moved to another secured unit following the incident, and that both residents were placed on 15-minute checks. The DON further stated that both were seen by behavioral health following the incident with no medication changes noted. The DON stated that the bite was the only injury noted, and the only other contact was the hair pulling. The DON concluded that it does not meet her expectation of how residents are treated. Based on clinical record review, interviews, facility documentation and review of facility policy, the facility failed to ensure one resident (#120) was free from abuse from an employee. The deficient practice could result in residents experiencing emotional, physical, and mental trauma from the abuse. Findings include: Related to Resident #120- Resident #120 was admitted to the facility on [DATE] with diagnoses that included unspecified dementia, anxiety disorder, and cognitive communication deficit. Review of the admission MDS, dated [DATE], revealed the resident had a BIMS score of 03 which indicated the resident had severe cognitive impairment. The same MDS also indicated Resident #120 exhibited hallucinations, delusions, and rejection of care. Review of the care plan indicated it was initiated on July 21, 2023. The care plan included that the resident had a behavior problem related to her dementia and anxiety. Interventions indicated staff were to anticipate and meet the resident's needs, provide opportunities for positive interactions, approach/speak in a calm manner, and to monitor the behaviors. A review of Resident #120's clinical record revealed a progress note, dated September 2, 2023 at 10:40 PM. The progress note was written by Licensed Practical Nurse (LPN/Staff #125) and indicated that she was informed that a staff member allegedly abused a resident. The progress note also indicated that Staff #125 had assessed the resident and there were no injuries noted. Resident #120 was unable to remember the situation. An employee separation information form was reviewed on 5/16/2025 and it indicated Staff #150 was fired/discharged for physical/verbal altercation. The termination date was listed as September 2, 2023. An interview was conducted on June 13, 2025 with LPN/Staff #125 at 10:02 AM. Staff #125 defined abuse as when you're doing something wrong towards another person. When you're being physical with them and not treating them the way you would want to be treated. Staff #125 recalled Resident #120 and stated that she was staffed 1:1 due to her behaviors. She also noted that she was calmer when her husband visited and he visited often. She also described Resident #120 as someone who would wander into other residents' rooms often due to her dementia. Staff #125 explained that Resident #120 would sometimes be combative. However, Resident #120 would eventually be redirectable as staff de-escalate her in a calming manner. She shared that she did not directly witness the alleged abuse, but was alerted to it by Certified Nursing Assistant (CNA/Staff #44). She remembered assessing Resident #120 and asking her, in several different ways, what had happened. Staff #125 indicated the resident was unable to recall the incident. An interview was conducted on June 13, 2025 with Staff #44 AT 11:13 AM. Staff #44 defined abuse as mentally harming residents, physically hurting them or restraining them. She also indicated that the facility provides some sort of abuse training on a monthly basis. Staff #44 indicated that she remembered Resident #120 and recalls her being a wanderer who would mumble when she spoke. She also indicated that the resident was not physical towards others during her stay. Staff #44 recalled the incident and shared that Resident #120 had gone into another resident's room and CNA/Staff #150 went into the room to get her out. Staff #44 also indicated that she was walking down the hallway to assist Staff #150, due to her being new, when she heard Staff #150 say If you hit me, I'm going to hit you back. She explained that she went into the room and saw Staff #150 hit Resident #120 on the face with a closed fist. Staff #44 then went between Resident #120 and the staff person in an effort to de-escalate the resident and had told Staff #150 that she was going to report her. Staff #44 then removed Resident #120 from the room and went to the nurses' station to notify staff #125 and another nurse what had happened. An interview was conducted on June 13, 2025 with the Director of Nursing (DON/Staff #21) at 12:25 PM. Staff #21 indicated that when staff are hired, they are trained on abuse. She also added that ongoing abuse trainings occur twice a month and this also included trainings provided by the Behavioral Health team as well. Staff #21 defined abuse as an unwanted action against another person. She explained that her expectation of staff, when they are de-escalating a resident, was to give them their space and provide the resident with privacy as well as ensuring that others around them are safe. If the resident was not able to be de-escalated, then they would call 911. Staff #21 recalled the incident with Resident #120 and Staff #150. She indicated that Resident #120 was being aggressive and had grabbed Staff #150's breast. When she grabbed the staff member's breast, staff then slapped the resident in the face. Staff #21 indicated that the altercation was witnessed by a CNA and that CNA had interjected herself between Resident #120 and staff #150. Staff #21 shared that she had spoken with Staff #150 after the incident and the staff person had told her that her first reaction was to slap the resident when she grabbed her breast. Staff #21 added that the situation did not meet her expectations of how staff are to interact with residents because she would never expect a staff person to strike a resident no matter what and that it was absolutely a form of abuse. Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to protect the rights of four residents (#106; #107; #108; #104) to be free from abuse by other resident(s) (#88; #105). The deficient practice could result in further resident abuse. Findings included: -Regarding Resident #88 and #106; #107; #108 Resident #88 was admitted into the facility on January 10, 2023, readmitted on [DATE], and had medical history that included unspecified dementia with other behavioral disturbance, unspecified psychosis, and anxiety disorder. A review of the Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 8 which indicated that the resident was moderately cognitively impaired. Care-plan initiated on January 11, 2023 with revision date of June 10, 2024 revealed that on April 13, 2024, May 22, 2024, and June 6, 2024 Resident #88 had incidents of aggression initiated resident to resident altercations. Interventions included: - April 13, 2024 behavioral evaluation after resident to resident altercation; - May 23, 2024 added to behavioral for re-evaluation and 1:1 supervision from staff for 30 days. Additional interventions related to behavior problem included: intervene as necessary to protect the rights and safety of others; divert attention; remove from situation and take to alternate location as needed, 1:1 attempt to figure out why/what is causing the behaviors; reorient and supervise as needed. Review of the electronic medical records (EMR) progress note dated April 13, 2024, 17:47, revealed resident came back from activities; commotion heard on hallway; staff intervene; Resident stated, I was heading to the patio, and Resident #106 kept grabbing and squeezing my hand, so punched him. Resident #88 placed in 15-minute checks and 1:1. Review of the electronic medical records (EMR) progress note dated May 18, 2024, 14:15, revealed Resident #107 spends his time pacing the hallway, pleasant mood but is easily agitated and triggered by others, resident has delusions about others talking about him, threatens to fight others. An additional progress note dated May 27, 2024, 00:21, revealed resident continues on 1:1 monitoring due to aggressive behavior. Further, progress note date May 28, 2024 revealed resident was seen by nurse practitioner for follow up after resident to resident altercation. Review of the electronic medical records (EMR) progress note dated June 05, 2024, 17:57, revealed resident hit his roommate; I asked what happened to the CNA that was the resident's one on one. Resident #108 stated My roommate (Resident #88) hit me in the face hitting the cheek and upper lip. An addition progress note revealed, Resident #88 hit his roommate in the face. Resident #88 stated, I don't like Mexicans and I will hit him again. Writer asked the assigned 1:1 how did Resident #88 get passed you to hit Resident #108, who stated he was so fast. Further, it was documented in the progress note Resident #108 stated, No, that f***** hits like a b****regarding to the details of the incident. Resident #106 was admitted into the facility on February 17, 2020 and had medical history that included tremor, aphasia following cerebral infarction, hemiplegia, and bipolar disorder. A review of the Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 3 which indicated that the resident was severely cognitively impaired. Care-plan initiated on November 26, 2021 with revision date of December 30, 2024 revealed that on April 13, 2024 Resident #106 had incident of resident to resident altercation with bruise to left eye. Interventions included: 15-minute monitoring related to resident to resident altercation on April 13, 2024. Review of the electronic medical records (EMR) progress note dated April 13, 2024, 17:47, revealed resident came back from activities; commotion heard on hallway; staff intervene; Resident stated, I was heading to the patio, and Resident #106 kept grabbing and squeezing my hand, so punched him. Resident #106 had swelling and discoloration to left eye. Review of the facility investigation report dated April 17, 2024, revealed Resident #106 was found to have discoloration of the left eye. Concluding details of facility's investigation revealed that Resident #106 was in his wheelchair when Resident #88 passed, Resident #106 grabbed Resident #88 by the hand then Resident #88 hit Resident #106 in the left eye; and that, the facility substantiated the allegation of abuse between these residents. An interview was conducted by Assistant Director of nursing (Staff #58) with Resident #88 who stated, That fool grabbed my hand and squeezed it, so I punched him. Staff #58 interviewed Resident #106 who stated, some guy was walking by me, and then I said, can I have something? He said, what do you want, I went Ha, Ha, Ha then he punched me. The investigation report was signed by facility Administrator (Staff #95). Resident #107 was admitted into the facility on June 15, 2023 with diagnoses that included schizoaffective disorder, bipolar disorder, antisocial personality disorder, and narcissistic personality disorder. A review of the Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 3 which indicated that the resident was severely cognitively impaired. Care-plan initiated on June 15, 2023 with revision date of July 08, 2024 revealed that on May 23, 2024 Resident #107 had unit change due to aggressive behaviors following incident of resident to resident altercation. Interventions included: monitor/record/report to Medical Doctor as needed risk for harming others. Review of the facility investigation report dated May 24, 2024, revealed Residents #88 and #107 were arguing, then separated. Following review of video surveillance - at 12:36 PM, Resident #107 wheeled over to Resident #88 who was at a bench in the patio. Resident #107 began flailing his arms and kicked Resident #88 who then moved Resident #107's wheelchair away then sat back in the bench. Resident #107 again reproached and kicked Resident #88, both postured to fight, and then Resident #88 took several [NAME] one of which caught Resident #107 in the face. Further, the investigation report revealed that as time went on Resident #107 developed discoloration and swelling under the right eye. Director of nursing (Staff #21) interviewed Resident #88 who stated, I hit him because he was trying to kick me. Staff #21 interviewed Resident #107 who stated, Resident #88 punched him after the one o'clock smoke break. The facility substantiated the allegation of abuse between these residents. The investigation report was signed by facility Administrator (Staff #95). Resident #108 was admitted into the facility on April 14, 2024 with diagnoses that included schizoaffective disorder, suicidal ideations, and diffuse traumatic brain injury with loss of consciousness. A review of the Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 14 which indicated that the resident was cognitively intact. Care-plan initiated on April 17, 2024 with revision date of June 30, 2024 revealed that Resident #108 had a behavior problem related to schizoaffective disorder bipolar. Interventions included: intervene as necessary to protect the rights and safety or others; approach/speak in a calm manner; divert attention; remove from situation and take to alternate location as needed. Review of the electronic medical records (EMR) progress note dated June 06, 2024, 09:10, revealed Resident #106 was moved to different room; and that, daughter was notified about the resident to resident altercation. Review of the facility investigation report dated June 06, 2024, revealed after the incident the certified nursing assistant (CNA/Staff #182) was suspended pending the outcome of the investigation after Staff #182 revealed, Resident #88 punched Resident #108; and that, assistant DON (Staff #58) took over the 1:1 post on Resident #88. The facility documented that Staff #182 shirked his duties as 1:1 which directly resulted in the incident. Staff #182 was terminated from employment and reported to the board of nursing for neglect. An interview was conducted on June 11, 2025 at 2:30 PM with licensed practical nurse (LPN/Staff #122) who stated abuse training is provided annually. Staff #122 state if abuse is suspected, staff report and take action right away, and move aggressor. If the abuse involves an employee they get suspended for 3 days while an investigation is conducted. Staff #122 stated abuse can be mental, physical, verbal, or sexual. Staff #122 stated physical abuse includes injury in skin or discoloration. Staff #122 stated that ideally 1 on 1 is to prevent incidents, the staff are there to prevent, ensure that no behavior is going to occur; and that, it would not meet the facility's expectation if an incident of abuse occurs while a staff are 1 on 1 with a resident because the staff should be arm's length. Staff #122 recalled incident between Residents (#88 and #107) occurred due to Resident #107 being the instigator. Staff #122 recalled incident between Residents (#88 and #108) occurred when they were new roommates. Staff #122 stated Resident #88 was a very aggressive guy he was 1 on 1 for a long time. Staff #122 stated he was physically aggressive and would mad dog a lot of the guys; and that he targeted certain residents a lot, he picked on staff as well - I would try to deescalate him a lot. An interview was conducted on June 12, 2025 at 11:01 AM with charge registered nurse (RN/Staff #60) who stated in-service training on abuse is received about at least every 2 months or after a new incident. Staff #60 stated abuse is reported Immediately - we have a 2-hour window to report and included physical, mental/emotional like condescending behavior or name calling, financial, sexual, physical as well as neglect if they weren't taken care of appropriately. Staff #60 stated physical abuse would include restraint, slapped, pinched, hair pulled, any type of physical contact that would result in distress or physical pain to the resident. Staff #60 confirmed it was a behavior policy that usually people with behavior will have a 1 to 1 to prevent any physical or verbal altercation; and that, physical abuse wouldn't meet the facilities expectations for residents who have 1 to 1 assignment. Staff #60 stated if staff are assigned 1 to 1 they would be responsible for the patient's needs, they would shadow, not allowed to leave them alone - all the duties fall on that staff non-stop. Staff #60 stated staff should be looking for target behavior would be able to tell by body language and always try to redirect; if they are dead set, separate them immediately; and that, it's my experience that if someone is 1 to 1 you can usually see the triggers and try to be preventative and proactive and be ahead of that to prevent the abuse. An interview was conducted on June 13, 2025 at 09:22 AM with staffing coordinator (Staff #110) who stated that Resident #88 was very unpredictable, his temperament always varied from being happy then doing what he wanted, so facility had to place a 1 to 1 with him. Staff #110 could not recall incidents, however recalled that they would occur readily around the smoking area, something always happens around the smoking patio. An interview was conducted on June 13, 2025 at 09:34 AM with assistant director of nursing (ADON/Staff #58) who stated, regarding the incident between Resident #88 and #106, Resident #106 was alert and was in a wheel chair and liked to antagonize. Staff #58 stated Resident #106 would name call and after antagonizing Resident #88 got up and hit Resident #106. Staff #58 stated that Resident #107 also liked to antagonize and would kick from his wheelchair. Staff #58 stated, regarding the incident between Resident #88 and #107, that Resident #88 was impulsive and Resident #107 being antagonistic did not really go together. Staff #58 stated that, regarding the incident between Resident #88 and #108, Resident #88 was 1 to 1 at that time to prevent any resident to resident incidents, therefore would not meet facility expectations if he hit another resident. Staff #58 stated that for that particular incident, I believe the staff that was assigned was afraid of the Resident (#88), so after that incident we had to be mindful of what staff we put 1 to 1. Staff #58 stated that the facility expectations are that resident to resident abuse do not occur. An interview was conducted on June 13, 2025 at 10:22 AM with director of nursing (DON/Staff #21) who stated that if staff are assigned 1 to 1 with a resident the expectation is that they are with the resident all the time and they should be engaging with the residents based on the resident's preferences. Staff #21 stated that during 1 to 1 assignment she does not want staff helping with anything else because that is their main task. Staff #21 stated that abuse occurring while a resident is 1 to 1 with staff or any physical abuse would not meet the facility's expectations. -Regarding Residents #105 and #104 Resident #105 was initially admitted into the facility on November 11, 2022 and readmitted on [DATE] and had medical history that included degenerative diseases of nervous system, major depressive disorder, and chronic kidney disease, stage 3A. A review of the Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 3 which indicated that the resident was severely cognitively impaired. Care-plan initiated on March 04, 2024 with revision date of May 30, 2024 revealed that on March 04, 2024 Resident #105 was moved to different room due to increased aggression. Additionally, Resident #105 was placed on 15-minute checks. Interventions included: monitor/document/report as needed any signs or symptoms of resident posing danger to self and others; when the resident becomes agitated: intervene before agitation escalates; guide away from source of distress. Review of the electronic medical records (EMR) progress note dated March 03, 2024, revealed one day prior to incident a nurse documented behaviors of aggression at 0700, Resident #105, ran at me with both fists fighting position and yelling that he was going to kill. On March 04, 2024, 05:31, note revealed Resident #105 in physical aggression with roommate causing injury. Resident #104 was initially admitted into the facility on December 18, 2017 and readmitted on [DATE] and had medical history that included alcohol-induced persisting dementia, psychotic disorder with delusions, and violent behavior. A review of the Quarterly MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 1 which indicated that the resident was severely cognitively impaired. Care-plan initiated on December 27, 2021 with revision date of April 19, 2024 revealed that on March 04, 2024 Resident #104 was moved to different room after roommate moved to other unit following altercation. Goal included: the resident will not harm self or others through the review date; the resident will seek out staff/caregiver when agitation occurs through the review date. Review of the electronic medical records (EMR) progress notes dated March 4, 2024, revealed Resident #104 was seen by behavioral nurse practitioner for resident to resident altercation; and that resident was moved to different room down the hall after altercation., Review of the facility investigation report dated March 06, 2024, revealed that on March 04, 2024 at 0515, behavioral residents (#104 and #105) and roommates were heard arguing. Resident #104 was relocated. The unit certified nursing assistants were providing care to other residents when Resident #105 could be heard saying, come get your buddy out of here. CNA/Staff #55 immediately went to the room and found Resident #104 bleeding above his right eye brow and had blood at his mouth. Investigation findings revealed Resident #104 was found with a laceration at the right eye brow. Upon interview, Resident #104 stated, he hit me. Facility investigation revealed adult protective services verified the allegations of neglect. The investigation report was signed by facility Administrator (Staff #95). An interview was conducted on June 13, 2025 at 09:34 AM with assistant director of nursing (ADON/Staff #58) who stated that if abuse occurs in the facility they will notify herself, director of nursing, or administrator whoever they are able to reach first. Staff #58 stated the types of abuse included verbal, physical, financial, sexual, and neglect; and, described physical abuse included hitting, and scratching. Staff #58 stated that the facility had a 2-hour time frame to report abuse. Staff #58 confirmed having a role in conducting the facility's 5-day investigations including making sure residents are safe, assessed for injuries, interview residents, set behavior evaluations, notify family of residents and update care plans. Staff #58 stated, regarding the incident between Resident #104 and #105, Resident #104 was very active and impulsive at the time of the incident; and that, I recall the incident occurring, but cannot recall details. Staff #58 stated that the facility expectations are that resident to resident abuse do not occur. An interview was conducted on June 13, 2025 at 10:22 AM with director of nursing (DON/Staff #21) who stated that staff are provided annual abuse and neglect training by psychiatry provider and if an incident occurs additional training is provided. Staff #21 stated during any new allegations of abuse she needs to be notified immediately and are reported to the health department, adult protective services, and the unit nurse will contact the police department. Staff #21 stated that if the nurse on the floor must provide some type of intervention if they have not done so after reporting. Staff #21 stated that any abuse would not meet the facility's expectations. -Regarding resident #24 (alleged victim): Resident # 24 was admitted to the facility on [DATE] with diagnoses that included: intracranial injury without loss of consciousness, sequela, aphasia following cerebral infarction, schizoaffective disorder, bipolar type, alcohol abuse (in remission), intermittent explosive disorder, major depressive disorder, recurrent, anxiety disorder, and epilepsy. Review of resident #24's care plan revealed a focus, revised on April 21, 2022 that the resident is/has the potential to be verbally aggressive in regards to schizoaffective disorder. Resident's care plan reveals no focus for physical aggression. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) score of 01, indicating severe cognitive impairment. Additionally, the MDS revealed that the resident exhibited behavioral symptoms not directed towards others 1-3 days during the assessment period. A nursing progress note dated June 6, 2025 at 1:58 p.m. stated that resident #24 was sitting on his bed with a laceration, swelling and a bruise to his left eye. According to the note, the resident stated that he was sitting on the toilet when another resident (#71) came into the restroom. Resident #24 told resident #71 to leave and when he refused, resident #24 was hit in the face by resident #71. Staff separated both residents and notified administration and management. At 2:26 p.m. another nursing progress note documented that resident #24 had slight bruising to the left eye and with no swelling noted. A nursing note dated June 8, 2025 indicated that resident had left eye bruising. The note stated that resident did not note any discomfort or pain. A progress note dated June 11, 2025 documented that resident has a bruise to his left eye which was healing. Review of resident #24's care plan revealed a focus, revised on April 21, 2022 that the resident is/has the potential to be verbally aggressive in regards to schizoaffective disorder. Resident's care plan reveals no focus for physical aggression. An observation and interview of resident #24 on June 11, 2025 at 1:32 p.m. revealed a red and swollen injury to his left eye. In an interview, resident #24 stated that his eye was still sore and that his injury was the result of being punched by another resident. He could not recall the date of the incident or the circumstances. -Regarding resident #71 (alleged perpetrator): Resident #71 was admitted to the facility on [DATE] with diagnoses that included: dementia with anxiety, parkinsonism, anxiety disorder, chronic ischemic heart disease, peripheral vascular disease, heart failure, Wernicke's encephalopathy, alcohol abuse (in remission), type 2 diabetes mellitus without complications, chronic obstructive pulmonary disease, presence of automatic implantable cardiac defibrillator, and iron deficiency anemia. A care plan revised May 22, 2024 revealed that resident #71 had the potential for verbal/physical aggression elated to his dementia with behaviors. Interventions included for staff to intervene prior to [TRUNCATED]

Based on clinical record review, interviews, facility documentation, and review of facility policy, the facility failed to ensure resident #1 was free from abuse from resident #2. The deficient practice could result in further incidents of resident to resident abuse. Findings include: Related to resident #1- Resident #1 was admitted to the facility on [DATE] with diagnoses that include alcohol induced Dementia, peripheral vascular disease, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed resident #1 had a Brief Interview for Mental Status (BIMS) assessment completed and scored a 03 which indicated the resident was cognitively impaired. Review of resident #1's care plan indicated that the resident had a behavior problem which included exit seeking, restlessness, and irritability. Interventions included administering psychotropic medications, monitoring for behaviors and remove him from the situation when staff notices he starts to escalate. Review of resident #1's Electronic Health Record (EHR) revealed a progress note dated January 30, 2025 at 5:39 AM. The note indicated that resident #1 was found in another resident's room with blood on his face and neck. The note further indicates that resident #1 reported that another resident (resident #2) had punched me real hard. The explained that the other resident (resident #2) had told staff that resident #1 was in his bed. Resident #1 was then removed from the room and his injuries were cleaned up. A second progress note, dated January 30, 2025 at 7:28 AM noted that resident #1's left cheek bone area was bruised and swelling was noted. The note also indicated that Registered Nurse (RN/Staff #87) contacted the Doctor to request an order for x-rays. Review of the facility's skin observation note, dated February 1, 2025, indicated that the resident had bruising on the left side of the face. An observation of the resident was conducted on February 6, 2025 at 10:55 AM. Resident #1's left cheekbone was purple and blue in color and there was a cut approximately 1/2 an inch on the same left cheekbone. An interview was conducted on February 6, 2025 at 11:02 AM and the resident indicated that he had fallen in the front yard. Related to resident #2- Resident #2 was admitted to the facility on [DATE] with diagnoses that include Dementia, schizoaffective disorder, and bipolar disorder. Review of the quarterly MDS, dated [DATE], indicated the resident completed a BIMS assessment and scored a 01 which indicated the resident was cognitively impaired. The same MDS also noted that resident #2 did have verbal behaviors directed towards others during the look-back period. Review of the care plan indicated that resident #2 had behaviors that included physical and verbal aggression, delusions, and hallucinations. Interventions included administering medications as ordered, monitoring the resident, and redirecting him as needed. Review of resident #1's EHR revealed a progress note, dated January 30, 2025 at 5:25 AM. The progress note indicated that staff heard resident #2 yelling get out of my bed! and staff found another resident (resident #1) standing at the foot of resident #2's bed. The note further indicates that resident #2 was observed to have blood on the back of his right and fourth knuckle. It also indicated that resident #2 told staff that he had hit (resident #1). An interview was conducted with resident #2 on February 6, 2025 at 10:36 AM in the unit courtyard outside. When asked if he had gotten into an altercation with another resident, resident #2 explained that another resident was in his room and it made him feel mad and nervous. Because of that, he hit him (resident #2) in the face. Resident #2 also added, that he wanted to stay at the facility and that he didn't hit him that hard. An interview was conducted with Certified Nursing Assistant (CNA/Staff #101) on February 6, 2025 at 10:14 AM. Staff #101 indicated that she did not see any physical contact between resident #1 and resident #2 however, she heard yelling when she was doing patient care around 5:15 AM on January 30, 2025. She saw resident #1 in room [ROOM NUMBER] standing at the foot of resident #2's bed with blood on his face. She also saw resident #2 in the room but doesn't remember where he was standing. Staff #101 explained that resident #1 tended to wander and she has had to remove him from other residents' rooms a few times to prevent them from escalating. She also indicated that she had not experienced resident #2 being physically aggressive during his shift as he would typically be verbally aggressive towards himself when he experiences hallucinations. An interview was conducted with the Director of Nursing (DON/Staff #113) on February 6, 2025 at 3:30 PM. When asked what had transpired between residents #1 and #2, staff #113 indicated that she was informed that resident #1 was in resident #2's room and was touching his things. Resident #2 had gotten upset and told him to leave. When resident #1 wouldn't leave, resident #2 then struck resident #1 in the nose. Staff #113 also shared that the nurse had intervened and separated the residents and then provided first aid to resident #1. Staff #113 also explained that resident #1 was always disoriented and doesn't know what is going on which was his baseline. Staff #113 also explained that they had a hall monitor that day of the incident to monitor residents but when the incident took place, the hall monitor had gone into another resident's room to assist someone. An interview was conducted with Registered Nurse (RN/Staff #87) on February 7, 2025 at 7:49 AM. Staff #87 confirmed that she was working on January 30, 2025 on the unit that housed residents #1 and #2. Staff #87 explained that during rounds she had heard resident #2's voice saying get out of my room. She then went to the resident's room and resident #1 was standing at the foot of the bed on the left side. She further explained that resident #2 had told her that he had punched resident #1 because resident #1 was in his bed and wouldn't get up. Staff #87 couldn't recall if resident #2 had injuries but she did recall that resident #1's left cheekbone was open and was swelling up. She also recalled resident #1 telling him that resident #2 had hit him. Staff #87 assessed both residents for injuries and removed resident #1 from the room and assisted with cleaning him up. Once the resident was cleaned up, she recalled giving him medication for the pain and a cold compress. When asked if either resident had behaviors in the past, staff #87 explained that resident #2 would clench his fists when he became upset but he had never hit anyone. He did make verbal threats to hurt people but had not acted upon it. She also explained that resident #1 was exit seeking and was very disoriented. When he exhibited those behaviors, staff watched him more closely due to him being confused as to where he was. When asked what the risks were to the residents when they are subjected to abuse, staff #87 explained that they could sustain injuries and anything could happen. Review of the policy titled Resident-to-Resident Altercations revised in September 2022 indicated that all altercations including resident-to-resident abuse are investigated and reported to the nursing supervisor. It also provided the following interpretation: Staff were to monitor residents for aggressive/inappropriate behaviors towards other residents including physically aggressive behaviors. It also explained that behaviors that may provoke a reaction by residents include wandering into others' rooms/space.

Based on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that four residents (#11, #111, #22, #3) were free from physical abuse. The deficient practice could result in further incidents of resident to resident abuse. Findings include: -Resident #1 was admitted on [DATE] and subsequently discharged on [DATE] with diagnosis including unspecified schizophrenia, type 2 diabetes mellitus and unspecified atrial fibrillation. A review of the admission MDS (minimum data set) dated October 30, 2024 revealed a BIMS (brief interview of mental status) score of 15, indicating that the resident was cognitively intact. The MDS further indicated that the resident had noted potential indicators for psychosis to include hallucinations and delusions. It was further noted that the resident has other behavioral symptoms directed toward others. A review of the progress notes revealed a nursing note entry for December 4, 2024 at 3:37 indicating that at approximately 10:00 A.M. staff #49 witnessed resident #1 threaten and try to hit another resident because he had been singing in the hallway. It was noted that resident #1 was de-escalated and noted to be calm thereafter. At approximately 12:30 P.M. it was noted that staff #49 observed resident #1 trying to hit another resident with a lotion bottle, which was taken away and resident #1 was escorted back to his room. Then at approximately 1:30 P.M. staff #49 was informed that resident #1 had hit 2 other residents and that Tucson Police Department had been called and all other notifications transpired. A review of the MAR (medication administration record) for resident #1 revealed that medications were administered as ordered. A review of the care plan revealed that the resident was noted to have behavior problems due to schizophrenia and noted interventions documented. It was further noted that the resident was admitted to the secure unit secondary to behaviors. A review of the facility 5-day investigative report dated December 6, 2024 revealed that a resident to resident altercation had occurred on December 4, 2024 at 1:10 P.M. It was noted that resident #1 had hit two other residents #11 and #111 with a part of his wheelchair which was hidden in a sock. It was further noted that resident #111 that a small bruise was discovered on December 5, 2024 post incident. Resident #1 was taken by the Tucson Police Department to the hospital for psychiatric treatment. It was noted that facility had substantiated the incident. -Resident #11 was admitted on [DATE] with diagnosis including diffuse traumatic brain injury with loss of consciousness of unspecified duration , type 2 diabetes mellitus, and schizoaffective disorder-bipolar type. A review of the quarterly MDS dated [DATE] revealed a BIMS score of 03, indicating severe cognitive impairment. A skin assessment conducted on December 4, 2024 revealed no new skin issues. -Resident #111 was admitted on [DATE] with diagnosis including unspecified dementia with unspecified severity and agitation, schizoaffective disorder, bipolar disorder and type 2 diabetes mellitus. A review of the quarterly MDS revealed a BIMS score of 01, indicating severe cognitive impairment. A skin assessment conducted on December 6, 2024 revealed a small bruise to the left forearm. An interview was conducted with an Licensed Practical Nurse (LPN/staff #49) on December 17, 2024 at 10:29 A.M. She stated that it started with resident #1 becoming agitated when another resident, #111, was signing in the hallway. She stated that resident #1 was taken to his room at approximately 10:00 A.M. at which time, she thought he was fine. She stated that the incident where he had hit 2 residents, #11 and #111, had occurred around noon. She stated that resident #1 would yell out but had never been violent or physically aggressive before. She stated that the morning of the incident his sister had dropped off his belongings, which she stated may have triggered the incident, as resident #1 had made comments that he just wanted to be out of here. She stated that resident #11 had no injuries and that resident #111 had a minor bruise as a result of the incident. She stated that the unit is well staffed. She stated that the expectation is that resident to resident altercations are not expected to happen and or are not okay. She stated that when a resident to resident altercation does occur, that the risk could be for a resident to get hurt. An interview was conducted with an LPN (LPN/staff #88) on December 17, 2024 at 10:43 A.M. Staff #88 stated that on the day of the incident, she was in the dining room assisting another resident and had heard noise outside. She stated that when she arrived outside, 2 other CNA's (certified nursing assistants) were already outside having separated resident #1 from the other residents. She stated that resident #1 had a leg rest from a wheelchair inside a sock which had been hidden in his jacket. She asked one of the CNA's to take resident #1 to his room. She stated that resident #1 had then ripped off the television from the night stand and used the cord to hit the CNA. She stated that she was able to de-escalate the resident. She stated that week prior the resident had an outburst wanting to leave and had kicked the door but then presented as remorseful. She stated that resident #1 had been regularly followed for his behavioral health needs. An interview was conducted with a Certified Nursing Assistant (CNA/staff #63) on December 17, 2024 at 10:58 A.M. Staff #63 stated that the resident had been going off all day. She stated that she only came on the scene after hearing all the commotion occurring in resident #1's room, when he was attacking the CNA. Staff #63 identified what the types of abuse were, that trainings were conducted almost on a monthly basis, steps to be taken when abuse occurs and further stated that she felt staffing was sufficient on the unit. A telephone interview was conducted with a CNA (CNA/staff #201) on December 17, 2024 at 11:04 A.M. Staff #201 stated that she had observed the incident. She stated that she was sitting in the dining room when resident #1 came out with a part of his wheelchair hidden in jacket. She stated that he had been targeting resident #111 all day. She said that she had gone out immediately to separate the residents when she saw what happened and had taken resident #1 to his room, at which time she stated that he started throwing things at her and hitting her and whipping her with the television cord. She stated that she thought it all started in the morning when resident #111 was singing in the hallway which upset resident #1, she stated that the nurse was made aware. ____________________________ -Resident #2 was admitted on [DATE] and passed away on June 3, 2023 with diagnosis including dementia of unspecified severity with agitation, primary open angle glaucoma-severe stage, chronic obstructive pulmonary disease and type 2 diabetes mellitus. A review of the quarterly MDS dated [DATE] revealed a BIMS score of 01, indicating severe cognitive impairment. The MDS further revealed noted potential indicators of psychosis to include delusions. It was further noted that the resident exhibited physical behavioral symptoms 1-3 days per week and other behavioral symptoms 4-6 days per week. A review of the facility 5-day investigative report revealed that on January 30, 2023 at approximately 2:35 P.M. resident #2 had asked for coffee and was told to shut-up by resident #22. It was further noted that resident #22 then rolled in his wheelchair across to resident #2 and scratched his face. It was noted that resident #2 had a small scratch on his cheek and under his right eye. A review of the skin assessment dated [DATE] revealed no new noted skin issues. -Resident #22 was admitted on [DATE] with diagnosis including hemiplegia and hemiparesis, aneurysm, mild cognitive impairment, unspecified psychosis, major depressive disorder-recurrent, post-traumatic stress disorder and localization related symptomatic epilepsy. A review of the admission MDS dated [DATE] revealed a BIMS score o evidence of a BIMS score; however, the 5-day investigative report from the facility did indicate a BIMS score of 11, indicating moderate cognitive impairment. A psychiatric encounter noted dated February 7, 2023 revealed that since risperdal started that the resident's behaviors have subsided. A telephonic interview was conducted with a Registered Nurse (RN/staff #215) on December 17, 2024 at 1:08 P.M. She stated that she had not worked at the facility for over a year but that she did recall the incident. She stated that she did not directly observe the incident but had come when she heard the CNA's hollering. She stated that resident #22 had come up to resident #2 and that resident #2 had wanted resident #22 to get out of his face and had raised his hand at which time resident #22 scratched resident #2's face. She stated that she thought there may have been a couple of scratches. Staff #215 stated that the residents were separated and assessed for injuries. She stated that she felt the residents were receiving appropriate services prior to the incident, that staffing was appropriate and that abuse training was conducted yearly and also after each incident. A telephone call was placed to an LPN (LPN/staff #227) on December 17, 2024 at 1:26 P.M. The call went to voicemail and a message was left requesting a call back. No return call was received. ____________________________ -Resident #3 was admitted on [DATE] with diagnosis including hemiplegia and hemiparesis, subarachnoid hemorrhage affecting left non-dominant side, major depressive disorder-recurrent, adjustment disorder with depressed mood, and polyneuropathy A review of the quarterly MDS dated [DATE] revealed a BIMS score 3, indicating severe cognitive impairment. The MDS further noted potential indicators of psychosis including hallucinations and delusions as well as verbal and other behaviors 1-3 days a week. -Resident #33 was admitted on [DATE] with diagnosis including unspecified dementia with unspecified severity and other behavioral disturbance, impulse disorder, unspecified psychosis, insomnia, anxiety disorder and extrapyramidal and movement disorder. A review of the MDS dated [DATE] revealed a BIMS score of 06, indicating severe cognitive impairment as well as noted potential indicators for psychosis to include hallucinations and delusions. A review of the progress notes for resident #33 revealed a nursing note entry on June 23, 2023 at 12:48 P.M. indicating that around 10:20 A.M. a verbal altercation had occurred on the patio between 2 residents. One resident, #3, was noted to be taunting the other, #33, and then #33 reached out and made light contact with resident #3. The progress notes revealed that there was redness to the left eye of resident #3. It was noted that notifications transpired. A review of the facility 5-day investigation dated July 28, 2023 noted that resident #33 was having a verbal argument with resident #3 on the unit patio. It was noted that a CNA, staff#116 had intervened and when she was redirecting resident #33 back inside, resident #3 was in the hallway. It was noted that resident #3 began taunting resident #33 who then reached out and made contact with resident #3. It was noted that resident #3 incurred redness to the left eye as a result of the interaction. The residents were noted to be separated and no further injuries were identified. Resident #3 was subsequently transferred to a different unit. A telephone call was placed to a CNA (CNA/staff #116) on December 17, 2024 at 10:20 A.M., the call went to voicemail and a message was left requesting a call back. An interview was conducted with the Administrator (admin/staff #77) on December 17, 2024 at 11:23 A.M. Staff #77 stated that the expectation is that resident to resident abuse does not occur, if the residents have a low BIMS score. Staff #77 stated that the frequency of abuse cases had been a little more in the past couple of months. She further stated that the facility had been going through renovations and room changes to ensure a good fit among residents. Staff #77 stated that the risk for resident to resident altercations could result in harm or death to the resident. An interview was conducted with an LPN (LPN/staff #109) on December 17, 2024 at 2:45 P.M. Staff #109 stated that the she recalled the incident but not the specifics. She stated that at the time resident #33 was able to walk, had mood swings and certain triggers, but did not recall the triggers. She stated that she could not recall if there were resulting injuries from the interaction, but did recall that contact was made. She stated that resident #3 was moved to another unit post interaction. She stated that staff receive abuse training at least every 6 months and that staffing at the time of the incident was not an issue. A follow-up telephone call was placed to a CNA (CNA/staff #116) on December 17, 2024 at 3:25 P.M. A second message was left requesting a call back. No return call received. An interview was conducted with the Director of Nursing (DON/staff #25) on December 17, 2024 at 3:12 P.M. Staff #25 stated that she was aware that the incidents had occurred and was familiar with it. She stated that her expectation is that abuse does not occur and if it should happen that staff would be knowledgeable enough to know how to deal with the situation to ensure resident safety, conduct notifications and follow the chain of command. She stated that the risk for a resident to resident altercation could be that it could cause a traumatic event for the alleged victim and the risk for the alleged aggressor could be that he could do it again. A review of the facility policy entitled Abuse, Neglect, Exploitation and Misappropriation and Prevention Program revised April 2021 revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. It is further noted that this includes physical abuse by a wide variety of individuals to include other residents.

Based on clinical record review, interviews, facility documentation, facility surveillance video, and policy review, the facility failed to ensure two residents (#1 and #4) were free from abuse from other residents (#2 and #5). The census was 123. The deficient practice can result in additional incidents of staff to resident abuse. Findings include: Regarding residents #4 and #5 - Resident #4 was admitted to the facility on [DATE] with diagnoses that included dementia, anxiety, and chronic heart disease. The quarterly Minimum Data Set (MDS), dated [DATE], included a Brief Interview for Mental Status (BIMS) score of 15 indicating the resident has no cognitive impairement. - Resident #5 was admitted to the facility on [DATE] with diagnoses that included Dementia, anxiety, and major depressive disorder. The admission MDS, dated [DATE], indicated that a BIMS assessment was not able to be completed. However, a staff assessment for resident #5's cognitive skills for daily decision making was determined to be severely impaired. Review of the care plan for resident #5, revised on October 29, 2024, revealed there was no focus or interventions related to resident #5's behaviors. A progress note for resident #4, dated October 26, 2024 AT 3:52 PM, revealed that an incident had occurred at 11:10 AM between resident #4 and another resident (resident #5) in the hallway. Resident #4 had stated that the first attack took place in resident #4's room when resident #5 had entered. Resident #4 attempted to redirect resident #5 prior to the start of the attack. The note explained that the 2nd altercation in the hallway was witnessed by staff and staff was able to separate the two residents. Resident #4 had a small laceration on the right eyebrow and on the middle back. Wound care was provided and there was no other pain or complaints from resident #4. A progress note for resident #5, dated October 26, 2024 at 7:30 PM, revealed resident #5 was witnessed having a physical altercation with another resident. The note also indicates that the victim of the altercation told staff that resident #5 had attacked (resident #4) while he was laying in his bed. The note also noted that resident #5 was observed punching resident #4 on his face which resulted in a small laceration on resident #4's right eyebrow. An interview was conducted with resident #4 on October 31, 2024 in his room. Resident #4 indicated that he currently felt safe in the facility and did not recall the altercation with resident #5. An interview was conducted with Certified Nursing Assistant (CNA/Staff #14) on October 31, 2024 at 1:11 PM. Staff #14 confirmed that she was working on October 26, 2024 and had witnessed the 2nd altercation between resident #4 and resident #5. Staff #14 indicated she was a resident's room when she had heard sounds like someone was punching a wall. When she had gone to investigate the sound when she saw resident #4 on the floor. Staff #14 indicated she asked for assistance from another CNA and they both assisted resident #4 from the floor. She observed resident #4 bleeding from the right eyebrow and attempted to de-escalate him as he was visibly upset. Staff #14 also indicated that the altercation took place right under a hallway security camera. Resident #4 was placed on 15-minute vital checks until 6:00 PM that day and resident #5 was moved to a different unit. An interview was conducted with Licensed Practical Nurse (LPN/Staff #15) on October 31, 2024 at 1:38 PM. Staff #15 confirmed that she was working on October 26, 2024 and she had witnessed part of the altercation between resident #4 and resident #5 via the security camera at the nurses station. Staff #15 stated that she saw resident #5 walk towards resident #4 in the hallway. Staff #15 indicated that when she went to the scene of the incident, she had not observed any physical altercation between the two residents. Staff #15 had indicated that resident #5 had just been admitted to the facility the night before the incident and they were still getting to know him. She had noticed that he would be triggered fast, but couldn't identify what the triggers were. Staff #15 also indicated that resident #5 was extremely confused before and after the incident and was still getting used to the new environment. After the altercation, resident #5 was moved to a new unit and both residents were placed on 15-minute neuro checks. A request was made on October 31, 2024 for a copy of the surveillance video. A copy of the video was received at 2:07 PM from the Administrator's (ADM/Staff #67) cell phone however, the video was not clear. A request was made to record the surveillance video with the State issued cell phone with staff #67 present. Surveyor and staff #67 recorded the surveillance video at 2:18 PM in the Human Resource office. An interview was conducted with the Director of Nursing (DON/Staff #41) on October 31, 2024 at 2:45 PM. When asked what abuse was, staff #41 indicated that it was willful touching or verbalizing anything that is going to have a negative effect on a patient. Staff #41 confirmed the incident took place between residents #4 and #5. She confirmed resident #4 received injuries above his left eye and a scratch on his back. Staff #41 indicated that resident #5 was just admitted so they did not any behavioral history to go on and his previous placement did not disclose the resident was aggressive. Staff #41 also confirmed that both residents were on and continued with the neuro checks and that resident #5 was moved to a different unit. A second interview was conducted with staff #41 on November 1, 2024 at 10:04 AM. The surveillance video was shown on surveyor's laptop and staff #41 was asked to describe what was taking place in the video. Staff #41 indicated that she saw resident #4 walking down the hall and start attacking resident #5 and they both started to hit each other. She also indicated that she saw several staff members enter the picture and a nurse went into a room to escort resident #4 out of a room. She also saw resident #5 continue to walk down the hall. Regarding residents #1 and #2 -Resident #1 was admitted to the facility on [DATE] with diagnoses that included bipolar disorder, antisocial personality disorder, narcissistic personality disorder, and trigeminal neuralgia (chronic pain disorder in the face). The quarterly MDS, dated [DATE], included a BIMS score of 01 indicating resident #1 had severe cognitive impairement. Resident # 2 was admitted to the facility on [DATE] with diagnoses that included schizophrenia, nicotine dependence, dementia, and bipolar disorder. The quarterly MDS, dated [DATE], revealed resident #2 had a BIMS score of 15 which indicates the resident was cognitively intact. The same MDS also indicated that resident #2 did have behaviors during the look back period but it was not directed towards others. The care plan, last revised on March 7, 2023, indicated resident #2 had the potential to be verbally and physically aggressive due to his diagnoses and that his behaviors fluctuated. Interventions included anticipating the resident's, assessing his coping skills, administer medications as ordered and maintain boundaries/personal space. Review of resident #1's progress notes revealed a progress note, dated October 26, 2024 at 7:35 PM. The progress note indicated that resident #1 was sitting in his wheelchair and another resident (resident #2) had kicked resident #1 in the right leg. The note indicates there was no injury or pain reported. Review of progress notes for resident #2 reveals an entry dated October 26, 2024 at 7:32 PM. The note indicated that resident #2 had returned from a smoke break and was upset which led to him kicking another resident (resident #1). The note indicated the incident was witnessed by a CNA (staff #14). An interview was conducted with a CNA (CNA/Staff #14) on October 31, 2024 at 1:23 PM. Staff #14 confirmed that she witnessed the altercation between staff #1 and #2 on October 26, 2024. She stated that prior to the altercation, resident #2 was off after he had a visit from his wife and brother, was more jumpy than normal, and was exit seeking. She stated that resident #2 is usually easily redirected and is able to calm down when staff talk with him but it wasn't the case on that day. Several residents including resident #2 were going back to the unit after the smoke break and resident #2 had stated that he wanted to fight staff #14 and was cursing. When they all went back to the unit and staff #14 informed the floor nurse of the situation. She then saw resident #2 hit resident #1 on the right leg as she was standing behind resident #2. Staff #14 stated that resident #1 was assessed and there were no injuries. An interview was conducted with an LPN (LPN/Staff #15) on October 31, 2024 at 1:38 PM. Staff #15 explained that resident #2 was returning from a smoke break and the CNA (staff #14) was holding the door open. She stated that both residents #1 and #2 were in their wheelchairs and resident #2 was going to his room from the hallway and kicked resident #1 with no warning. Staff #15 indicated that when resident #2 gets upset, there are no warning signs prior to the incident. An interview was conducted with the DON (DON/Staff #41) on October 31, 2024 at 2:57 PM. Staff #41 explained that residents who smoke go to the smoking area together as they move from their unit to the outdoor smoking area. She explained that resident #2 had gotten upset because he had finished smoking and did not want to wait for everyone to return back to the unit. When the CNA had asked him to wait, resident #2 had become agitated. Staff #41 indicated there was no injuries sustained during the incident and both residents were separated and placed on 15-minute checks. She also indicated that the facility changed the route that residents take to the smoking area and that specific unit is now able to go directly to the smoking area from their unit which allows residents to leave the smoking area once they are done instead of having to wait for everyone. If asked if there was anything staff could have done differently to prevent the incident from occurring, staff #41 indicated that staff could have recognized resident #2 being more aggressive than usual ad not allow him to walk by other residents when he was agitated. She stated that she is working with staff to recognize warning signs prior to an incident happening. A review of the facility policy titled Abuse shows abuse being defined as Physical abuse includes, but is not limited to hitting, slapping, biting, punching, or kicking. It also revealed that abuse can be resident-to-resident as well.

Based on clinical record review, interviews, and policy review, the facility failed to ensure one resident's (#3) rights were honored related to refusing medications. This deficient practice could result in further violations of resident's rights. Findings include: Resident #3 was admitted to the facility on [DATE] with diagnoses of Parkinson's disease, type 2 diabetes, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 10 indicating resident #3 had mild cognitive impairement. A review of the physician's orders indicated there was an order for Dulcolax suppository inserted rectally, as needed, if no bowel movement in 3 days. A review of resident #3's bowel elimination task chart reveals resident #3 having bowel movement on October 17, 2024 at 2:48 PM. The October medication administration record indicated Dulcolax suppository was administered on October 18, 2024 by Licensed Practical Nurse (LPN/staff 120). A progress note in resident #3's electronic health record (EHR), dated October 18, 2024 at 2:45 PM indicated that the resident was given a medication that she did not want and the resident's Power of Attorney (POA) was notified. An interview was conducted with resident #3 on November 1, 2024 at 8:53 AM. Resident #3 recounted a nurse (Staff #120) giving her a suppository two weeks prior. She shared that she had told her (staff #120) that she did not want the suppository but was given it anyways. An interview was conducted on November 1, 2024 at 9:05 AM with an LPN (LPN/staff #81). Staff #81 explained that if she is needing to offer a suppository to a resident she would try to encourage them to take it by educating them the purpose of the medication. If that didn't work then she would re-approach the resident later. When administering a suppository, staff #81 indicated they would figure out why a resident was needing a suppository and ask them if they wanted it. If they said no, then they wouldn't give it to them and let the provider know. Staff #81 also indicated that they would not give a resident a suppository if they did not agree to it because it would be a dignity issue and you cannot do something to a resident without their permission. An interview was conducted on November 1, 2024 at 9:15 AM with an LPN (LPN/staff #107). Staff #107 explained that she would offer a suppository as a PRN if they wanted it. If they didn't want it then she would let the provider know. Staff #107 also indicated she would not give the resident the suppository if they said no to it. She explained that it could cause the resident to feel violated and embarrassed. An interview was conducted on November 1, 2024 at 9:26 AM with an LPN (LPN/Staff #15). Staff #15 indicated she would follow the bowel movement protocol when needing to give a resident a suppository. First, she would try to give a resident oral medication to see if it works and if it didn't work she would try a suppository. If the resident did not want a suppository then she would notify the provider and go from there. Staff #15 also indicated that it was not an acceptable practice to give a resident a suppository if they had refused it. She continued by saying it could be a traumatic experience for them and there could be a reason behind why they had declined the medication. An interview was conducted with the Director of Nursing (DON/staff #41) on November 1, 2024 at 10:10 AM. Staff #41 indicated that she would give a resident a suppository after following the bowel protocol which indicates if the resident does not have bowel movement in 3 days they are to be administered oral medications. If after two doses of the oral medications there are no results, then a suppository is administered. If the suppository does not work then an enema is given. Staff #41 explained that if a resident did not have bowel movement after 3 days, then an alert would pop up in the EHR alerting staff of the issue. Staff #41 indicated that she would expect staff to explain the risks and benefits of not getting a suppository to the resident a few times to be sure they did not want the medication. Staff #41 also added that in this situation, the resident was alert and oriented so staff #41 believed resident #3 when she said she did not want it. Staff #41 indicated that it was not an acceptable practice to give resident #3 a suppository after she said she didn't want it. The harm to a resident when giving them medications, after they said no, would be psychological harm because it's a very evasive thing that is happening to them and the resident would not be as trusting of staff, especially nurses. Staff #41 concluded that (staff #120) did not act within my expectations and staff #120 was terminated after the facility's investigation. A review of the facility's bowel movement protocol indicates that normal bowel function is considered to be at least 3 stools a week and less than 3 stools a day. It also indicates that if there were no bowel movements in more than 3 days, staff are to ensure there are bowel sounds, determine if there is abdominal discomfort/distension, ensure the resident is drinking fluids and fiber, increase resident activity, obtain an order for bowel regimen protocol, and discuss additional interventions with the resident's physician.

Based on observation, staff and resident interviews, clinical record review, facility records and facility policy, the facility failed to ensure that one resident (#28) was free from abuse. This deficient practice could lead to further incidents of resident abuse. Findings include: -Resident #28 was admitted on [DATE] with diagnoses of Major Depressive Disorder, and Schizoaffective Disorder. A quarterly Minimum Data Set (MDS) dated [DATE] included that this resident was cognitively intact, used a wheelchair and had functional limitation for range of motion in both upper and lower extremities. A review of the care plan included that this resident has behaviors including false accusations, mood lability, voicing sadness related to Major Depressive Disorder and Schizoaffective disorder. -Resident #6 was admitted [DATE] with diagnoses of sexual disinhibition, Major Depressive Disorder and cerebral ischemia. A quarterly MDS dated [DATE] included that this resident was cognitively intact, uses a walker, and has no functional impairment for range of motion in both upper and lower extremities. A care plan dated November 18, 2021 included that this resident is/has potential to be physically aggressive and hypersexual related to poor impulse control and sexual disinhibition and included interventions of assessing and anticipating the residents' needs. A care plan included that resident #6 uses psychotropic/mood stabilizing medication with targeted behaviors including but not limited to sexual disinhibition with an intervention dated April 14, 2022 to monitor/record occurrence of for target behavior symptoms: sexual disinhibition, insomnia, etc. and document per facility protocol. A physician's order dated February 28, 2022 included monitor targeted behavior of: sexual disinhibition every shift. A Medication Administration Record dated October of 2024 included that this resident had exhibited sexual disinhibition on the 4th and the 9th. However, no additional interventions were noted for this resident. An observation conducted on October 21, 2024 at 2:00 PM included residents making craft items with beads in the main dining hall. Resident #6 and #28 were sitting at the same table doing crafts, across from each other. An interview was conducted on October 21, 2024 at 2:11 P.M. with resident #28 who said that resident #6 kissed her and that he's in here doing beading. She said that he used to be in the same hall but when she told someone he got moved. She said that she still has nightmares from the incident. She said that the incident happened this month in the patio out in front of the building. She said that she was sitting there and that he came up and kissed her then he said that he didn't want nobody to see and walked away. She said that the patio lights don't work and that it was after dark, and that no other persons were out there with them. She said that she still sees resident #6 at activities and said He gives me the creeps. She said that she told everyone. This resident pointed out that resident #6 was right there sitting across the table. An interview was conducted on October 21, 2024 at 2:23 P.M with resident #6 who said that he does not really know resident #28. This resident said that he does not really talk to her. Resident #6 said that he was in front of the building and that it was late in the evening. This resident said that yes, he kissed her. He said that she did not say anything when he did. He said that the facility may have moved him because of the incident, because I was in A wing and i moved to the other side, to B. An interview was conducted on October 21, 2024 at 2:28 P.M. with an activities staff (#34) who was monitoring the table resident #28 and #6 were sitting at. This staff said that she thought the incident between resident #6 and #28 occurred 2 weeks ago because she was talking with resident #28 and the resident said they were just talking and he stood up and smooched her. This staff said that she does not think that there was a staff present because it was evening time, and that residents are allowed to go out front whenever they want. This staff said that she believed that resident #6 was moved to a lockdown unit so he does not have as much freedom as he did before. This staff said that the two residents were sitting at the same table because they were monitored. An interview was conducted on October 21, 2024 at 3:22 P.M. with a Receptionist (staff #59) who said that her shift ends at 4 P.M. and that there would not be someone sitting at the reception desk overlooking the front patio when it began to get dark at 5 P.M. or later. An interview was conducted on October 21, 2024 at 3:26 P.M. with a Licensed Practical Nurse (LPN/staff #68) who said that resident #6 was transferred from another unit and that this nurse thought he might have kissed another resident. This nurse said that they are watching for sexual or invasive behaviors but that they had not worked with the resident very long and had not seen any behaviors. An interview was conducted on October 21, 2024 at 3:50 P.M. with a Unit Manager (staff #133) who said that resident #6 was transferred for kissing resident #28. This nurse said that she was told by resident #28 that it happened out in front of the building, she didn't know what day it happened. She said that resident #6 had not had sexually disinhibited behaviors for a very long time and that it was usually that he made compliments that were too friendly. This nurse said that resident#28 admitted to them that he said that he did kiss her and that he agreed to go to the locked down unit. An interview was conducted on October 21, 2024 at 4:22 P.M. with the Director of Nursing (staff #128) who said that her understanding was that residents #6 and #28 were sitting outside and resident #6 approached #28 and kissed her, she told him to stop and he did, she said she didn't report it till a week later, he admitted to it and that when she told him to stop he left her alone. This staff said that resident #28 has had a history of just sitting next to women, being close to him and that he had not had any behaviors for months. This DON reviewed the MAR which included that the resident had sexually disinhibited behaviors and said that she did not know what the incidents were but that It possibly could mean he was sitting next to or said something to a staff member, he has made comments to female staff sexually disinhibited statements. This DON said that there had not been any prior incidents between these 2 residents. This DON said that her expectations with abuse is that it never occurs. A policy titled Identifying Sexual Abuse and Capacity to Consent revealed Sexual abuse is non-consensual sexual contact of any type with a resident. A policy titled Identifying Types of Abuse revealed Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident requires but the facility fails to provide them and this has resulted in (or may result in) physical harm, pain mental anguish or emotional distress.

Based on staff and resident interviews, clinical record review, facility documents, and facility policies, the facility failed to ensure that residents do not abuse other residents. This deficient practice could result in physical and psychosocial harm to the residents. Findings include: Regarding the altercation between Resident's #4 and #10: A self report received 9/13/2024 included It is alleged that behavioral resident (resident #4) was walking past fell ow behavioral resident (resident #10) in the Tu Jhanu Unit Dining Room. As she passed by, she apparently brushed his back with her arm. It is alleged he turned around and swung his arm potentially hitting her in the back. (resident #4) was not injured. Residents were separated. (resident #10) is being relocated to another unit in the facility. Investigation has commenced and a 5-Day Report will follow upon completion. -Resident #10 was admitted on [DATE] with diagnoses of dementia with agitation, and Schizoaffective disorder. An admission MDS dated [DATE] included that this resident was severely cognatively impaired, was independent for most ADLs, and had verbal psychiatric behaviors directed at others 1-3 days of the 7 day assessment and other psychiatric behaviors 4-6 days of the 7 day assessment. A psychiatric note dated 8/23/2024 included this resident is transferred from haven behavioral Hospital Phoenix to be a long-term care resident at this facility. He has history of SMI dementia,schizophrenia and bipolar disorder. He was transferred from a local group home to haven Hospital on 5/8/2024. As per a notefrom a psychiatry care evaluation at haven behavioral Hospital in Phoenix on 5/9/2024by Dr. [NAME], DO, where it states that he has history of SMI managed byKodak on a court and was brought in byEMT from urgent psychiatric center forinpatient treatment of being aggressive athis group home and displaying symptoms ofpsychosis. He actually became acutely psychotic at his group home assaulting others in his group. He was aggressive inthe nursing home and refused to take medications. He was stabilized and subsequently transferred to [NAME] care on for ongoing long-term care. Multiple nursing notes from 8/24/2024 to 09/12/2024 including the resident experiencing symptoms of auditory hallucinations including agitation and aggression. A Behavior Note dated 9/12/2024 included that the resident was observed on outdoor patio yelling at himself appearing to be in an argument. This note included that the resident had his fists balled up and began punching the air while we yelled Get out of here! Get out of here! Resident then went to his room and continued to pace from his room to outdoor patio as he has been since 0400. A nursing note dated 9/12/2023 included that his resident was transferred to TJ unit. A nursing note dated 9/13/2024 included that a CNA approached nurses station stating that resident #10 had struck out at another resident and that staff states that a female resident wandered up to resident while he was sitting down in the dining room and brushed her hand up against residents' shoulder/back, and staff went to redirect resident, and as staff and the female resident walked away, he struck out, hitting the female resident in the back. -Resident #4 was admitted on [DATE] with diagnoses of dementia, Alzheimer's, and violent behavior. An admission MDS dated [DATE] included that this resident was severely cognitively impaired, was independent to walk, and had hallucination and physical behavioral symptoms 1-3 days of the 7 day assessment. A care plan dated 9/6/2024 included this resident has a behavior problem related to mood lability, exit seeking and PICA eating exhibited by combativeness, violent behavior and aggression related to advanced frontotemporal dementia/Alzheimer's. This focus has an intervention to intervene as necessary to protect the rights and safety of others, to divert attention and to remove from situation and take to alternate location as needed. A nursing note dated 9/13/2024 included that around 1515 while documenting at the nurse station heard some commotion at the dining room. This note included that during assessment redness noted around mid-back area and that ADON, ED and unit manager notified. A nursing note dated 9/13/2024 at 21:47 included that this resident continues to wander around the unit. Patient has been found going in and out of multiple rooms. Patient also tends to constantly touch other residents. Patient complaint with medications, requires constant redirection. Resident ambulates independently and requires moderate assistance with ADL's An interview was conducted on 9/24/2024 at 10:00 A.M. with an LPN (staff #23) who said that he had not directly cared for resident #4 but that she was pacing around the unit and that she did not take durections very well. This nurse said that she'll go into other patient's rooms and into nursing station. This nurse said that she doesn't talk. This nurse observed a camera and said that the resident is pushing another residents' wheelchair right now and that she will touch residents and and push their wheelchairs. An interview was conducted on 9/24/2024 at 10:15 with a CNA (staff #39) who said that resident #4 is our wanderer and that the moment she's up she will walk through hallway and dining room, will exit seek, and that they redirect her when necessary and redirect her from rooms. This CNA said that she likes to touch arms so we redirect when she does that. This CAN said that she was there at the incident and that resident #10 was sitting at the u shaped table, and that he already seemed like agitated. This CAN said that resident #4 touched resident #10, so she redirected her away from resident #10 and as soon as she walked away he did like this hitting motion on her back. This staff said that resident #4 said ow loud, and that you could hear that it was a hard hit. This staff said that resident #4 was brought to the nurse and she checked her out. This CNA said the staff redirect the best they can and that they do every 15 minute checks but not 1 to 1. This CNA said that resident 4 is not doing a bad or aggressive touch but that they keep an eye on it. This CAN said that resident #10 was in our unit a day or two before the incident happened and then they took him out so she did not know him well but that he paced, and would loudly let you know he didn't want people around. An interview was conducted on 9/24/2024 at 10:28 A.M. with an LPN (staff #96) who said that resident #4 is very pleasant, very touchy and will pat on back or shoulder, and that she wanders everywhere. This nurse said that she was not there for the incident and that when she came onto shift a few days later there was no mark on resident #4. This nurse said that resident #10 was on the unit for a couple days and that he was pleasant, and did pace a lot and would repeat stuff. Regarding the altercation between resident #3 and #8 A complaint received by the Department of Health dated 9/13/2024 included that In the facility Dining Room, behavioral resident( #8) threw his cup of coffee at behavioral resident (#3), hitting her in the face with liquid. (Resident #3) was immediately removed from the dining room and taken to the unit. She stated she told him he should not be smoking, and that he became angry and threw his drink on her. (Resident #8) initially denied the allegation, but then admitted to it, stating I had to do it. She talks too much. No injuries were noted to either party. -Resident #8 was admitted on [DATE] with diagnoses of Major Depressive Disorder, and Schizoaffective disorder, Bipolar type. A discharge return anticipated MDS dated [DATE] included that the resident was moderately impaired for daily decision making and had verbal and other behavioral symptoms 1-3 days of the 7 day assessment. This document included that this resident was independent for most ADL's. A care plan dated 6/5/2024 included that the resident has a behavior problem with intrusiveness, auditory and visual hallucinations and verbal aggression related to schizoaffective disorder bipolar type and Major depressive disorder. Interventions included intervene as necessary to protect the rights and safety of others. A review of the clinical record did not include notes regarding this incident. A Behavior Note dated 7/10/2024 included that this resident is being monitored for target behaviors of verbal aggression, intrusive, door slamming, audio and visual hallucinations. This note includes that the resident is impulsive and intrusive and that he gets easily agitated with staff when attempts to redirect are made. A communication note dated 9/12/2024 included that the writer spoke with resident regarding increase in verbal outbursts, and irritability towards others. Resident states that he has anger issues and gets mad fast he is aware that his behavior is not acceptable but states he cant help it. writer spoke with resident about moving to secure unit r/t increase in behaviors. resident agrees to move to secure unit and has signed secure unit consent. -Resident #3 was admitted on [DATE] with diagnoses of Schizoaffective Disorder, Bipolar Disorder and Major Depressive Disorder. A Quarterly MDS dated [DATE] included that this resident was not cognatively impaired and had no behaviors during the 7 day period. This assessment included that the resident was independent with most ADLs. A care plan dated 12/21/2021 included The resident has potential to be verbally aggressive related to ineffective coping skills and included interventions of when the resident becomes agitated: Intervene before agitation escalates and guide away from source of distress. A review of the clinical record did not include notes regarding this incident. An interview was conducted on 9/24/2024 at 9:54 A.M. with resident #3 who said that she liked it in the building, however one of the people sitting at her table threw coffee in her face. She said that the person who did was a wrestler, and he was violent at times. She said that he took things in the wrong manner. She said that the coffee was hot and got into her eyes and hurt her. She said that staff #53 helped her and that she was ok. She said that she was glad to get away from the person who did it because he hated her and wasn't done with her yet because he said she was a narc. She said that she was afraid to leave her room because he said he was going to hurt her and that she believed him. She said that she was doing good since he was put into lockdown but that for a little while she had to deal with him. An interview was conducted on 9/24/2024 at 11:07 P.M. with a RNA (staff #87) who said that she saw the incident when resident #8 had already thrown the coffee cup and it was midair. She said that the staff immediately went over there and asked one of the CNA's to remove resident #3 and then asked resident #8 asked why he had done it because they were not arguing. This staff said that both resident involved said they were talking about smoking and resident #8 was very annoyed and said she needs to shut up, she talks too much. This staff said resident #3 had said that he should stop smoking that shit, got more agitated after that. This staff said that resident #3 and #8 were friends prior to the incident and that she believed that resident #3 she came from a friendly place but resident #8 didn't appreciate it. This staff said the nurse was asking him questions about the incident like asking why and advising him not to do it again. This staff said resident #8 got very agitated, and he told the nurse to get away, I'm gonna beat you or maybe I'm going to hit you, something like that. This staff said she walked up and got in between because she thought resident #8 was going to throw his walker. This staff member said that staff asked him to go to his room and that she would take his tray to him and that she did and he stayed in his room. This staff said that resident #3 was ok, and had no burn marks and that she was just scared. An interview was conducted on 9/24/2024 at 10:50 A.M. with a **Nurse (staff #53) who said that residents #3 and #8 were on different wings and that the CNA's who were in the dining rooms saw and that they came to her right after. This nurse said that staff #87 witnessed it, and #54 witnessed the second part, when she spoke to resident #8 and and he got physically and verbally aggressive. She said that there was no visible injury on resident#3 and that usually by the time they served the coffee it was probably lukewarm. This nurse said resident #3's face and clothes and clothing was wet, and that there was no redness to the skin, no burn. She said that there were 3 residnets that sat at that table and that the other resident and resident #8 were talking about vaping, THC pens and that she believes that resident #3 overheard that and and she was lecturing them on the downfalls of doing that. This nurse said that she had a long talk with resident #3 about reporting to her instead of confronting residents. This nurse said that resident #8 was originally on a locked unit and was placed back on a secured unit. This nurse said that when resident #3 she told me, i had no doubt because he was an aggressive person.This nurse said that resident #3 and a CAN came over and told me what happened, then she went to the dining room and told the CAN and the resident to stay at the nurses station. She said that resident #8 initailly told her that he had dropped the cup but that she could see from the pattern of the coffee that it had not been dropped. This nurse said that she told resident #8 that he should not confront other residents or throw things and that he got really upset really quick, once he thought he was going to be confronted, he jumped up and he was pretty foul, saying fuck you, going to kill you and that's when staff #54 came up. She said that they rearrainged seating once the situation was resolved but that resident #8 was pretty quickly put on the locked unit. This nurse said that resident #3diana was upset but that she could be reactive and we reassured her. She said that they were sitting on opposite ends of the dining room but that she was afraid because of his size and he was more mobile. She said that resident #3 is now back at bingo, and it was just a one or two day thing. An interview was conducted on 9/24/2024 at 11:18 A.M. with a CNA (staff #54) who said I was walking in after it happened, resident #3 was being wheeled away, and that she saw her dripping, didn't know what happened yet, so this staff followed resident #3 and the aids. This staff said that the aids said that resident #8 put coffee in resident #3's face and so this staff walked to dining room. This staff said that when the nurse spoke to resident #8, he first denied throwing it then then admitted and said it because she didn't shut up. This staff said that the nurse continued talking to resident #8 and he stood up and grabbed walker like he was going to throw the walker at her, then a CAN asked him to not eat in dining room. This staff said that he then wrote a report on the incident and cleaned the floor. An interview was conducted on 9/24/2024 at 12:30 with the Director of Nursing (DON/staff #30) who said that her expectations were that abuse does not occur and that we prevent it from happening. This DON said that for the incident for resident #4/#10 she said that the resident were immediately separated and resident #10 was immediately taken to another unit. She said that there has been no more incidents since he was moved to the new unit. She said that resident #4 will just innocently will try to console or touch residents on the shoulder and that she gets redirected every time it is attempted. The DON said that regard residents #3/#8 that she was informed that all of the residents involved were sitting at same table and were having a discussion and resident #8 became angry and threw the coffee. This DON said that the coffee did hit resident #3. This DON said that she asked resident #3 about it and she said that she was talking to them about smoking and reprimanding them and resident #8 became offended. A policy titled Abuse, Neglect, Exploitation and Misappropriation Prevention Program revised April 2021 included that residents have the right to be free from abuse and neglect.

Based on record review and interviews, the facility failed to protect the rights of two residents (#4 and #1) to be free from abuse by other residents (#6 and #5). The deficient practice could result in further resident abuse. Findings include: Regarding Resident #4 Resident #4 was admitted on [DATE] with diagnosis of hemiplegia, hemiparesis, major depressive disorder, and adjustment disorder. A review of the MDS (minimum data set) assessment dated [DATE] revealed a BIMS (brief interview of mental status) score of 3 indicating severe cognitive impairment. A review of the care plan revealed that resident #4 had potential for psychosocial-well-being problem and had potential for behavior problem related to major depressive disorder with target behaviors that included taunting peers, slamming door, verbal agression, and physical aggression. Regarding Resident #6 Resident #6 was admitted on [DATE] with diagnoses of dementia with behavioral disturbance, impulse disorder, and unspecified psychosis. A review of the MDS assessment dated [DATE] revealed a BIMS score of 6 indicating severe cognitive impairment. Review of the care plan revealed that resident #6 had the potential for psychosocial well-being problem related to anxiety. Interventions include to encourage the resident to express feelings of anger, guilt, and frustration. The care plan also revealed that resident #6 had the potential to be physically and verbally aggressive related to poor impulse control, dementia and psychosis. Interventions inlcuded to monitor, document, report as needed any signs and symptoms of resident posing danger to self and others; redirections, one on one, activity distractions, and return to room; and communication by providing physical and verbal cues to alleviate anxiety. The 5-day investigative report dated July 28, 2023 revealed that resident #6 was having an argument with another resident on the patio when a certified nursing assistant (CNA/staff #80) intervened. It was noted that staff #80 was redirecting resident #6 back inside the unit when he encountered resident #4 in the hallway. It was documented that resident #4 was verbally taunting resident #6 and as the residents passed each other, resident #6 made contact with resident #4. It was noted that resident #4 had resulting redness to the left eye due to the encounter. A call was placed to a CNA (staff #80) on April 1, 2024 at 11:20 A.M. The call went to voicemail, and a message requesting a return call was left; however, no return call was received. A call was made to LPN (staff # 151) on April 1, 2024 at 1:55 P.M. The call went to voicemail and a message was left; however, no return call was received. An interview was conducted on April 1, 2024 at 2:15 P.M. with a CNA (staff #113). The CNA stated that she was not aware of any other incidents involving either of the residents. She stated that resident #4 can be a little verbally aggressive, but does not touch anyone. Staff #113 stated that all new hires were trained on the types of residents that they may encounter. She stated that she has had training on abuse and abuse prevention. She stated that the facility provides reminders when trainings are due. She further stated that abuse should not occur and if it does happen then staff should intervene, separate the residents, make sure they are safe, report the incident and conduct the written documentation of the incident. An interview was conducted April 1, 2024 at 3:36 P.M. with the ADON (assistant director of nursing). The ADON stated that both residents reside on a secure behavioral unit and that on July 23, 2023 resident #4 and resident #6 had a verbal altercation in the hall. She stated that resident #4 had called resident #6 a nigger. She stated that she did not recall further specifics of this incident, but stated that when a heated conversation or yelling is observed the focus is to separate the residents involved, get control of the situation and ensure the safety of everyone involved. She further stated that the expectation was that abuse do not occur, but when incidents do occur, that they are reported and that resident's safety is ensured, medications are reviewed and potential behavioral health referrals are made as warranted. --------------------------- Regarding Resident #1 Resident # 1 was admitted on [DATE] with diagnosis of senile degeneration of the brain, anxiety disorder, insomnia and COPD (chronic obstructive pulmonary disease). A review of the MDS assessment dated [DATE] revealed a BIMS score of 0 indicating severe cognitive impairment. A review of the resident's care plan revealed the resident had potential to be physically aggressive related to dementia and poor impulse. In addition, the care plan revealed that on August 22, 2023 resident was a victim of a resident to resident. Regarding Resident #5 Resident #5 was admitted on [DATE] with diagnosis of unspecified dementia, obsessive compulsive disorder, atrial fibrillation, major depressive disorder, and mood disorder. A review of the MDS assessment dated [DATE] revealed a BIMS score of 6, indicating severe cognitive impairment. Review of the resident's care plan revealed that the resident had potential for psychosocial well-being problem, non-compliance with potential risk for injury related to the noncompliance, impaired decision making, a history of being resistive to care, resident elopement risk, potential for communication problems due to impaired cognition and dementia. The care plan also noted that resident was the aggressor in a resident to resident altercation in August 22, 2023. The 5-day facility investigation report dated August 23, 2023 revealed that on August 22, 2023 at 4:40 P.M. residents #1 and #5 were in the dining room prior to dinner. Resident #1 was seated on resident #5's walker and resident #5 was seated on a chair. The report further noted that resident #5 wanted to get up and use his walker and motioned for resident #1 to get up; however resident #1 did not get up. Resident #5 then pushed resident #1 and subsequently struck resident #1 on the cheek when he failed to get up from the walker. A skin assessment for resident #1 and revealed initial redness, which was noted to have subsided by August 23, 2023 at 7:43 A.M. A telephone interview was conducted on April 1, 2024 at 1:38 P.M. with a RN (registered nurse, former staff #152). Former staff #152 stated that she did not observe the incident but did assist with separating the residents immediately after the incident and insured their safety. She stated that to her recollection, resident #1 did have some scratches as a result of the incident, but because it occurred so long ago, she stated that she was uncertain. She stated that post incident, the resident meal times were staggered to mitigate any future encounters. An interview was conducted on April 1, 2024 at 1:58 P.M with a hospitality aide (staff #153). Staff #153 stated that she had observed the incident from a distance. She stated that resident #5 had become upset with resident #1 for sitting on his walker and had observed resident #5 reaching out to hit resident #1. She stated that she told resident #5 that it was not nice to hit. Staff #153 stated that the dining room is a smaller space and that on this date chairs were limited and that resident #1 had sought out any available place to sit. Staff #153 stated that resident #5 did not like resident #1 taking things from him. She stated that there have been no further incidents between the two residents as resident #1 just ignores resident #5 now. She stated that there were enough staff on the unit that day but not present in the day room. She further stated that that there were days where she was in the day room all by herself with a large number of residents making it hard to keep track of everyone. She stated that sometimes, especially in the mornings it could get a little overwhelming. An interview was conducted on April 1, 2024 at 2:15 P.M. with a CNA (staff #113). Staff #113 stated that she was familiar with both resident and that staff #1 was noted to be a wanderer and on occasion would take things from other residents. She stated that on occasion she has had to redirect resident #5 regarding the placement of his walker in the dining room. She stated that the outburst from resident #5 that day would have been willful. Staff #113 further stated that the facility provided regular training regarding abuse and abuse prevention. Staff #113 stated that abuse should never occur. She stated that if there was an incident, she would separate the resident, ensure their safety, report it to the nurse and conduct her write-up. An interview was conducted on April 1, 2024 at 3:48 P.M. with the Administrator. The Administrator stated that training regarding abuse was conducted annually and post any abuse related incidents. The administrator stated that the expectation was that abuse do not occur and that if everyone followed policy, then there would be no need for these types of investigations. A review of the facility policy entitled abuse, neglect, exploitation and misappropriation prevention program, revised April 2021, noted that residents have the right to be free from abuse; however, per facility documentation and interviews, both verbal and physical abuse occurred.

Based on observations, staff interviews and facility policy, the facility failed to ensure that proper food safety measures were implemented. Failure to meet this requirement could result in the spread of food borne illness. Findings include: An observation was conducted on October 25, 2023 at 10:34 AM of a female staff filling pitchers with ice, and then filled some with iced tea and juice with her face mask on her chin. An interview was conducted on October 27, 2023 at 7:33 AM with the Dietary Manager who said that kitchen staff should be wearing an N95. An observation was conducted on October 25, 2023 at 11:30 AM of food items being temperature checked by the kitchen manager. A container of biscuit puree was checked to be at 123.6 F. The staff began dishing up and serving the biscuit puree. An interview was conducted during this observation with a chef (staff #135) who said that the biscuit puree had been prepared at 10:20 AM. An interview was conducted during this observation with the Dietary Director (staff #54) who said that bread does not have a temperature, so puree did not have a temperature. A follow up interview was conducted approximately 10 minutes after this observation with the Dietary Director (staff #54) who asked a cook (staff #135) what temperature the biscuit puree had been reheated to and he said 145 F. This dietary manager said she would get the biscuit puree and heat it to 165 F and that she would be retrieving the puree already sent to the residents and provide new biscuit puree. An interview was conducted on October 27, at 11:26 AM, with the Administrator (staff #160) who said that he was not aware of the temperatures required for food holding but that he knew where to find the temperatures. He said that food that was held outside of proper holding temperatures did not meet his expectations. A Policy and Procedure Manual titled General HACCP Guidelines for Food Safety was undated and revealed that Food and nutrition services staff will be educated and supervised on all HACCP information and procedures. This document also included that food in hot holding should be maintained greater than 135 F and that If food drops less than 135 F, reheat to 165 F for minimum of 15 seconds.

Based on observations, clinical record reviews, staff interviews, and policy review, the facility failed to ensure the medication error rate was not more than 5%, by failing to administer medications as ordered to one resident (#44). The medication error rate was 20%. The deficient practice could result in further medication errors. Findings include: Resident #44 was admitted to the facility on [DATE] with diagnoses that included Dementia, Anxiety, and Hypertension. During a medication administration observation conducted on October 26, 2023, at 7:24 AM, a Registered Nurse (RN/staff #72) was observed administering crushed medications to resident #44. Staff #72 was asked how they know medications are to be crushed prior to administering. Staff #72 indicated they reference the daily roster list which identifies residents on that wing and how they take their medications. Review of the physician's orders indicates an order for crushing medications as needed was added to the record on October 26, 2023 at 8:28 AM. An interview was conducted with staff #72 on October 26, 2023 at 9:37 AM. She stated she reviews medication orders in the morning before starting with medication administration. She also stated if there are no orders for a specific medication then she would either report it to the Director of Nursing or call the provider to obtain an order. When asked if there was an order for resident #44 to have their medications crushed, she stated there was as an order put into her chart after she administered the crushed medications. Staff #77 stated after she administered the medications she informed the Licensed Practical Nurse/Unit Manager (LPN/staff #40) that she had given the crushed medications to resident #44 with no orders. Staff #72 stated she had been giving that resident crushed medications since started working at the facility in May of this year. An interview was conducted with staff #40 on October 26, 2023 at 9:50 AM. Staff indicated she had been working at the facility for two years but has been the unit manager for two months. She stated that providers are to give them orders for medications to be crushed before they are able to administer crushed medications. She stated that staff #72 approached her earlier this morning and informed her that she had given resident #44 crushed medications because it was easier. Staff #40 then texted the physician at 8:19 AM and asked for orders to crush medications. An interview was conducted with the Director of Nursing (DON/staff # 161) on October 26, 2023 at 10:02 AM. She stated that her expectations are medications are to be administered per physician's orders. She also stated that RNs need to obtain an order from a provider that specifically states a medication may be crushed and be given with food, if needed. A review of a policy titled Crushing Medications, last revised on August 16, 2023, indicates medications should be crushed when ordered by a physician as long as it is safe to do so.

Based on clinical record reviews, staff interviews, and facility policies, the facility failed to ensure that a Preadmission Screening and Resident Review (PASARR) level I was sent to the state for determination for a PASARR level II for one resident (#19). The deficient practice could result in residents not receiving the appropriate service they need. Findings include: Resident #19 was admitted to the facility on [DATE] with diagnosis that includes unspecified mental disorder due to known physiological condition, bipolar II disorder, and major depressive disorder. Review of the quarterly Minimum Data Set (MDS), dated [DATE] revealed the resident had a Brief Interview for Mental Status (BIMS) and scored a 15, which indicated the resident was cognitively intact. Review of the PASARR I, dated April 18, 2023 indicated the hospital did not have a record of the resident having a mental health diagnosis. However, the form had a notation on it indicating, per the Arizona Health Care Cost Containment System, the resident did have a mental health diagnosis. A progress note created by the Social Services Director (staff #119) indicated they reviewed the PASARR from the hospital. The note also indicated the SSD reached out to the resident's Long-Term Care Case Manager who would follow up the following Monday. There was no documentation in the resident's chart indicating follow up was done to determine the resident's PASARR I status. Review of the psychiatric Nurse Practioner note, dated April 25, 2023, an initial evaluation was done and revealed the resident had anxiety, bipolar, and an unspecified mental disorder due to known physiological condition. A care plan initiated on April 21, 2023 indicated the resident has a potential psychosocial well-being problem related to anxiety. Interventions identified were to establish a daily routine based on input from the resident and to encourage the resident to express feelings of anger, guilt, and frustrations, administer medications as ordered, consult with behavioral health as needed, and to monitor any risk for harm to self. The same care plan also indicated the resident uses psychotropic medications to address behaviors such as verbal aggression, physical aggression, paranoia, demanding behavior, false accusations, and racial remarks. Interventions besides medications include, coordinating medication needs with a provider, a behavior management program, and to monitor/report any adverse reactions of the psychotropic medications. An interview with Social Services (staff #119) was conducted on October 25, 2003 at 9:41 AM. Staff #119 stated they receive the completed PASARR forms from the hospital or the resident's case managers. Once it is received, it is their job to review the form for accuracy and then submit it to the state PASARR coordinator for a level II screening, if needed. They stated they did not have the correct PASARR level I for resident #19 that indicated the resident has a serious mental illness. Staff #119 revealed they have been in the process of cleaning up PASARRs due to a lot of changes happening due to COVID. An interview with the facility Administrator (staff #90) was conducted on October 27, 2023 at 11:12 AM. Staff #90 stated their expectation for the PASARR process was the facility will receive the PASARR from the hospital, if not, the facility's Social Services Director will complete the form. The PASARR is expected to be completed within 30 days of admission and is used to identify the level of services a resident might need for their mental health. Staff #90 stated they expect the PASARR should be reviewed by the resident's care planning team to ensure the accuracy of the document and if it was not correct, it must be re-done and re-submitted with the correct information. Staff #90 dated they were aware of the PASARR for resident #19 not following the established process and as a result, it did not meet staff #90's expectations. The policy titled, Preadmission Screening and Resident Review (PASRR) Policy/Procedure noted the complete screening process for new admissions per the Arizona's revised PASRR Level I Screening Tool. The policy also identifies the Social Services Director as the primary person responsible to ensure the accuracy of the PASARR and the completed document is sent to the appropriate state-designated authority, if needed.

Based on review of resident council minutes, resident and staff interviews, and policy and procedures, the facility was unable to demonstrate that concerns brought forth at resident council were responded to by the facility. The facility census was 80. The deficient practice could result in the concerns, views, grievances or recommendations by residents not being considered or acted upon by facility staff. Findings include: A review of the resident council minutes for the previous six months, revealed no evidence of resident council minutes for the month of September 2023. The resident council further revealed no evidence of documentation that outcomes were reported back the residents on concerns brought forward during previous meetings. An interview was conducted on October 26, 2023 at 10:39 A.M. with the activities director, staff #162 She stated that she had only assumed the role as activities director on September 26, 2023. She further stated after reviewing the previous minutes that there was no evidence of documentation that reflect a report back to resident council on previously identified issues. Staff #162 stated that she had scheduled a resident council meeting for November 7, 2023 and will seek to address concerns and report back to the resident council going forward. Staff #162 stated that the risk for not conducting regularly scheduled resident council meetings and reporting back to the resident council on outcomes could result in resident rights violations as well as a loss of trust from the residents. An interview was attempted with the resident council president, resident #30 on October 26, 2023; however, the council president was unavailable due to an appointment. The interview was rescheduled for October 27, 2023 at 10:00 A.M. Resident # 30 stated that she concurred with resident # 24, that she rarely received any responses regarding issues brought forward during resident council. She further reported that the September 2023 resident council meeting had not been held. An interview was conducted on October 26, 2023 at 1:56 P.M. with resident #24. Resident #24 stated that he attends the resident council meetings frequently, but rarely receives a verbal response from issues brought forward during the resident council meetings. He stated he has not received any written responses. An interview was conducted on October 26, 2023 at 2:11 P.M. with the administrator, staff #90. Staff #90 stated that frequency of resident council meetings is monthly. Staff #90 reviewed the meeting notes and stated that there was no meeting held in September, 2023. He further stated that the expectation is that communication between the facility and residents occur from one meeting to the next and that the activities department will convey and document that communication each time. He stated that the risk for missing meetings and or not conveying facility response back to the resident council would include not addressing resident concerns. A review of the resident council policy with a revise date of February 2021, revealed that resident council meetings are scheduled monthly or more frequently if requested by residents. The policy further states that the resident council form will be utilized to track issues and their resolution; however, no resident council meeting was held in September and feedback response to the council was not being documented consistently.

Based on record review, staff interviews, and review of policies and procedures, the facility failed to ensure one resident (#99) was free of any significant medication error. The deficient practice could result in resident having adverse effects and complications. Findings include: Resident #99 was admitted on [DATE] with diagnoses included epilepsy, schizophrenia, heart disease, peripheral vascular disease, macular degeneration, and hypertension. The care plan dated 01/18/2022 revealed the resident had seizure disorder. The goal was that the resident will be free from injury related to seizure activity. Interventions included to give seizure medication as ordered by the physician, to monitor/document side effects and effectiveness and to monitor labs and report any sub-therapeutic or toxic results to the physician. A physician order dated 03/29/2022 included for 100 mg (milligram) Dilantin capsule (anti-epileptic) to be given by mouth every Tuesday, Thursday, and Saturday. Another physician order dated 03/29/2022 for 200 mg Dilantin capsule to be given by mouth every Monday, Wednesday, Friday and Sunday. The physician order dated 11/09/2022 included for Phenytoin (generic for Dilantin) level every January and July in the morning every 180 days. The laboratory report dated 07/07/2023 included Phenytoin level of 11.4 ug/ml (micrograms per milliliter). Per the report, the reference range was 10-20 ug/ml. The pharmacy shipping manifest dated 07/07/2023 included an instruction to check all medications upon delivery against this manifest and not any discrepancies on this form; and that, the manifest constituted the orders had been requested for fill/refill and had been received. The manifest documented Phenytoin Sodium 100 mg cap for resident #99 with quantity of 71. The received by and delivered by sections of the manifest were not signed and dated. A review of progress notes revealed that on 7/19/2023 at 3:41 p.m., the resident wanted to stay in bed again and complained about her hands not working and poor vision. She did not eat breakfast, and required staff to feed her lunch. On 7/19/2023 at 10:07 p.m., the progress not included that the resident was confused and complained of nausea, but denying pain. It also noted that the physician on duty was notified; and at 10:23 p.m., the nurse practitioner placed an order for immediate urinalysis (UA). The progress note dated 7/20/2023 at 1:05 p.m. revealed the resident was alert and oriented, was compliant with medications and complained of bilateral hand pain and stiffness. Per the documentation, the resident stated I don't feel well, it's my hands, and my eyes, I can't see or do anything. It also included that the resident did not eat breakfast, declined offer for staff to assist her to eat, wanted to stay in bed again, and that speech was slightly slurred at times. A progress note dated 7/21/2023 at 3:52 p.m. revealed that resident #99 was again medicated for hand pain once this shift with positive effect; but that the resident still stated that her vision was poor and her hands would not work. Per the documentation, the resident continued with increased anxiety and yelled out frequently for nurse to come to room. It also included that an .extra sodium dose given; and that, the resident was compliant with medications and care and the UA was still pending. The progress note dated 7/21/2023 10:44 p.m. included that the resident was sent to the hospital at approximately 6:58 p.m. Per the documentation, at around 4:00 p.m., resident was given her scheduled medications and no abnormal behavior/symptoms were noted. At approximately 4:30 p.m., resident started yelling hysterically for the nurse. According to the note, when the nurse entered the room, the resident started swinging arms into the air and slurred speech was noted; and that, the nurse was not able to understand what the resident was trying to communicate and had to ask the resident several times what the resident wanted to say. The documentation included that the nurse understood that the resident was not feeling well, could not speak and felt left arm weakness. Per the documentation, the resident was assessed and revealed bilateral hand grip was present, with minor right sided facial drooping noted as well as her right eye halfway closed, smile prominent on the left side and was not present on the right side, and continued to have major slurred speech present The administration note dated 7/22/2023 included the resident was at the hospital. Review of the MAR (medication administration record) for July 2023 revealed Dilantin was documented as administered as ordered. The record included that Dilantin was last administered to the resident on 07/21/2023; and that, on 07/23/2023 the documentation included a code of 6 indicating the resident was hospitalized . The incident note written by licensed practical nurse (LPN/staff #4) dated 7/24/2023 revealed that the resident's CT-scan (computed tomography) at the hospital was negative for CVA (cerebrovascular accident), but her Dilantin levels were toxic - 'accidental phenytoin poisoning level 32.5 According to the note, the LPN called pharmacy when they opened the medications to double check resident Dilantin dose of medications on hand; and that, the LPN was aware that the capsules delivered last were different color and size, and sticker on med label stated 'THIS IS THE SAME MEDICATION YOU HAVE BEEN GETTING. COLOR, SIZE OR SHAPE MAY APPEAR DIFFERENT.' Med dose on label was 'phenytoin sod ext 100 mg cap', which is correct dose ordered for res. Further, the documentation included that the LPN spoke with the pharmacist who checked the medication and said that the dose the facility had on hand sent by the pharmacists was actually 300 mg capsules. The medication error report dated 7/31/2023 included that on the week of 7/17/2023, phenytoin sodium 300 mg was administered orally. Per the report, the physician order was for phenytoin sodium 100 mg. The reason for making the error was that the pharmacy sent the wrong dosage of medication in the bubble pack. The report included that the error has endangered the life or welfare of the resident and that the resident phenytoin level was life threatening. The actual effect of the error made on the patient included that resident was admitted to the hospital with phenytoin poisoning. Per the clinical record, the resident was readmitted at the facility on 08/01/2023. A NP (nurse practitioner) post hospital exam note dated 08/03/2023 included resident #99 was transferred to the hospital with altered mental status; and that, upon examination and diagnostics at the hospital the resident was diagnosed with encephalopathy, elevated Dilantin levels and hyponatremia. Per the documentation, resident #99 spent 10 days in the hospital, was stabilized and was readmitted back at the facility. Assessment included encephalopathy secondary to hyponatremia and elevated phenytoin level. Review of the medication card for the Dilantin for resident #99 revealed two labels: -Phenytoin Sod Ext 100 mg capsule NDC 65162-212-10; and, -Phenytoin Sod Ext 300 mg capsule, 62756-43288. There were 20 total capsules popped out, and presumably administered. During an interview with the LPN (with staff #4) conducted on 8/8/23 at 3:08 p.m., the LPN stated that a nurse will sign off on pharmacy deliveries and the they do not do any medication reconciliation when they receive the medication. The LPN said that if a medication was an overflow then it will go on the bottom of the cart; and if it was a new medication or something that was different, the receiving nurse would notice this because the receiving nurse was the one who placed the order in. The LPN stated that after the overdosing incident with resident #99, the pharmacy came at the facility and conducted an audit. The LPN said that there was a second sticker they were not aware about that staff was just trained on now to reconcile before accepting the medications. Regarding the incident with resident #99, there was a sticker that said it was a different color, size, shape on the medication card of resident's Dilantin when it was delivered that she had noticed; and that, she also saw that the sticker on the card was only signed by a pharmacy technician and was apparently not checked by the pharmacist. The LPN said that when resident #99 returned from hospital, the resident had another new medication that was still not signed by a pharmacist and both orders were in one bubble. When asked how this could be prevented from happening again, the LPN stated that staff was now aware of the Dilantin problems, had an in-service on accepting medication deliveries, and there were not any agency staff that were working. The LPN stated that when the resident was being transferred at the time of the incident, resident #99 was not herself, was very tired and did not want to get out of bed. The LPN said that the resident was usually alert and oriented to person, place, time, and situation and was typically up and out and goes to the dining room for meals. The LPN stated that since the incident, she no longer accepts medications upon delivery if they are not signed by pharmacy technician plus the pharmacist; and that, she will not sign the receipt, will call the pharmacy, send it back, and let unit manager and management know. The LPN further stated that she estimated that resident #99 had been getting the 300 mg daily for approximately a few weeks. An interview with the pharmacist (staff #89) was conducted on 8/8/23 at 3:25 p.m. The pharmacist stated there was an NDC (national drug code) to make sure what was ordered was what was being dispensed. The pharmacist said that on the resident's medication card, there were two NDC's in different places and these two codes need to match in order to verify it was the same medication. She stated that there may also be a green sticker on the medication card which states this is the same medication you have been getting. Color, size, or shape may appear to be different. Regarding Dilantin toxicity, the pharmacist stated every resident would be different, but typical indicators could be lethargy and slurred speech. She stated labs should be completed periodically as the resident ages and especially if adding additional medications. Further, the pharmacist said that it would also be a good idea to check levels if there were any mentation changes. During an interview with the Director of nursing (DON/staff #6) conducted on 8/8/2023 at approximately 3:44 p.m., the DON stated that to ensure that medications delivered were the correct medication, the pharmacy will send a list of medications and the receiving staff will make sure that medications matched with the label. The DON stated that she recently educated staff on how to check both labels on the medication cards which they should have been checking on all this time. Nurses must make sure they match. If they notice a medication seems different in size, shape, etc. they will need to contact the pharmacist. A review of the facility policy on Accepting Delivery of Medications revealed that all staff follow a consistent procedure in accepting medications and any errors noted in receiving medications are brought to the attention of the pharmacist and the director of nursing services. It also included that a nurse accepts each medication delivery. The nurse must reconcile meds with delivery ticket/order receipt before signing to accept the delivery. If an error is identified when receiving medications from the pharmacy, the nurse verifying the order: informs the delivery agent of any discrepancies and notes them on the delivery ticket; returns incorrect medications (e.g., wrong strength, form, etc.) to the dispensing pharmacy and reorders the correct medication; if the number of a medication or packages of medications is incorrect, the medication is not an emergency order, returns the order to the pharmacy; and, if the number of a medication or packages of medications is incorrect and the medication is an emergency order, accepts the order and writes that information onto the delivery ticket/order receipt. A nurse signs the delivery ticket, and keeps a copy. Both the receiving nurse and delivery agent must sign any notation about errors. The facility policy on Medication and Treatment Orders included that medications shall be administered only upon the written order of a person duly licensed and authorized to prescribe such medications in this state. The facility policy on Pharmacy Services Overview revealed that the facility shall accurately and safely provide or obtain pharmaceutical services, including the provision of routine and emergency medications and biologicals, and the services of a licensed consultant pharmacist.

Based on staff interviews, clinical record review, facility documentation, and policy review, the facility failed to ensure one resident (#304) received treatment and care in accordance with the resident's choice, regarding full code status. The deficient practice could result in residents' choices regarding code status not being implemented. Findings include: Resident #304 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The Advanced Directive dated February 22, 2017 revealed the resident had chosen to be a Full Code, that he wanted his life to be prolonged to the greatest extent possible. Review of a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The quarterly Minimum Data Set assessment dated [DATE] revealed the resident scored a 3 on the Brief Interview for Mental Status, indicating severe cognitive impairment. The resident required two-person total assistance for most activities of daily living. Per the Census record, the resident was moved into a new room onto the male secured dementia unit (La Pagosa) on [DATE]. A nursing progress note dated [DATE] at 8:17 a.m., revealed the resident's blood sugar was 43 and that the nurse went to search for [MEDICATION(S)] after an attempt was made to give the resident pudding with sugar and glucogel. The note also revealed [MEDICATION(S)] was not available. The note stated that the resident's response was minimal, but that the resident responded to pain. The note included the nurse notified the Director of Nursing (DON) that he was going to call 911. The note stated that when the nurse returned to the resident's room, the Certified Nursing Assistant (CNA) stated that she thought the resident was gone. The note included the resident was assessed to have no pulse and no heart rate. The note also included the resident had been pronounced dead at 7:07 a.m. by the fire department and that the physician and case manager were notified via message. Review of a Record of Death dated [DATE] stated the time of the resident's death was 7:07 a.m. and that the principal cause of death was [CONDITION(S)]. Contributory causes of death were listed as coronary artery disease and [CONDITION(S)]. The record was signed by the DON (staff #38). However, further review of the clinical record did not reveal measures were implemented regarding the resident's choice to be a full code. A phone interview was conducted on [DATE] at 2:58 p.m. with a Licensed Practical Nurse (LPN/staff #109). Staff #109 stated that the incident happened early on the morning of [DATE], at around 6:30 a.m. Staff #109 stated that the CNA reported to him that there was something wrong with the resident. The LPN stated that after observing the resident, he thought the resident's blood sugar might be low. He stated that the resident was conscious, so he brought the resident a snack (pudding). The LPN said that he instructed the CNA to give it to the resident. The LPN stated that the resident would not swallow it. He stated that he left the room to look through his medication cart for [MEDICATION(S)], but that there was none there. The LPN said he left the secured unit and went to the adjoining unit (B-Wing) to look for [MEDICATION(S)] in the emergency kit, but there was none there either. He stated that there was a unit supervisor/nurse and a CNA on the B-Wing. The LPN stated that he asked the nurse about the [MEDICATION(S)] and she told him that it was on order. He stated that he then walked to the DON's office to speak with her. He stated that he did not know why he went himself instead of sending the CNA. The LPN stated that he knew that if he had asked for someone to help him, they would have come to help. He stated that he spoke with three nurses, but did not ask any of them for help. The LPN further stated that he was not aware the resident was a Full Code and that was why he had not started cardiopulmonary resuscitation (CPR). He stated that the resident had been moved to his unit a couple of days earlier, but that the resident's chart had been left on the prior unit. The LPN stated that he did not look at the resident's electronic clinical record because he was old school that way. Staff #109 stated that he had it stuck in his head that he needed to get the [MEDICATION(S)]; he said he did not understand why the pharmacy had not sent it. The LPN stated that he did not start CPR and that he may have panicked. He stated that he felt really bad that he did not know the resident was a Full Code. On [DATE] at 12:15 p.m., an interview was conducted with a Registered Nurse/Unit Clerk (RN/staff #91). Staff #91 stated that when a resident is transferred/admitted to her unit, the transferring nurse will bring the resident, the resident's chart, and medications at the time of transfer. She stated that the transferring nurse will typically give report at that time. The RN stated that the resident's code status may be found in the resident's hard chart, in the electronic record, and on the resident roster which is kept at the nurses' station. The RN stated that as soon as the nurse is made aware of the code status, CPR will be started immediately for a resident that is not breathing or has no pulse. Staff #91 said that the nurse may instruct the CNA to get the crash cart or the nurse may bring it with them. The RN stated that during an emergency, the nurse will stay with the resident per policy and professional standards of practice. She said that the CNA may call 911 on the unit phone or their own personal cell phone. The RN stated CNAs may also notify nursing on the other units by phone, or they can just yell for help. Staff #91 stated that the fire department is right around the corner, so the response time is very short. A phone interview was conducted on [DATE] at 1:42 p.m. with a CNA (staff #51). The CNA stated that she was informed that something was wrong with the resident at approximately 5:45 - 6:00 a.m. on [DATE]. Staff #51 stated that she had worked the overnight shift with staff #109. She stated that she had been assisting a resident in another room when staff #109 came and told her that resident #304's blood sugar was really low. The CNA stated that she and the nurse went into resident #304's room and the nurse told her to put the head of the bed up and to try to keep the resident awake while he went to find some [MEDICATION(S)]. She said the nurse told her to stay in the room with the resident. She stated that the resident looked like he was asleep. The CNA stated that the nurse brought the resident some pudding and told her to give it to him, then he left again to look for [MEDICATION(S)]. The CNA stated the pudding just sat in the resident's mouth when she gave it to him. She stated that the nurse instructs the CNAs during an emergency, and that she was following protocol. She stated that she stayed in the room the whole time with the resident. The CNA stated that she knew what [MEDICATION(S)] gel looked like and how it was administered. Staff #51 stated that neither she, nor the nurse, gave the resident [MEDICATION(S)] gel. Then, she stated that the nurse may have given the resident [MEDICATION(S)] gel, but she could not remember for sure. She stated that on the date of the incident her CPR certification had been active, but she did not start CPR because she was not instructed to do so. She stated that she was agency staff at that time and had been instructed to follow the facility policy. On [DATE] at 9:29 a.m., an interview was conducted with the DON (staff #38). She stated that the Code Blue process begins with the staff first checking the resident's code status on the resident's chart, the resident roster, or the electronic record. The DON stated after that, staff have been educated to call 911 and start CPR. She stated that all staff have been educated on the process both in the facility in-services and in their CPR training. In regard to resident #304, the DON stated the nurse should not have left the resident. The DON stated the CNA should have called 911, and the nurse and CNA from the adjoining unit should have been called to assist. Staff #38 stated that staff #109 did not call 911 until after he had walked to her office and spoken with her. She stated this did not meet her expectations. She stated that the CNA would not have been allowed to start CPR. The DON stated that she knew CPR was not started that day, for whatever reason, and it did not meet her expectations. A phone interview was conducted on [DATE] at 8:56 a.m. with an LPN (staff #2). She stated that she was waiting for report on the morning of [DATE] when staff #109 came to her and reported resident #304's blood sugar was low. The LPN stated that she asked staff #109 if he had given the resident anything, and that staff #109 said he had given the resident orange juice. She said that she just looked at staff #109 because she thought that he should have been providing CPR to the resident at that time. The LPN stated that the paramedics were just arriving on the unit, so she waited to continue speaking to staff #109. After the paramedics had left, she stated that she asked staff #109 why he had not started CPR. She said he told her that he did not know what he was thinking. She stated that he seemed very nervous and scared. The facility's policy titled Medical Emergencies, reviewed [DATE], stated the purpose is to establish facility procedures for the management of a code, i.e., code blue, and the minimal practice requirement for such events. The policy stated that in the event of a life-threatening medical emergency or disaster involving a resident or an employee, the person who first becomes aware of the emergency will immediately notify the nearest nurse or use the intercom system to announce that CODE BLUE is needed immediately (i.e., STAT). The announcement must include the location or unit where the emergency is occurring. The first nurse on site will take the following actions or designate another to do so: call 911, start emergency care of the victim (e.g., CPR or other emergency care as indicated), take the crash cart to the emergency location, notify the senior nurse on duty. When the senior nurse on duty has arrived, she/he will notify the primary care physician, ambulance, emergency room , victim's emergency contact, and others as indicated.