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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, facility documentation, staff interviews, and policy review, the facility failed to ensure one resident (#96) was free from misappropriation of the resident's property. The deficient practice could result in resident rights being violated due to the misappropriation of personal property. Findings Include: Resident #96 was admitted to the facility on [DATE] with diagnoses that included peripheral vascular disease, anxiety disorder and cellulitis. Resident #96's inventory sheet dated December 7, 2022 revealed that the resident had 1 phone and 1 charger in her possession. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 12, indicating intact cognition. Review of the facility's investigative report revealed that Resident #96's cell phone went missing the night of April 9, 2023 or early in the morning on April 10, 2023, and was reported to the former Director of Nursing (DON) on April 10, 2023. The report details that Resident #96's family member was alerted via email that changes had been made to the phone. The report also included that staff and residents were interviewed as a part of the ongoing investigation, and one registry-contracted Certified Nursing Assistant (CNA/Staff#71) was unable to be contacted. The report revealed that the facility attempted to contact staff #71 by text, phone call, and registry app message platform, but could not contact her because she used a false phone number. The report included that one other resident was noted to have missing property in this time period. Review of progress notes revealed an entry from the Interdisciplinary team (IDT) on April 19, 2023 which revealed that the IDT team met with the resident to discuss the investigation of her missing iPhone and steps to replace the item. On April 24, 2023, an officer from Scottsdale Police Department responded to a call and went to the facility, where he took a report from resident #96. In this report, resident #96 reported that her iPhone 11, along with a pair of tweezers and a bottle of over-the-counter pills, was stolen out of her room between midnight and 4:00AM on April 10, 2024. In this report, Resident #96 also stated she suspected that her items were taken by her CNA that night, and gave Staff #71's name and description. Review of the facility's complaint to the Arizona State Board of Nursing (AZBN) dated May 20, 2023 revealed that Staff #71 was reported to the AZBN by the facility, detailing the incident of the missing phone on April 9th and April 10th, 2024. The complaint also states that staff #71 was found to be in possession of the missing item, with the location of staff #71 being unknown. An interview was conducted on October 10, 2024 at 8:28AM with a Licensed Practical Nurse (LPN/Staff #64), who stated that every item a resident comes into the facility with is tracked on the inventory sheet. She also stated that if an item were to go missing, she would attempt to find the item first, and then report it to the administrator if she could not find it. She would then help to fill out a grievance form and notify family. An interview was conducted on October 10, 2024 at 10:37 AM with the Executive Director (ED/Staff #21), who described the facility process for a missing item to be to search for the item thoroughly, check the inventory sheet, check the lost and found, and report the item as lost. He reported that if an item is not found, the facility will typically replace it. The ED also added that if residents bring in items after admission, these items should be added to the inventory sheet. When asked about the investigation for resident #96's missing cell phone, the ED stated that it was reported and investigated by the previous administrator. The ED brought up the report made to the AZBON, stating that he did not believe that staff #71 was found in possession of the missing item. He believed that this was written incorrectly, stating that the previous administrator was just unable to contact staff #71. The ED inquired about submitting an addendum to the 5-day report to include that the allegation could not be substantiated by the facility. Review of the facility's policy titled, Resident Rights/Dignity: Resident Rights, revealed that residents had the right to be free from abuse, neglect, and misappropriation of resident property.

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

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

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

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

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel file review, staff interview, and facility policy review, the facility failed to ensure that three of three sampled Certified Nursing Assistants (CNA/ Staff#48, Staff#61, and Staff#42) maintained valid Cardiopulmonary Resuscitation (CPR) and first aid certifications. The deficient practice could result in potential harm to residents due to staff not being knowledgeable about how to provide emergency care to residents as part of the CPR team. Findings include: Review of the personnel file for a CNA (Staff#48) revealed a hire date and signed job description on [DATE]. Continued review of the personnel file revealed no evidence that Staff #48 obtained a CPR or First Aid certification. Review of the personnel file for a CNA (Staff#61) revealed a hire date of [DATE], and a signed job description on [DATE]. Continued review of the personnel file revealed no evidence that Staff #61 obtained a CPR or First Aid certification. Review of the personnel file for a CNA (Staff#42) revealed a hire date and signed job description on February 27, 2024. Continued review of the personnel file revealed no evidence that Staff #42 obtained a CPR or First Aid certification. Review of the CNA job description revised in September of 2016 that was signed by all certified nursing assistants at the facility revealed that an Active, Class-Instructed CPR Certification was a Minimum Requirement for the position. Review of a new CNA job description was presented during an interview and revealed that on this new document, the CPR certification was preferred and not required. The job description did not have an effective date listed, and there was no evidence that any CNA in the building had signed or used it. On [DATE] at 1:08 p.m., an interview was conducted with the Director of Nursing (DON/Staff#28) who stated that CNAs did not need to have a CPR card, and only nurses do. Staff #28 was shown the job description that revealed a CPR certification was a requirement for the CNA position and she stated she was going to review the personnel files for staff #48 and #61 to see if they had obtained CPR certifications. Staff #28 stated she did not think staff #48, #61, or any CNA in the building had a CPR certification. On [DATE] at 2:11 p.m., an interview was conducted with the Corporate HR Operations Manager (Staff#70) who stated that a new policy and new job description for CNA ' s was put in place starting [DATE], and did not require CNA ' s to be CPR certified. Staff #70 gave an undated copy of the new job description and stated that CPR was a preference, not a requirement. Staff #70 stated that anyone hired as of [DATE] would have signed the new job description. Staff #70 was shown two examples of CNA job descriptions hired after [DATE], and stated that both CNA ' s signed the incorrect job description. On [DATE], an interview was conducted with Human Resources (HR/Staff#58) who stated that none of the CNA ' s hired after [DATE] had signed the new job description. Review of the facility policy effective on [DATE] titled, Emergency/First Aid: Emergency Procedure - Cardiopulmonary Resuscitation (CPR) revealed that the facility ' s CPR team shall include at least one nurse, one LPN/LVN, and two CNAs, all of whom have received training and certification in CPR/BLS. The policy also revealed that there should have been an identified CPR team for each shift in the case of an actual cardiac arrest.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, clinical record review, and facility policy, the facility failed to file and investigate a grievance per policy for one resident, #34. Findings include: Resident #34 admitted to the facility on [DATE] and discharged on 04/15/2024 with diagnoses that included Hypertension, pain in left shoulder, delirium, hallucinations and presence of Pacemaker. Review of discharge Minimum Data Set assessment dated [DATE], reident #34 scored an 11 on the Brief Interview for Mental Status (BIMS) which suggested moderate cognitive impairment. The care plan initiated on 04/13/2024 stated her goal is to establish an appropriate discharge plan with interventions being to coordinate with the Interdisciplinary Team and help provider services according to care plan to enhance optimum well being. In a statement from Resident #34's husband on 06/11/2024 at 12:54pm, he stated that he spoke with nursing staff, resident relations, and the executive director on 04/14/2024 and 04/15/2024. He stated the executive director told him he would investigate and get back to him by noon. He was asked to put his narrative in writing, which he declined to do since he stated he had seen multiple staff writing his concerns down already. In a social services progress notes from 04/15/2024, documented that Resident #34 and spouse had initiated a request to discharge that same day. In an interview with the Resident Relations Manager, Staff #42, on 06/13/2024 at 2:24pm she stated that she recalled Resident #34 and her husband and had gone to talk to him at the request of the executive director. She stated the husband had not want to further discuss because he wanted to just take his wife home. She stated she did not get enough information for why they wanted to discharge and did not know if it was connected to his complaints. She stated that resident relations will receive grievances from many sources including staff and family, but the majority of the time it is resident relations is the one who fills out the grievance form. Grievance investigations are not put in the electronic chart and will be filed with resident relations in her records. She keeps a log, and then the investigation and steps completed for each incident is listed on the grievance investigation form she fills out. A review of the facility grievance log for April and May 2024 revealed no grievances had been reported or investigated for Resident #34. In an interview with the executive director on 06/13/2024 at 1:48pm, he stated that he recalled the name but needed to reference his notes from his personal notebook. He read a note from April 15th. He stated the husband of Resident #34 reported to him that there was water damage in the room, the patient was left sitting on the side bed in just a brief, unsure who staff member was, came into room and she was lying in bed in just a brief. He stated that he did not report the incident as a self report due to the husband not alleging abuse, but a quality of care concern. He stated this was short stay and normally they would do an investigation and follow up with staff to see what had happened and if it was isolated or a trend that would need to be addressed. He stated he did not identify the staff members involved at the time. He stated that he husband had insisted the discharge and it was not Against Medical Advice (AMA). When the husband brought in a list of concerns, he refused to fill out the grievance form. He said he would just like to get his wife out of the facility immediately. The facility was not able to provide any documentation of a grievance being filed nor an investigation being completed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility documentation and policy review, the facility failed to ensure that the resident #3 received adequate supervision during medication and treatment administration to prevent accidents. The sample size was 1. The deficient practice could result in medication errors and/or ingestion of hazardous materials. Findings include: Resident #3 was admitted to the facility on [DATE], went home on November 9, 2023 and re-entered the facility on November 10, 2023. Resident #3 had medical diagnoses with included end-stage renal disease with dependence on renal dialysis, type 2 diabetes mellitus. Review of the admission Minimum Data Set (MDS) assessment dated [DATE], the resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was cognitively intact. It was also noted that the resident had pressure and surgical wounds and was receiving pressure injury and surgical wound care. Review of the Physician's History and Physical dated November 2, 2023 revealed resident #3 had an abdominal wound for which she was receiving wound care. Review of the physician's orders revealed a treatment order for the abdominal surgical wound that included to pack the wound with 1/4 strength Dakin's Solution (a bleach solution) every night shift. The physician's orders also contained an order for polyethelene glycol 3350 powder, 17 grams by mouth one time a day, dissolve in 4-8 ounces of beverage. Review of the incident note of November 22, 2023 at 13:24 (1:24 PM) revealed the nurse had administered a treatment and had placed the Dakin's solution soaked gauze in a small plastic cup, the same type of cup residents are given for drinking water. The nurse further reported that there were 3 or 4 of this type of cup on resident # 3's bedside table. The note continues that the nurse threw away treatment supplies and as the nurse was leaving the room the resident called to her and stated I took a sip of water from my plastic cup and it was Dakin's. The nurse reported taking resident's vital signs and notified the resident's physician and called the paramedics. An interview was conducted with resident #3 on November 28, 2023 during which the resident confirmed that she had accidentally had a drink of Dakin's solution, and that now the treatment nurse writes on the cup to identify it's contents. During the interview a nurse entered the room and placed a cup with colorless clear liquid in it on the resident's tray. The nurse pointed to the cup and said, that's your Miralax, and then pointed at the other cup and said, that's your water and left the room. When the interview ended, as the surveyor was leaving the resident's room, the resident stated, I've forgotten which is the water and which is the Miralax. An interview was conducted with the Assistant Director of Nursing (ADON/staff #10) on November 28, 2023 at 4:05 pm. The ADON stated that she was acting Director of Nursing as the Director of Nursing was at another facility that day. When asked what her expectation is regarding how the nurses administer medications, she replied that she expects the nurse to follow the 6 rights of medication administration, meet the needs of the resident, re-order medications as needed. When asked what she expected the nurse do if the resident requested the medication be left at the bedside, she stated that the nurse should take the medication away and ask the resident to let them know when they are ready to take the medication. She stated further that if this causes a problem she would expect the nurse would escalate the problem to herself or the Director of Nursing. Review of the facility policy regarding medication administration revealed the 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 personnel record review, staff interview, and the job description, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in not providing activities that meet the physical and psychosocial needs of the residents. Findings include: Review of the personnel file for the Activity Manager (staff #56) revealed staff #56 was hired on March 10, 2017 as an activity's assistant for 25 hours per week and promoted to the Activity Manager on April 12, 2018. Continued review of the file did not reveal documentation that staff #56 met the qualifications for the Activity Manager. Review of the Activity Manager Job Description revealed the Activity Manager works under the direction of the Executive Director and is an active member of the Interdisciplinary Care Team. The Activity Manager directs the development, implementation, supervision and ongoing evaluation of the activities program. This includes the completion of the activity's component of the comprehensive assessment along with the comprehensive care plan goals and approaches. The Activity Manager oversees the direction of an activity program, which includes scheduling of activities; both individual and groups, and the implementation of such programs. The Activity Manager directs the monitoring of the residents' responses as-well as the evaluation of responses to the programs to determine if the activities meet the assessed needs. The minimum requirements are: background check, fingerprint clearance card, TB clearance, employee screening post hire and must be able to speak and understand English. However, the job description did not include the requirements for an Activity Manager. During an interview conducted on July 20, 2022 at 10:15 a.m. with human resources staff (staff #40) and the Executive Director (ED/staff #75), the job description for Activity Manager was reviewed along with the resume for the Activities Manager (staff #56). Staff #40 agreed that the job description did not include minimum requirements, such as education/certification or experience, and staff #56's resume revealed no education/certification, and one year of experience as an activity aide. Staff #75 agreed that staff #56 did not meet the requirements needed for the position as Activity Manager as per CMS regulation because staff #56 did not have two years of prior experience or the education/certification required.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one resident's (#5) environment was free from accident hazards. The sample size was 4 residents. The deficient practice could result in residents being injured. Finding include: Resident #5 was admitted to the facility on [DATE] with diagnoses that included chronic kidney disease, chronic pain syndrome, anxiety, and muscle spasm. The care plan dated April 9, 2020 revealed the resident had activities of daily living self-care performance deficit. The interventions stated staff participation in transfers and 1 staff participation for toileting. The annual Minimum Data Set assessment dated [DATE] included a Brief Interview for Mental Status score of 15 indicating the resident was cognitively intact. The assessment also included the resident required supervision when transferring with one-person assistance and supervision when toileting with two persons assistance. Diagnoses included arthritis. A progress note dated July 15, 2022 at 1:10 p.m. revealed the resident stated she had a fall last night and hit her hand on the commode. Bruising and swelling were noted to the left pointer finger and wrist. The resident complained of pain to the left shoulder and bruising was noted. The physician was notified and ordered for x-rays to be obtained. A progress note dated July 15, 2022 at 1:29 p.m. revealed the resident reported to the nurse that she fell last night. The resident's hand was assessed. The resident stated it was painful, she has medal plates in her hand, and she does have pain in her hand occasionally. Upon further assessment a purple bruise to the left shoulder approximately the size of quarter was noted. The resident stated she was able to get herself back into bed last night without any trouble. Upon further questioning, the resident stated she did not fall onto the floor but more into the commode and her hand got caught in the commode. The physician was notified and ordered x-rays to be done to the areas. Review of an Interdisciplinary Team (IDT) meeting progress noted dated July 16, 2022 at 3:56 p.m. revealed the immediate interventions placed post-fall were X-rays ordered, the resident was educated to call for assistance when needed. The resident was educated on the need to report any falls or near falls to the nurse when the incident occurs. An investigation of the fall was completed by the IDT with the following results: The resident is alert and oriented X 4 (person, place, time, and situation), a very modest and private person who is able to toilet herself. The resident has been educated to call for assistance when needed. During an interview conducted on July 18, 2022 at 1:15 p.m. with resident #5, bruising was observed on the palm and dorsal side of her left hand. She stated that she fell trying to get off the commode. The commode was observed parallel to the bed approximately 1.5 feet away from the bed facing the resident. The facility telephone and an empty box of tissues were observed on top of the commode. A brown box was observed under the commode. The resident stated that there were canned goods in the box. Continued observations revealed that next to the commode was a medium size brown packing box with bottles of sprays/cream. Water bottles were observed on the floor. A medium size brown packing box with food items such as, Frosted Corn Flakes, nestle chocolate milk mix and plastic ware was observed. A plastic cart drawer directly under the resident's mobile tray covered with food items lined up parallel to the bed created a walking space of approximately 1.5 feet running from the head of the bed to the foot of the bed. The resident's fan was positioned at the foot of the bed and the electrical cord ran parallel to the bed from the foot of the bed to the head of the bed along the 1.5 feet walking space, where it was plugged into an extension cord on the floor in front of the commode. The resident's personal cell phone was also plugged into the extension cord. The cord ran up to the drawer of the bedside table to where the resident had her cell phone. A large blue bag with angels on it full of personnel items within reach of the resident was on the floor partially under the bed and partially exposed. The blue bag was within the stepping distance of the resident in the 1.5 feet pathway. Next to the blue bag was a plastic bag full of empty tissue boxes and cups. Also observed were personal items piled up along the other side of the bed, closest to the wall, taking up approximately a foot of space. The items were a foot high going from the foot to the head of the bed creating limited sleeping room. The resident stated that her drawers were full, so there was nowhere to put anything. Another observation of the resident's room was conducted on July 20, 2022 at 11:55 a.m. The area was observed to be the same except the facility phone was now on the floor with the cord on the floor between the bed and the bedside commode. There was still approximately 1.5 feet between the bed and the commode with the phone in the middle. Also, the fan cord was still running parallel from the end of bed to the head of the bed and plugged into the extension cord. A grabbing stick was observed on top of the commode along with a box of tissues. During an interview conducted on July 20, 2022 at 12:01 p.m. with a Certified Nursing Assistant (CNA/staff #73), she stated that the resident ambulates from the bed to the commode by herself. Staff #73 observed the resident's room and stated that it was not safe because the area between the commode and the bed was obstructed by the phone, cords and other objects which did not leave enough room to maneuver. She stated that there was approximately 1.5 feet between the resident's bed and the personal items lined up parallel to the bed. The CNA told the resident the phone and wires should not be on the floor because the resident could fall, and began clearing the area. The CNA also stated the cluttered area was a big fall risk. On July 20, 2022, an interview was conducted at 12:38 p.m. with the Maintenance Manager (staff #21). The Executive Director (staff #75) was present. Staff #21 stated that he is the director of maintenance and housekeeping, which entails supervising maintenance and housekeeping staff. He said part of his duties include ensuring it is a safe environment. He said that the housekeepers clean the residents' rooms daily and it is his expectation that they report unsafe and unclean areas to him immediately. He stated that he has been in the resident's room and observed that there was way too much stuff in the area, and thinks the walking space is about 2-3 feet. Staff #21 stated the resident would need approximately 4 feet of walking space to be safe. An interview was conducted on July 20, 2022 at 12:57 p.m. with a Registered Nurse (RN/staff #70), who stated that the resident is non-weight bearing on one side and is able to ambulate and use the commode by herself. The RN stated staff do try to encourage the resident to call for help. She said they could probably remove some of the clutter for safety. Staff #70 stated she thinks there is less than a foot between the bed and the commode. She stated that if the cord runs along the bed in the walkway, it does create a safety issue. The RN stated if the resident has things on top of the commode, she thinks it would create a barrier. Staff #70 said she does consider all the belongings/clutter to be a safety issue. The facility's policy, Safety and Supervision of Residents, revised July 2017 stated the facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities. System approach to safety included facility-oriented and resident-oriented approaches to safety are used together to implement a systems approach to safety, which considers the hazards identified in the environment and individual resident risk factors, and then adjusts interventions accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and policy review, the facility failed to ensure one resident (#45) was not administered an unnecessary medication, by failing to administer an opioid pain mediation in accordance with the physician's ordered parameters. The sample size was 5 residents. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #45 was readmitted to the facility on [DATE] with diagnoses that included chronic kidney disease, low back pain, major depression, and drug induced constipation. The care plan initiated on June 30, 2022 stated the resident has pain and takes Oxycodone (opioid analgesic) and Tylenol (analgesic). Interventions included administered analgesia medication as per orders. The admission Minimum Data Set assessment dated [DATE] included a Brief Interview for Mental Status score of 14 indicating the resident was cognitively intact. The Order Summary revealed an order dated July 5, 2022 for Oxycodone 15 milligrams (mg) by mouth every 4 hours as needed for pain level 4-10/10 and to hold from July 14, 2022 to July 15, 2022. A provider's note dated July 7, 2022 revealed the resident and nursing were encouraged to use adjuvant pain and symptom management through focused positive imagery reviewed with the resident. The resident and nursing endorse the goal to wean the resident off opioid pain medications. The note included it was discussed with nursing. Review of the Medication Administration Record (MAR) dated July 2022 revealed the following: -July 5, 2022 at 11:59 p.m. 15 mg of Oxycodone was given for a pain level of 1. -July 14, 2022 at 8:56 a.m. and 4:55 p.m. 15 mg of Oxycodone was given when the order stated to hold the medication. -July 15, 2022 at 11:07 a.m. and 5:12 p.m. 15 mg of Oxycodone was given when the order stated to hold the medication. -July 17, 2022 at 7:10 p.m. 15 mg of Oxycodone was given for a pain level of 0. An interview was conducted on July 21, 2022 at 11:45 a.m. with a Licensed Practical Nurse (LPN/staff #69), who stated that she assesses the resident to identify the location of the pain and the level of the pain. She stated she reviews the pain medication orders to ensure pain medication is given within the parameters. She stated that giving a stronger pain medication outside of parameters could cause lethargy, affect blood pressure, and contribute to addiction. She reviewed the MAR dated July 2022 and stated that the resident was administered Oxycodone outside the parameters at a pain level of 1 and 0. The LPN stated staff could have given the resident Tylenol for a pain level of 1. On July 21, 2022 at 11:57 a.m., an interview was conducted with the Director of Nursing (DON/staff #30), who stated that it is her expectation that the nurses assess the resident's level of pain and administer pain medication within the parameters on the order. She also said there is a risk to giving opioids outside the parameters, such as increased falls, dehydration, addiction, and loss of appetite. The DON reviewed the MAR dated July 2022 and stated Oxycodone was given for a pain level of 1 and 0. She reviewed the medication progress/administration notes and said she could not find any note to explain why the pain medications were given for a pain level of 1 and 0. The facility's policy, Administering Medications, revised 2012 stated medications must be administered in accordance with the orders, including any required time frame. Medications are administered in accordance with the written order of the prescriber.

Based on review of facility logs, staff interviews, and policy review, the facility failed to provide evidence that temperatures for the walk-in freezer and refrigerator, dishwasher, and food were consistently monitored, and that sanitizing solutions were consistently checked. The deficient practice could result in foodborne illness. Findings include: During the initial kitchen observation conducted on July 18, 2022 at 12:20 PM, the kitchen log book for July 2022 was reviewed. Review of the July 2022 temperature log for the walk-in freezer revealed no evidence the temperature was checked the morning of July 15, and all day on July 16 and 17. A review of the July 2022 temperature log for the refrigerator revealed no evidence the temperature was checked the morning of July 12 and 15, and all day on July 16 and 17. Review of the July 2022 log for the sanitizer test strips for the cleaning buckets revealed no evidence the sanitizing solution level was checked the morning and afternoon on July 15, and all day on July 16 and 17. Review of the log for the dishwasher temperatures for July 2022 revealed no evidence the dishwasher temperature was monitored the morning of July 15 and all day on July 16 and 17. A review of the log for checking food temperatures for July 2022 revealed no evidence that food temperatures were checked for breakfast and lunch on July 15, no meals on July 16 and 17, and for breakfast on July 18. During an interview conducted on July 18, 2022 at 11:45 AM with the Kitchen Manager (staff #34), she stated that the records should have been completed during the shifts that the kitchen staff worked. She provided copies of the temperature logs and sanitation records during the interview. During an interview conducted on July 18, 2022 at 12:25 PM with the facility cook (staff #49), he stated that he had worked over the weekend but had forgotten to fill in the worksheets with the temperatures and sanitation levels. He added that he was going to fill them in later this shift. During an interview conducted on July 20, 2022 at 1:21 PM with the Kitchen Manager (staff #34), she stated that the cook is responsible for entering the food temperatures in the log book prior to serving the meals to the residents. She added that the dietary aides and the cook share the responsibility to document the sanitation levels in the buckets, and the temperatures for the dishwasher as well as the walk-in freezer and refrigerators. In an interview conducted on July 20, 2022 at 1:38 PM with the [NAME] (staff #49), he stated that food temperatures are checked prior to the food being served to the residents, and documented on the Food Temperature Log. He further stated that the sanitation checks can be done by either himself or one of the dietary aides and placed in the log book on the sanitizer log sheets. Staff #49 stated that in his rush to get the food out, he forgot to write down the temperature checks. Review of the facility policy Food Storage and Date marking revealed that all refrigerators are to be checked to ensure temperatures remain below 41 degrees and that the freezer temperatures should be checked daily.

Based on personnel file reviews, staff interview, facility document, and policy review, the facility failed to provide evidence that 1 of 10 sampled staff (#56) was provided training on abuse, neglect, exploitation, and misappropriation of resident property; and that 4 of 10 sampled staff (#12, #22, #10, and #60) were provided dementia management training. The deficient practice could result in staff not being educated regarding abuse, neglect, exploitation, misappropriation of resident property, and dementia management. Findings include: -Review of the personnel file for staff #56, the Activity Manager, revealed a hire date of April 29, 2018. The file revealed no evidence of training on abuse, neglect, exploitation, misappropriation of resident property. -Review of the personnel file for staff #12, a Licensed Practical Nurse (LPN), revealed a hire date of July 29, 2020. The file revealed no evidence of dementia management training. -Review of the personnel file for staff #22, an LPN, revealed a hire date of September 10, 2021. The file revealed no evidence of dementia management training. -Review of the personnel file for staff #10, a Certified Nursing Assistant (CNA), revealed a hire date of February 24, 2021. The file revealed no evidence of dementia management training. -Review of the personnel file for staff #60, a Temporary Nurse Aide (TNA), revealed a hire date of April 29, 2022. The file revealed no evidence of dementia management training. During an interview conducted on July 21, 2022 at 12:08 p.m. with the Director of Nursing (DON/staff #30), she stated that abuse, neglect, exploitation, misappropriation of resident property, and dementia management training is required during orientation and annually by staff. The facility's Individual In-Service Education Record form included abuse, neglect, exploitation, and dementia training. The facility policy New Employee Orientation Guide, stated it is the policy of this facility to prohibit, prevent and report any form of abuse to residents regardless of the source. As part of the New Employee Orientation program, new employees will review the facility's formal policies regarding reporting abuse to facility management, reporting abuse to state agencies and other agencies and the policies and procedures for abuse investigation. New employees will receive instruction on the definition, effects and conditions of Alzheimer's Disease, dementia and other mental health conditions affecting residents and interaction with them. The facility's annual education included resident rights and abuse and dementia and managing behaviors to prevent abuse training.