**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, review of clinical record, and facility policy, the facility failed to protect the residents' (#3, and #2) right to be free from physical abuse. The deficient practice could result in physical and psychosocial harm. -Regarding Resident #3: Resident #3 was admitted to the facility on [DATE], and re-admitted [DATE], with diagnoses that included Alzheimer's disease, dementia with agitation, history of falling, anxiety disorder, mental disorder not otherwise specified, and spinal stenosis.A quarterly minimum data set (MDS) assessment dated [DATE], revealed Resident #3 had a Brief Interview for Mental Status (BIMS) assessment score of 5, indicating severe cognitive impairment.A care plan for behaviors revised September 3, 2025, revealed that Resident #3 had a resident to resident altercation, and an additional intervention was initiated on September 3, 2025, which indicated for a medication review.A Behavior Note dated July 24, 2025, revealed that Resident #3 was verbally inappropriate with staff and other residents. Resident #3 attempted to touch a female resident inappropriately, and the staff redirected the resident and spoke to him regarding his behavior.A Behavior Note dated July 28, 2025, revealed Resident #3 continues with sexual comments toward female staff.A Late Entry Incident Note dated September 2, 2025, revealed that Resident #3 was walking to the dining room for lunch pushing his wheelchair, as Resident #3 passed by another resident, the other resident said hi to Resident #3 who did not acknowledge the other resident. The other resident punched Resident #3 on his upper back, and Resident #3 reacted with punching the other resident on the left upper chest. The residents were separated by staff, vitals were taken, assessment completed, and no injuries were noted.Regarding Resident #2:Resident #2 was admitted to the facility April 12, 2024, with diagnoses that included unspecified dementia, anxiety disorder, unspecified hearing loss, and chronic obstructive pulmonary disease.A quarterly MDS assessment dated [DATE], revealed Resident #2 had a BIMS assessment score of 4, indicating severe cognitive impairment.A care plan initiated June 24, 2024, revealed Resident #2 had behaviors of attempting to hit and kick staff, yelling toward other residents, and a resident to resident altercation. An additional intervention was initiated on September 3, 2025 to place Resident #2 close to staff when awake.A Behavior Note dated July 24, 2025, revealed Resident #2 hit a staff on the arm as the staff passed by the resident, and the resident was redirected and asked not to be hitting others. Resident #2 was unable to verbalize understanding due to expressive aphasia.A Behavior Note dated July 30, 2025, revealed a staff opened Resident #2's room door for her, and Resident #2 hit the staff on the left arm, and that later in the day, Resident #2 walked toward her room and stopped in the hallway, pulled her pants and brief down, and squatted and urinated on the floor. Staff helped her dress herself, and took Resident #2 to the restroom to assist with care.A Behavior Note dated August 2, 2025, revealed that after lunch, a Certified Nursing Assistant (CNA) removed Resident #2's lunch plate from in front of her. Resident #2 stood up quickly and started yelling at the CNA and grabbed the CNA's arm tightly. The resident's arm had to be pried off of the CNA. Additionally, the note revealed that Resident #2 was known to be very obsessive and territorial to anything she thinks is hers.A Behavior Note dated August 11, 2025, revealed that Resident #2 was observed to be very agitated throughout the shift. Scheduled medication was administered as ordered; however, it was not effective in reducing agitation. Resident #3 displayed exit-seeking behaviors and became physically aggressive when staff attempted redirection, including attempts to strike staff.A Psych Follow-Up Note dated September 2, 2025, revealed that staff reports that Resident #2 has been aggressive. Resident #2 did hit another resident and has a history of hitting staff as well. Today she is refusing to talk to us, is very flat and guarded, and has isolating behavior.A Late Entry Incident Note dated September 2, 2025, revealed that Resident #2 was sitting in the dining room when another resident walked by. Resident #2 said hi and the other resident did not stop to acknowledge her, and as the other resident continued to walk by, Resident #2 got upset and punched the other resident on his back. The other resident turned around and punched Resident #2 on her chest. The residents were separated by staff, vitals were taken, assessment completed, and no injuries were noted.A facility investigation report submitted to the state agency on September 8, 2025, revealed that following the initial report of the incident on September 2, 2025, Resident #3 and Resident #2 were separated and checked to ensure safety. An investigation was initiated and two staff members were interviewed who were present during the interaction, a CNA and a nurse. According to staff accounts, around lunch time, Resident #3 was walking past Resident #2. Some form of verbal interaction occurred between the two residents. Resident #3 acknowledged that Resident #2 had said something, but was unable to discern what Resident #2 was communicating. Resident #3 felt Resident #2 make contact with his back and turned and pushed her away as it surprised him. The investigation report further revealed that the CNA's statement indicated that Resident #2 reached out with a semi open hand and made a swinging motion before intervening. The nurse also responded to the interaction and assisted in the separation of the two residents. Assessments were conducted with no injuries noted.An interview was conducted with a CMA (Staff #45) on September 16, 2025, at 9:49 A.M. who stated that he was present during the incident between Resident #3 and Resident #2 on September 2, 2025. Staff #45 stated that the incident occurred just before lunch in the dining area, and Staff #45 was sitting with his back facing Resident #3 and Resident #2. He stated that he heard a noise that sounded like physical contact, and then he heard Resident #3 yell out. Staff #45 stated that then he saw the nurse (Staff #50) intervene and separate Resident #2 and Resident #3. Staff #45 stated that right after the incident, Resident #3 was complaining that the back side of his shoulder was hurting, but then later in the day, Resident #3 was saying that his shoulder was fine.An interview was conducted with a CNA (Staff #9) on September 16, 2025, at 10:06 A.M. Staff #9 stated that in the case of an abuse allegation, that staff are expected to report it to their immediate supervisor immediately, the residents are separated, and then afterward an investigation is conducted by the Administrator. Staff #9 stated that she was present for the incident between Resident #3 and Resident #2 on September 2, 2025. Staff #9 stated that it was around 11:00 A.M., and Resident #3 was walking into the dining room. Resident #2 was sitting in the dining room already, and Staff #9 was positioned about 15 feet away in the dining room. Staff #9 stated that she heard Resident #2 say something that couldn't be understood to Resident #3, and then she heard what sounded like a punch, and then heard the nurse call out Resident #2's name. Staff #9 stated she did not see any physical contact made, but then she heard Resident #3 say that Resident #2 had just hit him. A telephonic interview was conducted with a Registered Nurse (RN / Staff #50) on September 16, 2025, at 12:06 P.M. Staff #50 stated that she was present for the incident between Resident #3 and Resident #2 on September 2, 2025. Staff #50 stated that Resident #3 was pushing his wheelchair into the dining room and walked past Resident #2 who was already sitting in the dining room. Resident #2 said something to Resident #3 that did not make sense, and Resident #3 acknowledged Resident #2, but then Staff #50 stated that she saw that Resident #2 got up and punched Resident #3 in the upper back between the shoulder blades. Staff #50 stated that then, she saw that Resident #3 reacted and punched Resident #2 in the upper chest region toward the front of the resident's shoulder area. Staff #50 stated that she intervened and separated the residents, and then Resident #3 apologized and stated that his punch was just a reaction. Staff #50 stated that when she saw Resident #2 punch Resident #3, that Resident #2 looked angry and that the punch was aggressive in nature. Staff #50 stated that after the incident, she assessed the residents for injury and did not see any, and then notified the Director of Nursing (DON) and Administrator, and that she wrote a progress note in the medical record that accurately described the incident. Staff #50 stated that this is not the first time Resident #2 has been physically aggressive toward other residents.An interview was conducted with the Director of Nursing (DON / Staff #1) on September 16, 2025, at 12:27 P.M. The DON stated that her expectation for staff to prevent resident to resident altercations would be to know the residents well enough to identify changes in behavior and triggers. Regarding the incident between Resident #3 and Resident #2 on September 2, 2025, the DON stated that her understanding of the incident was that Resident #2 had tried to talk to Resident #3 and when he did not respond, Resident #2 became agitated and struck Resident #3, and then Resident #3 struck Resident #2 back. The DON stated that she did not know the location on the body where Resident #3 or Resident #2 were struck. The DON stated that in the case where one resident hits another resident, that would be considered abuse.An interview was conducted with the Administrator (Staff #66) on September 16, 2025, at 12:24 A.M. Staff #66 stated that physical abuse is when a person is intentionally trying to cause harm to a resident, and examples of physical abuse included hitting or pinching. Staff #66 stated that his understanding of the incident was that Resident #3 was walking down the hallway pushing his wheelchair and Resident #2 may have said something to Resident #3. Staff #66 stated that then, Resident #3 felt something on his back and turned around and pushed Resident #2. Then, Staff #66 stated that the nurse intervened and separated the residents. Regarding the question if Staff #66 believed that physical abuse occurred in the incident, Staff #66 did not answer the question directly, but Staff #66 did state that he did not believe that Resident #2 was trying to hurt Resident #3.A telephonic interview was conducted with a family member of Resident #3 on September 16, 2025, at 2:14 P.M. Resident #3's family stated that after the incident occurred on September 2, 2025, that the nurse (Staff #50) called the family to notify the family of the incident. Resident #3's family stated that the nurse stated that a resident went up to Resident #3 and hit him as hard as she could and then Resident #3 turned around and punched the other resident in the chest.Review of the policy titled Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, dated January 1, 2024, revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:26Number of residents cited:2The facility failed to protect the resident's right to be free from verbal and physical abuse in 2 of 26 residents.Based on closed record review, resident and staff interviews, as well as review of facility documentation and policy, and through observation of current practice, the facility failed to protect the resident's right to be free from verbal and physical abuse in 2 of 26 residents.Findings include:- Regarding Resident #26:Resident #26 was initially admitted to the facility on [DATE] and remains in the facility with medical diagnoses that included: end-stage renal disease, dementia, muscle weakness, glaucoma, lack of coordination, and anxiety disorder.The quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 10, indicating moderate cognitive impairment. The MDS revealed that the resident demonstrated no hallucinations, delusions, physical or verbal behaviors toward others or other behaviors not directed to others including physical symptoms such as hitting or scratching of self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds. The MDS revealed that the resident demonstrated rejection of care 1-3 days and demonstrated no exit-seeking behaviors. The MDS further revealed that the resident used a manual wheelchair and documented no functional impairment of upper or lower extremities.However, a review of the resident's comprehensive care plan dated 5/12/2025 revealed that resident #26 had impaired functional mobility with an associated goal to remain free from complications of impaired range of motion through the next review date and an intervention to report and document any decline in function and refer to therapy as needed.The care plan further revealed that the resident had a visual impairment requiring glasses to improve visual acuity. The care plan revealed that the resident exhibited a behavior of touching another resident's arm that was perceived to be inappropriate and was redirected. The resident also reportedly refused to go to bed on time, refused to be changed, and refused to be toileted despite staff encouragement and assistance. The care plan revealed that the resident had impaired thought processing due to dementia with an associated goal of communicating basic needs on a daily basis and interventions for the care team to communicate with the resident, family, and caregivers regarding the resident's capabilities and needs. Additional related interventions included discussion of concerns about confusion, engage resident in simple, structured activities that avoid overly demanding tasks, keep routine consistent, report changes in cognitive function specifically, changes in decision making ability, memory, recall and general awareness, difficult expressing self, difficulty understanding others or changes in mental status or level of consciousness to MD and to use task segmentation to support short-term memory deficits.A review of progress notes dated 5/14/2024 revealed that the resident was involved in a small altercation with another resident; however, the resident had no memory of the event and had no complaints or concerns reported to staff.A review of physician orders revealed no issues or concerns specific to this allegation.A review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no omissions or inconsistencies. - Regarding Resident #107:Resident # 107 was initially admitted to the facility on [DATE] and discharged on 2/18/2025 with diagnoses that included: chronic obstructive pulmonary disease, age-related osteoporosis with current pathological fracture of the vertebrae, bipolar disorder, atherosclerotic heart disease, chronic diastolic heart failure, morbid obesity, hypertensive heart disease, difficulty in walking, retention of urine, due to obstructive and reflux uropathy, depression, anxiety disorder and non-ST elevation myocardial infarction (NSTEMI).A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Mental Status Interview (BIMS) score of 14, indicating no cognitive impairment. The MDS revealed that the resident had no hallucinations, delusions, verbal behaviors directed towards others, and no behavioral symptoms not directed toward others, such as hitting or scratching of self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds. The MDS further stated that the resident exhibited physical behavioral symptoms directed toward others, such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually on 1-3 days, and revealed that the resident demonstrated no rejection of care or exit-seeking behaviors. The MDS further revealed that the resident used a manual wheelchair and indicated no functional impairment of upper or lower extremities. The MDS revealed that resident #107 had an indwelling urinary catheter, smoked, and used oxygen through a nasal canula.A review of the resident's Comprehensive Care Plan dated 9/8/2023 revealed that the resident had an actual or potential problem with psychosocial well-being due to anxiety, with a related goal of verbalization of feelings related to emotional state by review date. Interventions related to this goal included: allowing the resident time to answer questions and verbalize feelings, perceptions and fears, assist, encouraging and supporting the resident to set realistic goals, and encouraging participation from resident who depends on others to make own decisions. The Care Plan further revealed that the resident had a mood problem related to anxiety and depression with a related intervention to observe/monitor/record/report to MD the risk for harming others, increased anger, labile mood or agitation, or if the resident feels threatened by others of has [NAME] of harming someone, possession of weapons or objects that could be used as weapons. The Care Plan revealed that the resident was at risk for a resident to resident altercation due to lack of awareness when driving the chair backwards, despite staff education. The Care Plan further revealed additional risks for resident to resident altercations due to impulsiveness despite staff redirection, including hitting staff when redirected.A review of physician orders dated 2/3/2025 revealed that the resident was placed on Buspar and duloxetine related to increased agitation and behaviors.A review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no omissions or inconsistencies. A review of the progress note dated 6/3/2025 revealed that a staff member was called to respond to an incident that occurred during the resident's scheduled activities, in which another resident was involved. The physician's progress note dated 5/14/2025 revealed that staff reported that the resident got into an argument about the weather that escalated to physical aggression with another resident; however, the resident's record revealed no prior incident describing the event that occurred on 5/12/2025.A review of the Weekly Skin Check and Wound assessment dated [DATE] revealed a skin assessment notation marked as ‘yes' for Does resident have skin impairments -new and/or ongoing? The remainder of the document contained no information. No progress note was identified for the resident to resident abuse allegation that occurred on 5/12/2024.An interview was held with resident #26 on 8/8/2025 at 08:52 AM, who stated that he feels happy and safe at the facility. The resident denied any memory of arguing or having an altercation with another resident. When asked specifically about an issue with resident #107, resident #26 stated that he had no memory of the event in question. Resident #26 stated that he had no memory of any disagreements or altercations with other residents. The resident stated that his needs are being met and that he would go to any staff member if he had additional concerns.An interview was conducted with Registered Nurse, (RN) Staff #108, on 8/12/2025 at 09:06 AM. The RN stated that abuse can be verbal, physical, emotional, financial, or sexual, and stated that any abuse requires prevention, observation, and notification to the facility Director of Nursing or Executive Director. Staff # 108 stated that abuse can occur between staff and residents or residents to residents and between residents who have dementia. The RN stated that preventative measures for residents with dementia include low beds, frequent monitoring, floor mats, non-slip footwear, and care planning to communicate resident needs to staff, baseline fall risk and skin assessments and ongoing discussions among the teams about their status and behaviors. If residents did not have dementia, but were at risk for abusing each other, the RN stated that prevention would be largely the same, but staff would also work to educate residents about coping strategies, reminding them to use call lights for assistance and to ensure they know how to report any issues or concerns. Staff #108 stated that resident- to- resident abuse is rare but would not meet expectations as the risk could be injury or harm to the residents. An interview was conducted with Staff #52, Certified Nursing Assistant (CNA), on 8/12/2025 at 11:59 AM. The CNA stated that abuse can be verbal, physical, emotional as well as others. Staff #52 stated that if abuse is witnessed, she would make sure that residents are safe and report the event immediately to the supervisor as it is her understanding that they have a timeline to report the event. The CNA stated that she would notify the nurse, obtain vital signs of the involved residents, complete a skin assessment, and make sure that blood pressure was not too high, as blood pressure can go up with adrenaline, and check the resident for any injuries. The CNA stated that she recalled the specific event as it was the first resident-to-resident abuse incident she witnessed in her career. Staff #52 stated that the residents didn't have a great relationship, and they didn't get along and tended to avoid each other. She stated that the event occurred when one resident was wheeling down the hallway and the other one came up behind him in the wheelchair (facing the same direction and bumped into him from behind, explaining it occurred like a rear-end collision between cars. The CNA stated that she was alerted when the residents started fighting. Staff # 52 stated that when she got to them, they were both in their wheelchairs, facing each other, yelling and throwing punches. The CNA reported that she separated the residents with the help of a co-worker and got the nurse who talked to the Executive Director, as she did after the residents were assessed and the situation had settled down. The CNA stated that she had no memory that either resident was injured in the event. The CNA stated that one of the residents still resides in the facility, and the other one moved to an assisted living facility approximately two months after the altercation. The CNA stated that prevention efforts before the event were based on the observation that the two individuals did not get along with staff giving them verbal cues to de-escalate by saying, Stop, it's okay, don't look at him, let's go over here, and so on. The CNA stated that staff received training on abuse through video trainings that occur monthly and the topics include abuse, infection control, and others that relate to being a CNA. The CNA stated that having residents fight would not meet her expectation. The CNA stated that the risk to the residents could be that they would feel uncomfortable, unwelcome, not want to be here, and could, go to another facility. Staff # 52 stated that, in retrospect, possible prevention measures could have included moving residents so that they were not on the same hallway or discharging the more independent of the two residents sooner. An interview was conducted with resident #83 on 8/12/2025 at 12:10 PM. The resident stated that she has been in the facility for two weeks and denied any concerns. Resident #83 stated that she feels safe in the facility and has not witnessed or experienced any abuse between residents, but if she did, she would tell a nurse.An interview was conducted with resident #10 on 8/12/2025 at 12:15 PM. The resident stated that she had been in the facility for three months and feels safe. The resident stated that when she had a concern, she addressed it with staff, and it was resolved to her satisfaction. Resident #10 stated that she had no issue with staff or other residents, stating, everyone loves me. The resident stated that if she witnessed or experienced abuse, she stated that she would notify the social work staff.An interview was conducted with resident #67 on 8/12/2025 at 12:20 PM. The resident stated that she is not sure how long she has been at the facility, having come from the hospital after having a minor heart attack. The resident stated that she has not experienced abuse and feels safe in the facility. The resident stated that if she witnessed or experienced abuse, she would report it to the head nurse, or take it further if needed.An interview was conducted with Housekeeping Aide, Staff #75, with translation assistance from Environmental Services Supervisor, Staff #71, on 8/12/2025 at 2:15 PM. Staff #75 stated that she works in all areas of the facility and occasionally speaks with residents, but if care needs are identified, she would find a CNA to help them. The housekeeping aide stated that she has only witnessed resident-to- resident abuse once, that was a long time ago when she saw two residents fighting in the 100 hallway.When asked to describe the event, Staff #75 stated that the two residents were in in their wheelchairs, moving them in the same direction, one behind the other. The one in the rear bumped into the one in front, and the one in front became angry, and the two started yelling at each other. Their yelling got the housekeeping aide's attention, and she ran to get a CNA, and both responded to the resident #26 and resident #107 to help. Staff # 75 further stated that by then, the residents were facing each other, yelling, Get out of my way, and other loud statements, and hitting each other. The Housekeeping Aide stated that she was unsure if either one was hit. Staff #75 stated that lots of staff responded because of the yelling and separated the residents and got them settled down. Staff #75 stated that when others responded, she went back to work. She has no memory of damage or injury to either resident, and because she works the night shift and her supervisor works on the day shift, she reported the event to her supervisor the next day. An interview was conducted with Licensed Practical Nurse (LPN), Staff #147, on 8/13/2025 at 0918 AM. The LPN stated that abuse can be physical, sexual, verbal, or financial, and further stated that the facility has zero tolerance for any abuse. Staff #147 stated that we don't want abuse here, but are aware that it can happen, and we do all that we can to prevent it.The LPN stated that she would identify residents who are at risk for resident-to-resident abuse by their behaviors, such as responding in anger, being irritable, as we work with them and observe them. Staff #147 stated that another factor identifying residents who are at risk for resident-to-resident abuse because they may have complaints or they may not be satisfied with care. The LPN stated that staff try to match residents who are compatible with each other and with staff so everyone can be happy and not have any arguments. Staff #147 stated that this is true on their dementia unit because residents get agitated and do not understand when we try to redirect them, but their way of thinking is not like ours.An interview was conducted with staff #126, Director of Nursing (DON), on 8/13/2025 at 0959 AM who defined abuse as physical, emotional, verbal, or misappropriation. The DON stated that when resident-to-resident abuse occurs, the residents are separated and made safe, and the event is immediately reported. When resident-to-resident abuse occurs, the staff look for any bruising, skin tears, and assesses for injuries. Staff #126 stated that following resident-to-resident abuse, an incident report is generated, as is a note in the resident's electronic health record. The DON stated that resident-to- resident to abuse does not meet her expectations and that she doesn't like it, but sometimes it is difficult to avoid and stated that the risk to the resident is injury or emotional distress.A review of the Haven Health Policy # 003: Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, effective January 1, 2024 revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual, or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. The policy further states that the facility employs a facility-wide commitment and resource allocation to protect residents from abuse from facility staff, other residents, consultants, volunteers, staff from other agencies, family members, legal representatives, friends, visitors, and/or any other individual.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, and policy review, the facility failed to ensure food items were labeled and dated, and food was prepared under sanitary conditions. The deficient practice could increase the risk of foodborne illness.Findings include:Regarding food labeling and dating:During the initial kitchen observation conducted on August 5, 2025, at 10:52 a.m., a small, light-colored round cake was found in the walk-in freezer. Upon inspection of the cake, it was noted that the cake was past its expiration date of 7/24. Additionally, a clear, plastic bag containing French toast sticks and another clear, plastic bag containing cinnamon rolls were found not marked with use-by or expiration dates. Upon verification that the cake had expired and the bags containing the French toast sticks and cinnamon rolls were undated, the three items were immediately removed from the freezer and disposed of in the trash.An interview with the Dietary Aide (staff #100) was conducted on August 5, 2025, at 10:58 a.m. He was asked about the policy regarding dates listed on food items. He responded that everything should be labeled and should have a use-by date. He was then asked what the concern is if an item is not used by the expiration date. He responded that the food could go bad. He was then asked what risk that was to the resident. He responded that the resident could get sick.An interview with Dietary Manager (staff #26) was conducted on August 7, 2025, at 1:16 p.m. She was asked what the expectation is for food storage. She replied that all food must be dated. They get it, put it up, mark it, date it, first in, first out. If it is taken out of the box, it has to be dated. She was then asked if there is a risk if the food is not dated. She replied yes. When asked what the risk is, she said that whoever eats it could get sick. She was then asked what if there was something past the expiration date. She said that it would get thrown out. When asked if there was a risk if the expired food was eaten, she responded that someone could get sick. The Executive Director (Staff #147) was interviewed on August 7, 2025, at 1:29 PM. The Executive Director was asked what his expectations were for food storage. His response was making sure that things were dated or labeled, items defrosting are on the bottom shelf, making sure things that could drip are on the bottom shelf, making sure things aren't mixed, and making sure containers are closed completely. He was then asked what the risk is if items aren't properly dated in the fridge or freezer, to which he replied foodborne illness and adverse reactions. When asked what should be done if a food item was discovered that had expired in 2024, he responded that it should be discarded. The facility's policy titled Food Storage and Date Marking states that dates for items will be checked prior to use, and expired items discarded. Furthermore, the policy indicated that all foods will be checked to ensure that they are consumed by their use-by dates or discarded. Regarding kitchen sanitation and conditions:During a puree observation on August 7, 2025, at 11:05 AM, a cook (Staff #54) was observed to use a bare hand to remove the blades of a Ninja brand blender after it was used to puree noodles. When the incident was noted, the kitchen staff immediately disposed of the contaminated food and took the Ninja blender and blades to be washed and sanitized. She then stated that she usually wears gloves. She then attempted to make a puree a second time using the Robot Coup. Upon completion of the puree cycle on the Robot Coup, the food was then transferred to a container. She then removed the blades from the Robot Coup with a bare hand. When the second incident was noted, the kitchen staff immediately disposed of the contaminated food and took the Robot Coup blender and blades to be washed and sanitized. The dry Ninja brand blender was then used, and the puree was completed without incident. An interview with Dietary Manager (staff #26) was conducted on August 7, 2025, at 1:16 p.m. [NAME] was asked what the expectations are for the puree process. She responded that her expectations are that they do exactly as trained. She was then asked what that entails, to which she said, always wear gloves. The equipment has to be clean and dry. When she was asked what the risk is of putting your hand in a turned-off food processor, she answered cross-contamination.The Executive Director (Staff #147) was interviewed on August 7, 2025, at 1:29 PM. The Executive Director was asked what his expectations were for food safety. He responded that food should be prepped properly and at a safe temperature. He was then asked if he would have concerns if someone reached their bare hands into a processor. He replied with yes. When asked what risk that would pose, he replied with risk-safety and infection control, cleanliness, and maintaining a sanitary environment.The facility's policy titled Bare Hand Contact with Food and Use of Plastic Gloves states that single-use gloves will be worn when handling food directly with hands to ensure that bacteria are not transferred from the food handlers' hands to the food product being served. Bare hand contact with food is prohibited. The policy also says that staff will use clean barriers such as single-use gloves, tongs, deli paper, and spatulas when handling food. Furthermore, the policy states that clean barriers such as single-use gloves are to be used anytime hands would otherwise touch food directly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:26Number of residents cited:1The facility failed to ensure that the medical record for 1 resident (#107) out of 26 was complete and accurate.Based on resident and staff interviews, review of the clinical record, facility documentation, and policy, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete, accurately documented, and readily accessible for one resident (#107). The deficient practice could result in miscommunication between health care providers, leading to delayed or incorrect care and inappropriate treatment planning.Findings Include:Resident # 107 was initially admitted to the facility on [DATE] and discharged on 2/18/2025 with diagnoses that included: chronic obstructive pulmonary disease, age-related osteoporosis with current pathological fracture of the vertebrae, bipolar disorder, atherosclerotic heart disease, chronic diastolic heart failure, morbid obesity, hypertensive heart disease, difficulty in walking, retention of urine, due to obstructive and reflux uropathy, depression, anxiety disorder and non-ST elevation myocardial infarction (NSTEMI).A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Mental Status Interview (BIMS) score of 14, indicating no cognitive impairment. The MDS revealed that the resident had no hallucinations, delusions, verbal behaviors directed towards others, and no behavioral symptoms not directed toward others, such as hitting or scratching of self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming or disruptive sounds. The MDS further stated that the resident exhibited physical behavioral symptoms directed toward others, such as hitting, kicking, pushing, scratching, grabbing, or abusing others sexually on 1-3 days, and revealed that the resident demonstrated no rejection of care or exit-seeking behaviors. The MDS further revealed that the resident used a manual wheelchair and indicated no functional impairment of upper or lower extremities. The MDS revealed that resident #107 had an indwelling urinary catheter, smoked, and used oxygen through a nasal canula.A review of the resident's Comprehensive Care Plan dated 9/8/2023 revealed that the resident had an actual or potential problem with psychosocial well-being due to anxiety, with a related goal of verbalization of feelings related to emotional state by review date. Interventions related to this goal included: allowing the resident time to answer questions and verbalize feelings, perceptions, and fears, assisting, encouraging, and supporting the resident to set realistic goals, and to encouraging participation from resident who depends on others to make their own decisions. The Care Plan further revealed that the resident had a mood problem related to anxiety and depression with a related intervention to observe/monitor/record/report to MD the risk for harming others, increased anger, labile mood or agitation, or if the resident feels threatened by others of has thoughts of harming someone, possession of weapons or objects that could be used as weapons. The Care Plan revealed that the resident was at risk for resident-to-resident altercation due to lack of awareness when driving the chair backwards despite staff education. The Care Plan further revealed additional risks for resident-to- resident altercations due to impulsiveness despite staff redirection, including hitting staff when redirected.A review of physician orders dated 2/3/2025 revealed that the resident was placed on Buspar and duloxetine related to increased agitation and behaviors. A review of the resident's Medication Administration Record (MAR) and Treatment Administration Record (TAR) revealed no omissions or inconsistencies. A review of the progress note dated 6/3/2025 revealed that a staff member was called to respond to an incident that occurred during the resident's scheduled activities, in which another resident was involved. The physician's progress note dated 5/14/2025 revealed that staff reported that the resident got into an argument about the weather that escalated to physical aggression with another resident; however, the resident's record revealed no prior incident describing the event that occurred on 5/12/2025. A review of the Weekly Skin Check and Wound assessment dated [DATE] revealed a skin assessment notation marked as ‘yes' for Does resident have skin impairments -new and/or ongoing? The remainder of the document contained no additional information. No progress note was identified for the resident- to-resident abuse allegation that occurred on 5/12/2024.An interview was conducted with Licensed Practical Nurse (LPN), Staff # 147, on 8/13/2025 at 09:18 AM. The LPN stated that if a resident had a possible change in status following a fall or following an altercation between residents, staff would separate the residents and assess them for injury. Staff # 147 stated that the assessment would include taking vital signs, conducting a check of their skin to ensure they did not get hurt. The LPN stated that when the resident assessment was completed, she would follow the facility chain of command to first notify the unit manager and then the Assistant Director of Nursing, followed by the Director of Nursing and the facility Administrator. The LPN described the process of skin assessment as wheeling the resident to their room or an available open room, changing the resident into a gown, and completing a full-body observation while looking for any bruising or skin tears. The LPN stated that the observation would be comprehensive because while looking for bumps and bruising, even a scratch to the cornea could happen, so we check head to toe, because you just never know. When asked how the skin assessment is documented in the resident's electronic health record, the LPN stated that it would be entered in a form following completion of the assessment. The LPN was asked to pull up the record for resident #107 and stated that H on the form represented history. The LPN stated that the skin assessment showed positive entry, noting yes, but revealed no further information on what was reported. The LPN then demonstrated the correct process for entering a new skin assessment. The LPN stated that if a skin assessment had new findings or if there was an incident of resident-to-resident abuse resulting in injury, there would be a progress note entered describing the incident. Staff # 147 searched for a progress note in resident #107's electronic health record, but found no entry for the event that was reported during the week of 5/20/25 through 5/27/2025. The LPN stated that not finding these documents would not meet her expectations, as it would contain additional information. The LPN further stated, that the progress note should be in there.An interview was conducted on 8/13/2025 at 09:59 AM with the Director of Nursing (DON), Staff # 126. The DON stated that a skin assessment is not always required as long as there is documentation in the notes or in incident reports. The DON stated that if a skin assessment was started and a skin issue was identified, the skin assessment form in the electronic health record should be filled out. Staff # 126 stated that not filling out the document would not meet her expectations, as the resident may not receive appropriate care, and you would not know what the skin issue is. The DON searched for a progress note during the time period of the alleged abuse allegation, but no notes were identified in the electronic health record. The DON stated that it should have been documented in a progress note or an incident report. The DON reported that all incident reports are maintained in Point Click Care, the facility's documentation platform. A review of the Haven Health Policy, B001 Documentation: Charting and Documentation, Version 051123, effective January 1, 2024, revealed that all services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional, or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:16Number of residents cited:13The facility failed to ensure the protection/management of resident funds for 13 of 16 residentsBased on interviews, review of clinical records, facility 5 day report to the state agency (SA) and review of facility policy and procedures, the facility failed to ensure the protection/management of resident trust funds for 13 residents out of 16 (#3, #5, #18, #31, #32, #58, #63, #75, #76, #77, #86, #95, #96, #108, #109, #110). The deficient practice could result in continued misappropriation/exploitation of other residents.Findings Include:Resident #108 was admitted to the facility on [DATE], with diagnoses that included hypertension, dementia, muscle weakness and history of falling.A review of the minimum data set (MDS) dated [DATE] for Resident #108 revealed a brief interview mental status (BIMS) score of 09, which shows moderate cognitive impairment.Resident #75 was admitted to the facility on [DATE], with diagnoses that included dementia without behavioral disturbance, major depressive disorder, myocardial infarction and anxiety disorder.A review of the minimum data set (MDS) dated [DATE], for Resident #75 revealed a brief interview mental status (BIMS) score of 03, which shows severe cognitive impairment.An interview was conducted on August 6, 2025 at 1016 am with Public Fiduciary Lead (PFL), who works under the court appointed Adult Public Fiduciary (APF). On July 27, 2022, the court appointed APF to be the fiduciary over Resident #108. The new administrator, executive director Staff #147 contacted us and informed the office of a situation. He became aware of some inconsistencies, looked and found theft. The police, adult protective services (APS), department of health services (DHS) were contacted and business office manager Staff #148 was terminated.An interview was conducted on August 6, 2025 at 1029 a.m. with APF for Resident #108. Based on a short time, Staff #148 was putting transactions as spending money due to dementia. Some expenses included: digital expense $498.29, flowers at $72, food snack shop Instacart $289.71, coloring books and pencils 1542.45, miscellaneous items- basketball hoop, description not for figurines, cushion covers $1254.38, $810.76 and $4067.69. For Resident #75, expenses included a grill, cupcakes, macaroons, Apple TV, Prime Video, remote control monster trucks, miniature figurines, basketball hoop items, gumball machine, decorations. Restitution total $20,565.93. Food, Amazon, pictures, flowers $1157.82. That was from June 7, 2022 through June 30, 2024. He did not have any clothing or any items. Radio, clothing and a lot of purchases on Amazon totaling $9483.90. Purchases titled as shopping. Shopping sprees on bedding and clothing, $570. Resident #75 did not have a lot. There was a lot of Amazon, door dash, Sunny Skin-tanning place, Instacart, Target shopping for clocks, thermal water bottles, bedding items. Resident #75's purchases were going straight to Staff #148's use. Resident #75 did not have any of those items and we had to purchase bedding and clothing for him after going to his room at the facility to see the purchased items on his account.Review of the facility's 5 day report to the SA, showed that Resident #75's account had multiple purchases from Audible, Amazon and recurring purchases. Resident #75 was unable to be interviewed and a visual review was conducted of his room with none of items charged to his account being found.Resident #5 was admitted to the facility on [DATE], with an original admission date of October 12, 2020, with diagnoses that include respiratory failure, kidney failure, chronic obstructive pulmonary disease (COPD), muscle weakness, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side.A review of the minimum data set (MDS) dated [DATE] for Resident #5 revealed a brief interview mental status (BIMS) score of 15, which shows cognitive intact.An interview was conducted on August 8, 2025 at 907 a.m. with Resident #5 and revealed that Resident #5 was informed by the office of a $500 stay at a hotel. Resident #5 did not stay at a hotel and did not have a receipt for a hotel stay. The office did not have the receipt either. The court said that they will have to pay back the money and Staff #148 took other residents' money too.Review of the facility's 5 day report to the SA, showed that a receipt was procured in relation to a hotel stay on April 25, 2024 to April 28, 2024 at the Delta Phoenix Mesa Hotel. It was confirmed that the purchase was made using the resident trust fund debit card and an identical charge was matched to Resident #5's resident account in April. The dates correlated to Staff #148's daughters dance competition that was posted on social media. The dance competition website confirms that the hotel was used for participants that week as well.Resident #63 was admitted to the facility on [DATE], with diagnoses that include type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, anxiety.A review of the minimum data set (MDS) dated [DATE] for Resident #63 revealed a brief interview mental status (BIMS) score of 14, which shows cognitive intact.An interview was conducted on August 8, 2025 at 9:03 a.m. with Resident #63 and revealed that a month ago, was notified that someone had purchased a ring at Dillard's and things from Fast Eddy's. Resident #63 does not know the total amount used from the account, but it was someone who worked in the business office.Review of the facility's 5 day report submitted to the SA revealed that Dillard's was able to provide the exact item purchased based on the submitted receipt, a silver sized 11, men's ring with a cross. A post on social media was found of Staff #148's family member with a ring identical to the picture provided by Dillard's. A review showed that this purchase was applied to Resident #63's resident account. The resident was questioned regarding purchasing any new jewelry in the last couple months and stated she had not received anything and does not shop at Dillard's.Resident #77 was admitted to the facility on [DATE] with an original admission date of May 6, 2023, with diagnoses that include Alzheimer's disease, dementia, anxiety, type 2 diabetes mellitus, depression and a history of falling.A review of the minimum data set (MDS) dated [DATE] for Resident #77 revealed a brief interview mental status (BIMS) score of 03, which shows severe cognitive impairmentAn interview was conducted on August 6, 2025 at 1:19 p.m. with a family member of Resident #77 and revealed that the family members were notified of Resident #77 having $260 to $280 dollars taken from his account from Staff #148. The case is going to court because this was that person's second offense. 19 other people are involved.Resident #110 was originally admitted to the facility on [DATE] with diagnoses that include cerebral infarction with speech and language deficits, chronic kidney disease, major depressive disorder and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #110 revealed a brief interview mental status (BIMS) score of 11, which shows moderate cognitive impairment.An interview was conducted on August 6, 2025 at 2:11 p.m. with a family member of Resident #110 and revealed that the family member was notified after Resident #110 passed away that he had an outstanding bill of $18. Then was notified that Staff #148 took money from Resident #110. The family member stated that they could not understand how money was taken since Resident #110 had nothing and they let the $18 go. No amount was given as to how much was taken from Resident #110.Resident #18 was originally admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, dementia and legal blindness.A review of the minimum data set (MDS) dated [DATE] for Resident #18 revealed a brief interview mental status (BIMS) score of 11, which shows moderate cognitive impairment.An interview was conducted on August 6, 2025 at 12:36 p.m. with a financial power of attorney (FPOA) to resident #18 and revealed that the FPOA was notified of some discrepancies of Resident #18's account and it was reported right away. No clue as to how much was taken, but to ask Resident #18 because some days Resident #18 is sharp as a tac.An interview was conducted on August 12, 2025 at 10:02 a.m. with Resident #18 and revealed that someone stole money and does not know the amount. Three different figures were given and does not know which is right. The police came and told Resident #18 that someone from the facility took money from Resident #18's account.Resident #109 was originally admitted to the facility on [DATE] with diagnoses that include dementia, Alzheimer's disease, anxiety, major depressive disorder and repeated falls.A review of the minimum data set (MDS) dated [DATE] for Resident #109 revealed a brief interview mental status (BIMS) score of 00, which shows severe cognitive impairment.An interview was conducted on August 6, 2025 at 11:36 a.m. with a family member of Resident #109 and revealed that $1200 of Resident #109's share cost was put into the trust account and not the share account. Resident #109's family member never signed to have a trust account at the facility. Staff member #147 has been on top of this and is communicating as much as he can. This was also reported to the police, because if you do not report it, nobody else will and it can happen to someone else. Staff #148 did this at another facility and it went unreported.Resident #31 was originally admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, COPD, major depressive disorder, anxiety and obstructive sleep apnea.A review of the minimum data set (MDS) dated [DATE] for Resident #31 revealed a brief interview mental status (BIMS) score of 13, which shows cognitive intact.An interview was conducted on August 7, 2025 at 10:23 a.m. with Resident #31 and revealed that someone in the office stole $2000 from Resident #31 and that the person who stole the money does not work at the facility anymore. Money was taken from other residents. Staff #147 informed Resident #31 of the money being taken from his account.Resident #86 was originally admitted to the facility on [DATE] with diagnoses that include cerebral palsy, hypothyroidism, type 2 diabetes mellitus and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #86 revealed a brief interview mental status (BIMS) score of 15, which shows cognitive intact.An interview was conducted on August 7, 2025 at 1028 a.m. with Resident #86 and revealed that a lady some time ago a lady was taking money from the trust and $190 was taken from Resident #86. The case is ongoing and there are court dates. Around $40,000 has been taken from all the residents involved and another facility.Resident #95 was originally admitted to the facility on [DATE] with diagnoses that include anoxic brain damage, type 2 diabetes mellitus, anxiety disorder, major depressive disorder and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #95 revealed a brief interview mental status (BIMS) score of 08, which shows cognitive impairment.An interview was conducted on August 8, 2025 with Resident #95 and revealed that $100 had been taken from the trust account and has not been returned or replaced. Resident #95 had tried to purchase something from the store and the money was not there. Resident #95 now wears a lanyard to keep track of the card to the account.An interview was conducted on August 7, 2025 at 3:38 p.m. with business office manager Staff #130 and revealed that about 1.5 years into the job as the assistant in the business office, Staff #130 noticed that things were not okay with the trust account. Staff #130 did not report because the previous executive director would have fired Staff #130 before getting everything straightened out, due to the friendship between the former executive director and staff #148. Staff #130 stated that it was a personal opinion because that type of thing only happens in the movies. Staff #130 also revealed that if you do not report any suspicion of misappropriation, you can get in trouble, it will affect the residents, and will continue to happen if you do not speak up.Review of documents received by the SA on August 8, 2025 about 08:05 a.m. revealed copies of resident trust accounts that were compromised by Staff #148. The documents included Residents #3, #5, #31, #58, #63, #75, #76, #77 and #95.Review of a document received by the SA on August 8, 2025 about 0805 a.m. titled Unofficial Report Staff #148 Misappropriation 08/08/2025, from Staff #147. The document included information of audits being conducted. Staff #147 interviewed Staff #130 which revealed that Staff #130 was fairly positive that Staff #148 was using resident funds inappropriately for personal use and was terrified to bring it the previous administrator due to the close relationship that Staff #148 had with him. Staff #130 was scared that any accusation or report would result in retaliation and/or termination as Staff #130 had witnessed favoritism towards Staff #148 in past conflicts. Staff #130 felt that Staff #148 was utilizing funds for personal use and gain. Receipts were not being produced for all charges during reconciliation. Staff #130 saw alleged purchases for items on resident accounts that align with personal purchases that Staff #148 had made. Examples included food purchases, gift items and beauty products that Staff #130 did not see given to the residents. Staff #130 expressed that she did not have all the pieces of the puzzle but had bank statements and resident trust transactions that would potentially prove that misappropriation was occurring.Staff #147 began comparing partial bank statements against resident trust transaction reports. Three resident accounts were found that had incomplete documentation and there was a need to verify the purchases for the residents. The residents were Resident #5, Resident #75 and Resident #63. On June 4, 2024 Staff #148 was suspended while an investigation for the suspicious charges continued which included: Resident #75 - multiple amazon purchases for audio books. Resident #5 - Hotel stay in Phoenix, AZ. Resident #63 - Jewelry purchase at Dillard's. Resident #75's account was chosen for review based on his cognitive deficit and the increased number of amazon purchases being assigned to his trust account without proper documentation or receipts. Many of the amazon books were not purchased through the facility amazon account. Resident #75 does not possess any device to utilize for listening and does not hold the cognitive capacity to confirm any of the purchases. Resident #63 had a purchase from Dillard's on her account. One receipt with out a resident signature (indicating that the resident signed for reception of the item) was taken to Dillard's to confirm the purchase. The store associate scanned the receipt and provided a picture of the item. It was a silver sized 11 men's ring with a cross on it. Resident #63 was questioned about receiving or requested any men's jewelry and had not. Staff member #148 remembered running into Staff member #147 and her family while shopping at Dillard's and Staff #148 informed they were shopping for a family member's graduation. A search on Staff #148's Instagram account showed a photo of a family member wearing a ring that appears to be the same ring from Dillard's. Resident #5 had a suspicious charge on his resident trust account. A large specific sum that was labelled as a correction with no details to support the transaction. An amount matching the charge on Resident #5's resident trust account was found as a line item listed was a hotel room. Staff #147 drove to Phoenix to confirm with hotel staff that Staff #148 was the only person associated with the room, that Staff #148 would need to provide photo ID to be able to check in, and the card was used for the stay. Another search on Instagram revealed that Staff #148's family had a dance competition held at that hotel the days of the booked room. Staff #148 also posted pictures with correlating dates to the stay. In conclusion it was found that Staff #148 failed to follow proper policies and procedures according to Haven Health's company standards. Staff #148 employment was terminated on 6/7/24. The Yuma Police Department (YPD) was notified on 6/4/24 and the facility has provided all evidence requested and is cooperating in the active investigation and case against Staff #148. A forensic accountant was used by YPD to investigate transactions and impact. Specific amounts for potential resident loss have not been provided or shared at this time. No resident has experienced a loss of care due to this incident. An interview was conducted on August 8, 2025 at 9:46 a.m. with Executive Director Staff #147 and revealed that when misappropriation occurs in the facility you report, start the investigation with all parties including the family/resident. Reporting to the four main which are the SA, police, ombudsman and APS. The POA and or guardian are also notified. The state would be notified of each resident and three residents were listed on the 5 day. The police started asking for more documents, more residents were involved. The misappropriation policy states we should be reporting those. Staff #147 met with Staff #130 regarding the trust accounts and showed proof. No resident had ever had that many charges on the resident account and Staff #130 showed Staff #147 how to read the bank statements and it took some time to read. Staff #147 did not know there was a resident debit card and started to look at Staff #147's purchasing card and business card and trying to match them up to the resident debit card and they were both in Staff #148's name and Staff #148 could not find any charges that were connected to her. Her business card and what charges were being made and the resident card statements and they were not matching. Then Staff #147 realized there was another card being used. Found a receipt and Staff #130 was right that receipts were not being turned in, the 4 digits did not match the pea card. Then the resident trust to the resident debit card then there were a couple charges that were erroneous and suspicious. I acknowledged it and reported right from the get go. After that did the investigation, and she was suspended. There were multiple people that said she was solid and I did not have to worry, then I was scared that I had to, then that she was misappropriating funds. I thought I was going to get in trouble. I reported it and reported to my supervisor. Then we met with Staff #148 and said that we have suspicion, and we have an investigation to follow, do you have any receipts. We were able to see a hotel stay. Resident #75 did not have an [NAME], no device and nothing to use to listen on (for the audio books) then the police did the investigation and when they asked for a lot more evidence then requested more records for other people so it was provided. Staff #148 was terminated for not following policy/procedure. During the investigation, Staff #148 found out I was calling former jobs and friends of Staff #148 still worked there and then tipped Staff #148 off. I do not know if they were in on it. Can only prove there was misappropriation through Staff #148. The detective was working with me and asked for more records. A forensic account was brought in, there were some dead ends and some rabbit holes. I have not been privy to all of the information. There was an interview and the detective tried to present some evidence but was told not to by the defense attorney. The total amount is not known.Review of the policy titled, Resident Rights/Dignity: Resident Rights, Version 051123 (Policies and Procedures in effect on January 1, 2024), revealed that 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect, misappropriation of resident property and exploitation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:16Number of residents cited:13The facility failed to ensure the accounting and records of resident funds for 13 of 16 residentsBased on interviews, review of clinical records, facility 5 day report to the state agency (SA) and review of facility policy and procedures, the facility failed to ensure the accounting and records of resident trust funds for 13 residents out of 16 (#3, #5, #18, #31, #32, #58, #63, #75, #76, #77, #86, #95, #96, #108, #109, #110). The deficient practice could result in continued misappropriation/exploitation of other residents.Findings Include:Resident #108 was admitted to the facility on [DATE], with diagnoses that included hypertension, dementia, muscle weakness and history of falling.A review of the minimum data set (MDS) dated [DATE] for Resident #108 revealed a brief interview mental status (BIMS) score of 09, which shows moderate cognitive impairment.Resident #75 was admitted to the facility on [DATE], with diagnoses that included dementia without behavioral disturbance, major depressive disorder, myocardial infarction and anxiety disorder.A review of the minimum data set (MDS) dated [DATE], for Resident #75 revealed a brief interview mental status (BIMS) score of 03, which shows severe cognitive impairment.An interview was conducted on August 6, 2025 at 1016 am with Public Fiduciary Lead (PFL), who works under the court appointed Adult Public Fiduciary (APF). On July 27, 2022, the court appointed APF to be the fiduciary over Resident #108. The new administrator, executive director Staff #147 contacted us and informed the office of a situation. He became aware of some inconsistencies, looked and found theft. The police, adult protective services (APS), department of health services (DHS) were contacted and business office manager Staff #148 was terminated.An interview was conducted on August 6, 2025 at 1029 a.m. with APF for Resident #108. Based on a short time, Staff #148 was putting transactions as spending money due to dementia. Some expenses included: digital expense $498.29, flowers at $72, food snack shop Instacart $289.71, coloring books and pencils 1542.45, miscellaneous items- basketball hoop, description not for figurines, cushion covers $1254.38, $810.76 and $4067.69. For Resident #75, expenses included a grill, cupcakes, macaroons, Apple TV, Prime Video, remote control monster trucks, miniature figurines, basketball hoop items, gumball machine, decorations. Restitution total $20,565.93. Food, Amazon, pictures, flowers $1157.82. That was from June 7, 2022 through June 30, 2024. He did not have any clothing or any items. Radio, clothing and a lot of purchases on Amazon totaling $9483.90. Purchases titled as shopping. Shopping sprees on bedding and clothing, $570. Resident #75 did not have a lot. There was a lot of Amazon, door dash, Sunny Skin-tanning place, Instacart, Target shopping for clocks, thermal water bottles, bedding items. Resident #75's purchases were going straight to Staff #148's use. Resident #75 did not have any of those items and we had to purchase bedding and clothing for him after going to his room at the facility to see the purchased items on his account.Review of the facility's 5 day report to the SA, showed that Resident #75's account had multiple purchases from Audible, Amazon and recurring purchases. Resident #75 was unable to be interviewed and a visual review was conducted of his room with none of items charged to his account being found.Resident #5 was admitted to the facility on [DATE], with an original admission date of October 12, 2020, with diagnoses that include respiratory failure, kidney failure, chronic obstructive pulmonary disease (COPD), muscle weakness, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side.A review of the minimum data set (MDS) dated [DATE] for Resident #5 revealed a brief interview mental status (BIMS) score of 15, which shows cognitive intact.An interview was conducted on August 8, 2025 at 907 a.m. with Resident #5 and revealed that Resident #5 was informed by the office of a $500 stay at a hotel. Resident #5 did not stay at a hotel and did not have a receipt for a hotel stay. The office did not have the receipt either. The court said that they will have to pay back the money and Staff #148 took other residents' money too.Review of the facility's 5 day report to the SA, showed that a receipt was procured in relation to a hotel stay on April 25, 2024 to April 28, 2024 at the Delta Phoenix Mesa Hotel. It was confirmed that the purchase was made using the resident trust fund debit card and an identical charge was matched to Resident #5's resident account in April. The dates correlated to Staff #148's daughters dance competition that was posted on social media. The dance competition website confirms that the hotel was used for participants that week as well.Resident #63 was admitted to the facility on [DATE], with diagnoses that include type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, anxiety.A review of the minimum data set (MDS) dated [DATE] for Resident #63 revealed a brief interview mental status (BIMS) score of 14, which shows cognitive intact.An interview was conducted on August 8, 2025 at 9:03 a.m. with Resident #63 and revealed that a month ago, was notified that someone had purchased a ring at Dillard's and things from Fast Eddy's. Resident #63 does not know the total amount used from the account, but it was someone who worked in the business office.Review of the facility's 5 day report submitted to the SA revealed that Dillard's was able to provide the exact item purchased based on the submitted receipt, a silver sized 11, men's ring with a cross. A post on social media was found of Staff #148's family member with a ring identical to the picture provided by Dillard's. A review showed that this purchase was applied to Resident #63's resident account. The resident was questioned regarding purchasing any new jewelry in the last couple months and stated she had not received anything and does not shop at Dillard's.Resident #77 was admitted to the facility on [DATE] with an original admission date of May 6, 2023, with diagnoses that include Alzheimer's disease, dementia, anxiety, type 2 diabetes mellitus, depression and a history of falling.A review of the minimum data set (MDS) dated [DATE] for Resident #77 revealed a brief interview mental status (BIMS) score of 03, which shows severe cognitive impairmentAn interview was conducted on August 6, 2025 at 1:19 p.m. with a family member of Resident #77 and revealed that the family members were notified of Resident #77 having $260 to $280 dollars taken from his account from Staff #148. The case is going to court because this was that person's second offense. 19 other people are involved.Resident #110 was originally admitted to the facility on [DATE] with diagnoses that include cerebral infarction with speech and language deficits, chronic kidney disease, major depressive disorder and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #110 revealed a brief interview mental status (BIMS) score of 11, which shows moderate cognitive impairment.An interview was conducted on August 6, 2025 at 2:11 p.m. with a family member of Resident #110 and revealed that the family member was notified after Resident #110 passed away that he had an outstanding bill of $18. Then was notified that Staff #148 took money from Resident #110. The family member stated that they could not understand how money was taken since Resident #110 had nothing and they let the $18 go. No amount was given as to how much was taken from Resident #110.Resident #18 was originally admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, dementia and legal blindness.A review of the minimum data set (MDS) dated [DATE] for Resident #18 revealed a brief interview mental status (BIMS) score of 11, which shows moderate cognitive impairment.An interview was conducted on August 6, 2025 at 12:36 p.m. with a financial power of attorney (FPOA) to resident #18 and revealed that the FPOA was notified of some discrepancies of Resident #18's account and it was reported right away. No clue as to how much was taken, but to ask Resident #18 because some days Resident #18 is sharp as a tac.An interview was conducted on August 12, 2025 at 10:02 a.m. with Resident #18 and revealed that someone stole money and does not know the amount. Three different figures were given and does not know which is right. The police came and told Resident #18 that someone from the facility took money from Resident #18's account.Resident #109 was originally admitted to the facility on [DATE] with diagnoses that include dementia, Alzheimer's disease, anxiety, major depressive disorder and repeated falls.A review of the minimum data set (MDS) dated [DATE] for Resident #109 revealed a brief interview mental status (BIMS) score of 00, which shows severe cognitive impairment.An interview was conducted on August 6, 2025 at 11:36 a.m. with a family member of Resident #109 and revealed that $1200 of Resident #109's share cost was put into the trust account and not the share account. Resident #109's family member never signed to have a trust account at the facility. Staff member #147 has been on top of this and is communicating as much as he can. This was also reported to the police, because if you do not report it, nobody else will and it can happen to someone else. Staff #148 did this at another facility and it went unreported.Resident #31 was originally admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, COPD, major depressive disorder, anxiety and obstructive sleep apnea.A review of the minimum data set (MDS) dated [DATE] for Resident #31 revealed a brief interview mental status (BIMS) score of 13, which shows cognitive intact.An interview was conducted on August 7, 2025 at 10:23 a.m. with Resident #31 and revealed that someone in the office stole $2000 from Resident #31 and that the person who stole the money does not work at the facility anymore. Money was taken from other residents. Staff #147 informed Resident #31 of the money being taken from his account.Resident #86 was originally admitted to the facility on [DATE] with diagnoses that include cerebral palsy, hypothyroidism, type 2 diabetes mellitus and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #86 revealed a brief interview mental status (BIMS) score of 15, which shows cognitive intact.An interview was conducted on August 7, 2025 at 1028 a.m. with Resident #86 and revealed that a lady some time ago a lady was taking money from the trust and $190 was taken from Resident #86. The case is ongoing and there are court dates. Around $40,000 has been taken from all the residents involved and another facility.Resident #95 was originally admitted to the facility on [DATE] with diagnoses that include anoxic brain damage, type 2 diabetes mellitus, anxiety disorder, major depressive disorder and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #95 revealed a brief interview mental status (BIMS) score of 08, which shows cognitive impairment.An interview was conducted on August 8, 2025 with Resident #95 and revealed that $100 had been taken from the trust account and has not been returned or replaced. Resident #95 had tried to purchase something from the store and the money was not there. Resident #95 now wears a lanyard to keep track of the card to the account.Review of documents received by the SA on August 8, 2025 about 08:05 a.m. revealed copies of resident trust accounts that were compromised by Staff #148. The documents included Residents #3, #5, #31, #58, #63, #75, #76, #77 and #95.Review of a document received by the SA on August 8, 2025 about 0805 a.m. titled Unofficial Report Staff #148 Misappropriation 08/08/2025, from Staff #147. The document included information of audits being conducted. Staff #147 interviewed Staff #130 which revealed that Staff #130 was fairly positive that Staff #148 was using resident funds inappropriately for personal use and was terrified to bring it the previous administrator due to the close relationship that Staff #148 had with him. Staff #130 was scared that any accusation or report would result in retaliation and/or termination as Staff #130 had witnessed favoritism towards Staff #148 in past conflicts. Staff #130 felt that Staff #148 was utilizing funds for personal use and gain. Receipts were not being produced for all charges during reconciliation. Staff #130 saw alleged purchases for items on resident accounts that align with personal purchases that Staff #148 had made. Examples included food purchases, gift items and beauty products that Staff #130 did not see given to the residents. Staff #130 expressed that she did not have all the pieces of the puzzle but had bank statements and resident trust transactions that would potentially prove that misappropriation was occurring.Staff #147 began comparing partial bank statements against resident trust transaction reports. Three resident accounts were found that had incomplete documentation and there was a need to verify the purchases for the residents. The residents were Resident #5, Resident #75 and Resident #63. On June 4, 2024 Staff #148 was suspended while an investigation for the suspicious charges continued which included: Resident #75 - multiple amazon purchases for audio books. Resident #5 - Hotel stay in Phoenix, AZ. Resident #63 - Jewelry purchase at Dillard's. Resident #75's account was chosen for review based on his cognitive deficit and the increased number of amazon purchases being assigned to his trust account without proper documentation or receipts. Many of the amazon books were not purchased through the facility amazon account. Resident #75 does not possess any device to utilize for listening and does not hold the cognitive capacity to confirm any of the purchases. Resident #63 had a purchase from Dillard's on her account. One receipt with out a resident signature (indicating that the resident signed for reception of the item) was taken to Dillard's to confirm the purchase. The store associate scanned the receipt and provided a picture of the item. It was a silver sized 11 men's ring with a cross on it. Resident #63 was questioned about receiving or requested any men's jewelry and had not. Staff member #148 remembered running into Staff member #147 and her family while shopping at Dillard's and Staff #148 informed they were shopping for a family member's graduation. A search on Staff #148's Instagram account showed a photo of a family member wearing a ring that appears to be the same ring from Dillard's. Resident #5 had a suspicious charge on his resident trust account. A large specific sum that was labelled as a correction with no details to support the transaction. An amount matching the charge on Resident #5's resident trust account was found as a line item listed was a hotel room. Staff #147 drove to Phoenix to confirm with hotel staff that Staff #148 was the only person associated with the room, that Staff #148 would need to provide photo ID to be able to check in, and the card was used for the stay. Another search on Instagram revealed that Staff #148's family had a dance competition held at that hotel the days of the booked room. Staff #148 also posted pictures with correlating dates to the stay. In conclusion it was found that Staff #148 failed to follow proper policies and procedures according to Haven Health's company standards. Staff #148 employment was terminated on 6/7/24. The Yuma Police Department (YPD) was notified on 6/4/24 and the facility has provided all evidence requested and is cooperating in the active investigation and case against Staff #148. A forensic accountant was used by YPD to investigate transactions and impact. Specific amounts for potential resident loss have not been provided or shared at this time. No resident has experienced a loss of care due to this incident. An interview was conducted on August 8, 2025 at 9:46 a.m. with Executive Director Staff #147 and revealed that when misappropriation occurs in the facility you report, start the investigation with all parties including the family/resident. Reporting to the four main which are the SA, police, ombudsman and APS. The POA and or guardian are also notified. The state would be notified of each resident and three residents were listed on the 5 day. The police started asking for more documents, more residents were involved. The misappropriation policy states we should be reporting those. Staff #147 met with Staff #130 regarding the trust accounts and showed proof. No resident had ever had that many charges on the resident account and Staff #130 showed Staff #147 how to read the bank statements and it took some time to read. Staff #147 did not know there was a resident debit card and started to look at Staff #147's purchasing card and business card and trying to match them up to the resident debit card and they were both in Staff #148's name and Staff #148 could not find any charges that were connected to her. Her business card and what charges were being made and the resident card statements and they were not matching. Then Staff #147 realized there was another card being used. Found a receipt and Staff #130 was right that receipts were not being turned in, the 4 digits did not match the pea card. Then the resident trust to the resident debit card then there were a couple charges that were erroneous and suspicious. I acknowledged it and reported right from the get go. After that did the investigation, and she was suspended. There were multiple people that said she was solid and I did not have to worry, then I was scared that I had to, then that she was misappropriating funds. I thought I was going to get in trouble. I reported it and reported to my supervisor. Then we met with Staff #148 and said that we have suspicion, and we have an investigation to follow, do you have any receipts. We were able to see a hotel stay. Resident #75 did not have an [NAME], no device and nothing to use to listen on (for the audio books) then the police did the investigation and when they asked for a lot more evidence then requested more records for other people so it was provided. Staff #148 was terminated for not following policy/procedure. During the investigation, Staff #148 found out I was calling former jobs and friends of Staff #148 still worked there and then tipped Staff #148 off. I do not know if they were in on it. Can only prove there was misappropriation through Staff #148. The detective was working with me and asked for more records. A forensic account was brought in, there were some dead ends and some rabbit holes. I have not been privy to all of the information. There was an interview and the detective tried to present some evidence but was told not to by the defense attorney. The total amount is not known.An interview was conducted on August 13, 2025 at 10:31 a.m. with ED Staff #147 and revealed that to make sure this does not happen again, they have implemented a system with two business office managers. One of the managers will do the resident trust, then signs off. Then the other manager will review and then sign off. Training on abuse and misappropriation continues, following the policy. If you don't report it, it can continue if abuse and misappropriation is not reported. Review of the policy titled, Resident Rights/Dignity: Resident Rights, Version 051123 (Policies and Procedures in effect on January 1, 2024), revealed that 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident's right to: c. be free from abuse, neglect, misappropriation of resident property and exploitation and r. have the facility manage his or her funds (if he or she wishes).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Number of residents sampled:14Number of residents cited:97The facility failed to ensure residents are free from misappropriation for 14 of 97 residents.Based on interviews, review of clinical records, facility 5 day report to the state agency (SA) and review of facility policy and procedures, the facility failed to ensure 14 residents out of 16 (#3, #5, #18, #31, #63, #75, #76, #77, #86, #95, #96, #108, #109, #110) were free from misappropriation by a staff member (#148). The deficient practice could lead to misappropriation of resident money and belongings by other staff members.-Findings include:Resident #108 was admitted to the facility on [DATE], with diagnoses that included hypertension, dementia, muscle weakness and history of falling.A review of the minimum data set (MDS) dated [DATE] for Resident #108 revealed a brief interview mental status (BIMS) score of 09, which shows moderate cognitive impairment.Resident #75 was admitted to the facility on [DATE], with diagnoses that included dementia without behavioral disturbance, major depressive disorder, myocardial infarction and anxiety disorder.A review of the minimum data set (MDS) dated [DATE], for Resident #75 revealed a brief interview mental status (BIMS) score of 03, which shows severe cognitive impairment.An interview was conducted on August 6, 2025 at 1016 am with Public Fiduciary Lead (PFL), who works under the court appointed Adult Public Fiduciary (APF). On July 27, 2022, the court appointed APF to be the fiduciary over Resident #108. The new administrator, executive director Staff #147 contacted us and informed the office of a situation. He became aware of some inconsistencies, looked and found theft. The police, adult protective services (APS), department of health services (DHS) were contacted and business office manager Staff #148 was terminated.An interview was conducted on August 6, 2025 at 1029 a.m. with APF for Resident #108. Based on a short time, Staff #148 was putting transactions as spending money due to dementia. Some expenses included: digital expense $498.29, flowers at $72, food snack shop Instacart $289.71, coloring books and pencils 1542.45, miscellaneous items- basketball hoop, description not for figurines, cushion covers $1254.38, $810.76 and $4067.69. For Resident #75, expenses included a grill, cupcakes, macaroons, Apple TV, Prime Video, remote control monster trucks, miniature figurines, basketball hoop items, gumball machine, decorations. Restitution total $20,565.93. Food, Amazon, pictures, flowers $1157.82. That was from June 7, 2022 through June 30, 2024. He did not have any clothing or any items. Radio, clothing and a lot of purchases on Amazon totaling $9483.90. Purchases titled as shopping. Shopping sprees on bedding and clothing, $570. Resident #75 did not have a lot. There was a lot of Amazon, door dash, Sunny Skin-tanning place, Instacart, Target shopping for clocks, thermal water bottles, bedding items. Resident #75's purchases were going straight to Staff #148's use. Resident #75 did not have any of those items and we had to purchase bedding and clothing for him after going to his room at the facility to see the purchased items on his account.Review of the facility's 5 day report to the SA, showed that Resident #75's account had multiple purchases from Audible, Amazon and recurring purchases. Resident #75 was unable to be interviewed and a visual review was conducted of his room with none of items charged to his account being found.Resident #5 was admitted to the facility on [DATE], with an original admission date of October 12, 2020, with diagnoses that include respiratory failure, kidney failure, chronic obstructive pulmonary disease (COPD), muscle weakness, hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side.A review of the minimum data set (MDS) dated [DATE] for Resident #5 revealed a brief interview mental status (BIMS) score of 15, which shows cognitive intact.An interview was conducted on August 8, 2025 at 907 a.m. with Resident #5 and revealed that Resident #5 was informed by the office of a $500 stay at a hotel. Resident #5 did not stay at a hotel and did not have a receipt for a hotel stay. The office did not have the receipt either. The court said that they will have to pay back the money and Staff #148 took other residents' money too.Review of the facility's 5 day report to the SA, showed that a receipt was procured in relation to a hotel stay on April 25, 2024 to April 28, 2024 at the Delta Phoenix Mesa Hotel. It was confirmed that the purchase was made using the resident trust fund debit card and an identical charge was matched to Resident #5's resident account in April. The dates correlated to Staff #148's daughters dance competition that was posted on social media. The dance competition website confirms that the hotel was used for participants that week as well.Resident #63 was admitted to the facility on [DATE], with diagnoses that include type 2 diabetes mellitus, hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, major depressive disorder, anxiety.A review of the minimum data set (MDS) dated [DATE] for Resident #63 revealed a brief interview mental status (BIMS) score of 14, which shows cognitive intact.An interview was conducted on August 8, 2025 at 9:03 a.m. with Resident #63 and revealed that a month ago, was notified that someone had purchased a ring at Dillard's and things from Fast Eddy's. Resident #63 does not know the total amount used from the account, but it was someone who worked in the business office.Review of the facility's 5 day report submitted to the SA revealed that Dillard's was able to provide the exact item purchased based on the submitted receipt, a silver sized 11, men's ring with a cross. A post on social media was found of Staff #148's family member with a ring identical to the picture provided by Dillard's. A review showed that this purchase was applied to Resident #63's resident account. The resident was questioned regarding purchasing any new jewelry in the last couple months and stated she had not received anything and does not shop at Dillard's.Resident #77 was admitted to the facility on [DATE] with an original admission date of May 6, 2023, with diagnoses that include Alzheimer's disease, dementia, anxiety, type 2 diabetes mellitus, depression and a history of falling.A review of the minimum data set (MDS) dated [DATE] for Resident #77 revealed a brief interview mental status (BIMS) score of 03, which shows severe cognitive impairmentAn interview was conducted on August 6, 2025 at 1:19 p.m. with a family member of Resident #77 and revealed that the family members were notified of Resident #77 having $260 to $280 dollars taken from his account from Staff #148. The case is going to court because this was that person's second offense. 19 other people are involved.Resident #110 was originally admitted to the facility on [DATE] with diagnoses that include cerebral infarction with speech and language deficits, chronic kidney disease, major depressive disorder and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #110 revealed a brief interview mental status (BIMS) score of 11, which shows moderate cognitive impairment.An interview was conducted on August 6, 2025 at 2:11 p.m. with a family member of Resident #110 and revealed that the family member was notified after Resident #110 passed away that he had an outstanding bill of $18. Then was notified that Staff #148 took money from Resident #110. The family member stated that they could not understand how money was taken since Resident #110 had nothing and they let the $18 go. No amount was given as to how much was taken from Resident #110.Resident #18 was originally admitted to the facility on [DATE] with diagnoses that include atrial fibrillation, dementia and legal blindness.A review of the minimum data set (MDS) dated [DATE] for Resident #18 revealed a brief interview mental status (BIMS) score of 11, which shows moderate cognitive impairment.An interview was conducted on August 6, 2025 at 12:36 p.m. with a financial power of attorney (FPOA) to resident #18 and revealed that the FPOA was notified of some discrepancies of Resident #18's account and it was reported right away. No clue as to how much was taken, but to ask Resident #18 because some days Resident #18 is sharp as a tac.An interview was conducted on August 12, 2025 at 10:02 a.m. with Resident #18 and revealed that someone stole money and does not know the amount. Three different figures were given and does not know which is right. The police came and told Resident #18 that someone from the facility took money from Resident #18's account.Resident #109 was originally admitted to the facility on [DATE] with diagnoses that include dementia, Alzheimer's disease, anxiety, major depressive disorder and repeated falls.A review of the minimum data set (MDS) dated [DATE] for Resident #109 revealed a brief interview mental status (BIMS) score of 00, which shows severe cognitive impairment.An interview was conducted on August 6, 2025 at 11:36 a.m. with a family member of Resident #109 and revealed that $1200 of Resident #109's share cost was put into the trust account and not the share account. Resident #109's family member never signed to have a trust account at the facility. Staff member #147 has been on top of this and is communicating as much as he can. This was also reported to the police, because if you do not report it, nobody else will and it can happen to someone else. Staff #148 did this at another facility and it went unreported.Resident #31 was originally admitted to the facility on [DATE] with diagnoses that include type 2 diabetes mellitus, COPD, major depressive disorder, anxiety and obstructive sleep apnea.A review of the minimum data set (MDS) dated [DATE] for Resident #31 revealed a brief interview mental status (BIMS) score of 13, which shows cognitive intact.An interview was conducted on August 7, 2025 at 10:23 a.m. with Resident #31 and revealed that someone in the office stole $2000 from Resident #31 and that the person who stole the money does not work at the facility anymore. Money was taken from other residents. Staff #147 informed Resident #31 of the money being taken from his account.Resident #86 was originally admitted to the facility on [DATE] with diagnoses that include cerebral palsy, hypothyroidism, type 2 diabetes mellitus and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #86 revealed a brief interview mental status (BIMS) score of 15, which shows cognitive intact.An interview was conducted on August 7, 2025 at 1028 a.m. with Resident #86 and revealed that a lady some time ago a lady was taking money from the trust and $190 was taken from Resident #86. The case is ongoing and there are court dates. Around $40,000 has been taken from all the residents involved and another facility.Resident #95 was originally admitted to the facility on [DATE] with diagnoses that include anoxic brain damage, type 2 diabetes mellitus, anxiety disorder, major depressive disorder and muscle weakness.A review of the minimum data set (MDS) dated [DATE] for Resident #95 revealed a brief interview mental status (BIMS) score of 08, which shows cognitive impairment.An interview was conducted on August 8, 2025 with Resident #95 and revealed that $100 had been taken from the trust account and has not been returned or replaced. Resident #95 had tried to purchase something from the store and the money was not there. Resident #95 now wears a lanyard to keep track of the card to the account.An interview was conducted on August 7, 2025 at 3:38 p.m. with business office manager Staff #130 and revealed that about 1.5 years into the job as the assistant in the business office, Staff #130 noticed that things were not okay with the trust account. Staff #130 did not report because the previous executive director would have fired Staff #130 before getting everything straightened out, due to the friendship between the former executive director and staff #148. Staff #130 stated that it was a personal opinion because that type of thing only happens in the movies. Staff #130 also revealed that if you do not report any suspicion of misappropriation, you can get in trouble, it will affect the residents, and will continue to happen if you do not speak up.Review of documents received by the SA on August 8, 2025 about 08:05 a.m. revealed copies of resident trust accounts that were compromised by Staff #148. The documents included Residents #3, #5, #31, #58, #63, #75, #76, #77 and #95.Review of a document received by the SA on August 8, 2025 about 0805 a.m. titled Unofficial Report Staff #148 Misappropriation 08/08/2025, from Staff #147. The document included information of audits being conducted. Staff #147 interviewed Staff #130 which revealed that Staff #130 was fairly positive that Staff #148 was using resident funds inappropriately for personal use and was terrified to bring it the previous administrator due to the close relationship that Staff #148 had with him. Staff #130 was scared that any accusation or report would result in retaliation and/or termination as Staff #130 had witnessed favoritism towards Staff #148 in past conflicts. Staff #130 felt that Staff #148 was utilizing funds for personal use and gain. Receipts were not being produced for all charges during reconciliation. Staff #130 saw alleged purchases for items on resident accounts that align with personal purchases that Staff #148 had made. Examples included food purchases, gift items and beauty products that Staff #130 did not see given to the residents. Staff #130 expressed that she did not have all the pieces of the puzzle but had bank statements and resident trust transactions that would potentially prove that misappropriation was occurring.Staff #147 began comparing partial bank statements against resident trust transaction reports. Three resident accounts were found that had incomplete documentation and there was a need to verify the purchases for the residents. The residents were Resident #5, Resident #75 and Resident #63. On June 4, 2024 Staff #148 was suspended while an investigation for the suspicious charges continued which included: Resident #75 - multiple amazon purchases for audio books. Resident #5 - Hotel stay in Phoenix, AZ. Resident #63 - Jewelry purchase at Dillard's. Resident #75's account was chosen for review based on his cognitive deficit and the increased number of amazon purchases being assigned to his trust account without proper documentation or receipts. Many of the amazon books were not purchased through the facility amazon account. Resident #75 does not possess any device to utilize for listening and does not hold the cognitive capacity to confirm any of the purchases. Resident #63 had a purchase from Dillard's on her account. One receipt with out a resident signature (indicating that the resident signed for reception of the item) was taken to Dillard's to confirm the purchase. The store associate scanned the receipt and provided a picture of the item. It was a silver sized 11 men's ring with a cross on it. Resident #63 was questioned about receiving or requested any men's jewelry and had not. Staff member #148 remembered running into Staff member #147 and her family while shopping at Dillard's and Staff #148 informed they were shopping for a family member's graduation. A search on Staff #148's Instagram account showed a photo of a family member wearing a ring that appears to be the same ring from Dillard's. Resident #5 had a suspicious charge on his resident trust account. A large specific sum that was labelled as a correction with no details to support the transaction. An amount matching the charge on Resident #5's resident trust account was found as a line item listed was a hotel room. Staff #147 drove to Phoenix to confirm with hotel staff that Staff #148 was the only person associated with the room, that Staff #148 would need to provide photo ID to be able to check in, and the card was used for the stay. Another search on Instagram revealed that Staff #148's family had a dance competition held at that hotel the days of the booked room. Staff #148 also posted pictures with correlating dates to the stay. In conclusion it was found that Staff #148 failed to follow proper policies and procedures according to Haven Health's company standards. Staff #148 employment was terminated on 6/7/24. The Yuma Police Department (YPD) was notified on 6/4/24 and the facility has provided all evidence requested and is cooperating in the active investigation and case against Staff #148. A forensic accountant was used by YPD to investigate transactions and impact. Specific amounts for potential resident loss have not been provided or shared at this time. No resident has experienced a loss of care due to this incident. An interview was conducted on August 8, 2025 at 9:46 a.m. with Executive Director Staff #147 and revealed that when misappropriation occurs in the facility you report, start the investigation with all parties including the family/resident. Reporting to the four main which are the SA, police, ombudsman and APS. The POA and or guardian are also notified. The state would be notified of each resident and three residents were listed on the 5 day. The police started asking for more documents, more residents were involved. The misappropriation policy states we should be reporting those. Staff #147 met with Staff #130 regarding the trust accounts and showed proof. No resident had ever had that many charges on the resident account and Staff #130 showed Staff #147 how to read the bank statements and it took some time to read. Staff #147 did not know there was a resident debit card and started to look at Staff #147's purchasing card and business card and trying to match them up to the resident debit card and they were both in Staff #148's name and Staff #148 could not find any charges that were connected to her. Her business card and what charges were being made and the resident card statements and they were not matching. Then Staff #147 realized there was another card being used. Found a receipt and Staff #130 was right that receipts were not being turned in, the 4 digits did not match the pea card. Then the resident trust to the resident debit card then there were a couple charges that were erroneous and suspicious. I acknowledged it and reported right from the get go. After that did the investigation, and she was suspended. There were multiple people that said she was solid and I did not have to worry, then I was scared that I had to, then that she was misappropriating funds. I thought I was going to get in trouble. I reported it and reported to my supervisor. Then we met with Staff #148 and said that we have suspicion, and we have an investigation to follow, do you have any receipts. We were able to see a hotel stay. Resident #75 did not have an [NAME], no device and nothing to use to listen on (for the audio books) then the police did the investigation and when they asked for a lot more evidence then requested more records for other people so it was provided. Staff #148 was terminated for not following policy/procedure. During the investigation, Staff #148 found out I was calling former jobs and friends of Staff #148 still worked there and then tipped Staff #148 off. I do not know if they were in on it. Can only prove there was misappropriation through Staff #148. The detective was working with me and asked for more records. A forensic account was brought in, there were some dead ends and some rabbit holes. I have not been privy to all of the information. There was an interview and the detective tried to present some evidence but was told not to by the defense attorney. The total amount is not known.Review of the policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Version 051123 (Policies and Procedures in effect on January 1, 2024), revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation.

Number of residents sampled:16Number of residents cited:13The facility failed to ensure the implementation of abuse misappropriation policy for 13 of 16 residentsBased on interviews, review of clinical records, facility 5 day report to the state agency (SA) and review of facility policy and procedures, the facility failed to ensure the implementation of their abuse/misappropriation policy for 13 residents out of 16 (#3, #5, #18, #31, #32, #58, #63, #75, #76, #77, #86, #95, #96, #108, #109, #110). The deficient practice could result in continued misappropriation/exploitation of other residents.Findings Include:An interview was conducted on August 7, 2025 at 3:12 p.m. with Certified Nursing Assistant (CNA) Staff #63 and revealed that when a resident has concerns over missing money or items, the staff will check with the business office, look in the resident room, then if can not find it, report it to the group.An interview was conducted on August 7, 2025 at 3:22 p.m. with Licensed Practical Nurse (LPN) Staff #5 and revealed that when a resident says they are missing money or items, you go with the resident to their room, ask when they last had it. Then go to the manager, business office or ask the CNAs. Investigate what happened, notify the administrator, Director of Nursing (DON), report to the state and ombudsman.An interview was conducted on August 7, 2025 at 3:38 p.m. with business office manager Staff #130 and revealed that about 1.5 years into the job as the assistant in the business office, Staff #130 noticed that things were not okay with the trust account. Staff #130 did not report because the previous executive director would have fired Staff #130 before getting everything straightened out, due to the friendship between the former executive director and staff #148. Staff #130 stated that it was a personal opinion because that type of thing only happens in the movies. Staff #130 also revealed that if you do not report any suspicion of misappropriation, you can get in trouble, it will affect the residents, and will continue to happen if you do not speak up.An interview was conducted on August 8, 2025 at 09:46 a.m. with Executive Director (ED) Staff #147 and revealed that when there is an allegation of misappropriation in the facility, you notify the four main parties. State Agency (SA), police, Adult Protective Services (APS) and the Ombudsman. Also, the Power of Attorney (POA) and guardian. Three residents were listed on the 5 day report to the SA (Residents #5, #63 and #75). The following day the police started their investigation. The police started asking for more documents. The policy states we should be reporting those (misappropriation). The findings were reported to the supervisor of Staff #147. An interview was conducted on August 13, 2025 at 10:17 a.m. with Director of Nursing (DON) Staff #126 and revealed that when an allegation of abuse/misappropriation occurs, you make sure the resident is safe, then notify the appropriate entities and start investigating. Abuse, neglect and misappropriation training is done at least annually and any time there is a concern or allegation.An interview was conducted on August 13, 2025 at 10:31 a.m. with ED Staff #147 and revealed that to make sure this does not happen again, they have implemented a system with two business office managers. One of the managers will do the resident trust, then signs off. Then the other manager will review and then sign off. Training on abuse and misappropriation continues, following the policy. If you don't report it, it can continue if abuse and misappropriation is not reported.Review of the facility policy Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Version 051123 (Policies and Procedures in effect on January 1, 2024), revealed that section 2 reads: Develop and implement policies and protocols to prevent and identify: theft, exploitation or misappropriation of resident property. Section 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Section 9. Investigate and report any allegations with timeframes required by federal requirements.

Number of residents sampled:16Number of residents cited:13The facility failed to ensure the reporting of alleged violations for 13 of 16 residents.Based on interviews, review of clinical records, facility 5 day report to the state agency (SA) and review of facility policy and procedures, the facility failed to ensure the reporting of misappropriation/exploitation for 13 residents out of 16 (#3, #5, #18, #31, #32, #58, #63, #75, #76, #77, #86, #95, #96, #108, #109, #110). The deficient practice could result in continued misappropriation/exploitation of other residents.Findings Include:An interview was conducted on August 7, 2025 at 3:38 p.m. with business office manager Staff #130 and revealed that about 1.5 years into the job as the assistant in the business office, Staff #130 noticed that things were not okay with the trust account. Staff #130 did not report because the previous executive director would have fired Staff #130 before getting everything straightened out, due to the friendship between the former executive director and staff #148. Staff #130 stated that it was a personal opinion because that type of thing only happens in the movies. Staff #130 also revealed that if you do not report any suspicion of misappropriation, you can get in trouble, it will affect the residents, and will continue to happen if you do not speak up.An interview was conducted on August 8, 2025 at 09:46 a.m. with Executive Director (ED) Staff #147 and revealed that when there is an allegation of misappropriation in the facility, you notify the four main parties. State Agency (SA), police, Adult Protective Services (APS) and the Ombudsman. Also the Power of Attorney (POA) and guardian. Three residents were listed on the 5 day report to the SA (Residents #5, #63 and #75). The following day the police started their investigation. The police started asking for more documents. The policy states we should be reporting those (misappropriation).An interview was conducted on August 13, 2025 at 10:31 a.m. with ED Staff #147 and revealed that to make sure this does not happen again, they have implemented a system with two business office managers. One of the managers will do the resident trust, then signs off. Then the other manager will review and then sign off. Training on abuse and misappropriation continues, following the policy. If you don't report it, it can continue if abuse and misappropriation is not reported.An interview was conducted on August 13, 2025 at 10:17 a.m. with Director of Nursing (DON) Staff #126 and revealed that when an allegation of abuse/misappropriation occurs, you make sure the resident is safe, then notify the appropriate entities and start investigating. Abuse, neglect and misappropriation training is done at least annually and any time there is a concern or allegation.Review of the facility policy Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program, Version 051123 (Policies and Procedures in effect on January 1, 2024), revealed that section 2 reads: Develop and implement policies and protocols to prevent and identify: theft, exploitation or misappropriation of resident property. Section 8. Identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. Section 9. Investigate and report any allegations with timeframes required by federal requirements.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews and policy review, the facility failed to ensure that medications were not left at the bedside for three residents (#86 and #93). The deficient practice could result in harm to the residents, and/or visitors who have access to medications. Findings include: -Resident #93 was admitted on [DATE] diagnosis included pneumonia, acute and chronic respiratory failure with hypoxia, acute and chronic respiratory failure with hypercapnia, chronic combined systolic (congestive) and diastolic (congestive) heart failure, and type 2 diabetes mellitus. The quarterly Admissions Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 14 indicating that resident is cognitively intact. Resident #93 care plan did not address that resident is able to self-administer medication Review of the physician’s orders revealed no orders to self-administer medications. Review of progress note revealed no interdisciplinary meeting for self-administer medication. Review physician’s orders had start order of July 08, 2025 at 11:15AM for Wound care, abdomen, cleanse with Bath Wipes, pat dry, apply a liberal amount of miconazole nitrate 2% powder topical every shift as needed. Review of the assessments revealed not assessed to self-administer medications. An observation was conducted on August 05, 2025 at 10:37AM in Resident #190’s room and revealed that the resident was lying in his bed, table on the side of resident 93’s bed there was red tube laying with cap closed. Resident #93 stated that it is tube for rash and itchiness. He stated that sometimes staff members the tube very close to him or on the table. Immediately staff member was called. An interview was conducted on August 05, 2025 at 12:38 PM with Certified Nurse Assistance (CNA/staff #111), who identified the red tube as 3 oz of antifungal powder. Staff #111 stated this is not supposed to be left at the bedside. She stated that risk would having antifungal powder left on bedside would be that other resident could grab the powder and not being applied properly. An interview was conducted on August 05, 2025 at 12:42 AM with the Licensed Practical Nurse (LPN/staff #146), who identified the tube as antifungal powder. She stated that it is not supposed be left at the bedside. The risk of having antifungal powder left at the beside would that resident could misuse it and resident can administer incorrectly. An interview was conducted on August 13, 2025 at 11:43AM with Director of Nursing (DON/ Staff #126), who stated that their facility process is not have any medication left at the bedside. DON stated that if resident wants to self-administer, they would first require assessment, safe box will be given to resident to store medication, then resident will be educated to let the nurse know when they took the medication so they put on the chart. She stated that resident #93 does not have self-administer orders to use antifungal cream and no assessment is done for him. DON stated that antifungal cream should not been left at the bedside. She stated that there will risk pose to having antifungal powder left at the bedside such as another resident getting hold of it and intended resident can use it inappropriately. Staff #126 stated that having medication left at the bedside does not meet their facility policy. Reviewed the policy titled “Administering Medication” Revised date January 1, 2024 revealed 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. A review of the Clinical and Med-Pass Policies: Medications effective January 1, 2024, revealed that topical medications used in treatments are recorded on the resident’s treatment record (TAR). The policy further revealed that residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely. -Resident # 86 was admitted on [DATE], discharged on September 16, 2022 and readmitted on [DATE] with diagnosis including: cerebral palsy, hypothyroidism, abnormal results of lever function studies, hyperlipidemia, essential hypertension, allergic rhinitis, Type II Diabetes with hyperglycemia, diabetic retinopathy and polyneuropathy, obstructive sleep apnea, pancytopenia, iron deficiency anemia, non-alcoholic steatohepatitis, unspecified cirrhosis of the liver, diverticulosis of intestine, limitation of activities due to disability, other reduced mobility, abnormal posture, muscle weakness, personal history of COVID-19 and chronic superficial gastritis without bleeding. The resident remains at the facility. A review of the quarterly Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview of Mental Status (BIMS) score of 15, which indicated no cognitive deficits. The Patient Health Questionnaire (PHQ-2) revealed a score of 00, indicating no need for further mood assessment. Section E of the MDS revealed that the resident exhibited no delusions, hallucinations, physical or verbal behaviors, and no wandering or rejection of care. The MDS revealed no deficits in functional abilities of the upper or lower extremities; however, due to the diagnosis of Cerebral Palsy, the resident used an electric wheelchair for mobility purposes. The MDS revealed that the resident required set-up assistance for eating, substantial assistance with oral hygiene and upper body dressing, and dependence in lower body dressing and footwear application. A review of physician orders revealed use of mobility bars for bed mobility, full code status, incentive spirometry, chest percussion using percussion cup to assist in breaking up secretions and wound care to buttocks that specified: apply stoma powder, wipe away excess, cover with triad paste every shift and after incontinent episodes to prevent moisture-associated skin damage (MASD), and shearing every shift. There were no observed changes in medication orders. A review of physician orders revealed no orders for self-administered medications. A review of the comprehensive care plan dated June 27, 2025, revealed that the resident had bowel and bladder incontinence and was at risk for skin breakdown. The care plan further revealed that the resident had potential for functional decline due to the diagnosis of Cerebral Palsy, and goals that included that the resident would be free of complications related to hypertension, diabetes mellitus, and anemia. Further, the care plan revealed no evidence that the resident was authorized to self-administer medications. A review of the resident’s skin care assessment dated [DATE] revealed a new skin abrasion to the right buttocks area with no pressure injury. A review of the resident’s Treatment Administration Record revealed no deficits in incontinence or skin care treatments. A review of the resident’s Medication Administration Record revealed no deficits in medication administration. An observation was conducted on August 5, 2025 at 12:05 PM that revealed an unlabeled medication cup approximately 1/2 full of thick, white ointment located on an overbed table holding a number of the resident’s personal items at the resident’s bedside. The resident stated that she believed it contained triad cream that was used following the changing of incontinent briefs to treat a “shear” injury. Also observed on the bedside was a bottle of ketoconazole shampoo that was labeled with an illegible prescription label. An interview was conducted with Certified Nursing Assistant (CNA), Staff # 42, on August 5, 2025 at 12:10 PM. The CNA stated that residents cannot have medications at the bedside and that if they were seen, they would be removed from the room and taken to the nurse or a medication technician in the hall. Staff # 42 stated that it is the practice of staff to check for medications at bedside during tray checks, and defined medication as tablets, inhalants, or topicals. The CNA stated that the risk of finding medications at the bedside is that someone else may take them. An interview was conducted with Licensed Practical Nurse (LPN), Staff #146, on 8/5/2025 at 1215 PM. The LPN stated that medications at bedside could be anything that the doctor ordered that has an intervention and outcome. However, the LPN stated that no over-the-counter medicines are allowed at bedside. Staff # 146 stated that medications at the bedside that are unlabeled do not meet her expectations as the risk could lead to the medication not being taken for the intended purpose, drug interactions, or other residents taking the medication. Upon return to the room on August 5, 2025 at 12:38 PM, the medication cup containing the medication was observed to be in the resident’s wastebasket below the overbed table where it was previously located. Staff #87, Certified Medication Assistant (CMA), was asked to accompany the surveyor to identify the medication in the waste basket. An interview was conducted with the CMA, who stated that in her role, she checks medication, removes it from the medication cart, and carries it to the resident to administer it. Staff #87 stated that if she found unlabeled medication at the bedside, she would ask the nurse or ‘toss it’ but would not discard the medication in the resident’s room. When asked to identify the substance in the medication cup, the CMS stated that it appeared only to be zinc used as a skin barrier, as it “looks like bottom cream, but I cannot be certain.” The CMA stated that because she was not sure what the medication was, she could not identify the potential risk to the resident, but stated that she did not believe that it would cause harm. An interview was conducted on August 6, 2025 at 09:20 AM with Registered Nurse (RN), Staff # 108 who stated that medication administration is guided by the six rights of medication administration. The RN stated that she checks three times before administering medications; first checking the medication order, then checking the medication when removing it from the cart, and finally checking again when leaving the cart before taking it to the resident. Staff # 108 stated that if the medication is for oral administration, she would assess the resident’s ability to swallow and position them or crush the medication if needed and indicated. The RN stated that when using topical medications, she obtains the medication from the designated medication in the medication cart, and if a large tube or tub, places a small amount into a medication cup to take with her into the room. If the medication is in a small tube or container and the resident is in a private room, the medication may be taken into the room. The RN stated that following administration of the topical medication, she would throw the medication cup and gloves into the resident’s trash can and then bag the trash and remove it by carrying it to place in the trash in the dirty utility room. Staff # 108 stated that finding medication in a resident’s room would not meet her expectations, as the risk to residents would be that the resident may apply the medication to an area that didn’t need it, or someone could remove it and use it when it was not ordered. An interview was conducted with the Director of Nursing (DON), Staff # 32, on August 7, 2025 at 11:21 AM, who stated that the resident must be assessed for their ability to self-administer medications correctly. If they pass the assessment, orders are obtained and the item is care planned and reviewed quarterly, or sooner if there is a change in condition. Medications need to be secured at all times, and residents are not allowed to administer narcotics or any medications that could pose a danger to themselves or others. Having unlabeled medications at the bedside would not meet her expectations. The DON stated that the risk of this would be that someone else could find and use them when they were not prescribed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interviews, review of facility documentation and policy review, the facility failed to ensure resident #1 was free from abuse from resident #2. The deficient practice could result in residents experiencing emotional and mental trauma from abuse. Findings include: Related to resident #1- Resident #1 was admitted to the facility on [DATE] with diagnoses of type 2 diabetes, major depressive disorder, and partial paralysis on the left side following a stroke. Review of a quarterly Minimum Data Set (MDS), dated [DATE] revealed resident #1 completed a Brief Interview for Mental Status (BIMS) and scored a 15 which indicated the resident was cognitively intact. A review resident #1's progress note in her Electronic Health Record (EHR), a progress note dated November 26, 2024 at 4:32 PM indicated that resident #1 had made an inappropriate comment about her roommate's, at the time, mother. The roommate (resident #2) then grabbed resident #1's hair. Related to resident #2- Resident #2 was admitted to the facility on [DATE] with diagnoses of partial paralysis on the left side following a stroke, type 2 diabetes, schizoaffective disorder and major depressive disorder. Review of the admission MDS, dated [DATE] revealed resident #2's BIMS score was 12 which indicated the resident was moderately cognitively intact. The MDS also noted the resident had not exhibited any behaviors during the look-back period. The care plan for Resident #2 did not indicate the resident had a behavior problem towards others. Review of resident #2's progress notes in her EHR (Electronic Health Record) revealed a progress note dated November 26, 2024 at 4:47 PM. The note shared that resident #2 was witnessed pulling her roommate's pony tail because the roommate made an inappropriate comment about resident #2's mother. An interview was conducted on December 9, 2024 at 4:44 p.m. with resident #1 in her room. Resident #1 indicated that she currently felt safe in the facility. She also shared that the girl next door attacked me. Resident #1 continued to explain that the girl used to be her roommate but she had pulled resident #1's hair which was witnessed by a Certified Nursing Assistant (CNA/Staff #46). An interview was conducted on December 10, 2024 at 8:26 a.m. with resident #2 in her room. She explained that she has changed rooms many times at the facility during her stay because she can't get along with people. She also shared that she pulled the hair of her former roommate because she had called her mom a bitch. An interview was conducted on December 10, 2024 at 4:52 p.m. with a Certified Nursing assistant (CNA/staff #46). She confirmed that she was working on November 26, 2024 and had witnessed the altercation between residents #1 and #2. Staff #46 explained that both residents had returned to their room from an afternoon outing and she had walked into the room to assist resident #2. Both residents were relaxed, in their wheelchairs, and out of the blue, both residents started exchanging words and resident #1 had insulted resident #2's mother. Then resident #2 reached out to grab resident #1's hair bun and staff #46 had grabbed resident #2's hand and the resident released the hair. Staff #46 also added that she then wheeled resident #2 out of the room into the lobby to separate the two residents. Social services staff then pulled resident #2 aside to talk to her. Staff #46 indicated that there had been no other altercations between the two residents in the past and they had gotten along well with each other. An interview was conducted with the Resident Relations Manager (RRM/Staff #50) on December 10, 2024 at 5:08 p.m. When asked to explain what transpired between resident #1 and resident #2, staff #50 explained that resident #2 and grabbed resident #1's hair because resident #1 had made a comment about resident #2's mom who had passed away. Resident #2 had gotten upset and said that no one talks about her mom that way. After the altercation, the residents were put into different rooms. When asked what would the risks to the residents be if they were abused in the facility, staff #50 indicated that residents would be in an unsafe environment and it would cause issues such as behaviors. Staff #50 also added that the facility wants residents to feel safe and they knew if they did not feel safe, they could talk to social services. An interview was conducted with Licensed Practical Nurse (LPN/Staff #49) on December 10, 2024 at 5:26 p.m. Staff #49 shared that she did not witness the altercation between both residents but she was informed about it by staff #46. Once she was notified, she did an assessment with both residents and there were no injuries noted. Staff #49 also reported the incident and the police came to investigate and then social services investigated as well. An interview was conducted on December 10, 2024 at 5:39 p.m. with the Director of Nursing (DON/Staff #54). Staff #54 indicated that there was a verbal incident between resident #1 and #2 due to resident #1 saying something about resident #2's mother. This had caused resident #2 to become upset and grabbed resident #1's hair. She also indicated that a CNA was present during the altercation and was able to respond quickly and separate the two residents. Staff #54 was not aware of any other altercations that involved resident #2 but did note that resident #2 could be mean at times but it usually wasn't directed towards anyone. Review of a policy titled, Resident Rights/Dignity: Abuse, Neglect, Exploitation, and Misappropriation Prevention Program indicated that residents had a right to be free from abuse. The policy also noted that there was a facility-wide commitment to protect residents from abuse . from other residents.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, clinical record review, facility documents and facility policy, the facility failed to ensure a resident was free from abuse. This deficient practice could result in further incidents of physical abuse. Findings include: Resident #21 was admitted on [DATE] with diagnoses of anxiety disorder, and depression. A quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident had a BIMS (Brief interview for mental status) of 2, indicating that this resident was severely cognitively impaired and included inattention and disorganized thinking continuously present. A care plan dated April 15, 2024 included this resident had a behavior problem including impaired cognitive function, impaired safety awareness, wandering/exit-seeking, threatening, throwing water cups to staff despite staff reorientation/education and resident to resident altercation despite staff redirection with interventions. Interventions including intervene as necessary to protect the rights and safety of others. These interventions note a revision on November 25, 2024, however the revisions noted to the care plan do not include any changes or new interventions. No new interventions were added to this focus since April 15, 2024 A progress note dated July 13, 2024 at 6:01 p.m. included that the nurse writer witnessed an altercation between resident and another patient. This note included that a male resident sat down at a dining table and this resident started cursing at the other resident and lunged towards him. This note included that a CNA stopped resident this from making contact and that the male resident was escorted to another table . However, no new interventions were added to the care plan for this interaction and review of the tracking system did not find that this incident was reported. A progress note dated July 27, 2024 included Resident is aggressive towards other residents and staff; throw objects across table; difficulty redirecting. Will continue to monitor However, no new interventions were added to the care plan for this interaction and review of the tracking system did not find that this incident was reported. A progress note dated September 4, 2024 included at 3:30 p.m. (resident #21) was choking (resident #6) and that a CNA noticed and stopped her. This note included that (resident #21) said she was just playing and that no injuries noted on (resident #6). (Resident #6) stayed in the dining area and (resident #21) went to her room right after. A progress note dated November 18, 2024 at 7:50 p.m. included that Resident was upset due to another resident letting staff know that resident spit her pills out when staff turned away and that this resident got upset and threw plastic cup at the other resident. This note included that this resident attempted to kick resident and that she was redirected. However, no new interventions were added to the care plan for this interaction and review of the tracking system did not find that this incident was reported. -Resident #6 was admitted on [DATE] with diagnoses of dementia and anxiety. A quarterly MDS dated [DATE] revealed the resident had a BIMS of 3, indicating the resident was severely cognitively impaired with inattention and disorganized thinking continuously present. A care plan dated April 19, 2024 included that the resident has a behavior problem related to verbal behavior, wandering and unaware of safety precautions. This focus has an intervention to intervene as necessary to protect the rights and safety of others, and to remove from situation and take to alternate location as needed. This focus has no new interventions after May 10, 2024. A progress note dated November 24, 2024 included, Around 1930 nurse hear CNAs assisting resident and trying to get resident out of her room. At arrival (resident #21) was very agitated and screaming at CNAs. CNAs were trying to get (resident #6) out of room, CNA and nurse stayed with (resident #21) while other CNA help (resident #6) get out of room through the next room's shared bathroom, because (resident #21) was blocking the door. CNAs and nurse were able to separate residents and keep both safe. CNAs reported they witnessed resident walking and (resident #21) getting up from her bed. When resident was going back to her bed, resident pulled on her roommate's oxygen tubing, then (resident #21) grabbed resident's hair and pushing her away. CNA told roommate to let her go and roommate did. Both residents were separated for their safety. A full skin assessment was done to both residents. No injuries or open areas noted on either resident . An interview conducted on November 26, 2024 with a Registered Nurse (RN/staff #54) who said that she is the regular nurse for this hall. She said that resident #21 and resident #6 are sisters and that resident #21 can get aggressive at times and that she is upset by others in the chair she likes to sit in in the common area and that there was a male resident that she did not like. She said that resident #21 tried to kick a male resident when he was in her chair and also when he told a nurse that resident #21 did not take her medication. She said that she was informed that resident #21 had pulled someone's hair but that she had not yet reviewed the notes. She said that resident can't be in with her sister but can't be without her. She said that resident #21 tries to defend resident #6 from other residents and that resident #21 had tried to smack resident #6 before. She said that if no staff intervenes she could see resident #21 hurting another resident. She said that they had tried to move resident #21 and 6 to different rooms in the past but that the resident's guardian did not agree. She said that staff have to alternate on their jobs because they cannot take their eyes off of the residents or an incident would occur. This nurse said that the if it is needed that staff #32 and #71 will make changes to the care plan if it's needed and that it might be needed for resident #21. An interview was conducted on November 26, 2024 at 12:44 p.m. with a Certified Medication Assistant (CMA/staff# 37) who said that resident #21 is quiet but when we don't understand what she wants she gets mad, doesn't want anyone in her chair. This staff said that if a resident sits in her chair she gets mad and kicks and throws water. This staff said that resident #21 does not want resident #6 to get up and down. This staff said that they were told that over the weekend that resident #21 and resident #6 had fought and that the resident's representative wanted them in the same room. This staff said that this was not the first time that these two residents had fought. This CMA said that resident #21 had gotten angry at another resident who had said that resident #21 had not taken her medcation so when that staff asked her to open her hand, she got mad at the resident and threw the cup of water. This staff said that the staff asked resident #21 to go and apologize after she had calmed down, and that resident #21 came back and kicked the resident. An interview was conducted on November 26, 2024 at 12:28 p.m. with a Certified Nursing Assistant (CNA/staff #17) who said that this is the primary hall they work on. This staff said that resident #21 and resident #6 get along at times and that resident #21 wants to have control over #6's wandering. This staff said that resident #6 is unaware and just wanders. This staff said that resident #21 had tried to strangle resident #6 in the past and that usually if they go after another we try to separate them or stop that from getting out of hand. This staff said that there are interventions that the staff usually uses such as placing them at different tables and currently separating these residents but that they do not think that there are interventions on the care plan. An interview was conducted on December 5, 2024 at 12:31 p.m. with a CMA (staff #14) who said that they are a Medication Technician and that they work CNA shifts as well. This staff said that resident #21's triggers are if she sees residents arguing or if they are loud or if someone being mean to her sister, or if she goes to sleep and resident #6 is up and wandering it bothers her. This staff stated that was there when resident #21 pulled resident #6's hair. She said that she was finishing up care in the room and resident #21 was at the door and resident #6 was behind her trying to get out. She said that resident #21 was mad and just wanted her (#6) to get out. This staff said that she called the other CNA and that resident #21 was wearing her oxygen and that the tubing was going around the bed, so she told resident #21 that resident #6 would trip and then resident #6 wandered back to bed and got tangled with the oxygen tubing and pulled on it. Resident #21 turned around and grabbed resident #6 and was shaking her and shoved her to the foot of the bed and she bounced off of it and got scared. This staff said that she and the CNAs were telling resident #21 to be nice don't do that and the nurse got in front of her and told her to stop hurting her sister. This CNA said that resident #21 got upset that she was trying to get resident #6 out and that the nurse was distracting and calming her down, so she opened the bathroom where resident #6 was trying to hide and she helped her out the bathroom door to the adjoining room and kept her with us in the dining room through the ending of the shift. This CNA said that she was not on shift for the strangling though she had heard about it. She said that the staff do follow the care plan but also they try to ask the other CNAs to see what will help and tell each other that they have doing this to help that situation out. This CNA said that they get abuse training every month, mostly online and sometime in person. She said that she reports it to the nurse so that the nurse can take action and report it. An interview was conducted on December 23, 2024 at 2:04 p.m. with the Director of Nursing (DON/staff #43) who said that abuse is anything that can harm the residents and that abuse could be physical, or emotional. This DON said that someone who is not cognitively intact can abuse another person and that they care plan abuse. This staff said that usually the staff would care plan under the initiator and include any trigger that may have caused that, anything that would help the staff to recognize coming behaviors. This DON stated that the care plan was revised on November 25th but did not provide an answer as to why there was not a new intervention. She stated that any care plan revisions would be on the care plan and not documented elsewhere. This DON stated that that the staff report abuse immediately within the 2 hour window. She said that she did not know about the other issues of abuse that were noted in resident #21's clinical record. A policy titled Resident Rights/Dignity: Abuse, Neglect, Exploitation and Misappropriation Prevention Program dated January 1, 2024 revealed that residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation and that this includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the resident's symptoms. This document includes that this facility will investigate and report any allegations within timeframes required by federal requirements. A policy titled Assessments/Care Planning: Care Plans, Comprehensive Person-Centered revealed that a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. This document included that services provided for or arranged by the facility and outlined in the comprehensive care plan are trauma-informed and that assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, and facility policy, the facility failed to ensure one resident (#247) was provided services consistent with professional standards of practice. The deficient practice could result in unmanaged pain for the resident. Findings include: Resident #247 was admitted on [DATE] with diagnosis including surgical aftercare, bacteremia, sepsis, acute osteomyelitis, type 2 diabetes mellitus, peripheral vascular disease and right foot transmetatarsal amputation. Review of the electronic health record revealed that the BIMS (brief interview of mental status) had not yet been completed. A review of the physician's orders on September 14, 2023 revealed an order for pain evaluation each shift utilizing a 0 to 10 pain scale. A further review of the physician orders revealed an order to administer oxycodone-acetaminophen 5-325mg 1 tablet, by mouth, every 6 hours as needed for pain ranging 6 to 10. A review of the MAR (medication administration record) revealed the following administration history: 09/14/2023 Pain not assessed second and third shift 09/15/2023 Pain not assessed third shift 09/16/2023 Second shift-oxycodone-acetaminophen administered at a pain level 5 and no pain assessment for third shift 09/17/2023 First and third shift-oxycodone-acetaminophen administered at a pain level 5. 09/18/2023 First shift-oxycodone-acetaminophen administered at a pain level 4. Pain not assessed for second and third shift. An interview was conducted with Staff # 31 (CNA) on September 19, 2023 at 9:32 a.m. Staff #31 stated that resident's will either let her know verbally if they are in pain or via body language, include facial grimaces. She stated that is she is notifies or observes a resident in pain she would let the nurse know. She stated that the nurses assess how much pain the resident is in, but she would attempt non-pharmacological measures to include repositioning the resident or distracting them. An interview was conducted with staff # (145) on September 19, 2023 at 9:53 a.m. Staff #145 stated that she automatically introduces her self to each resident and asks if they are experiencing pain. She stated that she also watches for signs to include: restlessness and facial expressions. She stated that you become familiar with and get to know your patients. She stated that once it has been established that a resident is in pain, she would check on an order for pain medications. If the order was noted to be in the resident's file, she would administer the medication as prescribed and in accordance with the pain level expressed by the resident. She stated that there would never be a time that the pain medication would be administered outside of the prescribed parameters. She stated that the pain level, as expressed by the resident, would always be charted. However, the MAR did not reveal evidence of consistent pain level charting. A follow-up interview was conducted on September 21, 2023 at 11:50 a.m. with staff #145. Staff #145 stated that if a resident requested pain medications outside of the prescribed parameters, she would also check to see if there was another order for pain medication available that would fall inside of the designated parameters. She stated that if there were no other pain medications ordered, she would contact the doctor for other options. Staff #145 pulled up the MAR for resident #247 and stated that the oxycodone-acetaminophen appeared to have been administered outside of the designated parameters for September 16, 17 and 18. She stated that the risk of administering medications outside of parameters could include the resident being more drowsy and potential fall. An interview was conducted on September 21, 2023 at 12:19 a.m with staff #38 (DON). Staff #38 stated that her expectation for pain management is that each resident is assessed at least once per shift and that pain is managed or outreach to the physician is conducted for alternatives. She stated that her expectation is for staff to assess the pain, consult the chart for current orders and follow the orders as written. Staff #38 pulled up the MAR for resident #247 and stated that the facility had already identified this occurrence of administering medications outside of ordered parameters and that it was being reviewed. She stated that the risk for not following physician orders could include over-medication. A review of the facility's pain management protocol policy, with a review date of June 2023, revealed that staff will observe the resident for evidence of pain using a consistent approach and a standardized pain assessment instrument to identify the severity of the pain. The policy further revealed that during monitoring, staff is to reassess the individual's pain at least each shift.

Based on staff interviews, and review of facility documentation and policies, the facility failed to ensure that the QAA (quality assessment and assurance) committee collected data and monitored it's performance regarding adverse events for performance improvement. Findings include: An interview was conducted on September 21, 2023 at 2:32 p.m. with staff #8 (Administrator) and staff #38 (DON). Staff #8 stated that meetings are held every 3rd Wednesday of the month. Staff #8 shared that information as related to any PIP (performance improvement plans) is shared forward to the departments involved in the PIP. The administrator stated that the QAA committee is currently working on a PIP for falls, which had been implemented on September 20, 2023. The team is also working on a PIP for medications administered outside of ordered parameters. Staff #8 stated that a previous PIP that had been on resident showers, which had been resolved. He stated that as a result of QAA committee, a shower team had been integrated but stated that the results showed that the previous method had been more effective with ensuring timely resident showers; however, there was no evidence of data supporting how the performance measure was being tracked and monitored. The administrator stated that he was unable to locate any tracking data in support of the previous PIP. Staff #8 stated that the risk of not effectively tracking data as related to PIP's could impact the outcome of an effective performance improvement plan. A review of the facilities quality performance improvement program version 1017, copyright date 2017, revealed that the primary purpose of the quality assurance and performance improvement program is to establish data-driven, facility-wide processes that improve quality of care, quality of life and clinical outcomes for residents; however, there was no evidence of data utilized to track performance outcomes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident and staff interviews, clinical record review, and policy review, the facility failed to ensure one resident (#13) was treated with dignity by failing to knock and requesting permission before entering the resident's room. The sample size was 18. The deficient practice could result in residents not being treated in a dignified manner. Findings include: Resident #13 was admitted to the facility on [DATE] with diagnoses that included diabetes mellitus, Cerebral Palsy and hypertension. The quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident had intact cognition. An interview was conducted with the resident on 08/01/22 at 1:28 PM. The resident stated that often, the staff do not knock on the door before entering. During the interview, a CNA (Certified Nursing Assistant) was observed entering the resident's room without knocking. Further observations of residents' rooms revealed the following: Observation - 08/03/22 at 9:48 AM - Housekeeper entering without knocking on the resident's door. Observation - 08/03/22 at 11:11 AM - CNA entering without knocking on the resident's door. Observation - 08/03/22 at 12:07 PM - Housekeeper entering without knocking on the resident's door. An interview was conducted with a CNA (staff #96) on 08/03/22 at 11:12 AM. The CNA stated that she knows the policy is that they always knock on residents' doors before entering. She stated that she sometimes forgets and admits she has walked into residents' rooms without knocking, An interview was conducted with a housekeeper (staff #118) on 08/03/22 at 11:35 AM. Staff #118 stated that she knows the policy is to knock before entering a resident's room and that this should include residents who are sleeping. She admitted that she has become busy and entered a resident's room without knocking and asking permission to enter. An interview was conducted with the Director of Nursing (DON/staff #137) on 08/04/22 at 8:52 AM. The DON stated the facility policy is that staff knock on a resident's door before entering the room and that all staff should follow the policy. The DON stated it is her expectation that a resident's right to privacy be maintained by asking permission to enter a resident's room. The facility policy titled Quality of Life - Dignity stated each resident is to be cared for in a manner that promotes quality of life, dignity and respect. The policy further stated that staff will knock and request permission before entering residents' rooms.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interviews, facility documentation, and policy and procedures, the facility failed to ensure one resident (#0) was adequately supervised. The deficient practice increased the risk for resident-to-resident confrontations and accidents/hazards. Findings include: Resident #0 was admitted to the facility on [DATE] with diagnoses that included COVID-19, personal history of traumatic brain injury (TBI), and schizophrenia. Review of a Health Status Note dated 07/14/2020 at 5:47 p.m. revealed the resident had been admitted from the hospital positive for COVID-19 for recovery. The resident was described as alert and oriented to self and situation, and did not understand being placed in a skilled nursing facility. The resident was noted to be at risk for falling and wandering around trying to enter other rooms. The note included the resident had visual hallucinations, was able to answer questions, and did not know the date or place. Review of the clinical record did not reveal a Preadmission Screening and Resident Review (PASRR). An antipsychotic medication care plan dated 07/14/2020 related to impulsive behavior and visual hallucinations had a goal to reduce antipsychotic medication to the lowest dosage and still control psychotic disorder/disease. Interventions stated to administer medications as ordered. Review of the physician orders dated 07/14/2020 included: - buspirone HCl (anxiolytic) 10 milligrams (mg) 3 times daily for anxiety related to anxiety disorder as evidenced by agitation. - duloxetine HCl (antidepressant) delayed release sprinkle 20 mg 3 capsules 1 time a day for depression as evidenced by sadness and self-isolation. - olanzapine (antipsychotic) 5 mg in the evening related to schizophrenia as evidenced by visual hallucinations and impulsive behavior. - lorazepam (anxiolytic) 1 mg every 8 hours as needed for agitation related to anxiety disorder. Review of the care plan initiated on 07/14/2020 did not reveal if increased monitoring and supervision would be provided regarding the resident wandering around trying to enter other rooms, agitation, impulsive behavior, and being at risk for falling. A nursing progress not dated 07/15/2020 at 9:00 a.m. included the resident was under skilled services for increased nursing need and vigilance due to recent hospitalization and COVID-19 infection. Per the note, this was an effort to manage the resident's care within the facility due to local hospitals burdened with high influx of COVID-19 patients, decreasing ability to accept COVID patients, and limited personal protective equipment (PPE) at that time. Review of the admission Minimum Data Set assessment dated [DATE] revealed the resident scored 7 on the brief interview for mental status, indicating severely impaired cognition. The assessment revealed the resident displayed no evidence of psychosis, physical behaviors were evident for 1-3 days out of the 7-day look-back period with no impact on others, displayed wandering on 1-3 days out of the 7 days, which significantly intruded on the privacy or activities of others. The resident required limited assistance/supervision with locomotion on the unit. A physician progress note dated 07/22/2020 at 8:10 p.m. included the resident had significant confusion. The note stated that nursing staff had reported that the resident had been wandering and attempting to leave the building, and that nursing staff had to closely monitor the resident to prevent the resident from leaving the facility. A Health Status Note dated 7/24/2020 at 10:54 a.m. stated the resident was seen by the psychiatric physician assistant (PA) that morning. The PA recommended starting the resident divalproex sodium (antiepileptic/mood stabilizer) 125 mg 3 times daily for schizophrenia, and to increase olanzapine to 7.5 mg twice daily. The resident's family and the medical doctor (MD) approved the changes and consents were obtained. An antipsychotic medications care plan dated 07/24/2020 related to potential side-effects/adverse reactions of long-term use and behavior management had a goal for reduction in the use of antipsychotic medications. Interventions included administering medications as ordered. A progress note dated 07/24/2020 at 1:00 p.m. revealed the resident denied calling a resident a name and throwing a pack of wipes at another resident. An incident note dated 07/27/2020 at 10:38 a.m. revealed a Certified Nursing Assistant (CNA) had notified nursing staff that the resident had fallen on coccyx. The note stated that the last time the resident was seen was 10 minutes prior to the fall, eating breakfast in a wheelchair. The resident was found on coccyx near the wheelchair. The resident just mumbled a bunch of gibberish when asked what happened. The CNA stated that the resident had not hit head, just fell on butt. The resident was assisted back into bed, with no injuries upon assessment. The resident was told to call for assistance to get up. The MD, responsible party (RP), and the Director of Nursing (DON) were notified. A Health Status Note dated 07/27/2020 at 9:12 p.m. stated the resident continued to have increased agitation. The resident was noted to be wandering from room, with brief falling down. The note revealed the resident had been yelling from the room and required consistent redirecting. A Health Status Note dated 07/29/2020 at 7:00 a.m. revealed that during the night, the resident was found in another resident's room urinating on the floor. The note stated that the resident was frequently up during the night walking into other residents' rooms, and that the resident was impulsive, a fall risk, and extremely hard to manage. A Physician Progress Note dated 07/30/2020 at 12:54 p.m. revealed the resident had continued behavioral issues, and the nursing staff had been asked to monitor the resident closely to prevent injury. However, there was no indication that a monitoring plan had been put into place. A Health Status Note dated 07/31/2020 at 2:17 p.m. included the resident was seen by the psych PA that morning. Per the recommendation, divalproex sodium was to be increased to 250 mg 3 times per day and olanzapine was increased to 10 mg at bedtime. MD and RP notified and approved changes. Review of the July 2020 Medication Administration Record (MAR) revealed medications were administered in accordance with physician orders. A Health Status Note dated 08/3/2020 at 9:24 a.m. revealed that the resident COVID-19 test results were negative, and the MD had been notified. The note stated that the resident had been moved off the COVID hall. A Social Services Progress Note dated 08/3/2020 at 11:00 a.m. stated that at that time, there was no safe placement for the resident to discharge to. Per the DON, if the resident should continue to have additional behaviors, the resident may possibly need to go to a higher level of care. A Health Status Note dated 08/3/2020 at 1:47 p.m. included the resident was ambulating through the hallway, pacing, and wandering into another resident's room. The note stated that the resident had been redirected multiple times. According to the note, the resident went into another resident's room and defecated into a trash can. The resident was redirected, assisted to the room and bathroom. The resident was provided hygiene care and was cooperative with a shower. A history of TBI care plan initiated on 08/03/2020 related to behaviors of wandering and aggression toward others (staff and residents) had a goal for fewer episodes of behaviors. Interventions stated to intervene as necessary to protect the rights and safety of others. However, review of the care plan did not include increased monitoring and/or supervision of the resident. A Health Status Note dated 08/4/2020 at 8:45 a.m. revealed the resident continued to pace and wander down the hallway. Per the note, the resident was noted to continuously state, I got to go home, I got to go to work. The resident was able to be redirected 2 times, then sat in a chair in a dining room and yelled I want to go f ' ckin home, God damn it and grinned teeth. The note stated that the resident continued to display the psychotic episode, and stood up from the chair and started kicking the door in an attempt to get out. The note included that the resident demanded to go home, threatening staff. A call was placed to the doctor, and the resident behavior was reported. An order was received to send the resident to the ER (emergency room) for evaluation and treatment of the psychotic episode. An interview was conducted on 08/04/2022 at 10:24 a.m. with a Licensed Practical Nurse (LPN/staff #117). She stated that when a resident displays behavior that affects others, she will redirect and monitor the resident. She stated that she would define monitoring as observing and following the resident. She stated that if the resident was in another resident's room, she would ask them to come out. She stated that she would offer the resident snacks and ask them if they were in pain. The LPN stated that if the resident was not able to be redirected, they would monitor the resident to ensure the resident and the other residents are safe, observe for aggressive behaviors, etc. She stated that the first goal is to keep the residents safe, then she would administer as-needed medications and call the physician. The LPN stated that if the resident displayed behaviors such as urinating on the floors of other residents' rooms or throwing things, she would call the nurse supervisor to notify them of the increased behaviors and ask for additional help to monitor the resident. She stated that she would anticipate that a COVID-positive resident would be asked to stay in their room and not go into other areas. She stated that aggressive behaviors should be communicated to the provider as soon as possible because they could be related to an infection or a needed medication adjustment. The LPN stated that she thought that 3 weeks of dealing with this type of behavior would be too long without intervening. She stated that the risks of this type of behavior would include the resident being a danger to themselves or others. On 08/04/2022 at 10:39 a.m., an interview was conducted with the DON (staff #137). She stated that normally they admit residents that have behaviors related to dementia, but that sometimes they admit residents who have other types of behaviors. The DON stated that the norm is not to admit psychiatric patients. She said that admission of residents with schizophrenia are few and far between. She stated when that has been the case, it is usually something that is found out after the resident arrives. She stated that she felt like the former DON probably would not have admitted a resident with serious mental illness, but that the hospitals at that time were trying to discharge everybody to make room for other patients. The DON stated that if there were concerns about safety, nursing should have reported to leadership and social services. She stated that options might have included sending the resident to a behavioral facility. She said if a resident's behavior was increasing and/or escalating, she would want nursing staff to call the provider, get the resident a psych consult, and add a staff member to the unit. She stated that if they could not meet the resident needs, they would send the resident to the ER or a psych facility for further evaluation and treatment. The DON stated the risks associated with keeping a resident with these types of behaviors would include physical injury to the resident, other residents, or staff and psychosocial disruptions to the unit. The facility policy titled Behavioral Assessment, Intervention and Monitoring revised March 2015, stated behavioral symptoms will be identified using a facility-approved behavioral screening tool. Behavioral symptoms will be managed appropriately, Residents will have minimal complications associated with the management of altered or impaired behavior. The facility will comply with regulatory requirements related to the use of medications to manage behavioral changes. The interdisciplinary team will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential safety risk to the resident, and develop a plan of care accordingly. Safety strategies will be implemented immediately if necessary to protect the resident and others from harm.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident and staff interviews, and policy review, the facility failed to ensure one of three sampled residents (#86) received consistent catheter care. The deficient practice could result in residents having urinary tract infections. Findings include: Resident #86 was admitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side and neuromuscular dysfunction of the bladder. The Comprehensive Care plan initiated on 7/14/2022 revealed the resident had a suprapubic catheter due to a neurogenic bladder. The goal was for the resident to remain free from catheter-related trauma and show no signs or symptoms of urinary infection. Interventions stated suprapubic catheter care every shift. Review of Treatment Administration for July 2022, revealed no evidence the resident was provided catheter care on July 15, 2022. The admission Minimum Data Set assessment dated [DATE] revealed a Brief Interview for Mental Status score of 15, indicating the resident had intact cognition. The assessment also revealed the resident had an indwelling catheter. The physician order dated 7/20/22 stated to cleanse the suprapubic catheter exit site with normal saline, pat dry, apply split gauze dressing, and secure with tape one time a day. Notify the provider of any adverse signs or symptoms. During an interview conducted with resident #86 on 08/04/2022 at 10:04 AM, the resident stated staff does not always provide catheter care. The resident stated the staff changes the dressing every other day. An interview was conducted with the Director of Nursing (DON/staff #137) on 08/04/22 at 2:28 PM. The DON stated there is no process in place to monitor if residents are receiving catheter care. The TAR for July 2022 was reviewed with the DON. The facility Suprapubic Catheter Care policy stated the purpose of the procedure is to prevent skin irritation around the stoma site and to prevent infection of the urinary tract.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident (#36) was admitted on [DATE] with a diagnosis of fracture of unspecified part of scapula, left shoulder, subsequent encounter for fracture with routine healing. Review of a physician's order dated 4/8/2022 revealed Cozaar 25 mg 1 tablet by mouth two times a day for hypertension related to hypertensive chronic kidney disease and to hold for SBP<100. Review of the July 2022 MAR revealed Cozaar was given on July 13, 2022 when the SBP was 99. During an interview conducted with a Registered Nurse (RN/staff #116) on 8/3/22 at 9:46 AM, the RN stated parameters should be reviewed before administering medications and medications should be given as ordered. An interview with DON (staff #137) was conducted on 8/4/22 at 8:34 AM. The DON stated they try to audit once a month or once a week that medications are given within the parameters. Staff #137 stated that if there is an issue, she will speak to the nurse and educate them. Review of the facility policy Administering Medication revised December 2012 revealed the following: The Director of Nursing Services will direct and supervise all nursing personnel who administer medication and/or have related functions. Medications must be administered in accordance with the orders, including any required time frame. Based on clinical record reviews, staff interviews, and policy review, the facility failed to ensure two residents (#17 and #36) were free from unnecessary medications. The sample was 5 residents. The deficient practice could result in residents receiving medications that may not be necessary. Finding include: -Resident #17 was admitted on [DATE] with diagnoses that included peripheral vascular disease, type 2 diabetes mellitus without complications, and venous thrombosis/embolism. A baseline care plan dated May 2, 2022 stated a problem for chronic pain and that the resident takes an opioid and non-opioid analgesic related to right leg removal of external fixation. The interventions included administering analgesia medication as per orders, and evaluating effectiveness of pain interventions. Regarding Norco A physician order dated May 3, 2022 stated Norco 10-325 milligrams (mg) one table by mouth every 4 hours as needed for pain 1-5, not to exceed 3 grams/24 hour. Review of the medication administration record (MAR) for June 2022 and July 2022, revealed the resident received Norco outside the pain parameters on June 6, 9, 14, and 28, 2022, and July 15, and 24, 2022. Regarding Tramadol A physician order dated July 11, 2022 included Tramadol HCL 50 mg one tablet by mouth every 8 hours for pain scale 5-10. Review of the MAR for July 2022 revealed Tramadol was administered outside the pain scale parameters on July 12, 13, 16, 17, 21, 22, and 24, 2022. Regarding Metoprolol A physician order dated May 3, 2022 included Metoprolol Tartrate 25 mg one tablet by mouth two times a day for hypertension, hold for SBP (systolic blood pressure) less than 100 or heart rate less than 60. Review of the MAR for June 2022 and July 2022, revealed Metoprolol was administered more than 20 times in June, and more than 10 times in July for pulse less than 60. An interview was conducted on August 4, 2022 at 4:04 p.m. with the DON (Director of Nursing/staff #137). Staff #137 stated her expectations are for nurses to administer pain medications according to the pain scale number. Staff #137 stated pain level should be assessed and the pain medication administered based on the pain scale. She stated she would not administer pain medication for a different pain scale, she would call the physician. The DON stated medications cannot be given outside the parameter.

**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 (#17) who was receiving a psychotropic medication had ongoing behavior and adverse effects monitoring. The sample size was 5 residents. The deficient practice could result in residents receiving medications that may not be necessary. Findings include: Resident #17 was admitted on [DATE] with diagnoses that included major depressive disorder and anxiety disorder unspecified. A review of a physician order dated July 21, 2022, revealed an order for Duloxetine HCl Delayed Release Particles 30 milligrams 1 capsule by mouth one time a day for depression Review of the care plan problem dated July 21, 2022 stated resident #17 uses an antidepressant medication (Duloxetine) related to depression. The interventions included giving the antidepressant medication ordered by physician and monitoring/documenting side effects and effectiveness. An admission Minimum Data Set (MDS) assessment dated [DATE] revealed a Brief Interview of Mental Status score of 11, which indicated the resident had moderately impaired cognition. The MDS assessment also revealed the resident received an antidepressant medication for 6 days for depression. Continued review of the clinical record revealed no evidence that adequate monitoring for behavior/mood manifestation of depression and monitoring for adverse consequences related to the use of antidepressant medication were being done. An interview was conducted on August 4, 2022 at 3:46 p.m. with an RN (Registered Nurse/staff #15). Staff #15 stated the process for a resident receiving an antidepressant included monitoring for behavior, monitoring for adverse effects, getting a consent from the resident/family, educating the resident, and care planning the order. The DON stated the behavior monitoring and adverse effects monitoring are part of the orders and documented on the MAR (medication administration record). However, review of the MAR for July 2022 and August 2022, revealed no evidence of behavior monitoring and adverse consequences monitoring for the antidepressant. The facility policy, Psychotropic Medication Use, stated all medications used to treat behaviors must have clinical indication and be used in the lowest possible dose to achieve the desired therapeutic effect. All medications used to treat behavior should be monitored for efficacy, risks, benefits, and harm or adverse consequences. The policy also stated staff should monitor behavioral triggers, episodes, and symptoms, and document the number and/or intensity of symptoms and the resident's response to staff interventions.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** -Resident #291 was admitted on [DATE] with diagnoses that included pressure ulcer of right buttock, stage 3, pressure ulcer of sacral region, stage 2, and sepsis. Review of the admission skin assessment dated [DATE] at 7:36 p.m. stated pressure ulcers were present on admission to the right buttock and right heel. A baseline care plan initiated on July 22, 2022 included skin problems to the right buttock pressure ulcer, right heel pressure ulcer, sacrum pressure ulcer related to decreased mobility. The goal stated the pressure ulcer will show signs of healing and remain free from infection. The interventions stated to administer treatments as ordered, and avoid positioning the resident on the right buttock, sacrum, and right heel. A Weekly Skin Check and Wound Assessment - V 2 dated July 28, 2022 at 9:00 p.m., stated skin issues to sacrum, pressure ulcer and left trochanter (hip) pressure ulcer were being treated. Review of a physician order dated July 22 through July 31, 2022 stated to apply Santyl ointment 250 unit/gram topically every day shift for wound care for 30 days. Apply to wound on right gluteus and right heel as directed once daily (or more frequently if dressing becomes soiled). Review of the TAR dated July 2022 revealed no evidence the treatment was not provided on 7/22, 7/23, 7/24, and 7/26/2022. A physician order dated July 22 through July 31, 2022, stated to apply Bactroban Cream 2% to pressure ulcers topically two times a day for wound care. Review of TAR dated July 2022 revealed no evidence treatments were not provided on July 23, 24, and 26, 2022 at 8:00 a.m. An interview was conducted on August 4, 2022 at 4:04 p.m. with the DON (staff #137). Staff #137 stated her expectation for pressure ulcer management is that the physician order is followed, including the frequency as ordered. Review of facility policy, Wound Management Program, stated the facility's program structure is to provide a comprehensive wound management program with a goal to promote the highest level of functioning and well-being of the residents and to minimize the number of residents that develop in house acquired pressure ulcers. The treatment goals revealed for all residents with wounds to receive treatment and services consistent with the resident's goals of treatment. The wound management program is structured and implemented using processes founded on acceptable standards of practice, research driven clinical guidelines and interdisciplinary involvement. Residents with wounds are to be assessed weekly and reviewed in the skin and weight meeting while the wound is active and for two weeks after complete wound healing. Based on staff interviews, clinical record reviews, and review of policy and procedure, the facility failed to ensure 3 residents (#69, #12, and #291) received care and services to promote the prevention, healing, and prevent the development of additional pressure ulcers/injury consistent with professional standards of practice. The sample size was 4 residents. The deficient practice increases the risk of pain, infection, and rehospitalization. Findings include: -Resident #69 admitted to the facility on [DATE] with diagnoses that included chronic kidney disease stage 3, type 2 diabetes mellitus with hyperglycemia, and unspecified arthritis. The admission Minimum Data Set (MDS) assessment dated [DATE] revealed the resident scored 15 on the Brief Interview for Mental Status (BIMS) assessment, indicating intact cognition. The resident required limited to extensive 1-person physical assistance for most Activities of Daily Living (ADLs), and had no pressure ulcers/injury to skin. Review of the discharged with return not anticipated MDS assessment dated [DATE] revealed the resident did not have a pressure ulcer or injury. The resident subsequently readmitted to the facility on [DATE]. A health status progress note dated 02/24/22 at 9:08 p.m. included the resident had arrived at the facility at approximately 5:45 p.m. with bilateral heels described as boggy. A pressure injury care plan initiated on 02/25/22 related to an unstageable pressure injury on the left heel had a goal for intact skin, free of redness, blisters or discoloration. Interventions included weekly skin assessments. The admission MDS assessment dated [DATE] revealed one stage 2 pressure ulcer. The resident's care plan was revised on 03/02/22 to include pressure-relieving boots. A physician order dated 03/03/22 revealed instructions to cleanse the left heel with wound wash spray, pat dry and apply mepilex (absorbent foam dressing), every day for wound care. However, further review of the physician orders did not indicate that an order for the pressure-relieving boots had been obtained. In addition, review of the clinical record did not indicate the pressure ulcer to the resident's left heel was evaluated until 03/10/22. A Wound Note dated 03/10/22 at 2:58 pm included a full thickness injury. The wound bed was described as about 25% pink granulation tissue with 50-75% yellow/light brown dry slough. Measurements were 3.5 centimeters (cm) x 3.6 cm x 0.1 cm. The note did not include a description of the peri wound, the wound edges, whether or not there was exudate and/or how much, a description of the exudate, and whether or not the wound was producing an odor. The note stated that the wound was cleansed with normal saline (NS), dressings were applied per orders, and that the nurse practitioner had been notified of the wounds and was asked to please see them at the next visit. A physician order dated 03/15/22 revealed to cleanse the left heel with NS, apply Medihoney (enzyme), and to cover with a dry dressing every day. A physician progress note dated 03/17/22 at 5:16 p.m. described the wound to the left heel as an unstageable pressure injury with obscured full-thickness skin and tissue loss. Measurements were noted as 2.7 cm x 2.7 cm, with no drainage noted. The wound bed was described as having 26-50% eschar, 1-25% slough, and 1-25% pink granulation. The Pressure Ulcer Documentation and assessment dated [DATE] revealed a facility acquired, unstageable pressure ulcer to the left heel which measured 3.0 cm x 3.2 cm x 0.1 cm with scant yellow drainage, no odor, and the resident reported pain of 9 out of 10 on a pain scale. The wound bed was described as about 50-75% soft black eschar, 1-25% pink granulation tissue. The current treatment remained in place. Pressure Ulcer Documentation and Assessment was completed on 03/30/22. A physician order dated 04/06/22 revealed instructions to cleanse the left heel with wound wash, pat dry, apply santyl (callangenaze), cover with Dakin's (antiseptic) soaked gauze, apply an occlusive dressing and wrap with kerlix. Notify the provider of any adverse signs or symptoms; one time a day for wound care. The Pressure Ulcer Documentation and assessment dated [DATE] was completed and Glucerna (nutritional supplement) was added as a nutritional intervention. The physician order dated 04/12/22 stated to discontinue the Dakin's soaked gauze after cleansing, cover with an occlusive dressing, wrap with kerlix, and to cover the area with spandage one time a day for wound care. The Pressure Ulcer Documentation and assessment dated [DATE] revealed the wound was classified as a stage 3 pressure ulcer. The April 2022 Treatment Administration Record (TAR) revealed treatments were provided as ordered, with the exception of 04/18 and 04/19. The Pressure Ulcer Documentation and Assessment for 04/22/22 was blank and did not reveal evidence to indicate whether or not the wound had been evaluated. The physician order dated 05/04/22 stated to cleanse the wound with normal saline (NS) in lieu of wound cleanser. Review of the May 2022 TAR did not reveal evidence the wound treatment was provided 05/08 and 05/14. Per the clinical record, the resident was sent out to the hospital on [DATE] and returned on 05/22/22. Review of the May 2022 TAR did not reveal evidence the treatment was provided on 05/23/22. In addition, on 05/24/22, the code 9 was documented in the space provided to indicate instruction to see the nurse's note. However, review of the nursing progress notes did not include documentation to provide a rationale for why the resident did not receive treatment that day. The Pressure Ulcer Documentation and assessment dated [DATE] revealed the pressure ulcer to the left heel was unstageable due to slough and eschar. The wound measured 1.2 cm x 1.3 cm x 0.1 cm, with no tunneling. Drainage was described as a small amount of serous fluid, the wound bed was 25% epithelialization, 25% eschar, 25% slough, and 25% pink granulation. The resident reported pain during treatment. However, the severity of the pain according to a pain scale was not documented. Juven (supplement) was added as an additional nutritional intervention. The June 2022 TAR revealed the treatment orders for the pressure ulcer to the left heel remained in place. Treatments were completed as ordered with the exception of 06/03, 06/25, and 06/26. On 06/07 and 06/11 the code 9 had been documented in the space provided for treatment completion. However, review of the nursing progress notes did not include a rationale as to why the treatments had not been completed. Pressure Ulcer Documentation and Assessments were completed on 06/05, 06/13, 06/18, and 06/26/22. Review of the Pressure Ulcer Documentation and Assessments included wound evaluations on 07/03/22, and 07/09/22. The Pressure Ulcer Documentation and assessment dated [DATE] revealed the stage 3 pressure ulcer measured 0.9 cm x 1.0 cm x 0.2 cm, no tunneling was noted, and the drainage was described as a small amount of serous fluid. The wound bed was described as 25% slough 75% granulation. The July 2022 TAR revealed that treatments were administered as ordered with the exception of 07/20. The physician order dated 07/20/22 stated to cleanse the left heel with NS, pat dry, apply santyl, cover with Dakin's 0.25 soaked gauze, wrap with kerlix, and cover with spandage every other day for wound care. Review of the July 2022 TAR did not reveal evidence the treatment was provided on 07/21, 07/23, 07/26, and 07/28. Review of the Pressure Ulcer Documentation and assessment dated [DATE] revealed a stage 3 pressure ulcer to the left heel. The wound measured 0.8 cm x 0.8 cm x 0.2 cm, no tunneling, and a small amount of serous exudate with no odor. The wound bed was described as pink granulation and slough. The resident reported pain during the treatment. An observation of wound care was conducted on 08/03/22 at 1:34 p.m. with a Licensed Practical Nurse (LPN/staff #26) and LPN (staff #67). Staff #26 removed the soiled dressing and described the exudate as a moderate amount of serosanguinous drainage. He described the periwound as macerated, radiating approximately 2.0 cm around the wound edges. 6 additional open areas were noted to be surrounding the wound, measuring approximately 0.1 - 0.2 cm. The wound was cleansed with NS and patted dry with gauze. Staff #26 described the wound bed as 90-95% slough and 10% granulation tissue. The wound measured 1.5 cm x 1.7 cm x 0.3 cm with an undermining of 0.6 cm from 10 to 12 o'clock. Staff #26 applied santyl and 0.25 soaked Dakin's gauze to the wound bed. The area was covered with an occlusive dressing, wrapped with kerlix, and a pressure-relieving boot was applied. The resident grimaced throughout the dressing change and reported experiencing pain. On 08/04/22 at 12:55 p.m., an interview was conducted with an LPN (staff #67). She stated that she was certified in wound care, but that she was not the wound nurse at this facility. She stated that in her experience, she would anticipate improvement in a wound within 2-3 weeks. She stated that she would contact the provider if there was no improvement, and ask for/suggest a different treatment. She stated that the treatment needs to meet the wound and said that she would not anticipate that santyl would be placed on new granulation tissue. She stated that she would expect an order for skin prep to be obtained to protect the skin around the peri wound. She stated it would not meet her expectation for the treatment order not to change because the goal would be to see improvement and/or healing of the pressure ulcer. An interview was conducted on 08/04/22 at 1:14 p.m. with the Director of Nursing (DON/staff #137). She stated that once a wound is identified, the wound nurse will be notified and complete an assessment and call the provider for wound orders. She stated that general practice is for the wound assessment to be completed weekly. The DON stated visual assessment shall be completed daily during dressing changes. She stated that after 3 weeks with no change, she would expect the wound nurse to reach out to the provider to let him know the treatments have not been effective. She stated she would expect the wound nurse to ask for a different wound treatment and/or intervention, reach out to the wound Nurse Practitioner, and/or obtain a referral to the wound care center. She stated that she would anticipate that a different treatment would have been put into place. The DON stated that it did not meet her expectation that the peri-wound had not been protected with skin prep. She stated that the risks associated with the resident's pressure ulcer included pain, infection, and rehospitalization. -Resident #12 readmitted to the facility on [DATE] with diagnoses that included hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, type 2 diabetes mellitus, and mild protein-calorie malnutrition. A further potential impairment to skin integrity care plan dated 06/22/21 related to incontinence and limited mobility had a goal to be free from injury. Interventions stated to encourage food nutrition and hydration in order to promote healthier skin. A physician order dated 06/30/22 revealed to cleanse the sacral Moisture Associated Skin Damage (MASD) with NS, pat dry, apply Triad (sterile coating) and cover with a foam dressing one time a day for wound care. Review of the Weekly Skin Check and Wound assessment dated [DATE] revealed an open area had been identified on the resident's coccyx. The risk for nutritional problems care plan was updated to reflect a pressure injury to the resident's sacrum on 07/02/22. Review of the July 2022 TAR revealed treatments were administered 07/01 through 07/05 as ordered. A physician progress note dated 07/05/22 revealed the wound to the sacrum was described as MASD/shear measuring 4.2 cm x 0.9 cm x 0.1 cm, with a small amount of serous drainage noted. The wound bed was described as 26-50% epithelialization, 1-25% slough, and 1-25% pink granulation. Wound orders included to cleanse with NS, apply medical grade honey, and cover with a dry protective dressing daily. Review of the July 2022 TAR revealed treatments were administered per orders from 07/06 through 07/11. The physician progress note dated 07/12/22 at 4:06 p.m. revealed the wound to the sacrum measured 2.2 cm x 0.7 cm, with a small amount of serous drainage noted. The wound bed was described as 1-25% epithelialization, and 51-75% slough. The note stated that the wound was deteriorating. Dressings/recommendations included to clean the wound with NS, apply medical grade honey, and cover with a dry protective dressing daily. In addition, the note called for repositioning per facility protocol. However, the order was not added to the July 2022 TAR until 07/14/22. Further review of the TAR revealed that no evidence was provided to indicate whether or not treatments had been provided on 07/15 and 07/18. A physician progress note dated 07/19/22 at 3:05 p.m. included the resident was seen for follow up and management of wounds. Measurements of the sacral wound were 2 cm x 0.6 cm. No depth to the wound was identified. There was a small amount of serous drainage noted. The wound bed had 1-25% epithelialization, 1-25% slough, 26-50% pink granulation. The treatment remained the same. Further review of the July 2022 TAR revealed no evidence the treatment was provided on 07/21 or 07/23. The Pressure Ulcer Documentation and assessment dated [DATE] revealed a stage 2 pressure ulcer to the sacrum which measured 2.2 cm x 0.7 cm x 0.1 cm, with no tunneling noted. No drainage was identified, and the wound bed was described as epithelialization and slough. The treatment remained the same. Review of the July 2022 TAR revealed no evidence treatment was provided on 07/25, 07/26 and 07/27. The 07/29/22 Pressure Ulcer Documentation and Assessment revealed a stage 2 pressure ulcer which measured 2.0 cm x 0.6 cm x 0.1 cm, no tunneling, and a small amount of serous drainage noted. The wound bed was described as pink granulation, slough, and epithelialization. An observation of wound care was conducted on 08/03/22 at 10:06 AM with an LPN (staff #26) who was assisted by a second LPN (staff #67). Staff #26 stated that the wound on the resident's sacrum was a stage 2 pressure ulcer, according to his knowledge. Staff #26 performed hand hygiene and applied clean gloves to remove the resident's soiled dressing. Staff #26 stated that he did not know when the dressing had been changed prior to this because there was no date on the dressing. Staff #26 stated there was a small amount of serosanguinous drainage on the dressing. He described the wound edges as attached with scarring at the peri wound area. Hand hygiene was performed and the wound was cleansed. He identified the wound bed with 30-40% slough and 60-70% granulation tissue. Wound measurements were 4.0 cm x 3.0 cm x 0.1 cm. Medical grade honey and a dry foam dressing were applied. An interview was conducted with the DON (staff #137) on 08/04/22 at 3:23 PM. She stated that she would expect that upon identification of a pressure ulcer, the wound would be assessed within 24 hours. She stated that a complete pressure ulcer evaluation included an observation/description of the wound bed and the peri wound, the amount and color of exudate, whether or not there was odor, measurements of the wound, whether there was tunneling or undermining, and staging. She stated her expectations included providing treatments according to the physician orders.

Regarding catheter care An observation of suprapubic catheter care was conducted on 08/04/22 at 10:04 AM with an RN (staff #116). The RN was observed to perform hand hygiene, don gloves, and set up the equipment on a round table without disinfecting/sanitizing the table. The table where the treatment equipment was placed had dirty clothes, blue printed gowns, a white bed sheet, plastic bowls, and a large plastic graduate with a green lid on it. Staff #116 placed the unopened split 4x4 dressing and a stack of bulk gauze on top of the table, poured normal saline into an 8 oz plastic cup, and placed the bulk gauze inside the plastic cup. The RN explained to the resident what she was going to do. She removed the old dressing, doffed gloves and donned a pair of clean gloves without performing hand hygiene. She took a few clean gauzes from the plastic cup and cleansed the site. The RN then cleaned the site using a QTIP with NS, cleaning away from the stoma away from the tube. Staff #116 then pat dry the area going from the stoma away from the tube. Staff #116 removed the gloves and donned clean gloves without performing hand hygiene. She then opened a package of splint sponge 4x4 dressing, took the right glove off, took a pair of scissors from her pocket, and cleaned them with an alcohol pad. Staff #116 donned a glove to the right hand without performing hand hygiene. She then secured the dressing with hypafix tape, removed the gloves and dated the dressing. Staff #116 washed hands in the bathroom. The RN used a cleaning Sani cloth and wiped the saline wound wash and placed the item into the cart immediately after. Following the observation, an interview was conducted with the RN at 10:23 AM. The RN stated when she cleaned the sterile saline spray, she should have let it set for 3 minutes and let it air dry per manufacturing instructions of the disinfectant wipes that she used. Staff #116 stated she washed her hands prior to the treatment, and that she should have washed her hands in between dirty to clean glove changes. An interview was conducted with the DON (staff #137) on 08/04/22 at 2:28 PM. The DON stated staff attend a skills training to demonstrate proper catheter care. The DON stated there is no process in place related to monitoring residents receiving catheter care as ordered as well as following infection protocol while providing catheter care. Review of the facility policy Suprapubic Catheter Care Policy revised October 2010 stated the purpose of the procedure is to prevent skin irritation around the stoma site and to prevent infection of the resident's urinary tract. Review the resident's care plan to assess for any special needs of the resident. Based on staff interviews, clinical record review, and policy and procedures, the facility failed to ensure appropriate infection control guidelines were followed related to droplet precautions and catheter care for one resident (#86). The deficient practice increases the risk for transmission of infection. Findings include: Regarding Personal Protective Equipment (PPE) During an observation conducted on 08/01/22 at 12:33 p.m., a housekeeper was observed mopping the floor in a resident's room that had a droplet precaution sign on the door. A PPE cart was observed outside the room in the hallway. The housekeeper was observed wearing a gown, gloves, and a KN95 mask. She had not donned the protective eyewear or N95 mask as directed by the sign on the door. On 08/01/22 at 12:35 p.m. an interview was conducted with the housekeeper (staff #31). She stated that the resident in the room was on special precautions. She stated that the sign was on the door yesterday as well. Staff #31 said that sometimes she asks what the resident has, but that this time she had not asked. She stated that she was supposed to wear a gown, gloves, and mask into the room. The housekeeper stated that the KN95 was ok to wear in the room, but that she could not wear goggles or a face shield because she could not see. Staff #31 stated that she stopped wearing eye protection because of that. At 12:55 p.m. on 08/01/22, a Certified Nursing Assistant (CNA) was observed to exit the same resident's room, approach the PPE cart, then turn and quickly return into the resident's room without donning PPE. She was observed to be wearing a KN95 mask only, (no gown, gloves, or eye protection.) Upon looking further into the room, a nurse was observed at the resident's bedside. She was observed to have donned a KN95 face mask and gloves. She was observed attempting to assist the resident to drink a liquid supplement. On 08/01/22 at 1:04 p.m., an interview was conducted with the Registered Nurse (RN/staff #144) and the CNA (staff #145). Staff #144 stated that she did not work at the facility. She stated that the set-up for PPE requirements was different from the last time she was in the facility, and that the location of the PPE was different the last time she was there. She looked over at the PPE cart that was outside the resident's door and stated that she had missed it, My bad. Staff #145 stated that she had a gown with her in the resident's room, but she did not put it on because she did not transfer the resident. She reviewed the sign on the resident's door and stated that she understood the expectation was for staff to don eye protection, mask, gown, and gloves upon entering the resident's room. She stated that she had received in-service training regarding the requirements. An interview was conducted on 08/01/22 at 1:21 p.m. with the Director of Nursing (DON/staff #137). She stated that the expectation is that staff will don a gown, N95 mask, eye protection, and gloves upon entering the room whether they touch the resident or not. She stated that all the PPE supplies should be available in the PPE cart. She stated that the associated risks of not donning the appropriate PPE included transferring infection to other residents and staff. Review of the facility Infection Control Program dated 2013 included it is the policy of the facility to maintain an active infection control program with the focus of providing a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. The infection control program encompasses prevention, surveillance, containment, education, and reporting.