Haven Health Green Valley, LLC

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Quality of Life and Care Deficiencies

Ensure the activities program is directed by a qualified professional.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Perform COVID19 testing on residents and staff.

Egress Deficiencies

Meet other general requirements that are deficient.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Resident Assessment and Care Planning Deficiencies

Assess the resident when there is a significant change in condition

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Administration Deficiencies

Provide timely, quality laboratory services/tests to meet the needs of residents.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Based on observation, the facility failed to maintain several doors in the building. Failing to maintain doors in the facility could allow heat and/or smoke to transfer, which will cause harm to the patients and/or staff.

Based on observation the facility failed to have required signage on one delay egress exit doors located in the facility. Failing to provide signage the delay egress exit doors could cause confusion which can harm to patients and/or staff in an emergency NFPA 101 Life Safety Court, 2012, Chapter 19, Section, 19.2 Means of Egress Requirements. 19.2.1 General. Every aisle, passageway, corridor, exit discharge, exit location, and access shall be in accordance with Chapter 7, unless otherwise modified by 19.2.2. 7.2.1.6.1 Delayed-Egress Locking Systems. 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (4) A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1? 8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS Findings include: Observations made while on tour on May 28, 2024, revealed the following; 1) The behavior unit delay exit door did not have the required signage on the door. During the exit conference on May 28, 2024, the above findings were again acknowledged by the management team.

Based on observation and interview the facility failed to provide automatic sprinkler protection for the attached awning on the north side of the building that was over four feet in width. Failing to provide automatic sprinklers to all areas of the facility could cause harm to residents and/or staff in time of a fire. The facility failed to ensure that standard and rapid-response sprinkler heads were mixed in one room. Failure to ensure that sprinkler heads are of the same type throughout the room could cause one type to override the other decreasing the effectiveness of the system. NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3, 19.3.5.8(5) Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, 2010 Edition. Chapter 8, Section 8.6.6.1 "The clearance between the deflector and the top of storage shall be 18 in. or greater." (1.) NFPA 13, Standard for the Installation of Sprinkler Systems" NFPA 13, Section 8.15.7 NFPA 101 Life Safety Code, 2012, Chapter 19, Section 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5.." Chapter 9, Section 9.7.1.1, " Each automatic sprinkler system required by another section of this Code shall be installed in accordance with NFPA 13 Standard for the Installation of Sprinkler Systems." NFPA 13, 2010 Edition. Chapter 11, Section 11.2.3.2.3.1 "Where listed quick-response sprinklers, including extended coverage quick-response sprinklers, are used throughout a system or portion of a system having the same hydraulic design basis, the system area of operation shall be permitted to be reduced without revising the density as indicated in Figure 11.2.3.2.3.1 when all of the following conditions are satisfied: (1) Wet pipe system (2) Light hazard or ordinary hazard occupancy (3) 20 ft (6.1 m) maximum ceiling height. Exterior roofs, Canopies, Porte-Cocheres, Balconies, Decks or Similar Projections. Section 8.15.7.1 Unless the requirements of 8.15.7.2,8.15.7.3, or 8.15.7.4 are met sprinklers shall be installed under exterior roofs, canopies, Porte-Cocheres, balconies decks, or similar projections exceeding 4 ft in width. Findings include: Observations made while on tour on May 28, 2024 revealed the following; 1) The attached awning on the north side of the building which appeared to be made of combustible material and was greater than 4 feet in depth and was not sprinklered. 2) The sprinkler heads located in two areas of the therap

Regarding Resident #241: Resident #241 was admitted on May 16, 2024 with diagnosis including atherosclerotic heart disease of the native coronary artery, chronic atrial fibrillation, essential hypertension, chronic obstructive pulmonary disease, obstructive sleep apnea, hypertensive heart disease with heart failure, pleural effusion, cardiomegaly, atelectasis, cirrhosis of the liver, hypo-osmolarity and hyponatremia, fracture of T7-T8 vertebra, wedge compression fracture of the second lumbar vertebra, diverticulosis, abdominal aortic aneurysm, obstructive and reflux uropathy, type II diabetes, major depressive disorder-recurrent, constipation, and muscle spasms. The admission MDS (minimum data set) was noted to be in progress. A review of the physician orders, revealed no evidence of an order for Orajel or an order for self-administration of medication. A review of the electronic medical record revealed no evidence of an assessment for self-administration of medications. A review of the care plan for resident #241 revealed no evidence of medication self-administration. A review of the progress notes revealed no evidence that the resident had been assessed for self-administration of medication. An observation was conducted on May 20, 2024 at 10:37 A.M. A tube of Orajel was observed at bedside for resident #241. The resident's spouse, who was present at the time of observation, stated that the resident has gum pain and that she had brought the medication from home. She further stated that nursing staff were aware of the medication and had seen it when it was brought in. An observation was conducted on May 20, 2024 at 1:40 P.M. It was observed that Orajel was still on the resident's bedside table in plain view. An observation was conducted on May 21, 2024 at 7:40 A.M. It was observed that Orajel was still on the resident's bedside table. Regarding Resident #75: Resident #75 was admitted on March 27, 2024 with diagnosis including traumatic subdural hemorrhage , traumatic subarachnoid hemorrhage, traumatic hemorrhage of cerebrum, acute transverse myelitis in demyelinating disease of the central nervous system, ataxic gait, hypertension, hyperlipidemia, fibromyalgia, peripheral vascular disease, chronic pain syndrome, urinary incontinence, retention of urine, peripheral vascular angioplasty with implants and grafts, atrial fibrillation, convulsions, seasonal allergic rhinitis, lack of coordination, cognitive communication deficit, weakness, unsteadiness, abnormalities of gait and mobility, mild protein-calorie malnutrition, neuromuscular dysfunction, and displaced bimalleolar fracture of the right lower leg. A review of the MDS dated May 4, 2024 revealed a BIMS (brief interview of mental status) score of 12, suggesting mild cognitive impairment. A review of the physician orders revealed no evidence of an order for Voltaren, Flonase or for self-administration of medication. A review of the care plan for resident #75 revealed no evidence noting self-admi

Based on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to ensure that code status was accurate and consistent in the medical record for one resident, #242. Findings include: Resident #242 was admitted on May 15, 2024 with diagnosis including hypotension, hypertension, presence of a cardiac pacemaker, major depressive disorder-recurrent, obstructive and reflux uropathy, diverticulitis of large intestine and edema. A review of the MDS (minimum data set) revealed that the admission MDS was still noted to be in progress. A review of the physician orders dated May 15, 2024, revealed that the resident was a full-code, meaning that cardiopulmonary resuscitation and other resuscitation procedures should be used to keep the resident alive. A review of the care plan, dated May 16, 2024, revealed that the resident's advanced directives were in effect. Further stating that the resident's wishes should be carried out in accordance with her advanced directives and to ensure that her wishes are recorded correctly in her chart and follow physician orders. The primary landing page in the resident's electronic health record, at the top of the page, noted the resident to be a full-code. Further review of the electronic health record for resident #242 revealed that the resident had signed for DNR (do not resuscitate) on May 15, 2024. An interview was conducted on May 21, 2024 at 7:48 A.M. with staff #452, CNA (certified nursing assistant). Staff #452 stated that staff are able to locate a resident's code status in the electronic health record. She stated that the code status can be found on the top of the landing page in the electronic health record. Staff #452 pulled up the record for resident #242 and when asked, stated that resident #242 was noted to be a full-code. She stated that the expectation is that information in the record is accurate, and if for some reason it isn't, then it could be a problem for the facility as they would be going against the resident's wishes. An interview was conducted on May 21, 2024 at 7:55 A.M. with staff #508, RN (registered nurse). Staff #508 stated that the advanced directives are generally done by the admitting nurse. She stated that the nurse would review everything on the form with the resident to ensure that the resident understands what they are selecting and signing. Staff #508 stated that if the DNR option was selected, then the resident would sign the orange DNR form, which is then uploaded into the resident's electronic medical record. She stated that if it was necessary to obtain the code a specific resident, staff would first look in the electronic record to determine the code status. She stated that the DNR form is also available in hard copy on the unit, but it's generally a lot quicker to look in the electronic record. Staff #508 pulled up the electronic health record for resident #242 and stated that this resident is a full code. When staff #5

Based on documentation, staff interviews, and the facility policy and procedure, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level I for one resident (#24), and failed to submit the PASRR Level II to the state agency. Findings include: Resident #24 was admitted to the facility on June 6, 2023 with diagnoses that included schizophrenia unspecified, bipolar disorder, and Parkinsonism. The minimum data set (MDS) dated June 16, 2023 included a brief interview for mental status score of 11 indicating the resident had a moderate cognitive impairment. Review of the PASRR Level I dated June 6, 2023 did not reveal any serious mental illnesses, anti-psychotic medication, or assessment for substantial functional limitations. Due to the form not being completed, it was not submitted to the state agency for a PASRR Level II. Review of the care plan dated June 12, 2023 revealed that the resident uses anti-psychotic medications (Haldol) related to a diagnosis of schizophrenia as evidenced by episodes of verbal agitation and physical aggression. Interventions included to administer medications as ordered and monitor for side effects and/or toxic symptoms. Review of the care plan dated June 27, 2023 revealed that the resident has episodes of impaired cognitive function or impaired thought processes related to schizophrenia-bipolar disorder as evidenced by short term memory loss, and episodes of miscommunication related to hearing impairment. Interventions included to provide the resident with necessary cues, stop and return if the resident is agitated and to engage the resident in simple, structured activities that avoid overly demanding tasks. An interview was conducted on May 21, 2024 at 8:28 a.m. with the Resident Relations Manager (staff #473), who stated that she checks the PASRR Level I and it is updated after 30 days as per the regulation. She reviewed the clinical record and stated that the resident was admitted to long-term care, so the PASRR Level I should have been updated. She also acknowledged that the resident had a diagnoses of schizophrenia and a bipolar disorder, so the PASRR Level II should have been submitted to the state agency. She reviewed documentation with medical records and stated that she did not have a completed PASRR Level I for the resident. An interview was completed on May 22, 2024 at 2:40 p.m. with the Director of Nursing (DON/staff #417), who stated that it is her expectation that the PASRR is reviewed by staff #473 if the resident is going to stay more than 30 days. If the resident has an appropriate diagnoses, staff #473 should submit the PASRR Level I to the state agency. the PASRR Level two agrees that the purpose is to determine that the facility meets the needs of the resident and if additional services are needed. The facility policy, "Pre-Admission Screening and Resident Review (PASRR)" states that our facility will strive to verify that a Level I PASRR Screening has been conduct

Based on resident and staff interviews, review of the clinical record, facility documentation and policy, the facility failed to ensure that code status was accurate and consistent in the medical record for one resident, #242. The deficient practice could result in resident not receiving care consistent with their signed advance directive. Findings include: Resident #242 was admitted on May 15, 2024 with diagnosis including hypotension, hypertension, presence of a cardiac pacemaker, major depressive disorder-recurrent, obstructive and reflux uropathy, diverticulitis of large intestine and edema. A review of the MDS (minimum data set) revealed that the admission MDS was still noted to be in progress. A review of the physician orders dated May 15, 2024, revealed that the resident was a full-code, meaning that cardiopulmonary resuscitation and other resuscitation procedures should be used to keep the resident alive. A review of the care plan, dated May 16, 2024, revealed that the resident's advanced directives were in effect. Further stating that the resident's wishes should be carried out in accordance with her advanced directives and to ensure that her wishes are recorded correctly in her chart and follow physician orders. The primary landing page in the resident's electronic health record, at the top of the page, noted the resident to be a full-code. Further review of the electronic health record for resident #242 revealed that the resident had signed for DNR (do not resuscitate) on May 15, 2024. An interview was conducted on May 21, 2024 at 7:48 A.M. with staff #452, CNA (certified nursing assistant). Staff #452 stated that staff are able to locate a resident's code status in the electronic health record. She stated that the code status can be found on the top of the landing page in the electronic health record. Staff #452 pulled up the record for resident #242 and when asked, stated that resident #242 was noted to be a full-code. She stated that the expectation is that information in the record is accurate, and if for some reason it isn't, then it could be a problem for the facility as they would be going against the resident's wishes. An interview was conducted on May 21, 2024 at 7:55 A.M. with staff #508, RN (registered nurse). Staff #508 stated that the advanced directives are generally done by the admitting nurse. She stated that the nurse would review everything on the form with the resident to ensure that the resident understands what they are selecting and signing. Staff #508 stated that if the DNR option was selected, then the resident would sign the orange DNR form, which is then uploaded into the resident's electronic medical record. She stated that if it was necessary to obtain the code a specific resident, staff would first look in the electronic record to determine the code status. She stated that the DNR form is also available in hard copy on the unit, but it's generally a lot quicker to look in the electronic record. Staff #508 p

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#47) had the right to privacy. The deficient practice could result in residents being denied their rights and impact psychosocial well-being. Findings include: Resident #47 was admitted to the facility on October 24, 2022 with diagnoses that included unspecified dementia with other behavioral disturbance, adjustment disorder, and major depressive disorder. The minimum data set (MDS) dated October 30, 2022 included a brief interview for mental status score of 6 indicating the resident had a severe cognitive impairment. Review of the care plan dated February 14, 2023 revealed a behavior care plan related to impaired cognition as evidenced by verbal aggression toward staff, rejecting needed care, yelling at staff, and obsessing over particular items. A progress note dated October 11, 2023 revealed that the resident gets easily irritated with other residents and staff, yells out and is often impulsive. A behavior health service provider is present in the facility and advised. A progress note dated October 16, 2023 revealed that a nurse was called into the unit due to a resident-to-resident confrontation. Residents were heard yelling at each other in their room and the certified nursing assistants (CNAs) went into the room where residents were found arguing and pulling on each other's clothes. The roommate (#47) was upset because resident #23 was rummaging through her closet. Resident #47 stated that resident #23 slapped her. The residents were separated and one was moved to another room to prevent any further altercations. Both residents were assessed by the nurse and no injuries or marks were noted, vital signs were stable, and no complaints of pain from either resident. A physician's note dated October 23, 2023 included that resident #47 recently had an altercation with another resident. Both residents were yelling at each other and arguing about clothes. Resident #47 reported that she was slapped by the other resident. The incident was unwitnessed and there were no signs of injuries reported by nursing staff. -Resident #23 was admitted to the facility on August 31, 2023 with diagnoses that included Alzheimer's disease, hypertensive chronic kidney disease, anxiety disorder, and a major depressive disorder. The minimum data set (MDS) dated September 6, 2023 included a brief interview for mental status score of 3 indicating the resident had a severe cognitive impairment. Review of the the care plan dated September 12, 2023 revealed a behavior care plan related to dementia as evidenced by impaired safety awareness, physical behaviors, resistive to care, verbal behaviors, and wandering/exit seeking. Interventions included to administer medications as ordered, anticipate and meet the resident's needs, and encourage as much participation/interaction as possible during care activities. A behavior progress note dated September

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that floor tiles, laminate flooring, shower drain, and door frame in common areas were safe for residents ambulating and showering. The deficient practice could result in residents falling and/or being injured. Findings include: On May 21, 2024 at 4:23 p.m., a walk through of the facility was conducted and the following environmental issues were observed: -one rectangular panel of the laminate flooring in Hall 100, between rooms #127 and #128, was broken and approximately half an inch was missing from one of the corners of the laminate. -the laminate panel in the doorway of room #127 was observed to have approximately 16.5 inches in length broken and missing. -six tiles in Hall 100 were cracked and/or broken. -the transition strip between the laminate flooring and the tile flooring on Hall 100 by room #123 was cracked in multiple areas. -in the hallway, near room #124 a piece of the flooring, circular in shape, was compressed, so that the floor was uneven and there was cracked and broken laminate around the circumference of the circle. -one rectangular laminate floor panel located near room #118 on Hall 100 was not secured to the floor. -there was no transition strip between the tile and the laminate flooring toward the end of Hall 100 by room #119. -the drain in the bathroom shower on Hall 100 was approximately two inches in diameter and there was a square silver drain cover only partially covering the round open hole and the drain cover was not attached to the floor. -the doorframe of the bathroom on Hall 100 had areas were paint was missing and a brown rust color was observed. -upon entering the secured unit on Hall 100, one rectangular laminate floor panel was broken with approximately 3 inches by 1 inch of the panel missing. -in the hallway of the secured unit on Hall 100, a circular shape, approximately three inches in diameter, was compressed, so that the floor was uneven. -by the left door to the main dining room, the Azelea room, there were two eighteen by eighteen inch tiles broken and cracked. -by the right door to the main dining room, the Azelea room, the tile was not flush/even with the surrounding tiles, creating a dip of approximately one centimeter where residents would enter the dining room. -there was no transition strip between the tile and the laminate flooring near room #227 on Hall 200. An interview was conducted on May 22, 2024 at 8:37 a.m. with the Maintenance Manager (staff #430), who stated that anyone can put in a request for a repair and he prioritizes repairs based on resident safety, how it impacts the residents' stay, and anything to do with safety, should be repaired immediately. He stated that safety risks included falls and could include rust if the resident came into contact with the rust. He stated that he inspects the facility daily, and that he has laminate flooring, transition strips, and paint in

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of two residents (#50, and #3) to be free from abuse from each other. The deficient practice could result in further abuse of residents and appropriate action not taken. Findings include: Regarding incident involving residents #50 and 191: -Resident #50 (alleged victim) was admitted to the facility on July 18, 2023 with diagnoses that included Alzheimer's disease, dementia, auditory hallucinations, visual hallucinations, anxiety disorder, and disorientation. Review of the annual Minimum Data Set (MDS) assessment dated July 24, 2023 revealed that the resident's cognitive skills for daily decision making is severely impaired. The MDS also indicated that the resident was negative for indicators of psychosis, behavioral symptoms, and wandering during the assessment period. However, the MDS noted that the resident exhibited rejection of care which occurred 1-3 days during the assessment period. An incident note dated October 6, 2023 documented that according to a CNA (certified nursing assistant), this resident yelled at another resident to be quiet. The other resident then approached this resident, told her "nobody tells me what to do" and slapped her on the left cheek. The note documented that no visible injuries were noted. The note also indicated that the sheriff's department was contacted and informed family, and indicated that resident would be taken to the hospital. A behavior care plan revised on January 24, 2024 revealed that the resident #50 had behavior problems related to the effects of Alzheimer's dementia as evidenced by poor awareness of needed personal care, combativeness, and verbal outburst during personal care. Interventions included to anticipate and meet needs, assist to minimize disruptive behaviors, if issues arise, remove from situation. A care plan revised April 26, 2024 indicated that the resident #50 had impaired cognitive function related to Alzheimer's dementia with impaired thought processes, difficulty making decisions, short term memory loss that is not anticipated to improve. Interventions included supervision/assistance with all decision making, and keep routine consistent. -Resident #191 (alleged perpetrator) was admitted to the facility on October 4, 2023 with diagnoses that included dementia, malignant neoplasm of cerebral meninges, major depressive disorder, and anxiety disorder. A behavior note dated October 5, 2023 indicated documented that the resident was out of the room wandering the halls. The note stated that the resident had been tearful most of the afternoon and upset that her family had dropped her off. Resident was observed to be quickly agitated with loud sounds or voices but was easily redirected. Resident was noted as compliant with medication and care. A behavior note dated October 6, 2023 documented that a CNA (certified nursing assistant) reported that the r

Based on documentation, staff interviews, and the facility policy and procedure, the facility failed to complete the Preadmission Screening and Resident Review (PASRR) Level I for one resident (#24), and failed to submit the PASRR Level II to the state agency. The deficient practice could result in residents not receiving additional services that are needed. Findings include: Resident #24 was admitted to the facility on June 6, 2023 with diagnoses that included schizophrenia unspecified, bipolar disorder, and Parkinsonism. The minimum data set (MDS) dated June 16, 2023 included a brief interview for mental status score of 11 indicating the resident had a moderate cognitive impairment. Review of the PASRR Level I dated June 6, 2023 did not reveal any serious mental illnesses, anti-psychotic medication, or assessment for substantial functional limitations. Due to the form not being completed, it was not submitted to the state agency for a PASRR Level II. Review of the care plan dated June 12, 2023 revealed that the resident uses anti-psychotic medications (Haldol) related to a diagnosis of schizophrenia as evidenced by episodes of verbal agitation and physical aggression. Interventions included to administer medications as ordered and monitor for side effects and/or toxic symptoms. Review of the care plan dated June 27, 2023 revealed that the resident has episodes of impaired cognitive function or impaired thought processes related to schizophrenia-bipolar disorder as evidenced by short term memory loss, and episodes of miscommunication related to hearing impairment. Interventions included to provide the resident with necessary cues, stop and return if the resident is agitated and to engage the resident in simple, structured activities that avoid overly demanding tasks. An interview was conducted on May 21, 2024 at 8:28 a.m. with the Resident Relations Manager (staff #473), who stated that she checks the PASRR Level I and it is updated after 30 days as per the regulation. She reviewed the clinical record and stated that the resident was admitted to long-term care, so the PASRR Level I should have been updated. She also acknowledged that the resident had a diagnoses of schizophrenia and a bipolar disorder, so the PASRR Level II should have been submitted to the state agency. She reviewed documentation with medical records and stated that she did not have a completed PASRR Level I for the resident. An interview was completed on May 22, 2024 at 2:40 p.m. with the Director of Nursing (DON/staff #417), who stated that it is her expectation that the PASRR is reviewed by staff #473 if the resident is going to stay more than 30 days. If the resident has an appropriate diagnoses, staff #473 should submit the PASRR Level I to the state agency. the PASRR Level two agrees that the purpose is to determine that the facility meets the needs of the resident and if additional services are needed. The facility policy, "Pre-Admission Screening and Resident Review (PA

Based on observation, interviews and policy review, the facility failed to ensure that physician's orders was followed regarding one resident's (#31) AV (arteriovenous) fistula. The deficient practice could result in the resident's AV fistula failing. Findings include: Resident #31 was admitted to the facility on June 5, 2018 with diagnoses that included end stage renal disease, hypertensive chronic kidney disease, Parkinsonism, atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, and dependence on renal dialysis. Review of the order summary report revealed a physician order dated June 5, 2018 which indicated "No Blood pressure or venipuncture to AV fistula site every shift for left arm. A care plan initiated on June 28, 2018 and revised on March 2, 2023 indicated that resident needs dialysis related to end stage renal failure. The goal was that the resident would not have signs and symptoms of complications from dialysis. Interventions included: Do not draw blood or take B/P (blood pressure) in left arm with graft, and check and change dressing daily at access site. However, review of the resident's blood pressure (BP) log over the last six months revealed that it was taken on the left arm on the following dates: - December 11, 2023 - December 18, 2023 - January 1, 2024 - May 13, 2024 Further review of the BP log revealed numerous occasions since the resident was admitted in which her BP was taken on the left arm. Review of the quarterly Minimum Data Set (MDS) dated March 20, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The MDS assessment also noted that the resident receives hemodialysis treatment. The assessment also indicated that the resident is dependent to renal dialysis. An interview with a Certified Nursing Assistant (CNA/staff #510) was conducted on May 22, 2024 at 4:19 p.m. Staff #510 stated that for residents on dialysis, you use the opposite arm to take BP. The CNA said that you do not take the BP on the arm with the fistula. Staff #510 noted that the nurse normally informs CNAs not to take the BP on the same arm as the fistula site. During an interview with a Licensed Practical Nurse (LPN/staff #513) conducted on May 22, 2024 at 4:32 p.m., staff #513 stated that you cannot take vitals on the same site as the fistula. The LPN noted that you want to check for bruit and thrill on the fistula site and do a skin assessment. An observation was conducted on May 23, 2024 at 9:49 a.m. During the observation the CNA (staff #462) accomplished hand hygiene, wiped/disinfected the vitals machine then took resident #31's vitals. Staff #462 explained that the reason she was using resident #31's right arm is due to her having a fistula on the left arm. An interview with the Director of Nursing (DON/staff #417) was conducted on May 23, 2024 at 9:49 a.m. Staff #417 stated that her expectation is that staff will take

Based on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. The deficient practice could result in the activities provided not meeting the assessed needs of the residents. Findings Include: A review of the personnel file for the role of activity manager (staff #432) was conducted on May 21, 2024. However, review of file did not reveal evidence that staff #432 possessed the qualifications required for the role of activities director. An interview was conducted on May 21, 2024 at 1:12 P.M. with staff #498, human resource manager. Staff #498 stated that the role of activity manager had no additional qualifications needed beyond the scope of qualifications that staff #432 had. She stated that the facility did not require licensure or registration for the activity manager. An interview was conducted on May 21, 2024 at 2:14 P.M. with staff #605 , administrator. Staff #605 stated that he was aware that the current activities director was not licensed or registered, but stated that staff #432 was in the process and getting ready to test soon. He further stated that the facility already had a performance improvement plan in place and that the Occupational Therapist, staff #536 was currently supervising the activities director since January 2024 until her licensing/ registration has been completed. An interview was conducted on May 22, 2024 at 8:03 A.M. with staff #432, activity manager. Staff #432 stated that she was the activity manager and that she had 4 additional staff members assisting in the activities department. She stated that she had initially started with the facility by working in the kitchen for 3 years and then had worked as an activity assistant for 2 years and further stated that she had been in the role of activity manager for 7 years. Staff #432 stated that she was certified at one point, but had lost the certification 2 years ago. She stated that she had been working on recertification and was scheduled to test on May 24, 2024. She stated that she had maintained her continuing education requirements in spite of not being certified. Additionally, staff #432 stated that she had maintained her active membership with the Arizona state professional's organization for activity directors. She stated that her current activity calendars were being reviewed by the therapy department, but could not recall when this process had started. She stated that there 2 therapist providing oversight, one was staff #533 and she was unable to recall the name or appearance of the other therapist, who was later identified as staff #536. She stated that staff #533 would review her calendar and at times make recommendations as they pertain to tasks involving therapy. An interview was conducted on May 22, 2024 at 8:22 A.M. with staff #533, PTA (Physical Therapy Assistant). Staff #533 stated that there is coordination between activities a

Based on personnel file review, staff interview, and facility documentation and policy review, the facility failed to ensure the activities program was directed by a qualified professional. Findings Include: A review of the personnel file for the role of activity manager (staff #432) was conducted on May 21, 2024. However, review of file did not reveal evidence that staff #432 possessed the qualifications required for the role of activities director. An interview was conducted on May 21, 2024 at 1:12 P.M. with staff #498, human resource manager. Staff #498 stated that the role of activity manager had no additional qualifications needed beyond the scope of qualifications that staff #432 had. She stated that the facility did not require licensure or registration for the activity manager. An interview was conducted on May 21, 2024 at 2:14 P.M. with staff #605 , administrator. Staff #605 stated that he was aware that the current activities director was not licensed or registered, but stated that staff #432 was in the process and getting ready to test soon. He further stated that the facility already had a performance improvement plan in place and that the Occupational Therapist, staff #536 was currently supervising the activities director since January 2024 until her licensing/ registration has been completed. An interview was conducted on May 22, 2024 at 8:03 A.M. with staff #432, activity manager. Staff #432 stated that she was the activity manager and that she had 4 additional staff members assisting in the activities department. She stated that she had initially started with the facility by working in the kitchen for 3 years and then had worked as an activity assistant for 2 years and further stated that she had been in the role of activity manager for 7 years. Staff #432 stated that she was certified at one point, but had lost the certification 2 years ago. She stated that she had been working on recertification and was scheduled to test on May 24, 2024. She stated that she had maintained her continuing education requirements in spite of not being certified. Additionally, staff #432 stated that she had maintained her active membership with the Arizona state professional's organization for activity directors. She stated that her current activity calendars were being reviewed by the therapy department, but could not recall when this process had started. She stated that there 2 therapist providing oversight, one was staff #533 and she was unable to recall the name or appearance of the other therapist, who was later identified as staff #536. She stated that staff #533 would review her calendar and at times make recommendations as they pertain to tasks involving therapy. An interview was conducted on May 22, 2024 at 8:22 A.M. with staff #533, PTA (Physical Therapy Assistant). Staff #533 stated that there is coordination between activities and therapy regarding outdoor activities and getting in or out of activities. He stated that he was not the super

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that two residents (#75 , #241) were assessed, monitored and had orders for self-administration of medications and that one resident (#23) was monitored with appropriate level of supervision. The deficient practice could result in residents being injured. Findings include Resident #23 was admitted to the facility on August 31, 2023 with diagnoses that included Alzheimer's disease, hypertensive chronic kidney disease, anxiety disorder, and a major depressive disorder. The minimum data set (MDS) dated September 6, 2023 included a brief interview for mental status score of 3 indicating the resident had a severe cognitive impairment. Review of the the care plan dated September 12, 2023 revealed a behavior care plan related to dementia as evidenced by impaired safety awareness, physical behaviors, resistive to care, verbal behaviors, and wandering/exit seeking. Interventions included to administer medications as ordered, anticipate and meet the resident's needs, and encourage as much participation/interaction as possible during care activities. A behavior progress note dated September 16, 2023 revealed that a resident was restless, wandering/pacing the halls, and exit seeking. The resident was also noted hoarding objects in pockets and was difficult to redirect. A behavior progress note dated September 28, 2023 revealed that the resident was noted wandering into another resident's room this afternoon. The other resident became agitated and insisted that the resident leave. Staff was able to redirect both residents. Staff reported that the resident continues hoarding everyday objects in her purse, closet, and dresser drawers including dirty pull-ups. A progress note dated October 7, 2023 revealed that resident #23 was transferred to another room due to not getting along with her roommate. A progress note dated October 16, 2023 revealed that a nurse was called into the unit due to a resident-to-resident confrontation. Residents were heard yelling at each other in their room and the certified nursing assistants (CNAs) went into the room where residents were found arguing and pulling on each other's clothes. The roommate (#47) was upset because resident #23 was rummaging through her closet. Resident #47 stated that resident #23 slapped her. The residents were separated and one was moved to another room to prevent any further altercations. Both residents were assessed by the nurse and no injuries or marks were noted, vital signs were stable, and no complaints of pain from either resident. A progress note dated October 18, 2023 at 11:47 a.m. revealed that resident #23 continues to wander into other residents' rooms and take their belongings back to her room. Resident #23 took another resident's shoes and put them in her closet, upsetting the resident who looked for her shoes all morning. A progress note dated October 30, 2023 revealed that residen

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#41). The deficient practice could result in residents not receiving care and services for oral/dental conditions. Findings include: Resident # 41 was initially admitted to the facility on March 19, 2021 with diagnoses that included hemiplegia, hemiparesis, dysphagia, atherosclerotic heart disease, hypertensive heart disease, chronic diastolic heart failure, and chronic obstructive pulmonary disease. A dental note dated September 8, 2022 revealed that a consultation visit was completed. The findings/recommendations was ext (extraction) of #26 (lateral incisor), 27 (cuspid), and 28 (first bicuspid). The next schedule appointment was marked as October 5, 2022. However, further review of dental referral notes did not reveal any documentation of that visit or if that visit occurred. A care plan initiated on February 28, 2023 revealed that the resident is at risk for acute oral/dental health problems related to missing and/or cavity prone teeth. Interventions included coordinate arrangements for dental care, transportation as needed/as ordered. Review of dental noted dated January 2, 2024 indicated that an initial exam was conducted and found that resident had broken teeth. During the exam it was discovered that resident had a worn FUD (full upper denture) for over 3 years and never had lower dentures. It was noted that FUD fit loosely and needs adhesive for retention. The note indicated that recommended treatment included surgical exts (extraction) #26 (lateral incisor), 27 (cuspid), 28 (first bicuspid), and 29 (second bicuspid); and FUD/FLD (full lower denture). Review of the annual Minimum Data Set (MDS) assessment dated March 20, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident was cognitively intact. The MDS also documented that the resident had obvious or like cavity or broken natural teeth. An interview with the Unit Secretary (staff #424) was conducted on May 23, 2024 at 9:19 a.m. Staff #424 stated that nurse or providers informs her which residents need dental services. For new residents they sent the face sheet to the dental provider, for long term care residents, if they do not know if Medicare covers, they call the dental office to ask if they cover and if the dentist is contracted. One of the dental providers comes in and provides dental services and the other will send a list and they let her know which residents needs to be seen. Staff #424 noted that the process for scheduling is usually via email contact initiated by her. For example, if a resident has an appointment today, she annotates it then the day after, she calls and checks if the resident has a follow-up appointment. Regarding resident #41, her name was not on list prior to the dental provider coming in today. Looking at the chart, staff #424 stated that she

Based on documentation, staff interviews, and the facility policy and procedures, the facility failed to ensure that one resident (#47) had the right to privacy. Findings include: Resident #47 was admitted to the facility on October 24, 2022 with diagnoses that included unspecified dementia with other behavioral disturbance, adjustment disorder, and major depressive disorder. The minimum data set (MDS) dated October 30, 2022 included a brief interview for mental status score of 6 indicating the resident had a severe cognitive impairment. Review of the care plan dated February 14, 2023 revealed a behavior care plan related to impaired cognition as evidenced by verbal aggression toward staff, rejecting needed care, yelling at staff, and obsessing over particular items. A progress note dated October 11, 2023 revealed that the resident gets easily irritated with other residents and staff, yells out and is often impulsive. A behavior health service provider is present in the facility and advised. A progress note dated October 16, 2023 revealed that a nurse was called into the unit due to a resident-to-resident confrontation. Residents were heard yelling at each other in their room and the certified nursing assistants (CNAs) went into the room where residents were found arguing and pulling on each other's clothes. The roommate (#47) was upset because resident #23 was rummaging through her closet. Resident #47 stated that resident #23 slapped her. The residents were separated and one was moved to another room to prevent any further altercations. Both residents were assessed by the nurse and no injuries or marks were noted, vital signs were stable, and no complaints of pain from either resident. A physician's note dated October 23, 2023 included that resident #47 recently had an altercation with another resident. Both residents were yelling at each other and arguing about clothes. Resident #47 reported that she was slapped by the other resident. The incident was unwitnessed and there were no signs of injuries reported by nursing staff. -Resident #23 was admitted to the facility on August 31, 2023 with diagnoses that included Alzheimer's disease, hypertensive chronic kidney disease, anxiety disorder, and a major depressive disorder. The minimum data set (MDS) dated September 6, 2023 included a brief interview for mental status score of 3 indicating the resident had a severe cognitive impairment. Review of the the care plan dated September 12, 2023 revealed a behavior care plan related to dementia as evidenced by impaired safety awareness, physical behaviors, resistive to care, verbal behaviors, and wandering/exit seeking. Interventions included to administer medications as ordered, anticipate and meet the resident's needs, and encourage as much participation/interaction as possible during care activities. A behavior progress note dated September 16, 2023 revealed that a resident was restless, wandering/pacing the halls, and exit seeking. The resident was

Based on clinical record review, staff interviews, facility documentation, policies and procedures, the facility failed to protect the rights of two residents (#50, and #3) to be free from abuse from each other. Findings include: Regarding incident involving residents #50 and 191: -Resident #50 (alleged victim) was admitted to the facility on July 18, 2023 with diagnoses that included Alzheimer's disease, dementia, auditory hallucinations, visual hallucinations, anxiety disorder, and disorientation. Review of the annual Minimum Data Set (MDS) assessment dated July 24, 2023 revealed that the resident's cognitive skills for daily decision making is severely impaired. The MDS also indicated that the resident was negative for indicators of psychosis, behavioral symptoms, and wandering during the assessment period. However, the MDS noted that the resident exhibited rejection of care which occurred 1-3 days during the assessment period. An incident note dated October 6, 2023 documented that according to a CNA (certified nursing assistant), this resident yelled at another resident to be quiet. The other resident then approached this resident, told her "nobody tells me what to do" and slapped her on the left cheek. The note documented that no visible injuries were noted. The note also indicated that the sheriff's department was contacted and informed family, and indicated that resident would be taken to the hospital. A behavior care plan revised on January 24, 2024 revealed that the resident #50 had behavior problems related to the effects of Alzheimer's dementia as evidenced by poor awareness of needed personal care, combativeness, and verbal outburst during personal care. Interventions included to anticipate and meet needs, assist to minimize disruptive behaviors, if issues arise, remove from situation. A care plan revised April 26, 2024 indicated that the resident #50 had impaired cognitive function related to Alzheimer's dementia with impaired thought processes, difficulty making decisions, short term memory loss that is not anticipated to improve. Interventions included supervision/assistance with all decision making, and keep routine consistent. -Resident #191 (alleged perpetrator) was admitted to the facility on October 4, 2023 with diagnoses that included dementia, malignant neoplasm of cerebral meninges, major depressive disorder, and anxiety disorder. A behavior note dated October 5, 2023 indicated documented that the resident was out of the room wandering the halls. The note stated that the resident had been tearful most of the afternoon and upset that her family had dropped her off. Resident was observed to be quickly agitated with loud sounds or voices but was easily redirected. Resident was noted as compliant with medication and care. A behavior note dated October 6, 2023 documented that a CNA (certified nursing assistant) reported that the resident was pacing, going in to another residents' room and yelling at CNA. The CNA indicated that t

Based on clinical record review, staff interviews, and review of facility policy and procedure, the facility failed to ensure dental needs were met for one sampled resident (#41). Findings include: Resident # 41 was initially admitted to the facility on March 19, 2021 with diagnoses that included hemiplegia, hemiparesis, dysphagia, atherosclerotic heart disease, hypertensive heart disease, chronic diastolic heart failure, and chronic obstructive pulmonary disease. A dental note dated September 8, 2022 revealed that a consultation visit was completed. The findings/recommendations was ext (extraction) of #26 (lateral incisor), 27 (cuspid), and 28 (first bicuspid). The next schedule appointment was marked as October 5, 2022. However, further review of dental referral notes did not reveal any documentation of that visit or if that visit occurred. A care plan initiated on February 28, 2023 revealed that the resident is at risk for acute oral/dental health problems related to missing and/or cavity prone teeth. Interventions included coordinate arrangements for dental care, transportation as needed/as ordered. Review of dental noted dated January 2, 2024 indicated that an initial exam was conducted and found that resident had broken teeth. During the exam it was discovered that resident had a worn FUD (full upper denture) for over 3 years and never had lower dentures. It was noted that FUD fit loosely and needs adhesive for retention. The note indicated that recommended treatment included surgical exts (extraction) #26 (lateral incisor), 27 (cuspid), 28 (first bicuspid), and 29 (second bicuspid); and FUD/FLD (full lower denture). Review of the annual Minimum Data Set (MDS) assessment dated March 20, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 13 indicating that the resident was cognitively intact. The MDS also documented that the resident had obvious or like cavity or broken natural teeth. An interview with the Unit Secretary (staff #424) was conducted on May 23, 2024 at 9:19 a.m. Staff #424 stated that nurse or providers informs her which residents need dental services. For new residents they sent the face sheet to the dental provider, for long term care residents, if they do not know if Medicare covers, they call the dental office to ask if they cover and if the dentist is contracted. One of the dental providers comes in and provides dental services and the other will send a list and they let her know which residents needs to be seen. Staff #424 noted that the process for scheduling is usually via email contact initiated by her. For example, if a resident has an appointment today, she annotates it then the day after, she calls and checks if the resident has a follow-up appointment. Regarding resident #41, her name was not on list prior to the dental provider coming in today. Looking at the chart, staff #424 stated that she does not see anything else in reference to resident #41 seeing dental services other than the initial visit

Based on observation, interviews and policy review, the facility failed to ensure that physician's orders was followed regarding one resident's (#31) AV (arteriovenous) fistula. Findings include: Resident #31 was admitted to the facility on June 5, 2018 with diagnoses that included end stage renal disease, hypertensive chronic kidney disease, Parkinsonism, atherosclerotic heart disease of native coronary artery without angina pectoris, paroxysmal atrial fibrillation, and dependence on renal dialysis. Review of the order summary report revealed a physician order dated June 5, 2018 which indicated "No Blood pressure or venipuncture to AV fistula site every shift for left arm. A care plan initiated on June 28, 2018 and revised on March 2, 2023 indicated that resident needs dialysis related to end stage renal failure. The goal was that the resident would not have signs and symptoms of complications from dialysis. Interventions included: Do not draw blood or take B/P (blood pressure) in left arm with graft, and check and change dressing daily at access site. However, review of the resident's blood pressure (BP) log over the last six months revealed that it was taken on the left arm on the following dates: - December 11, 2023 - December 18, 2023 - January 1, 2024 - May 13, 2024 Further review of the BP log revealed numerous occasions since the resident was admitted in which her BP was taken on the left arm. Review of the quarterly Minimum Data Set (MDS) dated March 20, 2024 revealed a Brief Interview for Mental Status (BIMS) score of 15 indicating that the resident was cognitively intact. The MDS assessment also noted that the resident receives hemodialysis treatment. The assessment also indicated that the resident is dependent to renal dialysis. An interview with a Certified Nursing Assistant (CNA/staff #510) was conducted on May 22, 2024 at 4:19 p.m. Staff #510 stated that for residents on dialysis, you use the opposite arm to take BP. The CNA said that you do not take the BP on the arm with the fistula. Staff #510 noted that the nurse normally informs CNAs not to take the BP on the same arm as the fistula site. During an interview with a Licensed Practical Nurse (LPN/staff #513) conducted on May 22, 2024 at 4:32 p.m., staff #513 stated that you cannot take vitals on the same site as the fistula. The LPN noted that you want to check for bruit and thrill on the fistula site and do a skin assessment. An observation was conducted on May 23, 2024 at 9:49 a.m. During the observation the CNA (staff #462) accomplished hand hygiene, wiped/disinfected the vitals machine then took resident #31's vitals. Staff #462 explained that the reason she was using resident #31's right arm is due to her having a fistula on the left arm. An interview with the Director of Nursing (DON/staff #417) was conducted on May 23, 2024 at 9:49 a.m. Staff #417 stated that her expectation is that staff will take bp on the arm with the fistula before and after dialysis. The DON noted th

Based on observations, staff interviews, and the facility policy and procedures, the facility failed to ensure that floor tiles, laminate flooring, shower drain, and door frame in common areas were safe for residents ambulating and showering. Findings include: On May 21, 2024 at 4:23 p.m., a walk through of the facility was conducted and the following environmental issues were observed: -one rectangular panel of the laminate flooring in Hall 100, between rooms #127 and #128, was broken and approximately half an inch was missing from one of the corners of the laminate. -the laminate panel in the doorway of room #127 was observed to have approximately 16.5 inches in length broken and missing. -six tiles in Hall 100 were cracked and/or broken. -the transition strip between the laminate flooring and the tile flooring on Hall 100 by room #123 was cracked in multiple areas. -in the hallway, near room #124 a piece of the flooring, circular in shape, was compressed, so that the floor was uneven and there was cracked and broken laminate around the circumference of the circle. -one rectangular laminate floor panel located near room #118 on Hall 100 was not secured to the floor. -there was no transition strip between the tile and the laminate flooring toward the end of Hall 100 by room #119. -the drain in the bathroom shower on Hall 100 was approximately two inches in diameter and there was a square silver drain cover only partially covering the round open hole and the drain cover was not attached to the floor. -the doorframe of the bathroom on Hall 100 had areas were paint was missing and a brown rust color was observed. -upon entering the secured unit on Hall 100, one rectangular laminate floor panel was broken with approximately 3 inches by 1 inch of the panel missing. -in the hallway of the secured unit on Hall 100, a circular shape, approximately three inches in diameter, was compressed, so that the floor was uneven. -by the left door to the main dining room, the Azelea room, there were two eighteen by eighteen inch tiles broken and cracked. -by the right door to the main dining room, the Azelea room, the tile was not flush/even with the surrounding tiles, creating a dip of approximately one centimeter where residents would enter the dining room. -there was no transition strip between the tile and the laminate flooring near room #227 on Hall 200. An interview was conducted on May 22, 2024 at 8:37 a.m. with the Maintenance Manager (staff #430), who stated that anyone can put in a request for a repair and he prioritizes repairs based on resident safety, how it impacts the residents' stay, and anything to do with safety, should be repaired immediately. He stated that safety risks included falls and could include rust if the resident came into contact with the rust. He stated that he inspects the facility daily, and that he has laminate flooring, transition strips, and paint in stock. He stated that drain covers should be screwed down to make sure that the

Based on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident (#17) was free from sexual abuse from another resident (resident #51). The deficient practice could result in further incidents of resident to resident abuse. Findings Include: -Resident #17 (Alleged victim) was admitted to the facility on August 29, 2023, with diagnoses including Alzheimer's disease, dementia, depression, anxiety, chronic kidney disease, and type 2 diabetes. A behavioral care plan with a start date of August 29, 2023 revealed resident #17 has impaired cognitive function, impaired decision-making related to Alzheimer's dementia with noted interventions of resident needing approaches that maximize involvement in daily decision making and activity limit choices, use cueing, task segmentation, instructions, and to keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Review of a quarterly Minimum Data Set (MDS) assessment dated March 6, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident has major cognitive impairment. -Resident #51 (Alleged perpetrator) was admitted to the facility on December 30, 2022, with diagnoses including Alzheimer's disease, anxiety, hypertension, type-2 diabetes, and hyperlipidemia. A behavioral care plan with a start date of January 5, 2023 revealed resident #51 was at risk for behavior problems related to end stage dementia, as evidenced by verbal aggression towards staff and groping female residents without their consent, with noted interventions of identifying behavioral triggers, and keep the resident at arm's length from other female residents. Review of the facilities Reportable Event Record revealed that on the afternoon of April 1, 2024, resident #17 was seated in a day room where the resident's watch TV when a Certified nursing assistant (CNA/staff #119) entered and observed resident #51 with his hand down resident #17's shirt, appearing to be touching her breast. The CNA (CNA/staff #119) removed resident's #51 hand from resident #17's shirt, which made resident #51 upset and visibly agitated towards the CNA (CNA/staff #119). An interview was conducted with a CNA (CNA/staff #119) on April 9, 2024, at 11:06 a.m., Staff #117 stated that on the day of the incident they were working as a med tech and was passing medications when they observed resident #51 rubbing the shoulders of resident #17, and had his hand in her shirt. The CNA further stated that the resident can be physical too, and likes to grab at staff members also. In an interview conducted with the Director of Nursing (DON/staff #200) on April 9, 2024 at 2:30 p.m. The DON stated that resident #51 has lots of behaviors, verbally sexually suggestive among others. The DON also stated that the care plan states not to allow the resident within arms reach of female residents. The DON a

Based on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to ensure that one resident (#17) was free from sexual abuse from another resident (resident #51). Findings Include: -Resident #17 (Alleged victim) was admitted to the facility on August 29, 2023, with diagnoses including Alzheimer's disease, dementia, depression, anxiety, chronic kidney disease, and type 2 diabetes. A behavioral care plan with a start date of August 29, 2023 revealed resident #17 has impaired cognitive function, impaired decision-making related to Alzheimer's dementia with noted interventions of resident needing approaches that maximize involvement in daily decision making and activity limit choices, use cueing, task segmentation, instructions, and to keep the residents routine consistent and try to provide consistent care givers as much as possible in order to decrease confusion. Review of a quarterly Minimum Data Set (MDS) assessment dated March 6, 2023 revealed a Brief Interview for Mental Status (BIMS) score of 6 which indicated the resident has major cognitive impairment. -Resident #51 (Alleged perpetrator) was admitted to the facility on December 30, 2022, with diagnoses including Alzheimer's disease, anxiety, hypertension, type-2 diabetes, and hyperlipidemia. A behavioral care plan with a start date of January 5, 2023 revealed resident #51 was at risk for behavior problems related to end stage dementia, as evidenced by verbal aggression towards staff and groping female residents without their consent, with noted interventions of identifying behavioral triggers, and keep the resident at arm's length from other female residents. Review of the facilities Reportable Event Record revealed that on the afternoon of April 1, 2024, resident #17 was seated in a day room where the resident's watch TV when a Certified nursing assistant (CNA/staff #119) entered and observed resident #51 with his hand down resident #17's shirt, appearing to be touching her breast. The CNA (CNA/staff #119) removed resident's #51 hand from resident #17's shirt, which made resident #51 upset and visibly agitated towards the CNA (CNA/staff #119). An interview was conducted with a CNA (CNA/staff #119) on April 9, 2024, at 11:06 a.m., Staff #117 stated that on the day of the incident they were working as a med tech and was passing medications when they observed resident #51 rubbing the shoulders of resident #17, and had his hand in her shirt. The CNA further stated that the resident can be physical too, and likes to grab at staff members also. In an interview conducted with the Director of Nursing (DON/staff #200) on April 9, 2024 at 2:30 p.m. The DON stated that resident #51 has lots of behaviors, verbally sexually suggestive among others. The DON also stated that the care plan states not to allow the resident within arms reach of female residents. The DON also stated that her expectation is that the staff separate the resident's immediately wh