Advanced Health Care Of Glendale
Inspection history, citations, penalties and survey trends for this long-term care facility in Glendale, Arizona.
- Location
- 16825 North 63rd Avenue, Glendale, Arizona 85306
- CMS Provider Number
- 035275
- Inspections on file
- 19
- Latest survey
- February 5, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Advanced Health Care Of Glendale during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, post‑stroke deficits, dysphagia, and a primary language other than English experienced multiple falls, refusals of care and therapy, and behavioral symptoms while staff documented ongoing communication barriers and did not use interpreter services. The care plan noted communication and behavioral issues but lacked specific language‑access interventions, and a psychiatric consult ordered for behaviors was never completed before discharge. Therapy notes showed limited participation and refusals, yet discharge documentation conflicted on whether skilled services were completed or the resident’s needs could not be met, and physician documentation did not support an inability to meet needs. The resident’s son reported being told on short notice that the resident could no longer stay unless a family member or private sitter stayed overnight, leading him to hire a sitter and then take her home. Although facility policy and leadership interviews confirmed that a NOMNC must be given at least 48 hours before Medicare‑covered services end, the NOMNC in this case was dated with coverage ending the same day it was purportedly discussed and was actually signed by the son on the day of discharge, with no clear evidence that the required advance notice and appeal information were provided within the mandated timeframe.
A resident with multiple complex cardiac, respiratory, and metabolic conditions was admitted without any documented wrist or elbow wounds in the admission assessment or care plan. Later, the resident was observed with dressings on both wrists and one elbow that were not dated or initialed, and a review of the EHR showed no corresponding wound care orders or progress notes for these areas at that time. An RN subsequently obtained an order only for the right wrist before additional orders were later entered for all three sites, but the left wrist and elbow dressings continued to lack dates and initials. Interviews with RNs, the ADON, and the wound care nurse confirmed that facility policy requires wound care orders for each wound, documentation of all wounds and treatments in the EHR, and dated/initialed dressings, and that these requirements were not met for the resident’s wrist and elbow wounds.
A resident with severe cognitive impairment, post-stroke deficits, and a primary language other than English was admitted with documented communication barriers and behavioral symptoms. The care plan noted altered communication and a language barrier but did not include use of a communication board or translation app. Over several days, the resident repeatedly refused meds and blood glucose checks, had multiple unwitnessed falls, and exhibited escalating behaviors such as screaming, striking staff, throwing equipment, and barricading in the room, often without provider notification or care plan revision. Documentation showed no use of interpreter or translator services and no addition of 1:1 supervision to the care plan, even after three unwitnessed falls in one evening and a psychiatric consult order. The administrator and nursing leadership acknowledged the resident needed a sitter, stated the facility could not provide ongoing 1:1 care, and directed the family to hire a private caregiver, resulting in the resident receiving 1:1 supervision from a privately paid sitter while the facility’s own staffing and sitter resources, described in its policy, were not implemented.
Surveyors found that a resident had ZAL cream and Baqsimi (glucagon) stored on the room sink counter without a lockbox and without provider orders for either the medications themselves (for part of the review period) or for self-administration. The resident reported independently applying the ZAL cream since admission and stated staff were aware, but the care plan contained no self-medication focus and the record lacked a completed self-medication assessment. A CNA stated medications and creams should not be left at bedside, while an LPN acknowledged there were no self-administration orders and that Baqsimi should have been kept in the med cart. The DON confirmed that policy requires a provider order, documented assessment, and locked storage for self-administered meds, none of which had been implemented for this resident.
A resident reported a breach of privacy when staff entered the bathroom without knocking and experienced confusion due to staff's refusal to disclose their role, citing HIPAA incorrectly. The resident also faced issues with obtaining herbal tea, highlighting communication gaps and inconsistencies in staff understanding of resident rights and facility policies.
A resident experienced a breach of privacy when staff entered the bathroom without knocking and faced communication issues with staff who incorrectly cited HIPAA as a reason for not disclosing their role. The resident also encountered problems with meal service, highlighting inconsistencies in staff adherence to facility policies on resident interaction and privacy.
A resident with multiple health issues, including acute respiratory failure, received oxycodone outside the prescribed pain level parameters on six occasions without physician notification or documentation. The facility's policy requires adherence to physician orders and documentation of any changes, which was not followed in this case.
A CNA in the facility failed to treat residents with dignity and respect, as reported by multiple residents. One resident felt violated when the CNA checked his brief without waking him, while another resident filed a grievance due to the CNA's inappropriate comments and uncaring demeanor. A third resident described the CNA as rude and questioned his attitude. The facility's response was limited to reassigning the CNA without further investigation or direct communication with the residents.
Failure to Provide Timely NOMNC and Consistent Discharge Notice for a Cognitively Impaired, Non‑English‑Speaking Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a timely Notice of Medicare Non-Coverage (NOMNC) to a resident and/or the resident’s representative in accordance with federal requirements and the facility’s own NOMNC policy. The resident was admitted with significant neurologic and functional impairments, including hemiplegia and hemiparesis following a cerebral infarction, dysphagia, metabolic encephalopathy, type 2 diabetes, and gait abnormalities. Early assessments documented that the resident’s preferred language was not English, that staff were unable to determine if an interpreter was needed, and that the resident had slurred, sometimes understandable speech and severe cognitive impairment as evidenced by very low BIMS scores. A baseline care plan identified an alteration in communication, a language barrier, and aphasic, disorganized, and slurred speech, but did not include checked interventions such as a communication board, written communication, or translation applications. Throughout the stay, multiple therapy and nursing notes documented the resident’s limited cooperation, refusals of care and therapy, falls, and behavioral symptoms, often in the context of a language barrier and confusion. Nursing and therapy documentation repeatedly showed that staff attempted to communicate verbally or with a language board but were unable to verify understanding due to the language barrier, and there was no evidence of attempts to use an interpreter or translator application. The resident experienced several unwitnessed falls, episodes of combative behavior, refusal of medications, blood glucose checks, and care, and was at times described as barricading herself in her room. A psychiatric consult was ordered but there was no evidence in the clinical record that a psychiatric evaluation was ever completed before discharge. The care plan for behavioral symptoms did not include specific interventions addressing the resident’s primary non‑English language or use of interpreter services. As the stay progressed, therapy records showed that the resident participated in some OT, PT, and ST sessions but also refused multiple sessions, with therapy staff documenting refusals and minimal progress. Despite speech therapy documentation on one day recommending continuation of the plan of care, PT and ST discharge summaries were later completed indicating dates of service over a short period and noting minimal progress or refusal. Nursing and administrative notes indicated that staff communicated with the resident’s son about concerns for the resident’s safety at night and the need for a caregiver or private sitter, and the son ultimately arranged and paid for a private sitter overnight and then took the resident home. The discharge planning note stated that the NOMNC was signed by the son on a specific date and that discharge home was discussed, but the NOMNC form itself showed Medicare coverage ending on that same date and was actually signed by the son the following day, the day of discharge. There was no documentation that the NOMNC timeframe was waived, that appeal information was provided at the time of the initial notification, or that the discharge was resident‑ or family‑driven or due to the facility’s inability to meet needs as documented by a physician. Interviews with staff and the resident’s son confirmed that the son was informed of discharge plans only shortly before discharge, that he did not receive 48‑hour advance notice or appeal information, and that the facility’s own policy required the NOMNC to be delivered at least two days before Medicare‑covered services ended, which did not occur for this resident. Additionally, discharge documentation contained conflicting information about the reason and timing of discharge. The Discharge Instructions and Summary listed the reason for discharge as completion of skilled services and stated that the resident participated in therapy as tolerated, while the Notice of Transfer or Discharge cited that the resident’s needs could not be met in the facility and included appeal and Ombudsman information. The notice of transfer or discharge also contained inconsistent dates for when the notice was given. The clinical record lacked a physician note stating that the resident was unsafe to remain in the facility or that her needs could not be met there. Interviews with the LPN discharge nurse, DON, administrator, and other staff showed inconsistent explanations regarding whether the resident met therapy goals, whether she refused therapy, whether the discharge was rushed due to safety concerns, and whether 48‑hour advance notice of Medicare coverage termination and discharge was provided. The facility’s NOMNC policy required delivery of the NOMNC at least two days before Medicare‑covered services end, with proper documentation of communication and appeal rights, but the record for this resident did not show that these requirements were met.
Failure to Obtain Orders and Document Wound Care for Wrist and Elbow Dressings
Penalty
Summary
The deficiency involves the facility’s failure to obtain and document physician orders and corresponding wound documentation for dressings applied to a resident’s wrists and elbow. The resident was admitted with multiple complex medical conditions, including pleural effusion, acute respiratory failure with hypoxia, syncope and collapse, atherosclerotic heart disease, hypertensive heart and chronic kidney disease with heart failure, type 2 diabetes mellitus, sick sinus syndrome, left bundle branch block, endocarditis, metabolic encephalopathy, acute embolism and thrombosis of the left peroneal vein, long-term anticoagulant use, and a cardiac pacemaker. The 5‑day MDS showed no BIMS score, but the admission assessment documented the resident as alert, cooperative, oriented, and with clear comprehension, and showed no evidence of wounds to the wrists or elbow. The admission care plan also contained no documentation of wounds or wound care to these areas. During an observation, the resident was seen in a wheelchair with bandages on both wrists and the left elbow, none of which were dated or initialed. The resident’s daughter reported that the right wrist bandage was coming off, and nursing staff were notified. A review of the physician’s orders at that time revealed no wound care orders for either wrist or the left elbow, and there were no progress notes documenting wounds to these areas. Later that same day, an initial wound care order was entered only for the right wrist. On a subsequent observation, the right wrist dressing was dated and initialed, but the left wrist and left elbow dressings still lacked dates and staff initials. A follow‑up review of physician orders then showed wound care orders for the right wrist, left elbow, and left wrist, specifying cleansing with wound cleanser, patting dry, and applying a foam dressing twice daily as needed. Interviews with nursing staff and leadership confirmed that facility expectations and policies required wound care orders for each wound, documentation of all wounds and treatments in the electronic health record, and that all dressings be dated and initialed by the nurse providing care. The RN who identified the loose bandage stated she had requested a wound care order for the right wrist and later noticed additional areas without knowing how long the dressings had been in place, and confirmed there were no orders for the left wrist or elbow at that time. The ADON verified that wounds present on admission should be identified in the admission assessment with corresponding orders, and that any bandaging must have matching orders and documentation. The wound care nurse stated she was not aware when the wrist and elbow injuries occurred and acknowledged that orders, wound documentation, and dated/initialed dressings were expected. Facility policies on wound documentation, standards of nursing practice, and charting requirements all required comprehensive assessment, daily monitoring, and treatment documentation, which were not followed for these wrist and elbow wounds.
Failure to Provide Facility-Staffed 1:1 Supervision and Communication Support for a High-Acuity Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure sufficient and appropriate staffing, including provision of a caregiver/sitter, to meet the individualized needs of a resident with significant cognitive impairment, language barriers, and behavioral symptoms. The resident was admitted with hemiplegia and hemiparesis following cerebral infarction, dysphagia, metabolic encephalopathy, diabetes, and gait abnormalities. On admission, the nursing assessment documented that the resident’s preferred language was not English, that it was unclear whether an interpreter was needed, and that the resident had slurred, sometimes understandable speech and could only sometimes understand others. A BIMS score of 1 indicated severe cognitive impairment. The baseline care plan identified an alteration in communication, language barrier, and aphasic, disorganized, and slurred speech, with an intervention for a speech therapy consult, but did not include use of a communication board, written communication, or translation application. Over the following days, the resident exhibited repeated refusals of medications and blood sugar checks, falls, and escalating behavioral symptoms, while documentation showed limited or no use of interpreter tools and no timely care plan revisions. On one date, a provider notification note documented that the resident refused medications and blood sugar checks despite use of a language communication board, and staff were unable to verify understanding due to the language barrier; there was no evidence of attempts to use an interpreter or translator application. The resident experienced an unwitnessed fall and was unable to describe the event, yet the care plan showed no updates or added interventions after this fall. A second fall occurred with similar inability to describe the event, again without evidence of care plan revision. Subsequent nursing notes described the resident screaming, kicking, scratching staff, refusing care and medications, attempting to get out of bed unassisted, smacking staff, throwing equipment (including leg brace and sensor pad), and remaining combative and refusing all care and medications, with multiple entries lacking evidence of provider notification of these behaviors. Later documentation showed that the resident had three unwitnessed falls in one evening, was very distressed, would not allow staff to touch her, and seemed unable to be safe, prompting provider notification and a psychiatric consult order. Notes indicated the resident barricaded herself in her room, staff had difficulty accessing her, and the physician ordered transfer to the hospital. After return from the hospital with no acute findings, the administrator documented a conversation with the resident’s son stating concerns about the resident’s safety and a need for a caregiver from late afternoon to early morning, and provided information for a private caregiver company. The care plan still contained no revision or intervention specifying a need for 1:1 sitter or caregiver during those hours. A later nursing note documented that the resident had direct 1:1 supervision with a private sitter, paid for by the family, with continued refusal of medications and assessments and no evidence of use of a communication board, interpreter, or translator application. Interviews with staff and the administrator confirmed that the facility did not have an interpreter or translator service, relied on a basic picture sign for communication, and that the administrator believed the resident required care above what the facility could provide, specifically 1:1 sitter care. The administrator stated the facility could provide a sitter only for a very short period and otherwise referred families to private caregiver companies, and that he informed the resident’s son that the facility could not provide a sitter. The ADON stated that the facility did have staff who could act as sitters but that additional staffing required administrator approval, and that based on the record, the resident needed a sitter. Other nursing staff reported that the resident could sometimes be calmed and redirected and appeared appropriate for the facility, but also acknowledged uncertainty about the extent of the language barrier. The facility’s staffing policy stated that staffing is based on census and acuity, that the facility has the ability to hire sitters as needed, and that additional staff or agency personnel can be brought in when events require extra resources. Despite this policy, the record and interviews showed no evidence that the facility implemented or provided a facility-funded sitter or adjusted staffing to meet this resident’s identified need for 1:1 supervision, instead directing the family to hire and pay for a private sitter and proceeding with discharge while documenting that the resident’s needs could not be met in the facility.
Unsecured Bedside Medications and Lack of Self-Administration Orders
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications and biologicals were properly stored and not left unattended at the bedside, and failure to follow its own self-medication policies. During an observation of one resident’s room, two containers of ZAL cream with pharmacy labels were found on the counter next to the sink, with no lockbox present. The resident reported that she had been self-applying the ZAL cream to her buttocks and labia since admission, that staff were aware she was using it, and that one container was empty. Review of the clinical record from admission through the observation dates showed no provider orders for ZAL cream and no orders authorizing self-administration of any medications or treatments. The resident had diagnoses including Sjogren syndrome, urinary tract infection, and Type 2 diabetes mellitus, and an admission assessment showed she was alert and oriented, with a BIMS score of 13 indicating she was cognitively intact. The care plan included focuses on altered skin integrity and an indwelling catheter but did not include any focus or interventions related to self-administration of medications or treatments. Although provider orders were later written for a compounded topical preparation and ZAL cream, there was no evidence of any order permitting these medications to be stored at the bedside or self-administered by the resident during the period reviewed. A subsequent room observation found a container of ZAL ointment and a box of Baqsimi (glucagon) on the sink counter, again without a lockbox. Staff interviews revealed inconsistent understanding and implementation of facility policy: a CNA stated that medications and creams should not be left at the bedside and should be reported to the nurse, while an LPN stated that ointments could be left at the bedside only if there was a provider order for self-administration, and confirmed there were no such orders for this resident. The LPN acknowledged that Baqsimi should have been kept in the medication cart and that he had not been aware these medications were in the room. The DON stated that residents requesting to self-administer must be assessed using a Self-Medication Administration Assessment form, require a provider order, and that medications must be kept in a lockbox; review of the record showed no such assessment or orders for bedside storage or self-administration, despite the presence of ZAL cream and Baqsimi in the resident’s room. Facility policies required medications to be administered only on clear provider orders and required staff to remove any unauthorized medications found at the bedside, which had not occurred in this case.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident, identified as Resident #338, who was admitted with multiple diagnoses including pneumonia, type 2 diabetes mellitus, depression, and anxiety. The resident reported that staff entered the bathroom without knocking, which violated her privacy. Additionally, the resident experienced confusion and frustration when staff, specifically Staff #27, refused to disclose their role or shift, citing HIPAA as the reason, which is a misinterpretation of the regulation. This lack of transparency and communication contributed to the resident's anxiety and dissatisfaction with the care provided. Furthermore, the resident expressed dissatisfaction with the availability of herbal tea, which was initially denied by Staff #27 but later found in the dining room. Interviews with staff, including a CNA and the Director of Nursing, revealed inconsistencies in communication and understanding of resident rights and facility policies. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, which was not upheld in this instance, leading to the deficiency noted in the report.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to maintain the dignity and privacy of a resident, identified as Resident #338, who was admitted with multiple diagnoses including pneumonia, edema, type 2 diabetes mellitus, depression, and anxiety. The resident reported an incident where staff entered the bathroom without knocking, which compromised her privacy. Additionally, during an interaction, Staff #27 incorrectly cited HIPAA as a reason for not disclosing their role or shift to the resident, which led to confusion and a lack of transparency in communication. The resident also experienced issues with meal service, specifically not receiving herbal tea as requested, which was later found to be available in the dining room. Interviews with staff, including a CNA and the Director of Nursing, revealed inconsistencies in communication and adherence to facility policies regarding resident interaction and privacy. The facility's policy on resident rights emphasizes treating each resident with respect and dignity, which was not upheld in this instance.
Failure to Adhere to Opioid Administration Parameters
Penalty
Summary
The facility failed to ensure that a resident's opioid medication regimen was administered according to the physician's ordered parameters. The resident, who was admitted with multiple diagnoses including acute respiratory failure and dementia, had a physician's order for oxycodone to be administered only when the pain level was between 8-10 on a scale of 1-10. However, the medication was administered six times outside of these parameters, with pain levels ranging from 5 to 7, without notifying the physician or documenting any changes in the medication administration record (MAR) or progress notes. Interviews with the nursing staff and the Director of Nursing (DON) confirmed that the facility's policy requires adherence to physician orders, including pain level parameters, and mandates documentation of any changes or notifications to the physician. Despite this policy, there was no evidence of physician notification or documentation of order changes for the six instances where oxycodone was administered outside the prescribed parameters. This oversight could potentially lead to serious side effects, such as respiratory distress, due to the inappropriate administration of opioids.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure residents were treated with dignity and respect, as evidenced by multiple incidents involving a CNA, identified as Staff #42. Resident #20 reported that the CNA entered his room and changed his brief without providing peri care, and later checked his brief without waking him, which made the resident feel violated. The resident expressed that the CNA lacked compassion and did not communicate appropriately during care. Despite reporting these incidents to the charge nurse, the resident felt that the administration did not follow up adequately. Additionally, Resident #60 filed a grievance after an interaction with the same CNA, who made an inappropriate comment about getting paid to provide care. The resident felt the CNA was uncaring and only interested in money. The CNA's demeanor and comments led the resident to distrust him, prompting a request for the CNA not to return to his room. The facility's response was to reassign the CNA to another hallway without further investigation or direct communication with the affected residents. Resident #4 also expressed dissatisfaction with the CNA's attitude, describing him as rude and uncaring. The resident recounted an incident where the CNA questioned her about not wearing a fall bracelet, which the facility did not even provide. This pattern of behavior by the CNA, coupled with the facility's inadequate response to grievances, highlights a failure to uphold residents' rights to dignity and respect, as outlined in the facility's policy on Resident Rights.
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A resident with dementia, communication deficits, and significant physical impairment, who required extensive 2-person assist and used a walker and wheelchair, was physically assaulted by a cognitively intact roommate after refusing care from a CNA. When staff returned with a male CNA, the roommate stated he had "taken care of it," and the resident was found with a forehead hematoma, lip lacerations, and blood on the floor and bed linens. The roommate, who had alcohol abuse and a behavioral care plan noting potential for physical behaviors and poor impulse control, had no prior aggressive behaviors documented in the MDS or progress notes. Despite an abuse policy stating residents’ rights to be free from abuse, the incident demonstrated a failure to protect the resident from physical abuse by another resident.
Two residents identified as being at risk for malnutrition had physician orders and care plan interventions for weekly weights over a four-week period, but staff did not consistently obtain or document these weights as required. For one cognitively intact resident with multiple comorbidities, only two weights were recorded during the ordered period, with no documentation of a weight or refusal on one of the scheduled weeks, despite staff acknowledging poor intake and the existence of weekly weight orders. For another resident with severe cognitive impairment and multiple diagnoses, only two weights were documented, with additional dates showing no recorded weight values and only references to nursing notes, and missing entries on other ordered dates. Staff interviews and facility policies confirmed that newly admitted and nutritionally at-risk residents were to receive weekly weights, that weights and refusals were to be documented in the EHR, and that these physician orders were not accurately implemented or recorded.
Multiple residents with significant cognitive, neurological, and psychiatric conditions were not adequately protected from abuse and neglect. One resident, fully dependent for ADLs and assessed as needing a 2‑person assist for bathing, was showered by a single CNA and fell from a gurney, sustaining head injuries and requiring hospital care, after the care plan failed to reflect the 2‑person assist documented on the MDS. Two other behaviorally complex residents engaged in a verbal altercation that escalated to one striking the other, despite known histories of aggressive behaviors. In a separate case, a dependent, nonverbal resident who required a 2‑person Hoyer assist reported that a tall male staff member hurt her during care, was found with right wrist pain and swelling and blood on her lip, and was sent to the ER, while staff confirmed that all residents on that hall were supposed to receive 2‑person assistance for transfers and linen changes.
The facility failed to follow its abuse, neglect, and investigation policies for multiple residents. One resident with severe cognitive impairment and total dependence for bathing was assessed on the MDS as needing a 2‑person assist, but the care plan did not specify this, and a CNA provided a shower alone, during which the resident fell from a gurney and sustained head injuries. Another resident with impaired mobility and skin integrity needs was the subject of a complaint about lack of repositioning and rectal blisters, yet the 5‑day investigation contained no interviews with staff, the resident, or the complainant. A dependent, neurologically impaired resident alleged injury by a male CNA and was sent to the ER with wrist pain and lip bleeding, but the facility’s investigation, despite suspending and later terminating the CNA, did not include interviews with family or other residents cared for by that CNA. In a separate case, a non‑verbal resident with penile edema prompted an abuse allegation from family, but the DON conducted no staff or resident interviews, relying solely on her own assessment. Additionally, an altercation between two behaviorally complex residents was documented, but the excerpted records do not show a comprehensive abuse investigation consistent with policy, despite leadership acknowledging that such investigations must include thorough interviews and alignment of care plans with MDS findings.
The facility failed to conduct thorough investigations into multiple allegations of abuse, neglect, intimidation, and misappropriation. In several cases, residents with significant medical conditions reported or were the subject of concerns such as lack of repositioning leading to skin issues, pain and injury allegedly caused during transfers, penile swelling alleged as abuse, intimidating staff interactions, and missing money. For these events, the facility’s 5‑day investigations frequently lacked required interviews with the resident, family, staff on all relevant shifts, roommates, other residents cared for by the accused staff, and the original complainants, and in one case the investigation file could not be located. These omissions occurred despite facility policy and leadership statements that investigations must be timely, thorough, and include comprehensive interviews and written witness reports.
Surveyors found that the facility did not consistently complete and provide baseline care plans to residents or their representatives within 48 hours of admission. In three cases, residents with complex conditions such as anemia with mobility issues, acute kidney failure with MASD and Foley catheter, and ventilator-dependent respiratory failure with PEG and trach had baseline care plans initiated on admission, but resident/representative signature sections were left blank, completion dates were recorded months after admission and marked as “system completed,” and there was no clear evidence that copies were provided to the residents or, in one case, to a public fiduciary. Facility policy required timely, person-centered care plans with documented resident participation or documented reasons when participation was not practicable, but the records for these residents did not meet those requirements.
The facility failed to follow its infection control program by not posting Enhanced Barrier Precaution (EBP) signage for three residents who were documented as requiring EBP due to conditions such as MRSA infection, open lower-leg wounds, PICC use, and a urostomy. Observations showed that none of these residents had EBP signs or PPE instructions on their room doors, despite facility policy requiring door signage to alert staff and visitors to contact precautions. In interviews, a wound nurse, RT, RN, LPN, and the DON all confirmed that EBP signs are the established method to communicate when gowns, masks, and hand hygiene are needed for direct care and that the absence of such signage poses a risk for infection spread.
Surveyors found that a secured unit and its dining/communal area were not maintained in a safe, homelike condition, including missing and bent baseboards in the hallway and a wall hole near the nurse’s station partially covered by a broken outlet plate with jagged edges. A cognitively intact resident with multiple medical conditions reported that the damaged baseboards in the hall made the environment feel less homey. Staff, including CNAs and LPNs, acknowledged that damaged walls and baseboards affect the homelike environment and can pose safety concerns, and the Maintenance Director and Administrator confirmed awareness of the issues, noting that the hole and broken plate had been verbally reported but not repaired and that written work orders were not submitted. Review of work orders showed no entries for the baseboards or the wall hole, despite facility policy requiring a safe, clean, comfortable homelike environment.
A resident with severe cognitive impairment and total dependence for ADLs had MDS assessments and monthly summaries indicating a need for a two-person assist with bathing, but the comprehensive care plan was not updated to specify this requirement. As a result, a CNA provided a shower with only one staff member present, during which the resident became restless, pushed the gurney rail, fell, and sustained head injuries and oral bleeding, requiring hospital evaluation. Interviews with the MDS nurse and DON confirmed that the assessments showed a two-person bathing assist was needed, but this was not reflected in the care plan the CNA was following.
A resident with severe cognitive impairment, persistent vegetative state, chronic respiratory failure, prior brain hemorrhage, and a history of falls was documented in MDS assessments as totally dependent for bathing and requiring two-person assist. However, the care plan was not updated to clearly reflect this two-person assist requirement for bathing, and staff relied on room indicators that did not show the need for two-person help. A CNA, believing the resident to be a one-person assist, took the resident alone to the shower on a gurney; during or after the shower, the resident jerked, crossed his legs over the rail, and fell from the gurney, sustaining head injuries and oral bleeding that required hospital treatment. The DON and Administrator acknowledged that the resident should have had two-person support for bathing based on prior MDS data, and multiple staff stated that providing only one-person assist to a resident assessed as needing two-person assist, leading to a fall, constituted neglect.
Failure to Protect a Resident From Physical Abuse by a Roommate
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. One resident, identified as the alleged victim, had multiple diagnoses including cognitive communication deficit, dementia without behavioral disturbance, psychotic disturbance, mood disturbance, alcohol use, dizziness, giddiness, and anxiety. Despite these conditions, a recent MDS documented a BIMS score of 15, indicating intact cognition, and noted that the resident required extensive two-person assistance with care due to upper and lower extremity impairment and used a walker and wheelchair. The resident had an active cognition care plan addressing risk for impaired cognitive function and a communication care plan addressing hearing deficit, with interventions to provide a safe environment and anticipate needs. On the date of the incident, nursing documentation recorded a change of condition related to an altercation with the resident’s roommate. According to the nursing note and the facility-reported incident (FRI), the victim had refused care from a CNA, who left the room to obtain a male CNA. When staff returned, the roommate stated that he had “taken care of it” for staff, and blood was observed on the floor and on the victim’s bed sheet. The victim was found with a raised bump (hematoma) on the forehead and small cuts to the upper and lower lips, confirmed by a skin assessment that documented small lacerations to the lips and a bump on the forehead. A psychosocial care plan was later initiated for the victim related to an assault, identifying a potential psychosocial well-being problem. The alleged perpetrator, the victim’s roommate, had diagnoses including alcohol abuse and a need for assistance with personal care. A cognition care plan identified risk for impaired cognitive function or impaired thought processes, and a behavioral care plan initiated on the date of the incident documented potential for physical behaviors toward others related to a history of harm to others and poor impulse control. However, the admission MDS for this resident also showed a BIMS score of 15, with no psychosis or behavioral symptoms documented during the assessment period, and progress notes from admission up to the incident did not indicate prior aggressive behavior. The facility’s abuse policy, last reviewed in October 2022, stated that each resident has the right to be free from abuse, including physical abuse, but the occurrence of a resident-to-resident physical assault resulting in injury to the victim demonstrated that the facility failed to protect the victim’s right to be free from physical abuse by another resident. Interviews with other residents indicated that they felt safe and would report incidents to staff, and interviews with the Administrator and DON described general procedures and expectations for preventing and responding to abuse and resident-to-resident altercations. The Administrator initially could not verify the current abuse policy until directed to the DON, who confirmed the October 2022 policy was in effect. The FRI documented that the roommate physically assaulted the victim after the victim refused care, resulting in visible injuries and blood in the room. The FRI did not indicate whether the allegation of abuse was verified or not verified, but it did document that the roommate was sent to the hospital and would not be accepted back into the facility. These documented events and injuries form the basis of the deficiency that the facility failed to ensure the resident’s right to be free from physical abuse by another resident.
Failure to Follow Physician Orders for Weekly Weights for Residents at Nutritional Risk
Penalty
Summary
The deficiency involves the facility’s failure to follow physician orders for weekly weights and to document refusals or reasons weights were not obtained for two residents who were identified as being at risk for malnutrition. Facility policies required accurate implementation of physician orders and documentation of weights as ordered, including reasons when residents could not be weighed. The policy on vital signs specified that if a resident was unable to be weighed, the reason should be recorded and other provisions taken to monitor the resident’s size. Interviews with staff confirmed that newly admitted residents and those at nutritional risk were to receive weekly weights for four weeks, and that refusals or missed weights were expected to be documented in the electronic health record. For one resident with multiple diagnoses including a displaced trimalleolar fracture, type 2 diabetes, schizophrenia, chronic kidney disease, and a history of transient ischemic attack and cerebral infarction, a physician ordered weekly weights for four weeks starting in early February. An admission nutrition evaluation and progress note documented that this resident was at risk for malnutrition with a Mini Nutritional Assessment (MNA) score of 8.0. The care plan included an intervention to complete weekly weights for four weeks and then monthly if stable. Weight records showed a weight on February 6 and another on February 22, both 219.6 lbs on a mechanical lift scale, and the eMAR/eTAR showed weights on February 6 and 13, with a documented refusal on February 27. There was no evidence in the eMAR/eTAR that a weight was taken or refused on February 20, leaving a gap in the ordered weekly weights. Staff interviews revealed that the CNA recalled weighing this resident only once and noted poor oral intake, and the LPN and DON both acknowledged that the weekly weight order for four weeks was not followed, with only two weights documented during the resident’s stay and a “hole” in the eMAR documentation. For another resident with diagnoses including metabolic encephalopathy, muscle weakness, cognitive communication deficit, asthma, and hypothyroidism, a physician ordered weekly weights for four weeks beginning in early March. The care plan identified a nutritional problem or potential problem and noted that the resident was at risk on the MNA, with interventions to monitor and report signs of decreased appetite or unexpected weight loss. A progress note documented an MNA score of 9.0, indicating risk for malnutrition. Weight records showed a weight on March 5 of 156.6 lbs on a wheelchair scale and a weight on March 20 of 156 lbs on a standing scale. Progress notes on March 10 and March 17 indicated that staff were unable to obtain a weight and that the RNA was scheduled to obtain the weight the next day. However, the eMAR/eTAR contained no evidence that weights were taken on March 3 or March 24, and on March 10 and 17, no weight values were entered, only directions to see nursing notes. Staff interviews confirmed that weekly weights were expected for residents with such orders and that weights and refusals were to be documented in the EHR. The surveyors found that for both residents, physician orders for weekly weights were not consistently implemented or documented in accordance with facility policy and professional standards.
Failure to Prevent Abuse and Neglect and to Align Care Plans With Assessed Needs
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse and neglect by staff and other residents, and to ensure that care plans and assistance levels matched residents’ assessed needs. One resident with a persistent vegetative state, chronic respiratory failure, prior subarachnoid hemorrhage, severe cognitive impairment, and a history of falls was assessed on multiple MDSs as totally dependent for bathing and requiring a 2‑person physical assist. Despite this, the comprehensive care plan did not specify a 2‑person assist for bathing prior to mid‑December, and monthly summaries inconsistently documented the resident as needing only a 1‑person assist for bathing. On the day of the incident, a CNA provided shower care alone, believing the resident to be a 1‑person assist, and reported that the resident jerked and crossed his legs over the gurney rail, resulting in a fall from the gurney, head abrasions, a hematoma, and subsequent hospital transfer for a brain bleed. Staff interviews, including the MDS coordinator and DON, confirmed that the MDS showed a 2‑person assist for bathing months before the fall and that the care plan had not been updated to reflect this, leading to care that did not match the assessed level of assistance. Another deficiency involved two residents with significant psychiatric and cognitive diagnoses who had a verbal altercation that escalated into physical abuse. One resident, with metabolic encephalopathy and schizoaffective/bipolar disorder, and another resident, with hemiplegia, anoxic brain damage, schizoaffective disorder, bipolar disorder, and generalized anxiety disorder, were reported via a complaint to have engaged in a verbal altercation during which one struck the other. The facility’s 5‑day investigation documented that one resident struck the other on the arm after a verbal dispute, and that the altercation was witnessed by an LPN, who reported that the aggressor had hit the other resident before staff separated them. Staff statements described both residents as having behavioral issues, including threats to hit others and attempts to hit staff, and the aggressor as someone who would hit people when upset. Although the LPN later stated she did not document a skin check, she confirmed her original statement that a strike occurred, and the DON acknowledged that both residents had an altercation, with no injuries documented. A further deficiency concerned a resident with dysphagia, hemiplegia, aphasia, diabetic neuropathy, and cerebrovascular disease, who was dependent for all ADLs and required a 2‑person Hoyer lift assist. A CNA reported that this resident needed a splint for her right hand and wrist and was crying in pain when the wrist was moved, with blood noted on her lower lip. The resident was sent to the ER, where swelling and tenderness of the right wrist were documented, and EMS reported the injury was from staff moving her; the resident also indicated leg pain. The facility’s initial report to the State Agency stated that the resident said she was hurt by a tall man and had right‑hand pain, and the 5‑day report documented that she complained a tall guy hurt her, leading to hospital transfer for right arm swelling. Staff interviews indicated that the resident identified a male staff member as the person who caused the injury, that there was only one male CNA working with her that day, and that all residents on that hall were 2‑person assist, with linen changes and transfers expected to be done with two staff. The implicated CNA reported using a gait belt to transfer the resident back to bed after changing bedding, and the facility suspended and then terminated him for failure to follow safety rules and unsatisfactory job performance, while concluding the investigation as inconclusive based on imaging results. Another incident involved a resident with acute and chronic respiratory failure, schizoaffective disorder bipolar type, and PTSD, who was care planned for placement on a secured unit due to psych diagnoses, poor safety awareness, and behaviors that could place self or others at risk, including verbally abusive behaviors. This resident approached another resident with schizoaffective disorder and personality disorder from behind while both were in wheelchairs near double doors. According to nursing documentation, the second resident turned and struck the first resident in the left upper chest, and the first resident then struck back with a closed fist before a CNA separated them. Slight redness was noted on the first resident’s left upper chest. The second resident’s care plans and behavior notes documented a history of yelling profanities, threatening gestures, disruptive behaviors, and the need for redirection and environmental modification, yet the altercation still occurred when the residents were in close proximity in the hallway.
Failure to Implement Abuse/Neglect Policies and Conduct Thorough Investigations
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow its abuse, neglect, and investigation policies for multiple residents, resulting in incomplete care planning, inadequate supervision, and insufficient investigations of alleged abuse or neglect. For one resident with a persistent vegetative state and severe cognitive impairment, MDS assessments in June and September documented total dependence for bathing with a required 2‑person assist, but the care plan did not specify a 2‑person assist for bathing until mid‑December. Staff reported that they relied on room indicators and the care plan to determine assist levels, and a CNA stated she provided a shower alone because the resident was considered a 1‑person assist at that time. During that shower, the resident jerked his legs, went over the gurney rail, and fell, sustaining head injuries and oral bleeding, and was sent to the ER. The DON and Administrator acknowledged that the care plan did not match the MDS and that providing 1‑person assist when 2‑person assist was required would constitute neglect. The facility also failed to conduct thorough investigations into allegations of neglect and possible abuse for other residents. For a resident with multiple comorbidities and impaired mobility who required frequent turning and repositioning and comprehensive skin care, a complaint alleged the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but there was no evidence that staff, the resident, or the complainant were interviewed. The Nurse Manager and DON both stated that policy required thorough investigations with interviews, and the DON admitted she did not interview anyone in this case, relying instead on her own observations of the unit process. For another resident with significant neurologic deficits and dependence for all ADLs, including a 2‑person Hoyer lift, an allegation was made that a “tall man” hurt her, and she was found crying in pain with right wrist pain and blood on her lip. She was sent to the ER, where EMS reported the injury was from staff moving her, and imaging was performed. The facility’s 5‑day report noted that a male CNA was suspended and later terminated, but the investigation was deemed inconclusive based on imaging results and new diagnoses of decreased bone mineralization and osteoarthritis. The investigation lacked interviews with the resident’s family, other residents cared for by the alleged CNA, or the roommate’s family/guardian, despite the resident’s guardian later confirming a prior wrist fracture during a transfer and limited information from the facility. Another resident, non‑verbal with a trach, ventilator, and G‑tube, was completely incontinent and dependent for all ADLs. Nursing notes documented penile edema, with a physician assessment and topical nystatin ordered. The resident’s family later alleged abuse due to the swollen penis, prompting a 5‑day investigation. However, the investigation contained no evidence of interviews with witnesses, staff who provided care, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause of the swelling from her own assessment, despite acknowledging that the abuse policy required interviews during investigations. The facility also failed to fully investigate an altercation between two residents with significant psychiatric and behavioral histories. One resident had schizoaffective disorder, PTSD, a history of physical and verbal aggression, and was on a secured unit with interventions for redirection and behavior management. The other resident had schizoaffective and personality disorders, anxiety, major depressive disorder, and a history of yelling, self‑hitting, delusions, hallucinations, and was on 2:1 for cares due to false accusations and safety concerns. Nursing documentation described an incident where one resident, seated in a wheelchair at a doorway, turned and struck the other resident in the chest with his forearm, and the other resident struck back with a closed fist, with a CNA present who separated them. Although the event was self‑reported as an altercation, the report excerpt does not show that a comprehensive abuse investigation with required interviews and analysis of antecedent behaviors was completed in accordance with facility policy. Across these cases, staff interviews, including those with the DON, MDS/Care Plan Coordinator, Nurse Manager, and Administrator, confirmed that facility policy required thorough abuse/neglect investigations with interviews of involved staff, residents, and others, and that care plans should accurately reflect MDS findings. Nonetheless, the documented investigations for the cited residents lacked required interviews and failed to reconcile assessment data with care plans and actual care practices, leading to the cited deficiency for failure to implement and follow policies and procedures to prevent abuse, neglect, and to conduct complete abuse investigations.
Failure to Thoroughly Investigate Multiple Abuse and Misappropriation Allegations
Penalty
Summary
The deficiency involves the facility’s failure to conduct timely and thorough investigations into multiple allegations of abuse, neglect, and misappropriation, as required by its own abuse policy. For one resident with acute and chronic respiratory failure, Parkinson’s disease, morbid obesity, chronic kidney disease, and other serious comorbidities, a complaint alleged that the resident had not been repositioned and developed blisters in the rectal area. The 5‑day investigation report documented that the allegation was received via voicemail on a weekend and retrieved the following Monday, but did not identify whose voicemail it was. The investigative report contained no evidence that staff, the resident, or the complainant were interviewed about the allegation, despite the DON’s acknowledgment that interviews are always required for a thorough investigation and that the facility policy mandates interviews with involved parties. Another deficiency occurred when a resident with dysphagia, hemiplegia, aphasia, diabetes with neuropathy, and cerebrovascular disease reported right wrist pain and had blood on her lower lip, leading to transfer to the ER for imaging. EMS reported that the injury was from staff moving her, and the resident stated that a “tall guy” hurt her. The facility’s 5‑day report noted that a CNA matching the description was suspended and interviewed, and that imaging results were inconclusive for fracture. However, the investigation did not include interviews with the resident’s family, other residents cared for by the alleged CNA, or the family/guardian of the non‑interviewable roommate, even though the facility’s policy requires interviewing witnesses, roommates, and other residents to whom the accused employee provides care. A further deficiency involved a resident with anoxic brain damage, contractures, dysphagia, and total incontinence who required maximum assistance and frequent turning and repositioning. Nursing notes documented ongoing incontinence and total dependence for ADLs, and later noted penile edema for which a provider ordered topical nystatin. The DON received an allegation from the family that the resident had been abused because his penis was swollen. The 5‑day investigation showed no evidence of interviews with witnesses, staff who cared for the resident, the staff member identified as responsible, other residents cared for by that staff member, or any review of events leading up to the swelling. The DON stated she did not interview staff or residents because she believed she knew the cause after seeing the resident, despite acknowledging that the abuse policy requires interviews during investigations. The facility also failed to thoroughly investigate an allegation of intimidation and inappropriate staff interaction for a resident with sepsis, delirium, and anxiety who required 2:1 care and sometimes yelled out instead of using the call light. The resident reported feeling intimidated by the way staff spoke to him in a loud tone regarding his numerous complaints and stated that two CNAs could no longer care for him as a result. The facility’s investigation included interviews with the RN and two CNAs who denied speaking to the resident about staff being removed from his care or raising their voices. However, there was no evidence that other residents to whom the RN provided care or services were interviewed, contrary to the facility’s policy requiring interviews with other residents cared for by the accused employee. In another case, a resident with stage 4 CKD, dependence on dialysis, anxiety, and diabetic neuropathy reported missing money after multiple hospital transfers. Nursing notes documented that the resident returned from the hospital and reported that $70–$75 and four quarters were missing from a Ross bag left in her room when she went back to the hospital. The initial self‑report described the missing money and the 5‑day investigation concluded that the money may have been misplaced or thrown away with the bag, and documented that the money was replaced. The investigation included interviews with three CNAs, two who worked the day the resident returned and one who worked the day of discharge, but there were no interviews with staff who were on shift or cared for the resident on the earlier dates when she left and returned to the hospital, and no evidence that other residents were interviewed. The administrator later stated that they were unable to locate the investigation or any documents pertaining to the missing money, despite the facility’s abuse policy requiring timely and thorough investigations, written witness reports, and interviews with reporters, witnesses, the resident, roommates, and other residents to whom the accused employee provides care or services.
Failure to Complete and Provide Timely Baseline Care Plans to Residents/Representatives
Penalty
Summary
The deficiency involves the facility’s failure to ensure that baseline care plans were properly completed and provided to residents or their representatives within 48 hours of admission, as required by facility policy. For one resident admitted with acute posthemorrhagic anemia, unsteadiness of feet, difficulty walking, seizures, and COPD, nursing documentation showed the resident was alert, oriented, able to make needs known, and had signed all consents. A baseline care plan was dated the day of admission and listed social services and nutrition as attendees, but did not indicate that the resident or a representative participated in creating the plan. The section for initial goals based on admission orders was not fully marked, and the resident/resident representative signature and date section was left blank. The baseline care plan showed a completion date approximately seven months after admission and was marked as “system completed” without a specific staff member identified, and there was no evidence that a baseline care plan summary was provided to the resident or representative before the resident was later transferred to the hospital. For another resident admitted with acute kidney failure, a left knee contusion, and type 2 diabetes mellitus, admission nursing notes documented that the resident was alert and oriented, arrived via stretcher, had edema of the left upper extremities, a swollen and bruised left knee from a prior fall, MASD with redness to the gluteal cleft, and a Foley catheter in place after a failed voiding trial. The baseline care plan was initiated on the admission date and included significant diagnoses such as fall with left knee contusion, rhabdomyolysis, and dehydration, with a discharge plan to home and initial goals to use a walker and return home. The care plan listed the resident/resident representative, social services, DON, nutrition, and activities as participants and stated that a copy of the initial care plan was provided to the resident/representative that evening. However, the resident/resident representative signature and date section was not signed or dated, the completion date was recorded about six months after admission, and the plan was again documented as “system completed” without a specific staff member identified. A third resident was admitted with acute and chronic respiratory failure with hypoxia, pneumonia due to Pseudomonas, dysphagia, tracheostomy and PEG tube dependence, ventilator dependence, paraplegia, hypothyroidism, seizure disorder, paroxysmal atrial fibrillation, generalized anxiety disorder, polyneuropathy, GERD, delayed physiological development, schizophrenia, and a history of COVID-19. The baseline care plan was initiated on the admission date and listed significant diagnoses including respiratory failure, PEG and trach with ventilator use, developmental delay, schizophrenia, seizure disorder, and quadriplegia. Care plan participants were documented as the resident/resident representative, social services, and an RN, and the record stated that the facility spoke with the public fiduciary and faxed consents, with a discharge plan to remain in the facility and possible future discharge to a group home. The resident’s initial goals included PT/OT and transition to self-independence, and documentation noted the resident was alert and oriented x1, had a pressure call light, and that a copy of the initial care plan was provided to the resident/representative. However, the resident/resident representative signature and date section was not signed, there was no evidence that a copy of the baseline care plan was provided to the public fiduciary, and the baseline care plan completion date was recorded about six months after admission and marked as “system completed.” Interviews with nursing leadership and an LPN described the intended process for admission assessments and baseline care planning, including that baseline care plans should be completed within 48 hours and that residents or representatives should be offered copies, but the DON later confirmed that there was no documentation that the residents or their representatives for these three cases received copies of the baseline care plans. Review of the facility’s care plan policy showed that an individualized, comprehensive, person-centered care plan with measurable objectives and timetables is to be developed for each resident, that residents are to be informed of their rights to participate in treatment and given advance notice of care planning conferences, and that if resident or representative participation is not practicable, an explanation of the steps taken to include them must be documented in the medical record. In the three sampled cases, the records did not document resident or representative signatures on the baseline care plans, did not show timely completion dates consistent with the 48-hour requirement, and did not contain explanations when participation or provision of copies to representatives (such as the public fiduciary) did not occur. These documented omissions and inconsistencies in the baseline care plan process formed the basis of the cited deficiency.
Failure to Post Enhanced Barrier Precaution Signage for Residents Requiring EBP
Penalty
Summary
The deficiency involves the facility’s failure to implement its infection prevention and control program related to Enhanced Barrier Precautions (EBP) for multiple residents who required such precautions. For one resident with MRSA infection, rash, zoster, a breast wound, and a PICC line, the clinical record and facesheet indicated the resident was on EBP due to PICC, wounds, and recent MDRO infections. However, surveyor observations on two separate days showed there was no EBP sign posted outside the resident’s room and no instructions regarding what PPE to wear when providing care. Another resident with open wounds to both lower legs and a diagnosis of MRSA infection was documented as being on EBP for open wounds. The admission MDS showed the resident was cognitively intact and had an infection of the foot, and skilled observation notes confirmed open wounds and MRSA as the cause of disease. Despite this, an observation found no EBP signage outside the room and no posted PPE instructions. A third resident, admitted with type 2 diabetes with neuropathy, cystectomy, neurogenic bladder, obstructive uropathy, and an ostomy, was documented as being on EBP for a urostomy, yet an observation also revealed no EBP sign or PPE instructions posted outside that resident’s room. Multiple staff interviews confirmed that EBP signs are the facility’s method to alert staff and visitors when enhanced barrier precautions are required for residents with open wounds, catheters, IVs, MDROs, and similar conditions. The wound nurse, RT, RN, LPN, and DON each stated that EBP status is communicated via signage on the resident’s door and that such signs inform staff and visitors about when to wear PPE and how to prevent infection spread. The facility’s written policy on isolation and transmission-based precautions states that signs are used to alert staff of contact precautions and that the facility will implement a system to alert staff to the type of precautions required, specifically including a sign posted on the resident’s room/door instructing to see the nurse before entering. Despite these policies and staff expectations, the required EBP signage was not posted for the three residents identified as being on EBP.
Failure to Maintain Safe, Homelike Environment on Secured Unit
Penalty
Summary
The deficiency involves the facility’s failure to maintain a safe, clean, comfortable, and homelike environment, particularly on the 200‑hall secured unit and its dining/communal area. One cognitively intact resident, admitted with anemia, hypertension, diabetes mellitus, and depression, reported that while minor chipping baseboard in her own room was not an issue, she disliked the appearance of the baseboards in the hall and felt it did not make the environment feel homey. Surveyors observed missing and damaged baseboards immediately past the entrance doors of the 200‑hall, with approximately 2.5 feet of 4‑inch baseboard missing on the right side and 1.5 feet missing on the left side, and a section of baseboard bent forward about an inch into the hallway. A review of work orders from January through March 26, 2026, showed only 16 work orders for the facility and no work orders addressing the missing or damaged baseboards or the hole in the wall on the 200‑hall. Further observations in the 200‑hall dining/communal area revealed a visible hole in the wall near the nurse’s station, measuring about 3 inches by 2.5 inches, partially covered by a plain beige outlet plate that was broken in half, leaving jagged edges at the bottom. No visible wiring was present, but the broken plate and exposed hole remained unrepaired. Staff interviews confirmed awareness of the importance of a homelike environment, including the condition of walls, floors, ceilings, and furnishings. One LPN stated that cracks in walls and floors could be safety issues requiring immediate repair and that peeling baseboards might involve chemical adhesives that could be toxic. A CNA and another LPN both stated that missing or peeling baseboards did not look good and could make residents feel the building was not being taken care of, and the LPN acknowledged that staff could report issues to maintenance but was unaware of any current work on the 200‑hall until the hole was pointed out, at which time she described the broken, jagged plate and hole. The Maintenance Director reported that the department generally receives more than 20 work orders daily and prioritizes those with potential resident safety concerns, stating that renovations on the 200‑hall had begun about six months earlier and were still in progress. He acknowledged awareness of the missing baseboards and the partial plate cover over the hole by the nurse’s station, stated that the hole issue had been verbally reported to him on March 15, 2026, and agreed it should have been fixed by the time of the survey. He characterized the broken plate and hole as a high‑priority issue, especially because the 200‑hall is a lock‑down unit, and stated that the current condition of the 200‑hall did not constitute a homelike environment. The Administrator stated that a homelike environment includes residents feeling comfortable, having their belongings and privacy, and that holes in walls are supposed to be fixed as soon as maintenance is made aware, but noted challenges with staff not submitting written work orders. The facility’s policy on “Quality of Life‑Homelike Environment” emphasized providing residents with a safe, clean, comfortable homelike environment, which was not met in this instance.
Failure to Update Care Plan for Two-Person Bathing Assist Leading to Resident Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident’s care plan was revised to reflect an assessed need for a two-person assist with bathing. The resident was admitted with significant medical conditions, including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, and Crohn’s disease. An admission MDS documented total dependence for bathing with a one-person physical assist, and the initial care plan indicated total assistance for all ADLs, including bathing, but did not specify the number of staff required for bathing assistance. Subsequent MDS assessments dated in June and September 2023 documented that the resident remained totally dependent for bathing and now required a two-person physical assist. Monthly Summary forms showed inconsistent documentation, with one form indicating a one-person assist and later forms indicating two or more persons for bathing assistance. Despite these assessments and summaries identifying the need for increased assistance, there was no corresponding update in the comprehensive care plan to specify a two-person assist for bathing during this period. On a date in late November 2023, a CNA provided bathing care to the resident alone, consistent with the existing care plan that did not specify a two-person assist. During this shower, the resident became restless, pushed the rail on the gurney when the CNA turned away, and fell from the gurney, sustaining an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin. The resident was sent to the emergency room for evaluation. Interviews with the MDS/Care Plan Coordinator and the DON confirmed that the MDS assessments had identified the need for a two-person assist with bathing, but the care plan had not been revised to reflect this need prior to the incident, and that the CNA involved was following the existing care plan at the time of the fall.
Failure to Provide Required Two-Person Assist During Shower Resulting in Resident Fall and Head Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from avoidable accidents by not providing the level of assistance with bathing that had been identified in assessments, and by not maintaining adequate supervision during a shower. The resident had significant medical conditions including persistent vegetative state, chronic respiratory failure with hypoxia, traumatic subarachnoid hemorrhage, Crohn’s disease, encephalopathy, schizoaffective disorder, and a history of subdural hemorrhage. Multiple assessments and summaries documented that the resident was totally dependent for bathing and, over time, required increasing levels of physical assistance. Early documentation showed a need for total assistance with bathing with one-person physical assist, but subsequent MDS assessments indicated the resident required two-person physical assist for bathing and had a history of falls, including falls with injury. The resident’s care plan documented total assistance needs for all ADLs, including bathing, and identified the resident as at risk for falls related to weakness, with interventions such as frequent checks while in bed and supervision when out of bed. Later, the care plan also identified a behavioral symptom of placing self on the floor, with interventions to assess whether the behavior endangered the resident, maintain a calm environment, redirect as necessary, and notify the provider if behaviors interfered with care. Despite MDS assessments dated in June and September indicating that the resident was totally dependent and required two-person assist for bathing, the care plan was not updated to reflect a two-person assist requirement for bathing prior to December. Monthly summaries in August, October, and November continued to document total dependence for bathing, with the level of assist noted as one-person in August and two or more persons in October and November, but this did not translate into a clearly updated care plan directive for two-person assist with bathing before the incident. On the date of the incident, a CNA took the resident to the shower room on a gurney and provided bathing assistance alone, believing the resident to be a one-person assist based on the absence of a green sticker indicating two-person assist. During or immediately after the shower, the resident became restless, jerked, and crossed his legs over the gurney rail, resulting in a fall from the gurney. The resident sustained an abrasion to the left side of the head, a hematoma on the right side of the head, and bleeding in the mouth of undetermined origin, and was transferred to the hospital where surgery for a brain bleed was later documented. Interviews with the DON and Administrator confirmed that MDS assessments had identified the resident as requiring two-person support for bathing at the time of the incident, that the care plan did not reflect this requirement prior to December, and that only one CNA was assisting the resident in the shower when the fall occurred. Staff interviews, including CNAs and an LPN, characterized providing one-person assist to a resident assessed as needing two-person assist, resulting in a fall, as neglect and acknowledged that failure to update and follow the care plan could lead to resident injury.
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