Arizona State Veteran Home-phx
Inspection history, citations, penalties and survey trends for this long-term care facility in Phoenix, Arizona.
- Location
- 4141 North S Herrera Way, Phoenix, Arizona 85012
- CMS Provider Number
- 035234
- Inspections on file
- 33
- Latest survey
- December 9, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Arizona State Veteran Home-phx during CMS and state inspections, most recent first.
A resident with cognitive impairment and behavioral disturbances was subjected to physical abuse by another resident with a known history of disruptive behaviors. The incident occurred in a common area when one resident, aggravated by the other's vocalizations, physically grabbed and moved the other resident's head. Staff intervened and separated the residents, but the event highlighted a failure to prevent abuse despite existing care plans and supervision.
The facility did not submit required PBJ staffing data to CMS for one quarter due to the absence of a staffing coordinator and lack of clarity regarding responsibility for the submission. Interviews confirmed that key staff were either unfamiliar with the process or not available, and the prior leadership was aware of the missed submission.
The facility did not ensure accurate and complete documentation of resident weights, resulting in significant discrepancies and a lack of follow-up on abnormal findings. Staff used inconsistent methods for obtaining weights, particularly with Hoyer lifts, and there was insufficient training and unclear procedures, leading to inaccurate records and a failure to notify the physician or address potential errors.
A resident with multiple mental health diagnoses, including major depressive disorder, was admitted without all conditions being accurately reflected on the PASARR Level I screening. The assessment omitted the major depressive disorder diagnosis, leading to a lack of referral for further evaluation, despite facility policy and staff expectations that all mental health diagnoses be included.
A resident with multiple psychiatric diagnoses was receiving antidepressant medication, and the consultant pharmacist recommended discontinuing one medication due to the resident's weight and BMI, suggesting an alternative. The attending physician did not document review or response to this recommendation, and the psychiatric nurse practitioner also did not address it in her notes. Facility policy requires timely review and documentation of pharmacy recommendations, but no evidence was found that this process was followed for the resident.
A resident with multiple medical conditions and intact cognition was found with a fractured finger of unknown origin. Although the incident was reported to authorities, the facility did not follow its abuse investigation policy, as required interviews with staff, family, visitors, and others were not conducted or documented, resulting in an incomplete investigation.
A resident with multiple medical conditions and intact cognition reported unexplained pain in a finger, which was found to be fractured. The facility reported the incident but did not conduct a thorough investigation as required by policy, failing to obtain written statements from staff, family, or others who may have had relevant information. Staff interviews confirmed that the expected investigative process was not followed, resulting in an incomplete investigation.
The facility did not conduct thorough investigations into allegations of abuse, neglect, or misappropriation of property, as evidenced by missing interviews with residents, staff, and witnesses, incomplete documentation, and lack of follow-up on reported incidents such as injuries, missing items, and abuse allegations. Investigative reports often lacked key details, and staff were uncertain about investigation procedures and record retention.
A resident with a history of cognitive impairment and physical ability to leave the facility eloped multiple times, despite initial assessments indicating no elopement risk. Care plans and risk assessments did not consistently address the resident's potential for wandering, and staff interviews revealed inconsistent understanding and implementation of elopement prevention protocols. The resident was able to leave the premises unsupervised on more than one occasion, demonstrating a failure in adequate supervision and hazard prevention.
A resident with dementia and a cognitive communication deficit, who was care planned for elopement risk and required a Wander-guard with hourly checks, was able to leave the facility unsupervised in a wheelchair. The resident was found by a staff member at a nearby intersection after leaving to buy a drink, and was returned to the facility. Staff interviews revealed that the security guard responsible for monitoring did not know the resident's restrictions or how to use the video cameras, and required checks of the independent travel book were not performed.
A resident with multiple medical conditions experienced a Fentanyl overdose after staff failed to remove a previous Fentanyl patch before applying a new one, did not notify supervisors or the physician when the patch was missing, and did not follow facility protocols for patch application and disposal. The resident was found unresponsive, required hospitalization, and was diagnosed with Fentanyl overdose and related complications.
Two residents with cognitive and behavioral health issues engaged in a physical altercation that was initially unwitnessed by staff, resulting in a deficiency for failing to protect residents from abuse. Staff and camera footage confirmed the incident, and both residents had documented behavioral symptoms prior to the event.
A resident with multiple sclerosis and identified as a fall risk experienced a fall resulting in a fracture due to the facility's failure to implement the prescribed care plan. The care plan included maintaining the bed in a low position and placing a floor mat, but these interventions were not followed, as observed during a facility visit. Interviews with CNAs revealed a lack of awareness of the care plan requirements, and facility staff confirmed the resident's fall risk status and the importance of the preventive measures.
A resident with hypertension was administered Amlodipine outside the prescribed parameters, as the medication was given despite the diastolic blood pressure being below the threshold. This was confirmed by an LPN and the ADON, who acknowledged the risk of the resident's blood pressure dropping too low. The facility's policy requires adherence to prescriber orders, which was not followed.
A deficiency was identified when two residents with cognitive impairments and behavioral issues were involved in an altercation in the dining room, with one resident allegedly hitting the other. The incident occurred due to a lack of supervision, as no staff were present to monitor the residents during meal time, despite facility policy requiring such oversight. The Director of Nursing confirmed the absence of staff and acknowledged the need for targeted interventions to reduce risks.
A resident with Alzheimer's disease engaged in inappropriate behavior by using racial slurs towards another resident with quadriplegia, despite existing interventions to manage such behaviors. The incident was confirmed through staff and resident interviews, highlighting a failure to uphold the facility's policy on resident dignity and respect.
A resident with cognitive deficits reported being accosted by two staff members, but the facility failed to conduct a thorough investigation. The investigation lacked staff and resident interviews, and there was no evidence of a complete investigation as required by the facility's policy.
A facility failed to ensure a resident's right to independent travel by enforcing a policy requiring a 24-hour advance notice and physician's order. The cognitively intact resident felt restricted and degraded, and staff interviews confirmed the policy's enforcement despite its perceived excessiveness and disagreement from the resident's physician.
The facility failed to ensure residents' rights to independent travel, requiring a 24-hour advance notice and physician's order, leading to feelings of restriction and embarrassment among residents with functional quadriplegia, generalized anxiety disorder, and major depressive disorder.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
A deficiency occurred when a resident with dementia and behavioral disturbances was not protected from physical abuse by another resident with a history of socially inappropriate and disruptive behaviors. The incident took place in a common area, where one resident, aggravated by the other's habit of counting out loud, approached from behind and placed his hands over the other resident's ears, moving the resident's head side to side. This event was witnessed by a CNA, who intervened and separated the residents. No injuries were observed, but the resident who was subjected to the physical contact was unable to defend himself due to cognitive impairment. The resident who initiated the contact had a documented history of behavioral symptoms requiring continuous supervision and interventions such as redirection. Despite these known risks, the resident was able to approach and physically interact with another resident in a manner that constituted abuse. The care plans for both residents acknowledged their cognitive and behavioral challenges, but the measures in place did not prevent the altercation from occurring. Staff interviews confirmed that the incident was reported to supervisory staff and documented in the clinical records. The facility's policy states that residents have the right to be free from abuse, and the administrator acknowledged that the event constituted physical abuse. The report details the sequence of events and the failure to prevent resident-to-resident abuse, as well as the facility's recognition of the incident as a violation of resident rights.
Failure to Submit Required PBJ Staffing Data to CMS
Penalty
Summary
The facility failed to submit the required direct care staffing information and CASPER Payroll-Based Journal (PBJ) data to CMS for one quarter, specifically for fiscal year quarter four (July 1 - September 30) 2024. This deficiency was identified through a review of the facility's PBJ Staffing Data Report, which showed missing data for the specified quarter. Attempts to interview the staffing coordinator responsible for PBJ data submission were unsuccessful, as the individual was not available. Further interviews revealed that the previous staffing coordinator, who was responsible for submitting PBJ data, was no longer employed at the facility, and the new staffing coordinator had not yet assumed these responsibilities. The Assistant Director of Nursing (ADON) was not familiar with the PBJ data submission process, and the Regional Compliance Director of Nursing confirmed that there was currently no staffing coordinator in place. It was acknowledged by staff that the prior Administrator and DON were aware of the missed submission, but the reason for the failure was not provided.
Failure to Ensure Accurate and Complete Weight Documentation
Penalty
Summary
The facility failed to ensure that the medical record, specifically the documentation of resident weights, was complete and accurate for two residents. For one resident with diagnoses including cirrhosis of the liver, major depressive disorder, and enterocolitis due to clostridium difficile, there were significant discrepancies in the recorded weights over several months. The Minimum Data Set (MDS) did not indicate any weight gain or loss, but the documented weights varied widely, with one notably low weight not addressed or explained in the medical record. There was no evidence in the progress notes that staff acknowledged or investigated the low weight, nor was there documentation of staff notifying the physician or dietician of this abnormal finding as required by the care plan and physician orders. Interviews with staff revealed inconsistent practices and a lack of standardized procedures for obtaining and recording weights, particularly when using a Hoyer lift with a scale. Certified Nursing Assistants (CNAs) and Restorative Nursing Assistants (RNAs) reported varying methods, such as subtracting an estimated weight for the sling, which was not supported by facility policy. Staff also indicated insufficient training on proper weighing techniques, and some expressed concern that many staff did not know the correct procedures, potentially leading to inaccurate documentation. The Diet Technician and Nurse Supervisor both stated that re-weighs should be performed if a weight appears abnormal, but there was no clear timeframe or documentation of this process being followed in the case reviewed. Facility policy required significant weight changes to be reported to the nurse supervisor and outlined procedures for weighing residents using various types of scales, but did not address the use of a Hoyer lift with a scale. The Director of Nursing (DON) and Assistant DON acknowledged that the low weight recorded was likely an error but could not find any documentation that it was addressed or confirmed as inaccurate. The attending physician was not notified of the abnormal weight and stated that such discrepancies could affect resident care, especially for those with conditions requiring close weight monitoring.
Incomplete PASARR Assessment for Mental Health Diagnoses
Penalty
Summary
The facility failed to ensure that a resident's Preadmission Screening and Resident Review (PASARR) was completed accurately and that all relevant mental health diagnoses were included. The resident was admitted with diagnoses including diffuse traumatic brain injury, bipolar disorder, and major depressive disorder. Documentation review showed that the PASARR Level I screening did not reflect the resident's diagnosis of major depressive disorder, despite this diagnosis being present in the medical record and care plan. The PASARR indicated that a referral for a Level II evaluation was not necessary, based on incomplete information. Interviews with facility staff, including a medical social worker and the Director of Nursing, confirmed that the PASARR assessment did not accurately list all of the resident's mental health diagnoses. The facility's policy required that all mental health-related diagnoses be reflected in the PASARR assessment and that individuals meeting criteria for a mental disorder be referred for further evaluation. The omission of the major depressive disorder diagnosis on the PASARR resulted in the resident not being properly evaluated for specialized services.
Failure to Address Pharmacy Medication Recommendations
Penalty
Summary
The facility failed to ensure that pharmacy recommendations for a resident were reviewed and addressed by the attending physician, as required by facility policy. The resident in question had multiple psychiatric diagnoses, including dementia with agitation, depression, and schizophrenia, and was receiving antidepressant medication as part of his care plan. The consultant pharmacist conducted a monthly medication regimen review and recommended discontinuing the resident's mirtazapine due to the resident's weight and BMI, suggesting an alternative antidepressant. This recommendation was documented and a note was written to the physician. However, there was no evidence in the clinical record that the attending physician had reviewed or acknowledged the pharmacist's recommendation. The physician stated during interview that he typically reviews pharmacy recommendations every one or two weeks and responds by marking agree or disagree on the form, which is then uploaded to the medical record. In this case, the physician was unsure if the recommendation had been addressed and could not confirm whether he had seen it. The psychiatric nurse practitioner also did not document any review or consideration of the pharmacist's recommendation in her progress notes. Facility policy requires that within twenty-four hours of the medication regimen review, the consultant pharmacist provides a written report to the attending physician, who must document in the medical record that the irregularity was reviewed and what action, if any, was taken. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that the process involves placing pharmacy recommendations in the provider's folder for review and response, but upon review, they could not locate any documentation that the recommendation for this resident had been addressed. This resulted in a failure to ensure that medication irregularities identified by the pharmacist were reviewed and acted upon by the physician.
Failure to Adhere to Abuse Investigation Policy After Injury of Unknown Origin
Penalty
Summary
The facility failed to adhere to its abuse policy following an incident involving an injury of unknown origin for one resident. The resident, who had multiple diagnoses including type 2 diabetes, PTSD, and depression, was found to have a red, swollen, and painful pinky finger, which was later confirmed by x-ray to be a nondisplaced fracture. The resident was cognitively intact and did not recall any fall or incident that could have caused the injury. The facility reported the incident to the appropriate authorities and documented the event, but the internal investigation was unsubstantiated due to the resident's underlying bone conditions. Despite the reporting, the facility's investigation did not include interviews with staff, family, visitors, other departments, or other residents, as required by the facility's abuse policy. Interviews with facility staff, including the RN, CNA, DON, ADON, and Administrator, revealed that the expected process for investigating injuries of unknown origin included interviewing all relevant parties and obtaining written, signed statements. However, in this case, these steps were not followed, and the investigation documentation lacked evidence of comprehensive interviews. The facility's policy clearly stated that all allegations of abuse, including injuries of unknown origin, must be thoroughly investigated with interviews of all potential witnesses and involved parties, and that these interviews should be documented in writing. The failure to conduct and document these interviews represented a deviation from the established policy and resulted in an incomplete investigation of the incident.
Failure to Thoroughly Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an incident involving an injury of unknown origin for one of three sampled residents. The resident, who had a history of multiple medical conditions including type 2 diabetes, depression, and osteopenia, reported pain in the left pinky finger, which was found to be red, swollen, and fractured upon x-ray. The resident was cognitively intact and did not recall any fall or incident that could have caused the injury. The facility reported the incident to the appropriate authorities and documented the resident's statement, but the investigation was deemed unsubstantiated based on the x-ray findings and the resident's lack of recollection. Despite the facility's policy requiring a thorough investigation—including interviews with the person reporting the incident, witnesses, the resident or representative, staff members in contact with the resident, the resident's roommate, family members, and visitors—there was no evidence that such comprehensive interviews were conducted. The investigation documentation lacked statements from staff, family, visitors, other departments, or other residents who may have had relevant information about the incident. Interviews with facility staff, including the DON, ADON, and Administrator, confirmed that the expected process would involve obtaining written, signed, and dated statements from all potentially involved parties, but this was not done in this case. The deficiency was further highlighted by staff interviews, which revealed an understanding of the required investigative process, yet the actual investigation for this incident did not follow those protocols. The Administrator acknowledged that interviews were not conducted because the resident denied issues with staff, but also stated that interviews are required during such investigations. The facility's failure to follow its own policy and thoroughly investigate the injury of unknown origin resulted in an incomplete investigation for the resident.
Failure to Thoroughly Investigate Allegations of Abuse, Neglect, and Misappropriation
Penalty
Summary
The facility failed to ensure that allegations of abuse, neglect, and misappropriation of resident property were thoroughly investigated for multiple residents. In several cases, when residents or their families reported abuse, missing property, or injuries, the facility's investigative reports lacked critical components such as interviews with the alleged victims, potential perpetrators, or witnesses. For example, in one instance, a resident alleged that a male CNA threw him down the hall, but the investigation did not include interviews with the resident or the staff member in question, nor did it document a skin assessment following the allegation. Similarly, another resident reported missing clothing and rings, but there was no evidence that housekeeping staff were interviewed or that a thorough search was conducted. In other cases, residents reported abuse or injury during care or transportation, but the facility's investigations were incomplete. For example, a resident alleged rough handling by a CNA resulting in a skin injury, but the investigation did not include resident interviews or skin assessments. In several incidents involving transportation accidents or injuries, the facility failed to conduct or document interviews with the residents or staff involved, and there was no conclusive documentation of the investigation's findings. Additionally, reports of missing money and jewelry were not supported by documented investigations or interviews, and the facility was unable to provide records of grievances or investigations when requested. The facility's policies required that grievances and complaints be reviewed and investigated, with written reports maintained, but the documentation provided did not demonstrate compliance with these requirements. Staff interviews revealed uncertainty about the process for investigating and documenting allegations, as well as the retention of investigation records. The lack of thorough investigations and documentation could result in violations against residents not being identified or addressed appropriately.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Risk Assessment
Penalty
Summary
The facility failed to ensure that a resident was free from elopement, resulting in multiple incidents where the resident left the premises without authorization. The resident, who had diagnoses including hemiplegia, vascular dementia, psychotic disturbance, mood disturbance, anxiety, and major depressive disorder, was initially assessed as not being at risk for elopement or wandering. However, documentation and staff interviews revealed that the resident was physically able to leave the building independently, and there were previous unsuccessful attempts to elope prior to the documented incidents. Despite the resident's complex medical and cognitive history, care plans and risk assessments did not consistently identify or address the resident's potential for elopement. The resident was able to leave the facility on at least two occasions, once being found by his wife and another time by the director of rehab, both times outside the facility premises in his electric wheelchair. Staff interviews confirmed that the resident was not approved for independent travel and had not signed out, which was required for residents who were not independent travelers. The facility's process for monitoring and preventing elopement, including the use of wander guards and regular checks, was not effectively implemented or updated in response to the resident's changing behaviors and history of elopement. The deficiency was further evidenced by inconsistent documentation in care plans and risk assessments, as well as varying staff understanding of elopement protocols. Staff interviews indicated that while some interventions such as wander guards and increased monitoring were in place, these measures were not sufficient to prevent the resident from leaving the facility unsupervised. The facility's policy required monitoring and precautions for residents at risk of wandering or elopement, but these were not adequately followed, resulting in repeated incidents of elopement for this resident.
Failure to Prevent Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident with diagnoses including Parkinson's disease, unspecified dementia, and a cognitive communication deficit. The resident was assessed as rarely understood and had a care plan in place due to demonstrated unsafe travel outside the facility without authorization. Interventions included the application of a Wander-guard and hourly checks, as well as orders for staff to verify the Wander-guard was in place and to perform alert charting for elopement risk every shift. Despite these interventions, the resident was able to leave the facility unaccompanied and was observed by the Social Services Manager at a nearby intersection, propelling himself in a wheelchair toward a gas station to buy a drink. The resident was last seen by staff at 1:30 p.m. and was returned to the facility at 1:40 p.m. after being assisted by staff. Interviews revealed that the security guard, responsible for monitoring residents on the front patio and using video cameras, was not aware that the resident was not permitted to leave alone and did not know how to operate the video monitoring system. The DON stated that the expectation was for the receptionist and guard to check the independent travel book to verify if a resident could leave independently, but this was not done. The facility's policy required monitoring and precautions for residents at risk of wandering or elopement, but these measures were not effectively implemented, resulting in the resident's unsupervised departure from the facility.
Failure to Prevent Significant Medication Error Resulting in Fentanyl Overdose
Penalty
Summary
A resident with diagnoses including acute on chronic right heart failure, urinary tract infection, and Parkinson's disease was prescribed a Fentanyl transdermal patch to be applied every 72 hours, with specific instructions to remove the old patch before applying a new one. The care plan to monitor for adverse reactions related to Fentanyl usage was not initiated until after the incident, and prior documentation did not indicate any focus on monitoring the resident's Fentanyl use or risk for adverse reactions. Medication administration records showed that patches were applied and removed on alternating sides of the chest, but on one occasion, the nurse could not locate the previous patch and applied a new one without notifying a supervisor or the physician, as required by facility protocol. Subsequently, the resident was found to be lethargic, difficult to arouse, and had missed both breakfast and lunch. Upon assessment, the resident exhibited low blood pressure, decreased oxygen saturation, and altered mental status. The resident was sent to the hospital, where it was discovered that two Fentanyl patches were present on his body, leading to a diagnosis of Fentanyl overdose, hypoxia, and acute kidney injury. The resident required treatment in the ICU, including a Narcan drip. Interviews with nursing staff and the Assistant Director of Nursing revealed that facility procedures required two nurses to be present for both application and disposal of Fentanyl patches, and that any missing patch should prompt a full-body check and physician notification. However, these procedures were not followed: the nurse did not notify the supervisor or physician when the patch was missing, and an extra patch was later found and removed without reporting. Additionally, patches were not always placed according to the provider's specified locations. Facility policy required medications to be administered safely and as prescribed, but these protocols were not adhered to in this case.
Failure to Prevent Resident-to-Resident Physical Altercation
Penalty
Summary
The facility failed to protect two residents from abuse, specifically resident-to-resident physical altercations. One resident with a history of neurocognitive disorder, encephalopathy, and PTSD, and another resident with major depressive disorder and dementia, were involved in a physical altercation. Both residents had documented behavioral symptoms, with one resident noted for occasional aggression and recent sexually inappropriate behaviors, and the other for disruptive behavior evidenced by the altercation. On the day of the incident, the two residents were observed sitting next to each other when they raised their fists and engaged in a physical struggle. The initial contact was unwitnessed by staff, but a CNA intervened after seeing the residents with raised fists. Interviews with staff revealed that one resident had been exhibiting increased behavioral issues, including aggression and sundowning behaviors, while the other had no prior history of aggression. The altercation was later confirmed by both residents, each claiming the other initiated the contact. Skin assessments found no injuries, and both residents did not recall the incident the following day. Review of camera footage showed one resident maneuvering his wheelchair close to the other, after which both raised their arms and engaged in a brief physical struggle before being separated by staff. The facility's policy states that residents have the right to be free from all forms of abuse, including physical abuse. The failure to prevent and adequately supervise to avoid resident-to-resident physical altercations constituted a deficiency in protecting residents from abuse.
Failure to Implement Fall Prevention Care Plan
Penalty
Summary
The facility failed to implement a comprehensive care plan for fall prevention for a resident diagnosed with multiple sclerosis and other conditions, who was identified as a fall risk. The resident required extensive assistance for bed mobility and transfers due to lower extremity impairment. Despite these needs, the care plan was not properly executed, as evidenced by an incident where the resident was found on the floor after attempting to reposition himself in bed, resulting in a non-displaced fracture of the right posterior acetabulum. The care plan for the resident included specific interventions such as maintaining the bed in a low position, placing a floor mat on the right side of the bed, and ensuring the call light was within reach. However, during an observation, the resident was found in bed with the bed in a high position and the floor mat not in place, indicating a failure to follow the prescribed interventions. Interviews with CNAs revealed a lack of awareness and adherence to the care plan, as they were unaware of the requirement to lower the bed and place the floor mat. Further interviews with facility staff, including a registered nurse supervisor and the Director of Nursing, confirmed that the resident was identified as a fall risk and that preventive measures were in place. However, the failure to implement these measures as outlined in the care plan posed a risk of injury to the resident. The facility's policy on care plans and fall risk management emphasized the importance of identifying and implementing interventions to prevent falls, but these were not effectively executed in this case.
Failure to Administer Blood Pressure Medication Within Prescribed Parameters
Penalty
Summary
The facility failed to ensure that an order for blood pressure medication was administered within the prescribed parameters for a resident. The resident, who was admitted with diagnoses including generalized body pain, osteoarthritis, and essential hypertension, had a care plan indicating the need for pain monitoring and management, as well as a risk for complications related to hypertension. The medication order for Amlodipine 2.5 mg was to be administered every 12 hours for hypertension, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 or the diastolic blood pressure (DBP) was less than 70. However, the medication administration records for September and October 2024 showed that the medication was administered on several occasions when the resident's DBP was below the prescribed threshold of 70. Interviews with a licensed practical nurse and the Assistant Director of Nursing confirmed that the medication was given outside of the specified parameters, which could result in the resident's blood pressure dropping too low. The facility's policy on medication orders and administration emphasizes adherence to prescriber orders, including any required time frames, which was not followed in this instance.
Inadequate Supervision Leads to Resident Altercation
Penalty
Summary
The facility failed to provide adequate supervision to prevent an altercation between two residents, resulting in a deficiency. Resident #12, who has a moderate cognitive impairment and various mood disorders, was involved in an incident with Resident #55, who has severe cognitive impairment and a history of disruptive behaviors. On the day of the incident, a recreational therapist found the two residents shouting at each other in the dining room, with Resident #55 allegedly hitting Resident #12. The care plan for Resident #12 included monitoring for mood or behavior changes, while Resident #55's care plan noted a need for continuous supervision due to a history of socially inappropriate behaviors. The incident occurred when the recreational therapist briefly left the dining room, and upon returning, found the two residents in an altercation. Resident #55 was seen grabbing Resident #12's arm, but no injuries were reported. The facility's policy requires staff to monitor residents, especially those with dementia and behavioral issues, during meal times. However, at the time of the incident, there was no staff present in the dining room to supervise the residents, as confirmed by the Director of Nursing who reviewed the surveillance tape. Interviews with facility staff revealed that the dining room was supposed to be monitored, particularly on the unit where the incident occurred, due to the residents' cognitive impairments and behavioral issues. The Director of Nursing acknowledged the lack of supervision and noted that the unit had been opened to create more space, which may have contributed to the oversight. The facility's policy emphasizes the importance of targeted interventions to reduce risks related to environmental hazards, including adequate supervision, which was not adhered to in this case.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident was treated with dignity and respect by another resident, which could impact the emotional and psychological well-being of the affected resident. Resident #7, who is cognitively intact and has diagnoses including quadriplegia, chronic kidney disease, and Type II Diabetes, reported being verbally disrespected by Resident #25. Resident #25, who has Alzheimer's disease and unspecified dementia with behavioral disturbances, was documented to have engaged in socially inappropriate and disruptive behaviors, including verbal altercations with staff and peers. On April 6, 2024, Resident #25 yelled racial slurs at Resident #7, calling him derogatory names. Despite interventions in place to manage Resident #25's behavior, such as redirection and separation when agitated, the altercation occurred, and Resident #25 continued to use disrespectful language. Interviews with staff and residents confirmed the occurrence of these incidents, with Resident #7 expressing that the remarks were upsetting and derogatory. The facility's policy on Residents Rights emphasizes the right to be treated with respect and dignity, which was not upheld in this situation.
Incomplete Investigation of Abuse Allegation
Penalty
Summary
The facility failed to conduct a thorough investigation into an allegation of sexual abuse involving a resident who reported being accosted by two staff members. The resident, who had a history of cerebral infarction and slight cognitive deficits, alleged that the staff were verbally aggressive and physically invasive. The incident was reported to various authorities, including the local police and Adult Protective Services, but the facility's investigation lacked essential components such as staff interviews, interviews with other residents, and witness statements. The facility's policy requires comprehensive documentation and interviews with all relevant parties, but these steps were not completed. The Social Services Supervisor acknowledged that the investigation should have included interviews with other residents and staff, but there was no evidence that these were conducted. The absence of a thorough investigation was noted, and the facility's documentation did not provide evidence of a complete investigation into the allegations.
Facility Restricts Resident's Independent Travel Rights
Penalty
Summary
The facility failed to ensure that a resident was free to exercise his rights regarding independent travel. Resident #35, who is cognitively intact with a BIMS score of 13, reported feeling restricted and degraded by the facility's policy requiring a 24-hour advance notice and a physician's order for independent travel. This policy was implemented during the COVID-19 pandemic and has continued, despite the resident's grievances and repeated discussions in Resident Council meetings. The resident expressed that the policy made him feel belittled and restricted his rights, as he was unable to leave the facility freely without following the cumbersome process. Interviews with staff members, including LPNs, RNs, the DON, and the Administrator, confirmed the existence of the policy and its enforcement. Staff members acknowledged that the process might be excessive for residents who simply want to go out for short trips. The DON and Administrator stated that the policy was in place for the residents' protection and to ensure their safety, but they also admitted that the policy was enforced by corporate directives. The staff also indicated that the policy required residents to fill out a request form and obtain a physician's approval for each instance of independent travel, even if the resident had previously been deemed appropriate for independent travel. The resident's physician also expressed disagreement with the policy, stating that it was unnecessary and restrictive. The physician emphasized that residents who had already been deemed appropriate for independent travel should not need to request permission each time they wanted to leave the facility. The facility's policy on resident rights, revised in August 2021, stated that residents should be treated with respect and dignity and should be able to exercise their rights without interference. However, the policy requiring advance notice and physician approval for independent travel was seen as a violation of these rights by both the resident and some staff members.
Facility's Restrictive Travel Policy Violates Resident Rights
Penalty
Summary
The facility failed to ensure that three residents were free to exercise their rights regarding independent travel. Resident #35, who was admitted with a diagnosis of functional quadriplegia and was cognitively intact, reported feeling restricted and belittled by the facility's policy requiring a 24-hour advance notice and physician's order for leaving the facility. This policy was implemented during the COVID-19 pandemic and has continued, causing the resident to feel embarrassed and shamed when attempting to leave the facility without prior approval. Resident #55, diagnosed with quadriplegia and generalized anxiety disorder, also expressed feeling restricted by the new policy. Previously, residents only needed to sign out and inform staff of their whereabouts. However, the current policy requires a 24-hour advance request and physician's approval, which led to an incident where a code was called on the resident for elopement. This incident caused the resident to feel embarrassed and that their rights were being restricted. Resident #42, diagnosed with major depressive disorder and anxiety disorder, similarly reported feeling treated like a child due to the policy requiring a doctor's approval for independent travel. Interviews with staff, including LPNs, RNs, the DON, the Administrator, and a physician, revealed that the policy was seen as overly restrictive and unnecessary by some staff members. The facility's policy on resident rights states that residents should be able to exercise their rights without interference, but the current practice contradicts this policy, leading to feelings of restriction and embarrassment among the residents.
Latest citations in Arizona
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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